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The evolution of society has led to big challenges for health-care systems. Sociological, demographic, epidemiological, healthcare, environmental, technological, and economic factors along with the development of innovative health-care technology make it necessary to rethink the model of providing healthcare and organizing hospitals. This consensus, called The Oporto Consensus, statement reflects the societies’ views on the principal changes in hospital organization that will be necessary in upcoming years, especially changes in which internal medicine can and must play an important role. These changes could lead over 10 general principles that incorporate the changes related to the active incorporation of patients, climate change, the prevention of pandemics or alternatives to conventional hospitalization, or the existence of sufficient public funding. In the other hand, changes are necessary in the current model of organization of the health system, based on the integration of the different care levels, focused on processes, and patient-centered multidisciplinary teams, avoiding conventional hospitalization and promoting the use of new technologies in health care, among other. Hence, this document identifies the main challenges that health-care systems currently face and makes proposals for changes in hospital organization to respond to them. Both Spain and Portugal have seen good examples of innovative healthcare adapted to the populations’ needs that take advantage of scientific advances and current technology. These proposals provide a starting point for discussions about how to better organize the health-care system to meet the population’s changing health needs while guaranteeing equitable and sustainable care.

Apresenta-se o caso de um homem de 31 anos, fumador sem outras doenças conhecidas. É agente comercial numa empresa de produtos de higiene e, desde há 3 meses, iniciou a prática de cuspir fogo em espectáculos de rua. Recorre ao Serviço de Urgência (SU) por dor torácica anterior direita com características pleuríticas, tosse seca e febre (40ºC), quadro que iniciou poucas horas após a aspiração do líquido “água de fogo” (composto por derivados do petróleo) durante uma performance a cuspir fogo. Do estudo realizado, apresentava aumento dos marcadores inflamatórios e hipotransparência do lobo médio na radiografia torácica, pelo que teve alta medicado com azitromicina 500mg uma vez dia. Por persistência e agravamento dos sintomas, recorre novamente ao SU 3 dias depois. Objectivadas febre e crepitações no 1/3 inferior do hemitórax direito. TAC torácica a mostrar consolidação do segmento anterior do lobo inferior esquerdo e do segmento medial do lobo médio (figuras 1 e 2), com áreas de baixa densidade (-77HU) - seta da figura 1-, áreas em vidro despolido no lobo médio (figura 2) e ainda algumas opacidades lineares nos segmentos basais dos lobos inferiores. Apresentava também aumento franco dos marcadores analíticos de inflamação, com leucocitose 16000/µL, neutrofilia e PCR 233 mg/L. A gasimetria arterial excluiu insuficiência respiratória. Assumiu-se Pneumonia Lipóide Exógena Aguda com possível sobreinfecção, pelo que iniciou amoxicilina-clavulanato após colheita de rastreio séptico. Realizou broncofibroscopia, que não revelou alterações da mucosa brônquica, e colheu lavado brônquico (LB), tendo-se observado células muco-secretoras, macrófagos alveolares e escassos polimorfonucleares. Não foi isolado agente infeccioso e apresentou evolução clínica e analítica favorável, tendo tido alta após 4 dias de internamento, a completar antibioterapia empírica em ambulatório. A Pneumonia Lipóide Exógena é uma entidade rara, que resulta da inalação e/ou aspiração de substâncias lipídicas, podendo ocorrer de forma crónica ou aguda, sendo esta última uma condição rara e consequente de aspiração acidental de uma grande quantidade de material lipídico num curto espaço de tempo.1 Os sintomas mais comuns são tosse, dor torácica, dispneia, febre e hemoptises, sendo habitual surgirem nas primeiras 12 horas após aspiração da substância.1 O melhor método de imagem para o diagnóstico é o TAC de alta resolução, que frequentemente mostra consolidação e/ou áreas em vidro despolido, habitualmente bilateral e nos lobos inferiores (quando unilateral o pulmão direito é o mais afectado), podendo ainda observar-se espessamentos septais interlobulares.2 O achado imagiológico mais característico é a presença de consolidação com áreas de baixa densidade (entre -150 a -30HU), fenómeno que se deve à atenuação da gordura1-4. O estudo citológico do lavado broncoalveolar pode evidenciar macrófagos xantomatosos, o que corrobora o dignóstico. Contudo, este achado não é específico e os falsos negativos são frequentes.1,3 O diagnóstico é baseado na histórica clínica e nos achados imagiológicos e citológicos, sendo que nenhum isoladamente faz o diagnóstico1. Dado ser uma entidade pouco frequente, com poucos casos descritos, o tratamento baseia-se na experiência clínica, sendo essencial: a evicção do agente causal; o tratamento de suporte e das complicações, nomeadamente sobreinfecção bacteriana. O uso de corticóides é controverso devendo ser reservado para as situação clínicas mais graves.1-2 No nosso caso não foi possível constatar os macrófagos típicos no LB. Atendendo à evolução favorável, pareceu-nos desnecessário expor o doente a métodos mais invasivos, até porque a história clínica e os achados imagiológicos característicos apoiam fortemente o diagnóstico. 1. Marchiori E, Zanetti G, Mano CM et al: Exogenous lipoid pneumonia. Clinical and radiological manifestations. Respir Med, 2011; 105(5): 659–66 2. Pielaszkiewicz-Wydra M. , Homola-Piekarska B. et al: Exogenous lipoid pneumonia – a case report of a fire-eater. Pol J radiol, 2012; 7(4):60-64. 3. Gondouin A, Manzoni P, Ranfaing E et al: Exogenous lipoid pneumonia: a retrospective multicentre study of 44 cases in France. Eur Respir J, 1996; 9: 1463–69 4. Betancourt SL, Martinez-Jimenez S, Rossi SE, Truong MT, Carrillo J, Erasmus JJ. Lipoid pneumonia: spectrum of clinical and radiologic manifestations. AJR Am J Roentgenol 2010; 194:103-9

