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Abstract Background Countries with formal policies for palliative care, and advanced and integrated practices in this field, such as Portugal, face challenges in achieving excellence in care, particularly in home-based assistance. Issues include care coordination among providers, confusion regarding the roles of each health care professional in the network, and a lack of monitoring and evaluation of actions. Our objective was to analyze the implementation of palliative care in primary health care in Portugal. Methods We conducted a qualitative, descriptive, and exploratory study in Portugal involving health care professionals with experience in palliative care. The data were collected through semistructured interviews and focus groups between March and October 2023. Eighteen health care professionals participated. We used the Alceste software for lexicographic analysis. The research was authorized by an Ethics Committee. Results Four classes were identified; classes 1 and 2, comprising 77% of the corpus, addressed the study objectives. Participants highlighted inequitable access, strategic development plans with unattainable short-term goals; and low literacy. They emphasized the importance of legislation, professional training initiatives for generalist palliative care at home, and early referral. Home-based challenges included professionals’ lack of exclusive dedication, absence of 24/7 coverage, and unavailability of capable family caregivers. The networks’ response to hospital admissions and patient transitions from hospital to home, with access to the specialized team, was also inadequate. Conclusions Health care professionals aim to increase patients’ time spent at home, reduce emergency department visits, and minimize hospitalizations by leveraging the resources of the national palliative care network. In addition to investments to sustain network implementation and legally guaranteed palliative care rights, the country must focus on measurable indicators for evaluating and monitoring actions, providing better guidance in the short, medium, and long term.

Abstract Background The COVID-19 pandemic and related disruptive consequences in the economic, health, and educational sectors have impacted people’s lives, contributing to a context of increased economic and social vulnerability. The pandemic has revealed and accentuated social inequalities and discrimination based on racial or ethnic origin. This study aimed to contribute to the promotion of the mental health and well-being of migrant populations living in Portugal via the definition of an analytical framework and recommendations emerging from the EQUALS4COVID19 project. Methods To gather information on the impact of the COVID-19 pandemic and resilience determinants among immigrants, a mixed-methods approach was implemented in 2022, combining a cross-sectional survey targeting immigrant adults in Portugal, focus groups with immigrants, focus groups with healthcare professionals, and in-depth individual interviews with stakeholders involved in the implementation of measures related to mental health and well-being during the pandemic. The analysis followed an integrated framework; quantitative data informed the script of qualitative data collection methods, and qualitative analysis informed the reinterpretation of quantitative data. Results The survey with 604 Brazilian and Cape Verdean immigrants revealed that gender (being a woman) was associated with both psychological distress and depression-related symptomatology and that the perception of discrimination was a major risk factor for psychological suffering, while perceived social support and individuals’ resilience characteristics were protective factors. Qualitative data provided deeper insights into these findings, revealing the ways mental health is affected by social structures, such as gender and ethnic hierarchies. Migrants tend to work in precarious jobs requiring physical presence, which, together with dense housing conditions, puts them at higher risk of infection. The deterioration of the economic conditions of the general population has also increased the perception of ethnic-racial discrimination, which was found to be related to the increase in insecurity and anxiety-related symptomatology among the migrant population. Newly arrived migrants, with reduced support networks, experienced a greater sense of insecurity as well as concern and anguish regarding relatives who live far away, in their home country. Migrant women reported greater family-related distress, including work-life balance problems. Conclusions Proposals to address mental health inequalities should be considered in the context of the necessary global changes both at the societal level and in the delivery of mental health services. Additionally, they should be considered with the active involvement of migrants, families, and communities in the design and delivery of mental health promotion and care processes.

Abstract Background Reflecting people with diabetes’ self-management activities is often required in both research and clinical practice. This study evaluated the measurement properties of the Portuguese version of the Diabetes Self-Management Questionnaire-Revised (DSMQ-R) on a sample of people with type 2 diabetes mellitus (T2DM). Methods Translation and cultural adaptation were conducted according to guidelines for cross-cultural adaptation and validation of healthcare measurement instruments. A cross-sectional study was performed including 365 people with T2DM in primary care. Reliability, construct validity, and criterion validity were analyzed. Results The total scale of the translated DSMQ-R revealed sufficient internal consistency (alpha = 0.82), and most of the subscales performed adequately. The exploratory factor structure was robust, and confirmatory analysis showed a good model fit with the scale structure of the original scale. The scale scores correlated with the participants’ last HbA1c estimates, supporting convergent validity, and convergence was confirmed by the adequate average variance extracted. Conclusions The Portuguese version of the DSMQ-R is a reliable and valid tool for gauging self-management behaviors in people with T2DM and their relationship with glycemic values.

Abstract Background Social prescribing (SP) is a non-clinical approach, most commonly based in healthcare units, that aims to address non-medical health-related social needs by connecting individuals with community-based services. This qualitative study explores the perception of Portuguese older adults regarding the benefits of SP and their willingness to participate in SP initiatives. Methods Three face-to-face focus group sessions were conducted with 23 participants in different cities in Portugal. Open and semi-open questions were used to guide the discussions and thematic analysis was used to analyze the data. Results The participants recognized the potential benefits of SP for older adults, including diversifying leisure activities, improving mental health, and complementing existing support systems. They highlighted the need for external support, usually in the form of link workers, to facilitate personalized referrals and consider individual characteristics and preferences. While some participants expressed reluctance to engage in SP due to their existing busy schedules and a perceived sense of imposition, others showed openness to having new experiences and recognized the potential value of SP in promoting activity. Barriers to participation, including resistance to change, mobility issues, and family responsibilities, were identified. Conclusions The study emphasizes the importance of a person-centered and co-designed approach to SP, involving older adults in the planning and implementation of interventions. The findings provide valuable insights for the development of SP programs tailored to the unique needs and aspirations of older adults in Portugal, ultimately promoting active and healthy aging. Future research should consider the perspectives of family doctors and include a broader representation of older adults from diverse geographic areas.

Introduction: Psychiatric comorbidities have a significant impact on patients’ quality of life and often go undetected in neurologic practice. The aim of this study was to describe and characterize psychiatric comorbidities among patients hospitalized due to a neurologic disorder in mainland Portugal. Methods: A retrospective observational study was performed by analyzing hospitalization with a primary diagnosis of neurologic disorder defined as categories 76, 77, 79 - 85, 95, 109 of the Clinical Classification Software for International Classification of Diseases, Ninth Revision, Clinical Modification, occurring between 2008 and 2015 in adult patients (≥ 18 years of age). Psychiatric comorbidities were determined as the presence of a secondary diagnosis belonging to the Clinical Classification Software categories 650 to 670. Results: A total of 294 806 hospitalization episodes with a primary diagnosis of a neurologic disorder were recorded in adult patients between 2008 - 2015 in Portuguese public hospitals. Approximately 26.9% (n = 79 442) of the episodes had a recorded psychiatric comorbidity (22.1%; 32.2%, female versus male hospitalizations). Patients with registered psychiatric comorbidities were younger (66.2 ± 16.2 vs 68.6 ± 17.2 with no psychiatric comorbidities, p < 0.001), presented lower all-cause in-hospital mortality rates, and significantly longer mean hospital stays. ‘Delirium, dementia, amnestic and other cognitive disorders’ were recorded in 7.4% (n = 21 965) of the hospitalizations, followed by alcohol-related disorders in 6.5% (n = 19 302) and mood disorders in 6.1% (n = 18 079). Epilepsy/seizures were the neurologic disorders with the highest proportion of recorded psychiatric comorbidities (39.9%). Conclusion: Psychiatric comorbidities were recorded in more than a quarter of the hospitalizations with a primary diagnosis of a Neurologic disorder. Psychiatric comorbidities varied among neurological disorders and were associated with different demographic and clinical features.

