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Keywords: Biological Agents; Biosimilar Pharmaceuticals; Portugal; Psoriasis/drug therapy.

É já extenso o rol de pequenos manuais destinados a ensinar a bem escrever artigos de conteúdo científico, em especial na comarca da Medicina. Desde longa data que os países de língua inglesa se tem preocupado com esta matéria, estabelecendo preceitos rígidos que os editores das revistas médicas se esforçam por fazer cumprir. E já não há hoje publicação de qualidade que não estampe nas suas paginas um formulário a que devem obedecer os autores para que os seus escritos sejam aceites e publicados.

Internal hernias are a rare cause of bowel obstruction (1%) and can be caused by broad ligament defects in 4% to 7% of the cases. These defects may be congenital or acquired and are classified according to its anatomical location. This paper reports three cases of small bowel obstruction by broad ligament hernia. The patients, three women aged from 35 to 51 years old, were admitted to the emergency department with small bowel obstruction. An exploratory laparotomy was performed during which an internal hernia through a broad ligament defect was identified. In all cases the hernia content was reduced and the defect closed. One of the patients required a segmental enterectomy. All patients had a favorable outcome. This paper aims to raise awareness about the broad ligament hernia as a cause of bowel obstruction, namely in middle-aged women with no surgical history.

Introduction: Magnetic resonance imaging is recognized as the most important diagnostic test in the diagnosis of multiple sclerosis, differential diagnosis and evaluation of progression/therapeutic response. However, to make optimal use of magnetic resonance imaging in multiple sclerosis, the use of a standard, reproducible and comparable imaging protocol is of uttermost importance. In this context, the Portuguese Society of Neuroradiology and the Group of Studies of Multiple Sclerosis, after a joint discussion, appointed a committee of experts to create recommendations adapted to the national reality on the use of magnetic resonance imaging in multiple sclerosis. This document represents the second part of the first Portuguese consensus recommendations on the use of magnetic resonance imaging in multiple sclerosis in clinical practice. Material and Methods: The Portuguese Society of Neuroradiology and the Group of Studies of Multiple Sclerosis, after discussing the topic in national meetings and after a working group meeting held in Figueira da Foz, May 2017, appointed a committee of experts that have developed several standard protocols on the use of magnetic resonance imaging on multiple sclerosis by consensus. The document obtained was based on the best scientific evidence and expert opinion. Portuguese multiple sclerosis consultants and departments of neuroradiology scrutinized and reviewed the consensus paper; comments and suggestions were considered. Standardized strategies of magnetic resonance imaging referral in clinical practice for diagnosis and follow-up of multiple sclerosis were published in the first part of this paper. Results: We provide magnetic resonance imaging acquisition protocols regarding multiple sclerosis diagnostic and monitoring and the information to be included in the report for application across Portuguese healthcare institutions. Conclusion: We hope that these first Portuguese magnetic resonance imaging guidelines will contribute to optimize multiple sclerosis management and improve patient care in Portugal.

Introduction: Magnetic resonance imaging is established as a recognizable tool in the diagnosis and monitoring of multiple sclerosis patients. In the present, among multiple sclerosis centers, there are different magnetic resonance imaging sequences and protocols used to study multiple sclerosis that may hamper the optimal use of magnetic resonance imaging in multiple sclerosis. In this context, the Group of Studies of Multiple Sclerosis and the Portuguese Society of Neuroradiology, after a joint discussion, appointed a committee of experts to create recommendations adapted to the national reality on the use of magnetic resonance imaging in multiple sclerosis. The purpose of this document is to publish the first Portuguese consensus recommendations on the use of magnetic resonance imaging in multiple sclerosis in clinical practice. Material and Methods: The Group of Studies of Multiple Sclerosis and the Portuguese Society of Neuroradiology, after discussion of the topic in national meetings and after a working group meeting held in Figueira da Foz on May 2017, have appointed a committee of experts that have developed by consensus several standard protocols on the use of magnetic resonance imaging in the diagnosis and follow-up of multiple sclerosis. The document obtained was based on the best scientific evidence and expert opinion. Subsequently, the majority of Portuguese multiple sclerosis consultants and departments of neuroradiology scrutinized and reviewed the consensus paper; comments and suggestions were considered. Technical magnetic resonance imaging protocols regarding diagnostic, monitoring and the recommended information to be included in the magnetic resonance imaging report will be published in a separate paper. Results: We provide some practical guidelines to promote standardized strategies to be applied in the clinical practice setting of Portuguese healthcare professionals regarding the use of magnetic resonance imaging in multiple sclerosis. Conclusion: We hope that these first Portuguese magnetic resonance imaging guidelines, based in the best available clinical evidence and practices, will serve to optimize multiple sclerosis management and improve multiple sclerosis patient care across Portugal.

Acute porphyrias are a group of rare genetic metabolic disorders, caused by a defect in one of the enzymes involved in the heme biosynthesis, which results in an abnormally high accumulation of toxic intermediates. Acute porphyrias are characterized by potentially life-threatening attacks and, for some patients, by chronic manifestations that negatively impact daily functioning and quality of life. Clinical manifestations include a nonspecific set of gastrointestinal, neuropsychiatric, and/or cutaneous symptoms. Effective diagnostic methods are widely available, but due to their clinical heterogeneity and non-specificity, many years often elapse from symptom onset to diagnosis of acute porphyrias, delaying the treatment and increasing morbidity. Therefore, increased awareness of acute porphyrias among healthcare professionals is paramount to reducing disease burden. Treatment of acute porphyrias is centered on eliminating the potential precipitants, symptomatic treatment, and suppressing the hepatic heme pathway, through the administration of hemin or givosiran. Moreover, properly monitoring patients with acute porphyrias and their relatives is fundamental to preventing acute attacks, hospitalization, and long-term complications. Considering this, a multidisciplinary panel elaborated a consensus paper, aiming to provide guidance for an efficient and timely diagnosis of acute porphyrias, and evidence-based recommendations for treating and monitoring patients and their families in Portugal. To this end, all authors exhaustively reviewed and discussed the current scientific evidence on acute porphyrias available in the literature, between November 2022 and May 2023.

Introduction: Screening instruments specifically developed to identify genetic testing applicants who may need professional psychosocial support are much needed. However, there are no screening instruments validated for the Portuguese language. This paper presents the translation, adaptation, and validation process of the Genetic Psychosocial Risk Instrument in a sample of 207 Portuguese applicants to genetic testing in the context of inherited cancer risk. Material and Methods: Participants were mainly female (84.06%), with a mean age of 40.08 (SD = 12.89) and were recruited from the Portuguese Oncology Institute of Porto. Confirmatory factor analysis was conducted to confirm the Genetic Psychosocial Risk Instrument factorial structure. Convergent validity was assessed with the Impact of Events Scale, the Clinical Outcome Routine Evaluation – Outcome Measure, and the Hospital Anxiety and Depression Scale. Results: A model composed by the factors ‘Internal Impact of Genetic Testing’, ‘External Impact of Genetic Testing’ and ‘History of Mental Health Concerns’ was confirmed. These factors showed good internal consistency, convergent and discriminant validity. The factor ‘Personal Loss to Cancer’ proposed in the Canadian and French versions did not converge. We propose excluding this factor from the European Portuguese version of the scale. Conclusion: The European Portuguese version of the Genetic Psychosocial Risk Instrument is a reliable and valid instrument, although more research is needed to effectively use it in routine clinical oncogenetic departments.