Abstract A collaborative project in different areas of Spain and Portugal was designed to find out the variables that influence the mortality after discharge and develop a prognostic model adapted to the current healthcare needs of chronic patients in an internal medicine ward. Inclusion criteria were being admitted to an Internal Medicine department and at least one chronic disease. Patients’ physical dependence was measured through Barthel index (BI). Pfeiffer test (PT) was used to establish cognitive status. We conducted logistic regression and Cox proportional hazard models to analyze the influence of those variables on one-year mortality. We also developed an external validation once decided the variables included in the index. We enrolled 1406 patients. Mean age was 79.5 (SD = 11.5) and females were 56.5%. After the follow-up period, 514 patients (36.6%) died. Five variables were identified as significantly associated with 1 year mortality: age, being male, lower BI punctuation, neoplasia and atrial fibrillation. A model with such variables was created to estimate one-year mortality risk, leading to the CHRONIBERIA. A ROC curve was made to determine the reliability of this index when applied to the global sample. An AUC of 0.72 (0.7–0.75) was obtained. The external validation of the index was successful and showed an AUC of 0.73 (0.67–0.79). Atrial fibrillation along with an advanced age, being male, low BI score, or an active neoplasia in chronic patients could be critical to identify high risk multiple chronic conditions patients. Together, these variables constitute the new CHRONIBERIA index.

A collaborative project in different areas of Spain and Portugal was designed to find out the variables that influence the mortality after discharge and develop a prognostic model adapted to the current healthcare needs of chronic patients in an internal medicine ward. Inclusion criteria were being admitted to an Internal Medicine department and at least one chronic disease. Patients' physical dependence was measured through Barthel index (BI). Pfeiffer test (PT) was used to establish cognitive status. We conducted logistic regression and Cox proportional hazard models to analyze the influence of those variables on one-year mortality. We also developed an external validation once decided the variables included in the index. We enrolled 1406 patients. Mean age was 79.5 (SD = 11.5) and females were 56.5%. After the follow-up period, 514 patients (36.6%) died. Five variables were identified as significantly associated with 1 year mortality: age, being male, lower BI punctuation, neoplasia and atrial fibrillation. A model with such variables was created to estimate one-year mortality risk, leading to the CHRONIBERIA. A ROC curve was made to determine the reliability of this index when applied to the global sample. An AUC of 0.72 (0.7-0.75) was obtained. The external validation of the index was successful and showed an AUC of 0.73 (0.67-0.79). Atrial fibrillation along with an advanced age, being male, low BI score, or an active neoplasia in chronic patients could be critical to identify high risk multiple chronic conditions patients. Together, these variables constitute the new CHRONIBERIA index., (© 2023. The Author(s).)