BackgroundDigital patient-centered interventions may be important tools for improving and promoting social interaction, health, and well-being among older adults. In this regard, we developed a mobile app called DigiAdherence for an older adult population, which consisted of easy-to-access short videos and messages, to improve health-related knowledge among them and prevent common health conditions, such as falls, polypharmacy, treatment adherence, nutritional problems, and physical inactivity. ObjectiveThis study aimed to assess the usability and utility of the DigiAdherence app among Portuguese older adults 65 years or older. MethodsIn this pilot noncontrolled quasi-experimental study, older adults who were patients at the primary health care center in Portimão, Portugal, and owned a smartphone or tablet were recruited. Participants were assessed at baseline, given access to the DigiAdherence app for 1 month, and assessed again immediately after 30 days (first assessment) and 60 days after stopping the use of the app (second assessment). App usability and utility (primary outcomes) were analyzed in the first follow-up assessment using a structured questionnaire with 8 items. In the second follow-up assessment, our focus was on knowledge acquired through the app. Secondary outcomes such as treatment adherence and health-related quality of life were also assessed. ResultsThe study included 26 older adults. Most participants rated the different functionalities of the app positively and perceived the app as useful, attractive, and user-friendly (median score of 6 on a 7-point Likert scale). In addition, after follow-up, participants reported having a sense of security and greater knowledge in preventing falls (16/24, 67%) and managing therapies and polypharmacy (16/26, 62%). ConclusionsThe DigiAdherence mobile app was useful and highly accepted by older adults, who developed more confidence regarding health-related knowledge. International Registered Report Identifier (IRRID)RR2-10.2196/29675

BackgroundInformal caregivers (IC) play an important role in the community as health care providers for people who are dependent on self-care. Health literacy contributes to empowerment, better care, and self-management of one’s own health and can be developed using digital technologies. ObjectiveThis study aims to map scientific evidence about the use of digital technologies to promote health literacy and the empowerment of ICs. MethodsWe conducted a scoping review following the Joanna Briggs Institute methodology. The CINAHL, MEDLINE, Scopus, and PubMed databases were searched to find primary studies on the theme. Inclusion criteria were based on the Population, Concept, and Context logic. To be selected for analysis, studies must have involved informal or family caregivers aged ≥18 years who provide care to dependent persons and who have access to the internet and digital devices (computer, smartphone, and tablet). A total of 2 independent researchers (SS and LVH) performed the screening process. This study is part of a main project that was approved by the Ethics Committee for Health of the Regional Health Administration of Lisbon and Tagus Valley (reference 058/CES/INV/2022). ResultsA total of 9 studies were included in the review. The analysis of the studies showed that ICs use digital tools, such as computers and smartphones, with smartphones being the preferred tool. ICs use the internet to access information; manage home tasks; communicate with relatives, their peers, and health care professionals; and take part in forums. Due to difficulties in leaving their houses, forums are highly valued to preserve human connections. ConclusionsThe use of digital technologies to convey clear, objective, reliable, and accessible information is a strategic action for promoting health literacy and for contemplating the variable care needs of ICs. By working with ICs in the development of new technologies, researchers are building a new tool that meets ICs’ needs.

Abstract Background Adverse drug reactions (ADR), both preventable and non-preventable, are frequent and pose a significant burden. This study aimed to produce up-to-date estimates for ADR rates in hospitals, in Portugal, from 2010 to 2018. In addition, it explores possible pitfalls when crosswalking between ICD-9-CM and ICD-10-CM code sets for ADR identification. Methods The Portuguese Hospital Morbidity Database was used to identify hospital episodes (outpatient or inpatient) with at least one ICD code of ADR. Since the study period spanned from 2010 to 2018, both ICD-9-CM and ICD-10-CM codes based on previously published studies were used to define episodes. This was an exploratory study, and descriptive statistics were used to provide ADR rates and summarise episode features for the full period (2010–2018) as well as for the ICD-9-CM (2010–2016) and ICD -10-CM (2017–2018) eras. Results Between 2010 and 2018, ADR occurred in 162,985 hospital episodes, corresponding to 1.00% of the total number of episodes during the same period. Higher rates were seen in the oldest age groups. In the same period, the mean annual rate of episodes related to ADR was 174.2/100,000 population. The episode rate (per 100,000 population) was generally higher in males, except in young adults (aged '15–20', '25–30' and '30–35' years), although the overall frequency of ADR in hospital episodes was higher in females. Conclusions Despite the ICD-10-CM transition, administrative health data in Portugal remain a feasible source for producing up-to-date estimates on ADR in hospitals. There is a need for future research to identify target recipients for preventive interventions and improve medication safety practices in Portugal.

Abstract Background The COVID-19 pandemic has devastatingly affected Long-Term Care Facilities (LTCF), exposing aging people, staff members, and visitors. The world has learned through the pandemic and lessons can be taken to adopt effective measures to deal with COVID-19 outbreaks in LTCF. We aimed to systematically review the available evidence on the effect of measures to minimize the risk of transmission of COVID-19 in LTCs during outbreaks since 2021. Methods The search method was guided by the preferred reporting items for systematic reviews (PRISMA) and the reporting guideline synthesis without meta-analysis (SWiM) in systematic reviews. The search was performed in April 2023. Observational and interventional studies from the databases of PubMed, Web of Science, Scopus, Cochrane Systematic Reviews, CINAHL, and Academic Search were systematically reviewed. We included studies conducted in the LTCF with outbreaks that quantitatively assess the effect of non-pharmacological measures on cases of COVID-19. Two review authors independently reviewed titles for inclusion, extracted data, and undertook the risk of bias according to pre-specified criteria. The quality of studies was analyzed using the Joanna Briggs Institute Critical Appraisal. Results Thirteen studies were included, with 8442 LTCF experiencing COVID-19 outbreaks and 598 thousand participants (residents and staff members). Prevention and control of COVID-19 infection interventions were grouped into three themes: strategic, tactical, and operational measures. The strategic measures reveal the importance of COVID-19 prevention and control as LTCF structural characteristics, namely the LTCF size, new admissions, infection control surveillance, and architectural structure. At the tactical level, the lack of personal and long staff shifts is related to COVID-19's spread. Operational measures with a favorable effect on preventing COVID-19 transmission are sufficient. Personal protective equipment stock, correct mask use, signaling, social distancing, and resident cohorting. Conclusions Operational, tactical, and strategic approaches may have a favorable effect on preventing the spread of COVID-19 in LTCFs experiencing outbreaks. Given the heterogeneous nature of the measures, performing a meta-analysis was not possible. Future research should use more robust study designs to explore similar infection control measures in LTCFs during endemic situations with comparable outbreaks. Trial registration The protocol of this systematic review was registered in PROSPERO (CRD42020214566).