Quality of Life is a distinct and important emerging health focus, guiding practice and research. The routine Quality of Life evaluation in clinical, economic, and epidemiological studies and in medical practice promises a better Quality of Life and improved health resources optimization. The use of information technology and a Knowledge Management System related to Quality of Life assessment is essential to routine clinical evaluation and can define a clinical research methodology that is more efficient and better organized. In this paper, a Validation Model using the Quality of Life informatics platform is presented. Portuguese PC-software using European Organization for Research and Treatment of Cancer questionnaires (EORTC-QLQ C30 and EORTC-H&N35), is compared with the original paper-pen approach in the Quality of Life monitoring of head and neck cancer patients. The Quality of Life informatics platform was designed specifically for this study with a simple and intuitive interface that ensures confidentiality while providing Quality of Life evaluation for all cancer patients. For the Validation Model, the sample selection was random. Fifty-four head and neck cancer patients completed 216 questionnaires (108 using the informatics platform and 108 using the original paper-pen approach) with a one-hour interval in between. Patient preferences and computer experience were registered. Quality of Life informatics platform showed high usability as a user-friendly tool. This informatics platform allows data collection by auto-reply, database construction, and statistical data analysis and also facilitates the automatic listing of the questionnaires. When comparing the approaches (Wilcoxon test by item, percentile distribution and Cronbach's alpha), most of the responses were similar. Most of the patients (53.6%) reported a preference for the software version. The Quality of Life informatics platform has revealed to be a powerful and effective tool, allowing a real time analysis of Quality of Life data. Computer-based quality-of-life monitoring in head and neck cancer patients is essential to get clinically meaningful data that can support clinical decisions, identify potential needs, and support a stepped-care model. This represents a fundamental step for routine Quality of Life implementation in the Oncology Portuguese Institute (IPO-Porto), ORL and C&P department services clinical practice. Finally, we propose a diagram of diagnostic performance, considerating the generalized lack of mycological diagnosis in Portugal, which emphasizes the need for a careful history, focused on quantifying the latency period.

Depression is a disorder of mood that causes strong impact on the patient and his family's quality of life. The increasing number of cases and its social consequences have made depression a great public health problem. Some depressant patients develop suicide thoughts and may try suicide later. The disease occurs in all ages and its prevalence is of 7.4%. Women aged 15 to 29 are more likely to be affected, whereas people aged 50 or older are less affected. The presence of depression worsens the prognostic of other clinical conditions when compared to not depressant patients. This paper describes the main drugs used in the treatment of depression and correlates the drug with the neurobiology of the disease. Aiming the study of the pharmacologic and therapeutic characteristics of antidepressant drugs, a literature review was performed using electronic databases (Pubmed and Lilacs), papers and books related to the theme. The main antidepressant drugs are classified according to their chemical structure or their action on neurotransmitters. An important point in the therapy is the understanding of the pharmacokinetics of the drugs. The choice of the drug must consider the symptoms, the patient's age, other drugs in use, the history of pharmacological treatments and so forth. No drug is significantly better than the other in the treatment of depression. The important thing in choosing a drug is to have the best therapeutic response, the reduction of symptoms, a good adherence to therapy, few side effects and secure drug interaction. By understanding the use of these drugs, it will be possible to give the patient and his family a better quality of life.

Adult Still's Disease has systemic consequences, an inflammatory origin and unknown etiology. Knowledge about this disease is still limited, but some evolution has occurred in the last few years.Using a clinical case as example, the purpose of this paper is to review actual knowledge about Adult Still's Disease, giving special relevance to the most recent findings.Search in Pubmed and Cochrane database (1970-2009) for the terms Adultonset Still's Disease for all available papers. Those considered clinically and historically relevant were selected. An additional search was done in scientific journals and textbooks and other web sites. The information was analysed, using a clinical case in an atypical age as illustration.Adult Still's Disease as multiple manifestations, being fever, evanescent skin rash and arthralgia the most typical. Laboratorial parameters are inespecific, but high glycosilated ferritin is highly suggestive. Non-steroid anti-inflammatory, corticoids, immunosuppressors, and recent biological agents are used in treatment.Being uncommon, actual knowledge about this disease is based in isolated descriptions or very short series. There are no specific guidelines, but diagnostic criteria have been improved in recent years, as have the insights in pathophysiology and therapeutic resources.

We aimed to evaluate an automated method for collecting data for cancer patients' quality of life (QoL). We compared the traditional method of collecting data on paper with the new collecting method using a touch screen computer. We also studied its reliability as a feasible alternative to evaluate the QoL of cancer patients in real time.200 cancer patients completed the EORTC QLQ-C30 on paper and on the computer with a time interval of one hour. The first 100 patients answered first on paper and, subsequently, on the computer; the remaining patients followed the opposite procedure.There were no statistically significant differences between the paper and the computer answers. We observed high correlations and large agreements between them. The best correlation values were obtained for the subscales diarrhea and physical functioning. Besides these findings, we observed a higher acceptability among patients using the computer when comparing with the use of paper.The computer version of the QLQ-C30 showed similar results compared to the paper version and it proved to be better accepted and tolerated by the cancer patients included in the study. This method can be valid in oncology setting and useful for monitoring the patients' QoL in daily practice, in real time, and it could be a useful means to support clinical decision making.

This paper deals with the historical development of the legal protection of medical confidentiality in Portugal. Situations that have lead to its relativization, and the present Portuguese legal framework (Criminal Code and the Code of Professional Ethics of the Ordem dos Médicos) are analysed. Finally, the paper focuses on the implementation of the legal framework, taking into account the specific situation of HIV/AIDS.

Chronic Myeloid Leukemia (CML) is a clonal stem cell disease characterized by the expression of the fusion protein bcr-abl1, which has deregulated tirosine-kinase activity. Tyrosine kinase inhibitors (TKIs), and in particular imatinib, introduced fundamental changes in the treatment of CML, becoming, in most cases, the first-line treatment of choice in the chronic phase of this disease. Compared to other available therapies imatinib results in a marked increase in overall survival, tolerability and quality of life. The introduction of second generation TKI, with increased potency against bcr-abl1, expanded the number of therapeutic options for this disease and offers an alternative for patients resistant or intolerant to imatinib or who have progressed to the accelerated phase under this therapy. In order to achieve optimal outcomes, TKI therapy must be managed rigorously, requiring a careful monitoring of treatment response in pre-established time periods, thus permitting disease evaluation and safe decision of the most adequate option. Despite the definition of the criteria for imatinib treatment response, the therapeutic strategies to adopt according to the responses obtained are less clear. The objective of this paper is to review the criteria for CML diagnosis, treatment and monitoring, with recommendations as to the most adequate therapeutic choice according to the response to TKI therapy. The paper also focuses the current lines of investigation and debate areas that in the short term can significantly change the therapeutic scenario in this disease. These recommendations, supported by published scientific evidence and by the clinical practice of the expert panel involved in their elaboration, may constitute an important instrument for a better understanding and standardisation of the treatment and monitoring of CML in Portugal.

