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- Um Afrodisíaco Potencialmente Fatal: Intoxicação por CantaridinaPublication . Diaz, P; Carneiro, A; Montes, V; Alves, SCantharidin is a toxin extracted from coleoptera beetles, commonly known as 'Spanish fly'. Traditionally it was used as an aphrodisiac, a vesicant or as an abortifacient. Intoxication by this substance has been widely reported, generally associated with gastrointestinal complications, such as digestive hemorrhage, and genitourinary disorders, such as hematuria and acute kidney injury. The authors describe the case of a 51-year old male patient who developed severe cantharidin poisoning after ingesting a preparation ('tea formulation') containing the substance. The patient reported a burning sensation in his oral cavity, diarrhea and hematuria, having sustained acute kidney injury and atypical neurological symptoms. Due to the lack of an antidote, the available treatment options are reduced to supportive measures. This case strengthens the need for a thorough medical history to ascertain the use of 'natural' products and medicinal herbs (i.e. of unregulated origin), and the importance of educating the community to their potential toxicity.
- Beware of the air when diabetes is therePublication . Fernandes, B; Taborda, F; Lobão, MJ
- Carbapenemase-producing Enterobacteriaceae in a Portuguese hospital – a five-year retrospective studyPublication . Gorgulho, A; Grilo, AM; Figueiredo, M; Selada, JBackground: Our hospital experienced an outbreak of OXA-48-producing Enterobacteriaceae, triggering this study. We aimed to describe the population with carbapenemase-producing Enterobacteriaceae (CPE) in our hospital from 2014 to 2018, the phenotypic and genotypic characteristics of isolates, and strategies to stop the outbreak. Methods: We performed a retrospective study, including every patient with CPE species in a clinical sample. Epidemiology, risk factors, treatment and outcomes were gathered from medical records. Results: A total 113 patients were included, ranging from 5 in 2015 to 83 in 2018. In 2018 the number of CPE went from 4 in May to 20 in July. With the implemented measures, propagation stopped. Implantable devices were present in 36% of patients and open wounds in 34%. Antibiotics had been prescribed to 71% of patients in the prior 30 days and most of the patients had been hospitalized for more than 5 days prior to sample collection or had a hospital stay in the previous year.Klebsiella pneumoniae was the most common species (87%). OXA-48 (62%) and Klebsiella pneumoniae-carbapenemase (KPC) (15%) were the most common carbapenemases, with OXA-48 being implicated in the 2018 outbreak. The case fatality rate at 30 days was 32%. Combination therapy resulted in less mortality. Conclusions: While KPC is the most common carbapenemase in Europe and Portugal, we experienced an important OXA-48 outbreak. Surveillance should be in place as these isolates are probably spreading. Effective communication, multidisciplinary team work and proper infection control measures are some of the best strategies during outbreaks.
- Carotid Sinus Syndrome in a Patient with Head and Neck Cancer: A Case ReportPublication . Toscano, M; Cristina, S; Alves, ARSyncope is a common complaint among patients presenting to the emergency department. Its differential diagnosis is broad and its management varies significantly depending on the underlying etiology. This is especially complex in patients with head and neck cancer since it may appear as an initial manifestation of the disease, as a side effect of surgery or radiotherapy, or as an indicator of local recurrence. Carotid sinus syndrome is a rare disease, whose pathophysiology is not yet fully understood. Here, we present the rare case of a 79-year-old male patient with a left cervical lymph node metastasis from an occult primary malignancy, who was admitted due to recurrent syncope. Paroxysms of extreme bradycardia were detected and a definitive dual chamber pacemaker was placed; however, the patient remained symptomatic. Cervical CT-scan revealed incarceration and compression of the left carotid sinus. The patient underwent radiotherapy, with favourable response, and remains asymptomatic to date.