The importance of decentralised managers in the organisational decision-making process has been the subject of studies advocating different concepts. This study aims to comprehend the role of decentralised managers in the decision-making process of a large industrial company. To this end, the case study method was adopted. Semi-structured interviews were conducted with the organisation’s top manager and decentralised managers. Based on the results of this investigation, it was possible to see that the organisation’s decentralised managers have a high degree of influence on the decision-making process and are responsible for adapting strategies and decisions according to the specific needs of their areas of activity. Therefore, this study significantly contributes to the theoretical and practical understanding of organisational decision-making processes. Furthermore, it provides a valuable foundation for further research into the decision-making processes of decentralised managers, thereby addressing a gap in the existing literature on their influence on organisational decision-making.

Background: In order to address health inequalities, which have been exacerbated by the COVID-19 pandemic, and promote older adults’ quality of life, it is necessary to explore non-medical approaches such as social prescribing. Social prescribing is a person-centered approach that allows health professionals to refer patients to services provided by the social and community sectors. This study aimed to explore older adults' perceptions of social prescribing in mainland Portugal and to identify factors associated with these perceptions, providing insights for future implementation strategies. Methods: A cross-sectional study was conducted with 613 older adults aged 65 to 93. Participants' sociodemographic, economic, and health characteristics were assessed, along with their perceptions of social prescribing’s benefits and activity interest. Results: Over 75% of respondents agreed that social prescribing would benefit the health system and their community. Most participants (87.7% and 89.7%, respectively) thought that activities like personal protection and development activities and cultural enrichment would be particularly relevant to them. Factors such as marital status, education, health status, and pain/discomfort levels influenced the perceived relevance of these activities. Conclusion: This study reveals that older adults in mainland Portugal are open to social prescribing and suggests that tailored interventions considering individual preferences and characteristics can lead to more effective implementation and equal access to social prescribing. Further research and policy efforts should focus on integrating social prescribing into the healthcare system to support healthy aging in Portugal.

Abstract Surgical aortic valve replacement (SAVR) alters the natural course of severe aortic stenosis (AS). In this study, we aimed to determine the effects of the disease on dynamic cerebral autoregulation and vasoreactivity (VR) and to assess their changes after SAVR. We recruited 23 patients diagnosed with severe AS eligible for SAVR and 15 healthy matched controls. AS patients had lower mean VR to CO2 (P = 0.005) than controls, but dynamic cerebral autoregulation was preserved. Cerebral haemodynamics showed no significant change after SAVR. Patients with smaller baseline aortic valve areas presented with smaller low frequency phase changes after surgery (P = 0.016). Severe AS does not seem to impact dynamic cerebral autoregulation but does reduce VR to CO2. SAVR does not alter cerebral autoregulation nor vasoreactivity.

Tenofovir (TFV) is the active form of the prodrugs tenofovir disoproxil fumarate (TDF) and tenofovir alafenamide (TAF), both clinically prescribed as HIV reverse transcriptase inhibitors. The biophysical interactions between these compounds and human serum albumin (HSA), the primary carrier of exogenous compounds in the human bloodstream, have not yet been thoroughly characterized. Thus, the present study reports the interaction profile between HSA and TFV, TDF, and TAF via UV–Vis, steady-state, and time-resolved fluorescence techniques combined with isothermal titration calorimetry (ITC) and in silico calculations. A spontaneous interaction in the ground state, which does not perturb the microenvironment close to the Trp-214 residue, is classified as weak. In the case of HSA/TFV and HSA/TDF, the binding is both enthalpically and entropically driven, while for HSA/TAF, the binding is only entropically dominated. The binding constant (Ka) and thermodynamic parameters obtained via ITC assays agree with those obtained using steady-state fluorescence quenching measurements, reinforcing the reliability of the data. The small internal cavity known as site I is probably the main binding pocket for TFV due to the low steric volume of the drug. In contrast, most external sites (II and III) can better accommodate TAF due to the high steric volume of this prodrug. The cross-docking approach corroborated experimental drug-displacement assays, indicating that the binding affinity of TFV and TAF might be impacted by the presence of different compounds bound to albumin. Overall, the weak binding capacity of albumin to TFV, TDF, and TAF is one of the main factors for the low residence time of these antiretrovirals in the human bloodstream; however, positive cooperativity for TAF and TDF was detected in the presence of some drugs, which might improve their residence time (pharmacokinetic profile).

ObjectiveThis study aims to assess the active aging awareness of older adults in mainland Portugal and their levels of overall well-being and to identify social and health-related factors.MethodsA cross-sectional study was conducted with a representative sample of 613 older adults, aged 65 or older, who participated in the PROKnos – Knowing Social Prescribing needs of the elderly study in Portugal. The questionnaire consisted of the Active Ageing Awareness Questionnaire and the World Health Organization – Five Well-Being Index, as well as sociodemographic, economic, and health status questions. Correlation coefficients, t-tests for independent samples, and one-way ANOVA were used to explore potential associations between variables.ResultsThe active aging awareness levels were significantly higher for women (p = 0.031), and those who were younger (p = 0.011), more educated (p

Background: COVID-19 is mainly characterized by respiratory manifestations. Nevertheless, neurologic complications have been described, including delirium, which appears to be frequent, prolonged, and severe. Methods: We conducted a retrospective analysis of demographic, clinical, and laboratory data of two cohorts: patients with COVID-19 admitted to the infectious disease intensive care unit (ID-ICU) and patients admitted to the ID-ICU with other respiratory infections in 2018-2019. Outcomes were defined as the presence, duration, and severity of delirium. Doses of antipsychotics used to control delirium were converted to equivalents and used as delirium severity. Logistics regression models were used to correlate COVID-19 with the outcomes. Results: Ninety-nine patients with COVID-19 and 40 patients without COVID-19 were included. The mean age of the COVID-19 cohort was 63 years, with a male predominance. Delirium developed in 42%, with a median duration of 3 days and an equivalent dose of olanzapine use of 10 mg/day.In univariate analysis, COVID-19 was not associated with the development or different duration of delirium when compared with patients without COVID-19. There was an association between COVID-19 and severity of delirium in a binary logistic regression model controlled to confounding variables. Conclusion: COVID-19 is not associated with a higher prevalence or duration of delirium than in cohorts without COVID-19. However, it is associated with more severe forms of delirium.