Introduction: The aim of this study was to investigate the Portuguese authorship in publications resulting from trials initiated by the industry or investigators and run in Portugal. Material and Methods: Clinical trials with Portuguese institutions as sponsor or recruiting centers, and registered in four clinical trial registries, in the last 14 years, were assessed. Publications of completed trials, from both the initiative of the industry and investigatorswere screened and compared. Results: The percentage of published trials initiated by industry and investigators was similar (28.0%). However, the percentage of completed investigator-initiated trials (43.6%) was lower when compared to industry trials (69.7%). There was a higher percentage of Portuguese authorship in published investigator-initiated trials when compared with industry-initiated trials (47.1% vs 8.5%, respectively). Moreover, industry-initiated trials with Portuguese authors were published in journals with lower journal impact factor when compared with those published without authorship of Portuguese investigators. Oncology was the therapeutic area with the highest number of clinical trial registrations and publications. However, in publications with Portuguese authors, industry Initiated trials mainly focused on neurology while investigator-initiated trials had a higher number of papers in the fields of gastroenterology and infection diseases. Published trials with Portuguese authorship, initiated by the industry or investigators, also targeted different populations and had different purposes. In both cases, no significant differences were observed in terms of the journal impact factor or in the alignment of the published randomized trials with the respective reporting guidelines. Discussion: When compared with previous publications, this study showed an increasing trend in the number of clinical trials in Portugal, published within similar timeframes, after trial conclusion. Even though both industry and investigator trials are published within the standards for reporting trials, the low number of Portuguese authorships in industry publications might underline the need for invigorating these independent clinical trials in Portugal by capacitating and empowering national clinical research teams. Conclusion: This study confirmed that even though all registered trials had the involvement of Portuguese institutions as a recruiting center, not all the published trials had Portuguese investigators as authors, mainly those initiated by the industry.

Necrotizing fasciitis is a severe soft tissue infection with a high mortality rate and therefore requires emergent surgical treatment. Several microorganisms can cause this infection, Photobacterium damselae being one of them, with only eight cases previously published in the literature. We report the first ever case of necrotizing fasciitis, caused by this microorganism, in Portugal. In this case report the patient survived after several debridement procedures and reconstruction of the upper limb with acellular dermal matrix and skin graft. A brief review of the Photobacterium damselae soft tissue infection reports as well as the clinical presentation, diagnosis, pathophysiology and treatment of necrotizing fasciitis can also be found in this paper.

This paper describes the study aimed at validating the Portuguese version of the MOS SF-36 instrument of assessment. It starts by presenting the results of the implementation of this instrument in a sample of 930 pregnant women and the results of scaling tests, including the values of internal consistency and reliability. However, since a reliable instrument is not necessarily a valid one, the results of several validity tests are also presented. Finally, this paper ends by recommending the use of the Portuguese version of the SF-36 instrument of assessment.

No one aims at applying generic measures as substitutes for other more traditional clinical procedures. The whole history of the evolution of these types of measures has been based on comparisons with clinical measures, always seen by researchers as ways to validate health outcome measures and as a process to be recognized by clinicians as a way to detect changes in time not always detected by the usual measures. The measurement instrument presented in this paper is the Portuguese version of the MOS SF-36, originally a result of the Medical Outcomes Study, a study carried out by Rand Corporation researchers in the 80's. One of the objectives of these researchers was precisely to develop instruments to be used in continuous monitoring of outcomes. This paper describes the first time MOS SF-36 was culturally adapted to Portuguese, validated and implemented. The first part mentions some of the foundations and developments of the original instrument as well as some results obtained from some specific applications. The second part introduces operational definitions for each of the eight scales and describes the SF-36 measurement model as well as the factor structure with two dimensions. Next, we present the design used by us to transform the data from the time they are collected from the respondents to the time they are ready to be further used. Finally, the methodology used to culturally adapt the MOS SF-36 and create a Portuguese version which is culturally equivalent are presented.

This paper briefly reflects the author's ideas regarding hair transplantation based on 25 years of experience in this field. Hair transplantation is a technique that moves hair from the donor dominant scalp to the recipient scalp with a variety of methods and protocols. The first written report on this surgical art form was made by Sasgawa in 1930, who described an insertion technique. Okuda later wrote about punch autografts and homografts in humans and animals in 1939; after which time Tamura and Fujita demonstrated reconstructive techniques with small grafts. However, it was not until 1959 that modern-day hair transplantation began, when Orentreich published a paper describing the theory of donor dominance. Recently, the advent of mini- and micrografts has indeed refined the technique, especially in those with early alopecia, in women and in facial scar alopecias.

The common menopausal symptoms of a growing number of women treated for breast cancer poses difficult therapeutic decisions to the Gynaecologist. It has been extensively demonstrated that hormonal replacement therapy (HRT) is the most effective treatment of such symptoms, as well as protecting women from cardiovascular disease, osteoporosis and increased mortality related to these disorders. However, breast cancer is classically considered a contraindication to HRT. In this paper we review the existing evidence regarding the influence of HRT on breast cancer. A computerized bibliographical search (MEDLINE) of literature in the English-language literature published in the last 15 years was conducted, followed by a hand search of references found in these papers. Evidence on the response of breast cancer cells to HRT is derived from animal studies, tissue growth system experiments, indirect epidemiological data and clinical data. While the bulk of experimental evidence points towards a proliferative effect of estrogen on breast cancer cells, almost all clinical reports have found no adverse effects of HRT on these patients. In our opinion, currently existing evidence does not justify the denial of HRT to breast cancer patients whose quality of life is at stake. Such is the case of women with intense menopausal symptoms unresponsive to alternative therapies. This opinion is shared by numerous other authors and a small number of eminent institutions. We believe it is safer to avoid HRT, in asymptomatic women as long-term regimens would be needed for protection against cardiovascular disease and osteoporosis, and the risks of such regimens have yet to be evaluated. We also believe that large randomized trials are now ethically justified and greatly needed to obtain safer data on this subject.

The Paediatric Cardiology Service in Santa Marta Hospital accomplished 25 years of existence at the end of 1994. The Conde de S. Januário Hospital, in Macau also celebrated its 120th anniversary at the same time. The Paediatric Cardiology a paper entitled collaborated in these festivities with Service of Santa Marta Hospital Paediatric Cardiology, 25 years. Hospital de Santa Marta-Lisbon-Past, Present, Future. This paper is now published.