Background: Sexually transmitted infections (STIs) are a public health problem with a high risk of morbidity and community transmissibility. Evidence points to their continuous increase. This study describes the design, development, and implementation of a community-based STI prevention program for community healthcare users. Methods: Based on the Health Planning Process design method, a structured, community-based intervention program on STI counseling and detection was conducted in a primary health care unit in Lisbon. Two data collection instruments were applied in the diagnosis of the situation, namely the Health Literacy Survey Portugal (ILS-PT) and the STD Attitude Scale, to 47 patients who attended the health consultation on STI counseling and detection in a primary care unit in Lisbon. Two interventions were implemented, the health education session and the provision of an educational poster. In the evaluation of the project, the acceptance and satisfaction of the patients with the implemented interventions were considered as outcome indicators. A descriptive statistical analysis of the data was performed. Results: The participants shows considerably low levels of health literacy and high-risk behaviors for acquiring STIs. After an intervention, a high percentage of the participants point out the project as exciting and valuable and reveal having acquired knowledge that allowed them to improve their health. Furthermore, the patients were very satisfied with the implemented health education session and the educational poster. Conclusion: This project revealed the urgent and important need to implement community intervention projects to prevent STIs and promote health literacy among the most vulnerable groups.

BackgroundPeople aged ≥65 years are more likely to have health problems related to aging, polypharmacy, and low treatment adherence. Moreover, health literacy levels decrease with increasing age. ObjectiveThe aim of this study is to assess an app’s utility in promoting health-related knowledge in people aged ≥65 years. MethodsWe developed a simple, intuitive, and video-based app (DigiAdherence) that presents a recipe, nutritional counseling, and content on physical activity, cognitive exercise, motivation to adhere to treatment, fall prevention, and health literacy. A convenience sample of 25 older adults attending the Personalized Health Care Unit of Portimão or the Family Health Unit of Portas do Arade (ACeS Algarve II – Barlavento, ARS Algarve, Portugal) will be recruited. Subjects must be aged ≥65 years, own a smartphone or tablet, be willing to participate, and consent to participate. Those who do not know how to use or do not have a smartphone/tablet will be excluded. Likewise, people with major cognitive or physical impairment as well as those living in a long-term care center will not be included in this study. Participants will have access to the app for 4 weeks and will be evaluated at 3 different timepoints (V0, before they start using the app; V1, after using it for 30 days; and V2, 60 days after stopping using it). After using the app for 30 days, using a 7-point Likert scale, participants will be asked to score the mobile tool’s utility in encouraging them to take their medications correctly, improving quality of life, increasing their health-related knowledge, and preventing falls. They will also be asked to assess the app’s ease of use and visual esthetics, their motivation to use the app, and their satisfaction with the app. Subjects will be assessed in a clinical interview with a semistructured questionnaire, including questions regarding user experience, satisfaction, the utility of the app, quality of life (EQ-5D-3L instrument), and treatment adherence (Morisky scale). The proportion of participants who considered the app useful for their health at V1 and V2 will be analyzed. Regarding quality of life and treatment adherence perceptions, comparisons will be made between V0 and V1, using the t test for dependent samples. The same comparisons will be made between V0 and V2. ResultsThis study was funded in December 2019 and authorized by the Executive Board of ACeS Algarve II – Barlavento and by the Ethics Committee of NOVA Medical School (99/2019/CEFCM, June 2020). This protocol was also approved by the Ethics Committee for Health (16/2020, September 2020) and the Executive Board (December 2020) of the Regional Health Administration of the Algarve, IP (Instituto Público). Recruitment was completed in June 2021. ConclusionsSince the next generation of older adults may have higher digital literacy, information and communication technologies could potentially be used to deliver health-related content to improve lifestyles among older adults. International Registered Report Identifier (IRRID)PRR1-10.2196/29675

While it is well known that socioeconomic markers are associated with a higher risk of arbovirus infections, research on the relationship between socioeconomic factors and congenital Zika syndrome (CZS) remains limited. This study investigates the relationship between socioeconomic risk markers and live births with CZS in Brazil. We conducted a population-based study using data from all registered live births in Brazil (Live Births Information System) linked with the Public Health Event Record from 1 January 2015 to 31 December 2018. We used logistic regression models to estimate the OR and 95% CIs of CZS based on a three-level framework. In an analysis of 11 366 686 live births, of which 3353 had CZS, we observed that live births of self-identified black or mixed race/brown mothers (1.72 (95% CI 1.47 to 2.01) and 1.37 (95% CI 1.24 to 1.51)) were associated with a higher odds of CZS. Live births from single women compared with married women and those from women with less than 12 years of education compared with those with more than 12 years of education also had higher odds of CZS. In addition, live births following fewer prenatal care appointments had increased odds of CZS in the nationwide data. However, in the analyses conducted in the Northeast region (where the microcephaly epidemic started before the link with Zika virus was established and before preventive measures were known or disseminated), no statistical association was found between the number of prenatal care appointments and the odds of CZS. This study shows that live births of the most socially vulnerable women in Brazil had the greatest odds of CZS. This disproportionate distribution of risk places an even greater burden on already socioeconomically disadvantaged groups, and the lifelong disabilities caused by this syndrome may reinforce existing social and health inequalities.

Introdução: Portugal assiste a alterações demográficas da população, sobretudo o seu envelhecimento, o que leva ao aparecimento de doenças crónicas, sendo a família cada vez mais solicitada a desempenhar o papel de cuidador informal. É fundamental promover a sua capacitação. Objetivo: contribuir para o processo de capacitação dos cuidadores informais a partir dos recursos que existem na comunidade. Metodologia: Foi utilizada a metodologia do Planeamento em Saúde. Para realizar o diagnóstico da situação foi utilizado um instrumento de recolha de dados constituído por questionários e escalas de avaliação. Os participantes foram os cuidadores informais que prestavam assistência a familiares dependentes, com idade igual ou superior a dezoito anos em visita domiciliária pela equipa de enfermagem de uma unidade de saúde. Tratou-se de uma amostra não probabilística, por conveniência. Como estratégias de intervenção, utilizaram-se a Educação para a Saúde e Comunicação em Saúde. Resultados: Após análise descritiva dos dados apurou-se que os cuidadores informais tinham um conhecimento reduzido sobre os recursos existentes na comunidade e um nível problemático, no Índice Geral de Literacia em Saúde. Como intervenções realizadas para a capacitação do cuidador informal foram elaborados três produtos de informação sobre os recursos que existem na comunidade. Para possibilitar o diagnóstico precoce foi ainda realizada uma sessão de formação aos profissionais de saúde sobre a utilização da Escala Sobrecarga do Cuidador. Conclusão: Dada a importância do papel dos cuidadores informais na prestação de cuidados à pessoa com dependência, é fundamental traçar o seu perfil para adequar as estratégias de intervenção às suas necessidades.

Introdução: A fumicultura concentra-se sobretudo em áreas rurais do Sul do país. Reconhecidamente, as áreas rurais apresentam disparidades socioeconômicas, desigualdades no acesso geográfico, bem como dificuldade de retenção de profissionais na Atenção Primária à Saúde (APS). Apresentação do caso: Descrevem-se, neste artigo, as intersecções de determinantes socioeconômicos de saúde ao se abordar um paciente masculino, de 57 anos, em uso crônico de benzodiazepínicos para o tratamento de insônia. Ao se aprofundar a anamnese, os determinantes socioeconômicos que levaram ao desenvolvimento da insônia foram identificados como: dificuldades financeiras na produção de tabaco, preocupações excessivas com o trabalho e presença de depressão como comorbidade. Nesse sentido, ser produtor de tabaco e a relação com a empresa podem ser considerados determinantes socioeconômicos da saúde para o desenvolvimento de insônia. Conclusões: No contexto deste caso, a rotatividade de profissionais e a falta de criação de vínculo fez com que o paciente permanecesse cronicamente a tratar a insônia como benzodiazepínico, o que é proscrito. Assim, revelam-se a fragmentação do cuidado e a alta rotatividade de profissionais como determinantes socioeconômicos da saúde.

Introdução: A adolescência é uma fase da vida marcada por rápidas mudanças desenvolvimentais e, por isso, um período crucial para aumentar as capacidades para comportamentos de promoção de saúde. No âmbito da educação sexual e afetiva, o enfermeiro pode desempenhar um papel relevante na promoção da saúde dos adolescentes, contribuindo para os conhecimentos e atitudes dos mesmos, acerca da sexualidade. Objetivo: O objetivo geral do projeto foi contribuir para o aumento do conhecimento sobre sexualidade, de adolescentes do 9º ano de escolaridade de uma escola da área de intervenção de uma Unidade de Cuidados na Comunidade (UCC) do Agrupamento de Centros de Saúde (ACES) Almada/Seixal. Método: O projeto foi desenvolvido seguindo as fases da Metodologia do Planeamento em Saúde. O diagnóstico de situação foi realizado com recurso ao Questionário Perceção dos Alunos acerca da Educação Sexual. A amostra, obtida de forma não probabilística por conveniência, foi constituída por 16 adolescentes. O projeto foi sustentado pelo referencial teórico do Modelo de Promoção de Saúde de Nola Pender. Resultados e discussão: O diagnóstico de situação revelou conhecimento sobre a saúde comprometido e comportamento de procura de saúde comprometido. De modo a resolver os problemas de saúde prioritários, recorreu-se à educação para a saúde, como estratégia. Após a intervenção, mais de 80% dos estudantes responderam corretamente às questões sobre a temática, cerca de 72% dos estudantes identificaram dois comportamentos sexuais de risco, e 53% dos estudantes privilegiaram os profissionais de saúde como fontes de informação em assuntos relacionados com a sexualidade. Conclusões: Este projeto, alicerçado na Metodologia do Planeamento em Saúde e no Modelo de Promoção da Saúde de Nola Pender, permitiu contribuir para o conhecimento dos adolescentes, no âmbito da educação sexual, através da intervenção de enfermagem em contexto comunitário.

Abstract Background Community-acquired pneumonia (CAP) is one of the leading causes of morbidity and mortality worldwide, often leading to hospital admissions. In Portugal, the factors associated with in-hospital mortality due to CAP are not fully documented. The aim of this study was to characterize the trends of CAP hospitalization in all age groups and the factors associated with their mortality between 2000 and 2014. Methods We conducted a cross-sectional study using CAP hospitalization data in all age groups, in Portugal Mainland. Logistic regression was used to identify the factors associated with in-hospital mortality. Results Between 2001 and 2011, CAP hospitalization rate increased from 2.8 to 4.3 per 1000 population. Hospitalization rates were higher in the extreme ages ( ≤ 4 and ≥ 75 years). However, a decrease in the hospitalization rate and its mortality was observed, in the younger ages. A total of 548,699 hospitalization CAP episodes, between 2000 and 2014, were analyzed, with male (56.2%) and elderly ≥65 years (91.7%) predominance, resulting in 101,740 deaths (18.5%). Men had a significantly lower mean age (64.3 ± 26.4 years versus 67.9 ± 27.5 years; p

IntroductionThe promotion of health literacy of the population in a situation of migration, in the community, is a fundamental field of intervention in health promotion, for the reduction of inequalities in access to health care services. It is increasingly necessary to make health care services more equitable for migrant populations. The aim of the study was to characterize the level of health literacy of the population in a migrant situation, attending a primary health care unit in the Lisbon region, to identify priority areas for community intervention that will become the focus of intervention and contribute to the increase in the health literacy levels in this population.MethodsA cross-sectional study was carried out by applying the Health Literacy Survey (ILS-PT) to a sample of the population in a situation of migration, found by 27 participants.ResultsThe general health literacy index of the sample is inadequate (21.23 points). An analysis of the sub-indexes revealed that 75% of the participants had difficulties related to information about health care and 80% had difficulties in the field of health promotion.ConclusionsProblematic and inadequate levels of health literacy was significantly frequent among migrant population. So that enhancing health literacy among migrant is essential to reduce health inequalities to achieve better health outcomes and contribute to defense of human rights of this vulnerable population.

Neurological complications are frequently reported in an intensive care unit (ICU), as a manifestation of a critical systemic illness or of its treatment. On the specific setting of COVID-19 patients, peripheral nerve lesions can have a multiplicity of causes, such as post-infectious neuropathy, positioning-related neuropathy or iatrogeny. An unusual but potentially disabling complication of any peripheral nerve lesion is Complex Regional Pain Syndrome (CRPS). Although there have been no mechanistic studies assessing how SARS-CoV-2 might directly impact nociception, it is hypothesized that the systemic hyperinflammation seen in severe COVID-19 may contribute to peripheral and central neuronal sensitization, possibly increasing the risk of developing CRPS. This case report highlights the potential hazards and consequences of peripheral nerve injuries on an ICU setting in COVID-19 patients, as well as the importance of a multidisciplinary approach for an early diagnosis and treatment, which are directly related to a better prognosis.

Background Multiple sclerosis treatment has changed in the last years with the emergence of new disease-modifying therapies (DMTs). Despite a better efficacy profile, these drugs raise concerns about infectious risk, which needs to be mitigated. Objective To analyze the results of a systematic collaborative approach between Neurology and Infectious Diseases (ID) Departments in the management of infectious risk and complications in MS patients treated with DMT. Methods Retrospective collection of MS patients’ demographic and clinical data from clinical records of MS and ID outpatient clinics (2011–2017). Results We included 149 patients: most had evidence of previous contact with Herpesviridae, and half of them were not immune to hepatitis A and B viruses (HAV and HBV). Vaccines for HAV, HBV, and Streptococcus pneumoniae were administered in 91%, 78%, and 88% of non-immune patients, respectively. JC virus serology monitoring prevented natalizumab (NTZ) initiation or prompted its switch in 34/122 patients. Forty patients had latent tuberculosis, in which 88% were treated. Infectious events occurred in 33 patients, mostly mild urinary, respiratory, and herpes virus group infections. Only three patients required inpatient care. Conclusion Facing the expansion of the new DMT, we highlight the benefits of an interdisciplinary approach for safer use of the chosen treatment.

The population aging in Europe imposes challenges to societies that require adaptations and responses at various levels to minimize impacts and figuring out opportunities. Portugal has been committed to the World Health Organization and European Union's values and policy frameworks concerning active and healthy aging. In 2017, an inter-ministerial working group developed the National Strategy for Active and Healthy Aging. In the face of the COVID-19 pandemic that exposed the vulnerabilities of older populations, the launch of the Decade of Healthy Aging 2021–2030 and its baseline report and the 2018 Active Aging Index Analytical Report may constitute an opportunity to strategically think about the aging of the population as a national purpose in Portugal and in the other European countries that face similar challenges.