This paper consists the theorical review and the current concepts of the subject and the second includes the casuistry of the Stomatology Department of the Pulido Valente Hospital. From April 1989 to 1991 (2 years), a study was made on Sjögren Syndrome (Primary and Secondary) of multiple character with the particular co-operation of the Portuguese Institute of Rheumatology. With this paper we wish to point out the importance of the oral evaluation of the study of the plurisystemic diseases as well as to establish criterions of diagnosis for the Portuguese population. Eighty cases of suspected Sjögren's Syndrome have been assessed, 66 of which have been fully. The reason for the consultation was dry mouth, dry eyes and enlargement of parotid glands. The symptoms were isolated or in association with other pathologies after other causes had been excluded. We had to establish the salivary reference values for the Portuguese population in 22 healthy volunteers. The xerostomia was evaluated by the Sialochemistry, Sialography, Cintigraphy and biopsies of the lower lip and of the sublingual gland. The ophthalmologic examination took place in the Ophthalmology Department of Santo António dos Capuchos Hospital by means of Shirmer test, Rosa Bengala and B.U.T. In spite of Sjögren's Syndrome being, up to now, so remotely determined in connection with the treatment, these patients need medical care and Stomatology plays a fundamental role as far as the diagnosis and the therapeutic points of view are concerned. We maintain the notion that the Syndrome is not as infrequent as one would believe and the evaluation of the oral field is important to establish the degree of the disease and its treatment.

The author examines the objectives behind the possible adoption of a Credit System by the Portuguese Medical Association. Credits are units that allow physicians to keep a record of their educational and professional undertaking. The paper defines Postgraduate Medical Education and Continuing Medical Education and specifies to which group of physicians each term applies. It describes the types of activities and objectives of each form of medical education and explains the philosophy underlying both. The author also urges that the Portuguese Medical Association set up essential structures to ensure the efficient functioning of the system. The paper outlines the criteria to be used for awarding Credits and discusses the natures of credit-granting institutions. The Credits are grouped into pre-defined Categories of differing weight. The author also recommends a credit value for each activity and, taking into account the nature of each activity, assigns it to a specific Category. Several types of Forms for Applying for and Registering Credits are shown. The information on these Forms is to go on the physicians record, to be filed on a database with the Portuguese Medical Association at a place set aside for the purpose.

Fibromyalgia can be clinically defined by widespread pain lasting for longer than 3 months with tenderness on palpation in 11 or more of 18 specified tender points. Many people with fibromyalgia are significantly disabled, and experience moderate to severe pain for many years, for which conventional analgesics are usually not effective. For these patients treatment options generally include antidepressants like tricyclic agents, serotonin and noradrenaline reuptake inhibitors, or anticonvulsants like pregabalin or gabapentin. Pregabalin is a drug licensed for the treatment of fibromyalgia in the United States of America, with a mechanism of action similar to gabapentin. This mode of action confers antiepileptic, analgesic, and anxiolytic effects. This Cochrane systematic review included 8 randomized, placebo-controlled trials with low risk of bias, which studied the effect of a daily dose of pregabalin for the treatment of moderate to severe pain in adult patients suffering from fibromyalgia. Of the main results of this systematic review we highlight the major effect that a daily dose of 300 to 600 mg of pregabalin had in the reduction of pain intensity over a follow-up period of 12 to 26 weeks, with tolerable adverse effects, for a minority of people with moderate to severe pain due to fibromyalgia. This paper aims to summarize and discuss the main results and conclusions of this systematic review, as well as its implications for the daily clinical practice.

Introduction: According to the OECD, Portugal and Poland rank below average in several well-being measures such as income and wealth, and health status. Investigating how people perceive the threats to health in these two countries, is an important issue to address priority needs. To meet this need, the objective of this paper was to compare the perceptions of the threats to the health and well-being among the Polish and Portuguese older persons and explore differences between the countries in respect of patterns of self-rated health. Material and Methods: A Cross-sectional study with two convenience samples from primary health care services of Poland and Portugal was conducted; 480 adults aged 65 and over (247 Portuguese) were included. The EASYCare standard assessment of 2010 was applied under a joint project of both countries. The association between ‘self-rated unhealthy’ and socio-demographic and threats to health variables was examined using logistic regression. Results: In both countries about two thirds of the older persons self-rated their health as unhealthy. Having more than enough finances was associated with a significant lower odds of being unhealthy compared with those without enough finances at the end of the month (Portugal: OR = 0.25, 95% CI 0.10 to 0.63; Poland: OR = 0.33, 95% CI 0.12 to 0.88). Visual problems, bodily pain, memory loss, feeling bored or lonely and reporting shortness of breath during normal activities was consistently associated with fair or poor self-rated health. Discussion: These findings provide important information regarding the health profile of older people which can help in the development of people-centred health systems where their lives and well-being can be improved. Conclusion: The unhealthy perception of older people was consistently associated with indicators of major health threats.

Introduction: Lower limb amputees present a high risk of falling. This study aims to characterise fall history in unilateral lower limb amputees that are autonomous in the community, identifying differences between transfemoral and transtibial amputees and assessing fear of falling between fallers and non-fallers. Material and Methods: Descriptive, cross-sectional study of consecutive community-dwelling unilateral lower limb adult amputees of any aetiology, attending outpatient consultation in a Portuguese Physical and Rehabilitation Medicine central and university hospital department. Inclusion criteria: a prior 12 week individualised rehabilitation program for prosthesis training; regular prosthesis use for more than one year with autonomous gait; and a Functional Independence Measure® score equal to or greater than 100. Injury severity was classified according to the National Database of Nursing Quality Indicators® injury falls measure. In order to assess walking performance over short distances and fear of falling we used the 10-meter walk test and the Falls Efficacy Scale, respectively. Results: In a sample of 52 lower limb amputees, mainly men (80.8%) and of traumatic aetiology (63.5%), with a mean age of 57.21 ± 11.55 years, 36.5% reported at least one fall in the previous 12 months, all classified as minor injuries. Transfemoral amputees (n = 23) presented a higher number of falls (2.22 ± 3.23, p = 0.025) and lower gait velocity (0.77 ± 0.26 m per second, p < 0.001). Regarding fear of falling, we found no significant differences between fallers and non-fallers. Discussion: The prevalence of falls was low and of minor severity. Transfemoral amputees fell more often and were slower. There were no reported differences in fear of falling between groups. Conclusion: This paper contributes information about Portuguese lower limb amputees, whose studies are scarce and are rarely dedicated to falling.

The correct practice of specialized Clinical Pathology is dependent on the acquired aptitude and capacity gained by residents during their specialization. So, the adopted program for residents must be practical and detailed, obviously exceeding the simple and routine execution of laboratory methods and techniques. In this paper the authors describe a scheme for the Clinical Pathology residents practical program in hematology. The program is applied to a central laboratory (Hospital de Santa Maria - Lisboa). This scheme describes the basic principles for orientation of residents: systematic learning and training of laboratory technology, acquisition of experience in organization and valorizing this activity, introduction to methods and practice of quality control and administration of laboratory activity. Methodological studies and valorization are adapted to its clinical and technical specifications. Furthermore, specialization must include other theoretical and practical activities, which are in fact essential to systematization, organization and consolidation or residents knowledge. We schematized the discussion of technical reports, conception and discussion of investigation protocols and active participation in scientific meetings in this field. Responsibility for the execution of practical scientific work and for the presentation of the final report are fundamental to assess the experience and knowledge that has been acquired and simultaneously to give a mean of self criticism and perfectionism. In fact, this last aspect must be a part of the discussion and conclusion of the final report. In this paper, all these particularities are presented and the methods for their effective use are suggested in detail.(ABSTRACT TRUNCATED AT 250 WORDS)

Introduction: The aim of the study described in this paper is to screen medical curricula in relation to the attention paid to intimate partner violence, by applying a framework derived from the international literature. Material and Methods: We screened curricula of five Mozambican medical schools based on a state-of-the-art intimate partner violence curriculum framework. The latter framework was based on a review of the literature. Results: Few medical schools of Mozambique could be identified addressing intimate partner violence in their curriculum. When tackled, intimate partner violence content is mostly dealt within the context of Obstetrics and Gynaecology, Community Health and Forensic Medicine rotations. Intimate partner violence contents are integrated as stand-alone modules in some specific subjects. In none of the schools, specific teachers teaching intimate partner violence could be identified. No time allocation was specified to address the topic; no teaching and learning strategies could be identified invoking awareness or supporting basic knowledge acquisition; additionally, hardly any information about related assessment methods was found. Only in one medical school was the subject part of the formal curriculum. Discussion: Intimate partner violence content is hardly and inconsistently addressed. The limited intimate partner violence content tracked in the Mozambican medical schools’ curricula, mainly addresses violence in general, for instance as identified in Orthopaedics or Surgery contexts and sexual violence in Obstetrics and Gynaecology. The inclusion of elements of intimate partner violence in the curriculum remains restricted, questioning the impact of medical education of future practitioners’ competencies. Conclusion: Critical changes are needed in medical curricula to match the current epidemiology of intimate partner violence in Mozambique.

New generation oral anticoagulants — rivaroxaban, apixaban and edoxaban — represent an important medical achievement. Their therapeutic effectiveness and ease of use make them essential in the management of thromboembolic conditions. However, as warfarin, they have known haemorrhagic risks. This paper reports the case of a 50-year-old female who presented with ear pain and spontaneous blood discharge in her right ear, after a two-week treatment with rivaroxaban. The physical examination revealed a spontaneous tympanic haematoma in the inferior quadrants, adjacent to the umbus. She denied any manipulation of the ear canal. Our goal is to alert for a presumable side effect of this drug in clinical practise.

Hidrosadenitis supurativa is a chronic inflammatory disease with great physical and psychological impact. Although conservative treatments may be effective in mild forms of the disease, extensive surgical resection and reconstruction are necessary in more severe forms of the disease. The purpose of this paper is to describe our two-stage reconstructive procedure regarding this kind of disease. We present a clinical case of a patient with severe, bilateral axillary hidrosadenitis. In the first surgical step we excised the lesions and applied the artificial dermis secured with negative pressure wound therapy. In the second step we used a split thickness skin graft to close the wound and again applied negative pressure wound therapy. The graft take was very good, without complications. The cosmetic outcome is acceptable and shoulder mobility was not compromised. No recurrence was detected (nine months follow up).

Introduction: Otosclerosis is a common form of conductive hearing loss characterized by abnormal bone remodeling exclusively in the otic capsule. The prevalence of otosclerosis varies in racial populations and is described as being rare in black African populations. In this paper we aim to report five cases of clinical, and surgically confirmed, otosclerosis in black individuals, in São Tomé and Príncipe. Material and Methods: Since February 2011, Ear, Nose and Throat consultations and surgeries specialty have been carried out at Dr. Ayres de Menezes Hospital in cooperation with the project ‘Health for all’. A retrospective analysis was undertaken of the records of all patients subjected either to stapedectomy or partial stapedectomy until February 2014. Information regarding clinical presentation, audiometric data and surgery reports was recorded. Results: Five adult patients underwent stapedectomy or partial stapedectomy. All of them presented with normal otoscopy, conductive or mixed hearing loss on audiogram and normal tympanometry with absent stapedial reflexes. None of the patients had signs of infection or history of head trauma. Three cases showed improvement in the air-bone gap after surgery. The other two were lost to follow-up. Discussion: We documented and surgically confirmed five cases of clinical otosclerosis in this population. A thematic review was carried out and concluded that, despite being described as a rare event in this race, available literature on this topic is not enough to state that there is lower prevalence of otosclerosis amongst the African population. Conclusion: Even if not common, otosclerosis cannot be disregarded as a possible cause for conductive hearing loss among the population of São Tomé and Principe.

Introduction: Cape Verde is a small insular developing state. Its first experience of undergraduate medical education began in October 2015. The purpose of this paper is to describe and analyze the professional expectations and profile of the first class of medical students at the University of Cape Verde. Material and Methods: A piloted, standardized questionnaire, with closed and open-ended questions, was distributed to registered medical students attending classes on the day of the survey. All data were analyzed using SPSS. Results: Students decided to study medicine in their mid-teens with relatives and friends having had significant influence over their decisions. Other major reasons for choosing medical training include “to take care of other people”, “fascination for the subject matters of medicine” and “I have always wanted to”. The degree of feminization of the student population is extremely high (20/25; 80.0%). Medical students are in general satisfied with the training program, and have expectations that the training received will allow them to be good professionals. Nevertheless, they consider the course too theoretical. Medical students know that this represents an opportunity for them to contribute to public welfare. Nonetheless, their expectations are to combine public sector practice with private work. Medical students come mostly from Santiago Island where the Capital of the Country is located. They still do not know about their future area of specialization. But all of those who want to specialize want to do so abroad. They mostly expect to follow hospital careers rather than health administration or family and community medicine. Discussion: This study contributes to the growing body of knowledge about medical students’ difficulties and expectations regarding medical schools or curriculums in lusophone countries. The decision to invest in the training of local physicians is justified by the need to be less dependent on foreigners. Local postgraduate medical training programs are already considered a priority for the immediate future. Conclusion: Cape Verde is pursuing a bold strategy to deal with a shortage of medical doctors. The problems experienced by medical students provide an important insight to help the new medical school to provide a better learning environment for students. The fact that students are not sure about their future area of specialization is an opportunity to guide them towards the areas of the health system with pressing needs. The current feminization of the medical workforce will be sustained with the profile of the present intake, hence the need to take this into account in workforce planning.