Abstract Background The existing knowledge on the interplay between reproductive and sexual health, migration and acculturation is recent and inconsistent, particularly on the sociocultural motives and constraints regarding fertility. Therefore, sexual and reproductive health (SRH) surveys are needed to provide accurate and comparable indicators to identify and address SRH inequalities, with specific focus on under researched aspects, such as the interrelation between migration and gender. FEMINA (FErtility, MIgratioN and Acculturation) aims to investigate intersectional SRH inequalities among Cape Verdean immigrant and Portuguese native families and how they impact on fertility in Portugal. This study will use a comprehensive approach exploring simultaneously the components of SRH, namely regarding identities, perceptions and practices of both women and men among lay people and relevant experts and stakeholders. The project has three main goals: 1) to identify social determinants of SRH among Cape Verdean immigrant and Portuguese native men and women of reproductive age; 2) to gain understanding of the diversity of the sexual and reproductive experiences and expectations of Cape Verdean immigrant and Portuguese native men and women of reproductive age, considering the singularities of their migratory, social and family dynamics; and 3) to produce recommendations for policy makers, employers and service providers on how to better address the SRH needs of Portuguese-born and immigrant populations. Methods The study will address these goals using a mixed methods approach, including: a cross-sectional telephone survey with a probabilistic sample of 600 Cape Verdean immigrant and 600 Portuguese native women and men (women aged 18 to 49 and men aged 18 to 54), residents of the Greater Lisbon Area; a qualitative research through in-depth interviews with a subsample of 30 Cape Verdean immigrants and 30 Portuguese native men and women; and a Delphi technique for finding consensus on good practices in SRH for the entire population with a special emphasis on immigrants, namely extra-EU migrants. Discussion Data will be used to produce a comprehensive set of indicators to monitor SRH in Portugal, to foster a greater understanding of its specificities and challenges to policy and decision makers, and to provide targeted recommendations to promote inclusive and migrant sensitive SRH services.

Health literacy (HL) allows people to access, understand and evaluate health information. Informal caregivers’ levels of HL may impact long-term care outcomes. ‘Informal caregivers’ profile in Lisbon county: a health community approach’ is a nurse-led research project aiming to assess informal caregivers’ health literacy and associated factors in Lisbon county, as well as to foster the development of a local-specific health literacy strategy. A survey to identify a health/social caregiver profile, including questions about HL (HLS-EU-PT), was submitted to a representative sample of carers. Descriptive and bivariate inferential analysis was developed. Informal caregivers’ level of HL was mostly sufficient (n = 99, 38%). More than 60% of caregivers have limited HL regarding health promotion. ‘Access’, ‘Appraisal’ and ‘Use’ are the information processing stages with lower mean scores of HL. Carers with low HL levels appear to be older and to have less education, low knowledge of community resources and decreased wellbeing (p < 0.05). A strategy focused on health promotion-related HL through primary care resources can potentially improve caregivers’ knowledge, competencies and motivation, as well as health system sustainability. Reported HLS-EU-PT scores deserve special attention. Future work should emphasize the role of HL-associated factors and health outcomes for caregivers and cared-for persons.

Primary healthcare must guarantee health and well-being for the community as a whole, ensuring equity and quality in different responses. For this goal to be achieved, teams must be trained and integrated, and service flows must be functional. Continuing education in health, as a form of training professionals in the workplace, helps to center responses around the needs and preferences of people and families, and to balance the fulfillment of demands by using better work management as a starting point. The objectives of the present qualitative study were to elucidate the meaning given by health professionals who developed their activities in the Family Health Strategy in order to continue education in health, and to discuss the qualification and structuring of work management with this type of education as a background. The methodology used was Straussian grounded theory. Thirty professionals in four Brazilian health units who had experience in the family health field participated in the study. Data were collected between June 2018 and May 2019. Based on three categories, the emerging substantive theory was as follows: laying the foundations of continuing education in health in a collective dialogic and dialectical effort to contribute to the qualification of the work processes in the Family Health Strategy. The professionals’ accounts showed that they recognize the importance of continuing education in health and the need to discuss it, given its potential to transform and to assist in the education of professionals with autonomy in the management of their work processes.

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BackgroundFalls are a common cause of injury and pose an increased risk of morbidity, mortality, and lifelong disability. Falls encompass a troublesome definition and can pose challenges in epidemiological studies. Data on fall-related hospital admissions in Portugal remain unpublished. This study aimed to examine the epidemiology of fall-related hospital admissions in the Portuguese population between 2010 and 2018. It also aimed to examine annual rates of fall-related hospital admissions using three methodological approaches.MethodsThe Portuguese Hospital Morbidity Database was used to identify all cases resulting in one or more inpatient admission in public hospitals related to falls from 2010 to 2018. Fall-related hospital admissions were described by age groups, sex, geographical area of residence, and type of fall. Annual rates were computed using three approaches: i) based on the number of inpatient admissions with an ICD code of fall, ii) based on the number of patients admitted to inpatient care with an ICD code of fall, and iii) based on the number of inpatient admissions with a principal diagnosis of injury.ResultsBetween 2010 and 2018, 383,016 fall-related admissions occurred in 344,728 patients, corresponding to 2.1% of the total number of hospitalizations during the same period. Higher rates were seen among the younger (20-25) and the oldest age groups (+85), males until the age of 60, females from the age of 60, and areas of residence with a higher aging index. An overall rate of falls per 100,000 population was estimated at 414 (based on number of admissions), 373 (based on number of patients) and 353 (based on number of admissions with a principal diagnosis of injury).ConclusionsThis study provides an overall picture of the landscape of falls in a scarcely explored setting. The results aim to contribute to identifying appropriate preventive interventions and policies for these populations.

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Abstract Angiostrongylus vasorum is a pulmonary artery parasite of domestic and wild canid. On molluscs, intermediate host, first stage larvae (L1) are found after the first day of infection, in the 8th L2 and in the 30 th L3. It was evaluated L1, L2 and L3 recovered by Baermann technique from Achatina fulica infected with 1000 L1. Fifty larvae/stage were incubated with antibodies anti-β-tubulin, anti-α-tubulin, anti- α-actin, anti-β-actin and anti-collagen, and then with Alexa 633. Fifty larvae/stage were observed with picrosirius red and Oil Red O. It was also observed in the anterior region of L1 the beginning of the chitinous stems development, in the initial portion of the intestine and genital primordium. In L2 anterior region, the papillae, chitinous canes juxtaposed to the mouth and intestines bigger than L1. The L3 musculature is well defined, next to the chitinous stems, there are two round distally arranged from each other. It was observed the whole extension of the intestine genital primordium and intense cellularity in the L3 distal portion. With the picrosirius red the L1, L2 and L3 musculature could be observed, as the nerve ganglia on L3. Oil Red O revealed that L1, L2 and L3 store energy on lipid droplets.

Trata-se de reflexões sobre a experiência vivenciada pela Equipe de Formação em Ensino Médio da Escola de Aperfeiçoamento dos Profissionais da Educação (EAPE), Brasí­lia-DF, da Secretaria de Educação do Distrito Federal, no decorrer de 2013, por ocasião da elaboração da proposta e a execução do curso Currí­culo em Movimento: reorganização do trabalho pedagógico nos ciclos e na semestralidade. Foca-se em dois aspectos pilares à formação e à reformulação curricular: o letramento e uma prática pedagógica na perspectiva dos multiletramentos, e a ressignificação da coordenação pedagógica e do trabalho coletivo. Tais tópicos demandaram estudos e discussões pelos professores envolvidos no processo formativo, e aqui são apresentados a fim de contribuir para a reflexão e o debate a respeito de currí­culos, aprendizagens e saberes no Ensino Médio.

Abstract Background Cytomegalovirus (CMV) reactivation with neurological involvement in patients with acquired immunodeficiency syndrome (AIDS) is increasingly rare since the introduction of antiretroviral therapy (ART). Manifestations include encephalitis, myelitis, polyradiculopathy and, less commonly, mononeuritis multiplex (MNM). We report a case of disseminated CMV disease with gastrointestinal and peripheral and central nervous system involvement in a patient with AIDS, manifesting primarily as MNM. Case presentation A 31-year old woman with AIDS presented with a clinical picture of MNM. Electromyography confirmed the clinical findings. CMV DNA was detected in cerebrospinal fluid (CSF) and blood. Gastrointestinal involvement was histologically documented. HIV RNA was also detected in CSF and brain MRI was consistent with HIV encephalopathy. A diagnosis of disseminated CMV disease (with esophagitis, colitis, encephalitis and MNM) and HIV encephalopathy was made. Treatment consisted of ganciclovir and foscarnet, followed by maintenance therapy with valganciclovir. Evolution was favorable and valganciclovir was stopped after sustained immune recovery following ART initiation. Conclusion We discuss the diagnostic approach to CMV neurological disease, with a focus on MNM and CMV encephalitis. Combination therapy with ganciclovir and foscarnet should be considered for all forms of neurological involvement, although available data are scarce. Since there is significant overlap between CMV encephalitis and HIV encephalopathy, ART drugs with higher CSF penetration may have to be considered. ART and immune recovery are essential to improve outcomes.

Systemic lupus erythematosus is a heterogeneous and unpredictable autoimmune disease which can be complicated to approach and treat. Hemophagocytic lymphohistiocytosis and diffuse alveolar hemorrhage are rare disease complications. The authors describe a clinical case of a 32-year-old woman with lupus and fever of unknown origin. From the investigations performed, the myelogram revealed hemophagocytosis and Leishmania parasites, therefore liposomal amphotericin B was then started. In addition to directed therapy, she maintained fever that evolved with diffuse alveolar hemorrhage. The myelogram was repeated and showed that she still had hemophagocytosis but now without parasites. Corticotherapy was increased and intravenous Immunoglobulin was started, with improvement. Rituximab was started as a result of macrophage activation syndrome and diffuse alveolar hemorrhage. Months after discharge, she began once again to have sustained fever and Leishmania parasites were found again, therefore liposomal amphotericin B was started once more associated with miltefosine. She continues being followed-up as she is asymptomatic and using steroids in weaning scheme.

Abstract Background Uganda halved its maternal mortality to 343/100,000 live births between 1990 and 2015, but did not meet the Millennium Development Goal 5. Skilled, timely and good quality antenatal (ANC) and delivery care can prevent the majority of maternal/newborn deaths and stillbirths. We examine coverage, equity, sector of provision and content of ANC and delivery care between 1991 and 2011. Methods We conducted a repeated cross-sectional study using four Uganda Demographic and Health Surveys (1995, 2000, 2006 and 2011).Using the most recent live birth and adjusting for survey sampling, we estimated percentage and absolute number of births with ANC (any and 4+ visits), facility delivery, caesarean sections and complete maternal care. We assessed socio-economic differentials in these indicators by wealth, education, urban/rural residence, and geographic zone on the 1995 and 2011 surveys. We estimated the proportions of ANC and delivery care provided by the public and private (for-profit and not-for-profit) sectors, and compared content of ANC and delivery care between sectors. Statistical significance of differences were evaluated using chi-square tests. Results Coverage with any ANC remained high over the study period (> 90% since 2001) but was of insufficient frequency;

In the Algarve the potential for birdwatching tourism is widely recognized, especially in the Ria Formosa Natural Park (RFNP). This study aims to describe birdwatchers’ profile in the RFNP. For this purpose, a survey was applied. The results show that the most frequent nationalities of birdwatchers are: British (39%), Dutch (17%) and Portuguese (17%). The majority of birdwatchers are male (55%) and married (57%). The average age is 50 years old. They are highly educated (74% have an academic degree). Concerning profession, the most frequent answer was retired (41%). Respondents are committed to the activity as the majority possess special equipment and practice birdwatching in vacations. This study also tests if nationality is related to other characteristics of the birdwatchers, by using the Kruskal-Wallis and the Chi-square tests. Overall, the results of this study highlight that regional management organizations should invest in developing birdwatching in the RFNP.

Bullous pemphigoid is an autoimmune disease characterized by subepidermal blister formation. Can be self-limiting but when necessary treatment includes the use of corticosteroids, immunosuppressants, and biological agents. We present the case of a 37 year old patient with a severe and refractory presentation of bullous pemphigoid. After about a month of treatment with various first line drugs and with no response, we chose to start rituximab and clear improvement of the lesions was observed. The authors aim to highlight the usefulness and effectiveness of this drug in this disease.

Objective: to review studies that refer to interventions and responsibilities of public health nurses, since the creation of the Portuguese National Health Service (NHS) in 1979, to the present day. Method: scoping review, following the PCC - participants, concept and context version of The Joanna Briggs Institute. We consulted databases such as the Biblioteca do Conhecimento Online, Scientific Electronic Library Online, EBSCOhost Online Research Databases. The publication period was from 1979 to 2018. Results: we selected four published articles and six master's dissertations, between 2010 and 2016. The subjects have to do with nurses' activities and actions, autonomy and competences, normative foundations, perceptions of nursing teams, health, transmission and collection of health information. Conclusion: The results, even if scarce, provided clues for a reflection on the mode, type of intervention processes of these nurses, who, according to some of them, understand their competences more than they concretize them. RESUMO Objetivo: revisar os estudos que referenciam as intervenções e responsabilidades do enfermeiro de saúde pública, desde a criação do Serviço Nacional de Saúde (SNS) Português em 1979, até aos nossos dias. Método: scoping review, seguindo a versão PCC - participants, concept and context, do The Joanna Briggs Institute. Consultamos bases de dados como a Biblioteca do Conhecimento Online, Scientific Eletronic Library Online, EBSCOhost Online Research Databases. O período de publicação foi de 1979 a 2018. Resultados: selecionamos quatro artigos publicados e seis dissertações de mestrado, entre 2010 e 2016. Os temas têm a ver com atividades e atuações dos enfermeiros, autonomia e competências, fundamentos normativos, perceções de equipas de saúde, transmissão e obtenção de informação em saúde. Conclusão: Os resultados apurados, mesmo que escassos, forneceram pistas para uma reflexão acerca do modo, tipo dos processos de intervenção, destes enfermeiros, que segundo a opinião de alguns deles, compreendem mais as suas competências do que as concretizam. RESUMEN Objetivo: revisar estudios que se refieren a intervenciones y responsabilidades de enfermeros de salud pública, desde la creación del Servicio Nacional de Salud de Portugal (SNS) en 1979, hasta la actualidad. Método: revisión de alcance, siguiendo el PCC - participantes, concepto y versión de contexto del Instituto Joanna Briggs. Consultamos bases de datos como Biblioteca do Conhecimento Online, Scientific Eletronic Library Online, EBSCOhost Online Research Databases. El período de publicación fue 1979 a 2018. Resultados: seleccionamos cuatro artículos publicados y seis disertaciones de maestría, entre 2010 y 2016. Los temas tienen que ver con las actividades, acciones de los enfermeros, autonomía y competencias, fundamentos normativos, percepciones de los equipos de enfermería, salud, transmisión y recopilación de información sanitaria. Conclusión: los resultados, aunque escasos, proporcionaron pistas para reflexionar sobre el modo, tipo de procesos de intervención de estos enfermeros, quienes, según algunos de ellos, entienden sus competencias más de lo que las concretan.