Dietary supplementation with omega-3 polyunsaturated fatty acids from fish and plant sources is commonly prescribed as a nonfarmacological alternative to improve brain functions and slow down the progression of dementia. This use is mostly based on findings of preclinical studies which established the role of omega-3 polyunsaturated fatty acids in the development and integrity of the brain, as well as epidemiological research that found evidence of malnutrition in patients with dementia. This Cochrane systematic review included three randomized, placebo-controlled trials at low risk of bias, in which omega-3 polyunsaturated fatty acids were administered to people with mild to moderate Alzheimer’s disease in the form of supplements. Of the main results of this systematic review we highlight the lack of convincing evidence for the efficacy of omega-3 polyunsaturated fatty acids supplementation in the treatment of patients with Alzheimer’s disease, as well as the low frequency of reported adverse events, with a comparable overall frequency between omega-3 polyunsaturated fatty acids and the placebo groups. The effects on other populations with dementia remain unclear. This paper aims to summarize and discuss the main results and conclusions of this systematic review, as well as its implications for the daily clinical practice.

Introduction: Scientific medical publications are considered to be a source of unbiased and independent information. Authors are required to disclose relationships with the pharmaceutical industry for transparency purposes. The aim of this work was to assess conflict of interest disclosure in a Portuguese top-tier medical journal by comparing authors’ self-reported conflicts of interest with payments listed in the official database of Portuguese Ministry of Health. Material and Methods: All articles published in the Portuguese Journal of Cardiology from December 2015 to May 2016 were reviewed. Articles based on clinical images, with authors affiliated to foreign institutions, editorials, letters to the editor, or submitted before January 1st 2015 were excluded. Authors were categorized on concordance between self-reported disclosures and payments listed in the database. Authors who authored multiple articles were counted as new authors, since each paper offered a new opportunity for financial disclosure. Results: Of the 155 authors surveyed, 82 (53%) were in perfect concordance with the sunshine database, while 73 authors (47%) had one or more undisclosed payments. Undisclosed payments totaled over € 210 000. Four (17%) articles mentioned a conflict of interest, 24 articles (96%) had at least one author with undisclosed payments. Discussion: None of the payments listed in the database was acknowledged in self-reported conflicts of interest. This might indicate that authors do not consider their financial relationships with the industry to be relevant. Conclusion: The lack of concordance between self-reported conflicts of interest and payments found in the database raises concerns about incomplete disclosure.

Introduction: The ageing of populations is evident in most developed countries, and the oldest old group is one of the segments with the fastest growing. The aim of this paper is to examine sociodemographic and health related characteristics of the portuguese oldest old, using a census-based approach. Material and Methods: A descriptive study considering all residents aged 80 years and older at the time of the 2011 Census (n = 532 219) was conducted. Information on sociodemographic characteristics, sensory functions (seeing, hearing), functional status (walking/climbing stairs, bathing/dressing alone), cognition (memory/concentration), and communication (understanding others/being understood) as assessed by the Portuguese census official questionnaires were analyzed. Results: Findings revealed that most of the oldest old are women (64.5%), widowed (53.9%), illiterate (46.1%) and live in private households (88.8%). Walking/climbing stairs (57.1%), vision (39.1%) and hearing (35.1%) were the dimensions where the oldest old presented major constrains. In parallel, understanding others/being understood (25.9%) and memory/concentration (34.4%) were the dimensions with lower percentages of difficulties. Significant differences were found between octogenarians/nonagenarians and centenarians for vision, walk/climb stairs, and bathing/dressing alone, with centenarians presenting a higher percentage of difficulties. Discussion: Portuguese oldest old showed significant difficulties in activities of daily living, nevertheless cognitive and communication capacities seem to be commonly maintained. Taken together, these findings suggest the need for functional assistance, which can be ultimately managed by the older person him/herself. Conclusion: Based on the observed differences between centenarians and younger oldest old, specific interventions should be equated to better respond to their potentially distinctive needs.

Arterial hypertension is a public health problem that affects approximately 25% of the world’s adult population. The association between hypertension and hyperuricemia has been shown on epidemiological and experimental studies. However, it is unclear whether lowering serum uric acid might lower blood pressure. This Cochrane systematic review - a revised edition of a previously published one - intended as primary objective to evaluate the effect of hypouricemic drugs in patients with primary hypertension or prehypertension. The secondary objectives were to evaluate the efficacy and safety of hypouricemic drugs. A systematic search until February 2016 on controlled, randomized or quasi-randomized trials comparing the effect of hypouricemic drug versus placebo in hypertensive or prehypertensive patients was performed on the following databases: The Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, The World Health Organization International Clinical Trials Registry Platform, e ClinicalTrials.gov. LILACS database up to March 2016 was also searched and the authors of relevant studies were contacted. There were 349 identified papers, 21 were preselected and three randomized clinical trials (211 patients) were included in the qualitative analysis and in the meta-analysis. Two of the trials were conducted exclusively on adolescents. The authors conclude that hypouricemic drugs are not effective in lowering blood pressure in patients with hyperuricemia and primary prehypertension or hypertension. However, this strategy might be more effective in the specific population of adolescents with prehypertension or mild primary hypertension recently diagnosed. Hypouricemic drugs effectively reduce serum uric acid level and withdrawals of therapy due to adverse effects were not superior in the treated group, comparing to placebo; however, one patient withdrew due to a severe cutaneous reaction.

Introduction: In Europe, scant scientific evidence exists on the impact of economic crisis on physicians. This study aims at understanding the adjustments made by public sector physicians to the changing conditions, and their perceptions on the market for medical services in the Lisbon metropolitan area. Material and Methods: A random sample of 484 physicians from São José Hospital and health center groups in Cascais and Amadora, to explore their perceptions of the economic crisis, and the changes brought to their workload. This paper provides a descriptive statistical analysis of physicians’ responses. Results: In connection to the crisis, our surveyed physicians perceived an increase in demand but a decrease of supply of public health services, as well as an increase in the supply of health services by the private sector. Damaging government policies for the public sector, and the rise of private services and insurance providers were identified as game changers for the sector. Physicians reported a decrease in public remuneration (- 30.5%) and a small increase of public sector hours. A general reduction in living standard was identified as the main adaptation strategy to the crisis. Passion for the profession, its independence and flexibility, were the most frequently mentioned compensating factors. A percentage of 15% of physicians declared considering migration as a possibility for the near future. Discussion: The crisis has brought non-negligible changes to physicians’ working conditions and to the wider market for medical services in Portugal. Conclusion: The physicians’ intrinsic motivation for the professions helped counterbalance salary cuts and deteriorating working conditions.