Central nervous system (CNS) vasculopathy associated with Varicella Zoster Virus (VZV) infection, usually manifesting as stroke due to ischemic lesions by involvement of small arteries, is frequently misdiagnosed. Immunocompromised patients have a particularly higher risk of severe disease and also CNS involvement during or following VZV presentations. We report a case of an 84-year-old man, with myelodysplastic syndrome, who presented with herpes zoster ophthalmicus complicated with left periocular cellulitis and an abnormal neurological exam. Intravenous treatment with acyclovir and amoxicillin/clavulanic acid was began. VZV DNA was detected in the cerebrospinal fluid (CSF) and brain magnetic resonance imaging revealed three acute ischemic lesions in the left frontal and both cerebellar lobes. A VZV CNS multifocal vasculopathy was diagnosed and treatment with intravenous acyclovir continued for 21 days.Immunocompromised patients with VZV infection can have a more severe course of disease with disseminated involvement and multifocal vasculopathy. In these patients the CSF detection of anti-VZV IgG as well as VZV DNA can be helpful in the diagnosis of CNS VZV vasculopathy. The antiviral treatment can improve the outcome and should be adjusted taking in consideration the degree of immunosuppression. This clinical case and review of the literature highlights the challenges in the diagnosis and management of VZV CNS vasculopathy in immunocompromised patients. Keywords: Varicella Zoster Virus, Vasculopathy, Stroke, Immunocompromised, Acyclovir

Innovative toilets can save resources, but have higher embodied impacts associated with materials and electronic components. This article presents an environmental life-cycle assessment (LCA) of an innovative multifunctional toilet (WashOne) for two alternative configurations (with or without washlet), comparing its performance with those of conventional systems (toilet and bidet). Additionally, two scenario analyses were conducted: (i) user behavior (alternative washlet use patterns) and (ii) user location (Portugal, Germany, the Netherlands, Sweden and Saudi Arabia). The results show that the WashOne with washlet has a better global environmental performance than the conventional system, even for low use. It also reveals that the use phase has the highest contribution to impacts due to electricity consumption. User location analysis further shows that Sweden has the lowest environmental impact, while Germany and the Netherlands have the highest potential for impact reduction when changing from a conventional system to the WashOne. Based on the overall results, some recommendations are provided to enhance the environmental performance of innovative toilet systems, namely the optimization of the washlet use patterns. This article highlights the importance of performing a LCA at an early stage of the development of innovative toilets by identifying the critical issues and hotspots to improve their design and performance.

Identifying the opportunities and barriers of promoting and fulfilling the sexual health rights of migrants remains a challenge that requires systematic assessment. Such an assessment would include estimating the influence of acculturation processes on sexual and reproductive health, and mapping intersectional inequities that influence migrants’ sexual and reproductive health in comparison with the native population. The aim of this research was to locate, select, and critically assess/summarize scientific evidence regarding the social, cultural, and structural factors influencing migrants’ sexual and reproductive health outcomes in comparison with native population. An umbrella review of systematic reviews and/or meta-analyses, following preferred reporting items for systematic reviews and meta-analysis (PRISMA) standards was undertaken. Medline, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews were searched from their start date until June 2019. The quality of the included articles was determined using the assessment of multiple systematic reviews tool (AMSTAR 2). From the 36 selected studies, only 12 compared migrant with native populations. Overall, the findings indicated that migrants tend to underuse maternal health services and have an increased risk of poor sexual and reproductive health outcomes. Specific intersectional inequities were identified and discussed.

Cavernous angiomas are central nervous system malformations. Most common manifestations are seizures and acute focal neurological deficits. We present a case report of a seventy-one year-old man with a two-month history of behavior changes, attention deficit and indifference followed by gait unsteadiness. Neuropsychological evaluation showed severe cognitive impairment and executive dysfunction. Head computed tomography depicted a supraventricular hydrocephaly. Magnetic resonance imaging revealed a small hemorrhage, contiguous to a mesencephalic cavernous angioma, obstructing the Sylvius aqueduct, causing secondary hydrocephalus. Four months after endoscopic ventriculocisternostomy, neuropsychological evaluation showed improvement and the patient regained autonomy. Parenchyma cavernous angiomas causing direct hemorrhage and subsequent obstruction of the Sylvian aqueduct are uncommon. Sub-acute behavior and mental state abnormalities are rare first manifestations of cavernous angioma and requires high clinical suspicion for its correct diagnosis. Magnetic resonance imaging evaluation is crucial in the detection of such patients as prompt neurosurgical intervention may substantially improve cognitive function.

Large-cell neuroendocrine tumors (NETs) are poorly differentiated malignancies of rare incidence and aggressive nature. NETs mostly arise in the lung followed by the gastrointestinal tract, although they are potentially ubiquitous throughout the body. Primary unknown NET has a worse prognosis and shorter survival comparing with other NETs, with limited available data in the literature concerning this subgroup. The authors report the case of large-cell NET with supraclavicular lymph node presentation. Total excisional biopsy revealed an enlarged adenopathy 18 × 15 × 10 mm, which was extensively infiltrated by a solid malignant neoplasm composed of large cells with granular chromatin, nuclear pseudo-inclusions, high mitotic index, and focal necrosis, with a Ki 67 index 25-30% and positive immunohistochemical study for the expression of cytokeratin 8/18, chromogranin, synaptophysin, and thyroid transcriptional factor-1 (TTF-1). There was no evidence of primary location apart from two infracentimetric lung lesions that could not be accessed for biopsy and were negative at both somatostatin receptor scintigraphy and positron emission tomography. The NET relapsed with three mediastinal masses, so the patient was started on chemotherapy with carboplatin and etoposide with initial total response. Early progression showed no response to further chemotherapy regimens (temozolomide, oral etoposide); therefore, the patient was treated with local radiotherapy. This patient has an atypical long survival (54 months) compared to the literature data. In fact, there are few long-term survivors of large-cell NET and they are all related to complete surgical resection.