Introduction: Borderline personality disorder is the most common personality disorder, with a global prevalence rate between 1.6% and 6%. It is characterized by affective disturbance and impulsivity, which lead to a high number of self-harm behaviors and great amount of health services use. International guidelines recommend psychotherapy as the primary treatment for borderline personality disorder. This paper reviews evidence about the effects and efficacy of cognitive-behavioral oriented psychological treatments for borderline personality disorder. Material and Methods: A literature review was conducted in Medline and PubMed databases, using the following keywords: borderline personality disorder, cognitive-behavioral psychotherapy and efficacy. Results: Sixteen randomized clinical trials were evaluate in this review, which analyzed the effects of several cognitive-behavioral oriented psychotherapeutic interventions, namely dialectical behavioral therapy, cognitive behavioral therapy, schema-focused therapy and manual-assisted cognitive therapy. All above stated treatments showed clinical beneficial effects, by reducing borderline personality disorder core pathology and associated general psychopathology, as well as by reducing the severity and frequency of self-harm behaviors, and by improving the overall social, interpersonal and global adjustment. Dialectical behavioral therapy and schema-focused therapy also caused a soaring remission rate of diagnostic borderline personality disorder criteria of 57% and 94%, respectively. Discussion: Although there were differences between the psychotherapeutic interventions analysed in this review, all showed clinical benefits in the treatment of borderline personality disorder. Dialectical behavioral therapy and schema-focused therapy presented the strongest scientific data documenting their efficacy, but both interventions are integrative cognitive-behavioral therapies which deviate from the traditional cognitive-behavioral model. Conclusion: In summary, the available studies support cognitive-behavioral psychological treatments as an efficacious intervention in borderline personality disorder. However, the existing scientific literature on this topic is still scarce and there is need for more studies, with higher methodological rigor, that should validate these results.

Introduction: To be a college teacher requires a permanent effort in developing specific competencies, namely in the pedagogical domain. This paper aims both to describe the pedagogical professional development program offered by the Medical Education Office of NOVA Medical School of Universidade Nova de Lisboa and to analyse its role in the enhancement of reflection around curriculum and teaching practice. Material and Methods: Description of the pedagogical programme offered between 2010 and 2016. We focused the analysis on different kinds of data – opinions of the participants in the training programme (questionnaire before and after the training); pedagogical products elaborated by the participants in the programme – design of lessons, modules or curricular units; questionnaire sent in 2016 to NOVA Medical School teachers responsible for the curricular units, about the contribution of their disciplines to the accomplishment of the core learning outcomes of the NOVA Medical School medical graduates. Results: The pedagogical training needs identified by the teachers focused mainly on improving practice, critically analysing the curriculum and sharing experiences. Globally the training programme was deeply appreciated and considered very good by 97% of the participants. The lesson plans delivered showed that the teachers were able to integrate and apply the concepts developed during the training. The answers from the 46 faculty responsible for the curricular units (the majority of them had attended the Medical Education Office training programme) highlighted their capacity to critically approach content and pedagogical strategies within their disciplines as well as their contribution to the main goals of the medical curriculum. Discussion: The results underlined the importance of a pedagogical training focused on the critical analysis of curriculum and pedagogical practice. On the other hand, the pedagogical products analyzed revealed great mastery by teachers of the content and pedagogical strategies present in the curricula of their respective curricular units, as well as their alignment with the general objectives of the Mestrado Integrado em Medicina. Conclusion: In line with the literature of the specialty, pedagogical training in Higher Education, rather than aiming at the mere acquisition of techniques, should, above all, give priority to spaces for joint reflection on the curriculum and on the pedagogical options of teachers.

Introduction: Biological and biosimilar medicinal products have specific characteristics that call for a closer monitoring of their safety profile. Since the current legal framework stems from both European and national regulations, some gaps in the operational field may be expected. The goal of this paper is to identify these gaps and propose changes to the current information systems and pharmacovigilance regulations. Material and Methods: A qualitative analysis of current pharmacovigilance regulatory framework and supporting information system was conducted. Results: Current pharmacovigilance system does not seem to vouch for the safe use of biologicals and biosimilar drugs. The gaps found in reviewed materials may be attributable to their lack of specificity for biopharmaceuticals. Discussion: Biologicals therapy presents specific determinants related with the drugs, prescription, and traceability, without replication in any other segment of the pharmaceutical market. They are able to shape their safety profile. Conclusion: The existing pharmacovigilance’s regulatory framework should be adjusted in order to improve the safety related with biopharmaceutical therapy. Some intervention measures are proposed.

The effects of immunodepression on several disease states have constituted an important area of research, leading to the identification of relevant associations between immunodepression and a vast set of comorbidities, including infectious diseases, cardiovascular diseases and cancer. Research on the effects of immunodepression has mostly been conducted in individuals under immunodepression by the human immunodeficiency virus and transplant recipients under pharmacological immunosuppression, due to the difficulties in obtaining relevant samples sizes in other contexts of immunodepression. Overall, immunosuppressed individuals tend to show increased incidence of malignancies, but only transplant recipients show significantly increased incidence of skin cancer; human immunodeficiency virus-infected individuals only show increased incidence of malignancies of infectious origin. This paper presents a literature review on the effects of immunodepression in the development of tumours in humans, with special emphasis on the development of the different types of skin cancer.

Biomedical simulation is an effective educational complement for healthcare training, both at undergraduate and postgraduate level. It enables knowledge, skills and attitudes to be acquired in a safe, educationally orientated and efficient manner. In this context, simulation provides skills and experience that facilitate the transfer of cognitive, psychomotor and proper communication competences, thus changing behavior and attitudes, and ultimately improving patient safety. Beyond the impact on individual and team performance, simulation provides an opportunity to study organizational failures and improve system performance. Over the last decades, simulation in healthcare had a slow but steady growth, with a visible maturation in the last ten years. The simulation community must continue to provide the core leadership in developing standards. There is a need for strategies and policy development to ensure its coordinated and cost-effective implementation, applied to patient safety. This paper reviews the evolutionary movements of biomedical simulation, including a review of the Portuguese initiatives and nationwide programs. For leveling knowledge and standardize terminology, basic but essential concepts in clinical simulation, together with some considerations on assessment, validation and reliability are presented. The final sections discuss the current challenges and future initiatives and strategies, crucial for the integration of simulation programs in the greater movement toward patient safety.

Introduction: Obsessive-compulsive disorder is a psychiatric disorder stated as one of the most debilitating diseases in the developed world. However, not much is known about how this disease impairs patients’ quality of life in children. Material and Methods: We conducted a research in PubMed and Thomson Reuters Web Of Science using the following terms: ‘Quality of life’, ‘Obsessive-compulsive disorder’, ‘Child’, ‘Pediatrics’ and ‘Adolescent’. Of the 138 papers retrieved with this search, five articles corresponded to the aim of this review. We analyzed quality of life in children with obsessive-compulsive disorder comparing with general population and searching the relation with other clinical variables such as sex, age, comorbidities, symptoms dimension, symptoms severity, family accommodation and quality of life. Results: Albeit studies results not being concordant regarding the different dimensions analyzed, our findings pointed to an overall decrease of quality of life in children with obsessive-compulsive disorder. The presence of co-morbidities, symptoms severity and obsessions with harm/aggression content are the variables that have a higher influence in quality of life levels. Discussion: The small number of articles found and the fact that their methodology was extremely heterogeneous made it difficult to state robust conclusions. Despite that, our findings agree with other studies in adults. Conclusion: Quality of life in children and adolescents with obsessive-compulsive disorder must be better explored in future researches. We suggest the introduction of quality of life as a routinely used instrument in patient’s assessment and in treatment response evaluation.

Introduction: Peyronie’s disease, a fibrotic disorder of the tunica albuginea of the penis, has been associated with penile shortening and some degree of erectile dysfunction. It affects patient’s quality of life, leading to severe psychological, mental, and physical stress. Penile deformation hampers sexual life leading to depression, lack of sexual confidence, loss of sexual function and performance anxiety. Peyronie’s disease etiology is yet to be known. Material and Methods: Literature search was conducted in Medline, Embase, and Cochrane databases in January 2015 in order to identify papers related to Peyronie’s disease, concerning evolving surgical management, technique, outcomes as well as ancillary treatments. Publications not concerning humans were not considered. We identified original articles, review articles, and editorials addressing the subject. All articles published in the English language were selected for screening. The eligibility criteria for inclusion were based on relevance concerning the subject. Results: The variety of penile deformities associated with Peyronie’s disease still doesn’t have an effective and reliable non-surgical therapy. We summarize the updated surgical techniques and management algorithm described for Peyronie’s disease. Discussion: Surgical management shares similar goals: correcting the curvature, preserving erectile function and penile length, and minimizing morbidity. Conclusion: To date there is no high level of evidence-based data to determine the best surgical treatment of Peyronie’s disease. After proper diagnosis, surgical reconstruction should be based on giving a functional penis, that is, rectifying the penis with rigidity enough to enable sexual intercourse.

Introduction: Small bowel capsule endoscopy is currently the first line diagnostic examination for many diseases affecting the small bowel. This article aims to review and critically address the current indications of small bowel capsule endoscopy in clinical practice. Material and Methods: Bibliographic review of relevant and recent papers indexed in PubMed. Results and Discussion: Small bowel capsule endoscopy enables a non-invasive full-assessment of the small bowel mucosa, with high diagnostic yield even for subtle lesions. In patients with obscure gastrointestinal bleeding, diagnostic yield is higher when performed early after the onset of bleeding. Endoscopic treatment of angioectasias using balloon-assisted enteroscopy may contribute to reduce rebleeding, while the risk of rebleeding in patients with “negative“ small bowel capsule endoscopy is debatable. Cross-sectional imaging may be more accurate than small bowel capsule endoscopy for the diagnosis of large small bowel tumors. The Smooth Protruding Index on Capsule Endoscopy (SPICE score) may help to differentiate submucosal tumors from innocent bulges. Small bowel capsule endoscopy is also a key diagnostic instrument in patients with suspected Crohn’s disease and non-diagnostic ileocolonoscopy; it may also influence prognosis and therapeutic management, by determining disease extent and activity in patients with known Crohn’s disease. The role of small bowel capsule endoscopy to investigate possible complications in patients with non-responsive coeliac disease is evolving. Conclusions: Small bowel capsule endoscopy is a valuable diagnostic instrument for patients with obscure gastrointestinal bleeding and/or suspected small bowel tumors; it may also be a key examination in patients with suspected Crohn’s disease, or patients with known Crohn’s disease to fully assess disease extension and activity; finally, it may contribute for the diagnosis of complications of non-responsive coeliac disease.

Clinical Practice Guidelines are instruments to support decision to improve the quality of clinical care. An expert group from McMaster University (Canada) has developed - from high-quality literature sources – a guidance on the practical steps for their development, dissemination, implementation and evaluation. This is the 1st time anyone seeks to bring together in one document all information regarding the Clinical Practice Guidelines. Due to the interest of this paper, the Centre for Evidence Based Medicine at the University of Lisbon School of Medicine contacted the authors of the article and the journal where it was published (the Canadian Medical Association Journal) in order to translate the most relevant parts of the article (including the practice tables), which was agreed. This guide should be useful to those who, being interested in the development, dissemination and implementation of Clinical Practice Guidelines, want to ensure their intrinsic quality based on relevant and updated evidence.

Introduction: Obesity is an important public health problem because it is a risk factor for numerous diseases and is associated with a higher death risk. Evidence concerning the prevalence of excess weight in health professionals is scarce and this group is often overlooked in weight interventions programs. This paper aims to estimate the prevalence of obesity and overweight among Portuguese primary health care professionals and to describe differences between occupational groups. Material and Methods: This was a cross sectional study based on a primary care setting in Portugal in 2011. We collected data on occupation, age, sex and height of professionals from four primary care centers. We did a descriptive analysis of the main variables and an analysis of covariance to compare mean Body Mass Index. Results: Our sample represented 52.8% of the total population of the four primary care centers, and 38.6% were overweight and 16.9% were obese. When adjusted for age and gender, health service personnel had the highest average Body Mass Index, followed by nurses, physicians, and superior technicians, in that order. Discussion: Although we can’t ensure the generalisation of the results and cannot exclude the possibility of sampling bias, these results suggest high prevalence obesity and overweight in workers of primary health care in Portugal. Conclusion: In this primary care setting more than half of the health care professionals were overweight or obese. Tailored interventions might be needed to tackle this issue. Keywords: Body Mass Index; Health Personnel; Obesity; Portugal; Primary Health Care; Prevalence.

Introduction: Osteoporosis is a bone metabolic disease with increasing prevalence in ageing societies. Herein we reviewed recent epidemiologic findings and their impact in the individual patient management. In addition we dissected the major disease mechanisms which have uncovered new potential therapeutic strategies. Material and Methods: Using MeSH terms (osteoporosis, epidemiology, Portugal, Europe, pathogenesis, osteoblasts, osteoclasts, osteocytes, immune system, obesity, therapy, randomized controlled trial, efficacy, safety) as keywords. We have reviewed original studies, reviews and position papers indexed in PubMed. Results: Osteoporosis is increasingly prevalent, but recently an age-adjusted rate of fracture plateau was reached. A new fracture risk assessment tool was developed, FRAX™, which integrates the contribution of clinical risk factors associated with fragility fractures. It can be used either independently or in combination with bone mineral density. Osteoporosis treatment is offered only to a fraction of the affected individuals. In addition, 40% of the patients receiving Osteoporosis medication had a previous fracture. Relevant safety issues of different drugs used in Osteoporosis have been detected in post-marketing experience. Finally, advances in the understanding of the molecular pathways involved in Osteoporosis led to the development of new drugs. Discussion and Conclusion: Despite the existence of diagnostic tools and several effective treatments, Osteoporosis treatment is still offered only to a fraction of the affected individuals and mainly to a population with advanced disease. New and more effective treatments might change this scenario.