- O Conceito de Saúde e a Minha Prática da Medicina InternaPublication . Lobão, MJ
- Contributions to the Portuguese National Plan for Patient Safety 2021–2026: A Robust Methodology Based on the Mixed-Method ApproachPublication . Sousa, P; Paiva, SG; Lobão, MJ; Van-Innis, AL; Pereira, C; Fonseca, VIntroduction: Several countries prioritize patient safety in their health policies. In Portugal, following the implementation of the National Plan for Patient Safety (NPPS) 2015– 2020, the research team of the National School of Public Health (NSPH) carried out extensive work to continue improving aspects of the previous Plan. This work was focused on identifying the strengths and weaknesses of NPPS 2015– 2020 and aspects related to its applicability and main challenges and opportunities for the implementation of the NPPS 2021–2026. Methods: Methodological dynamic process was based on the most relevant international and national guidelines and the feedback from key patient safety stakeholders. We developed a cross-sectional mixed-methods study from January to August 2021. We used documentation and periodical reports from National Health Service (NHS) healthcare institutions as secondary sources of information. For primary data collection, we used an online survey (applied to elements in the different quality and safety structures of hospitals and primary care units), interviews, and focus groups to collect information from patient safety experts. Results and Discussion: Strengthening safety culture, patient safety training, communication, leadership involvement, patient and family engagement, and monitorization process is considered essential. We also identified local limitations such as the lack of resources and protected time for the healthcare professionals and lack of leadership involvement on patient safety strategies for dedicating to patient safety actions. Most of the patient safety stakeholders agreed that the safety and health of clinical teams and new modalities of healthcare (such as telemedicine, home hospitalization, home care) should be a priority for patient safety strategies. Conclusions: In our study, we used a robust methodology with a participatory process involving different stakeholders. An alignment between local, regional, and national levels in terms of measuring indicators, the definition of priorities, and actions and activities to improve patient safety is recommended. Reinforced partnerships and alignment between the institution’s mission, and safety priorities will be crucial to enhance patient safety. Additionally, this work highlights the added value for health systems achieved through strong partnerships between public administration and academic institutions to improve healthcare quality and patient safety
- Cutaneous Manifestations in Four Patients with COVID-19Publication . Grilo, AM; Ramos, MD; Taborda, F; Nabais, I; Antunes, AP; Andrade, MM; Gorgulho, AAs the numbers of SARS-CoV-2 infections increased globally, reports of cutaneous manifestations started to emerge. We describe several patients with COVID-19 who presented with skin changes. We noted such manifestations in four out of 110 patients (3.63%) and describe the clinical situation of each of these patients. Each patient had either a maculopapular or a urticariform rash. These manifestations have a broad differential diagnosis and it was difficult to exclude drug reactions. We hope to raise awareness of this possible manifestation of COVID-19 in order to raise suspicion of this diagnosis among clinicians when they encounter patients with fever and rash. Larger series that also include patients with mild disease and skin biopsies may be useful.
- Epidemiological and Clinical Aspects of Cutaneous and Mucosal Leishmaniases in Portugal: Retrospective Analysis of Cases Diagnosed in Public Hospitals and Reported in the Literature between 2010 and 2020Publication . Rocha, R; Conceição, C; Gonçalves, L; Carvalho, AC; Maia, A; Martins, A; Carujo, A; Maio, A; Forra, C; Melita, C; Couto, D; Fernandes, D; Pereira, D; Leal, E; Sarmento, H; Sousa, I; Gonçalves, JP; Marinho, J; Vasconcelos, J; Cunha, J; Rodrigues, J; Silva, JM; Caley, L; Malheiro, L; Santos, L; Garcia, M; Cunha, M; Lima, M; Andrade, MM; Marques, M; Alpalhão, M; Silva, M; Ferraz, R; Soares, R; Fernandes, S; Llobet, S; Cruz, S; Guimarães, T; Branco, T; Robalo-Nunes, T; Almeida, V; Maia, CLeishmania infantum, a zoonotic vector-born parasite, is endemic in the Mediterranean region, presenting mostly as visceral (VL), but also as cutaneous (CL) and mucosal leishmaniasis (ML). This study aimed to describe the epidemiological and clinical aspects of the CL and ML cases diagnosed in mainland Portugal between 2010 and 2020. Collaboration was requested from every hospital of the Portuguese National Health System. Cases were screened through a search of diagnostic discharge codes or positive laboratory results for Leishmania infection. Simultaneously, a comprehensive literature search was performed. Descriptive statistics and hypothesis testing were performed using IBM® SPSS® Statistics. A total of 43 CL and 7 ML cases were identified, with a predominance of autochthonous cases (86%). In CL, immunosuppressed individuals constituted a significant proportion of patients (48%), and in this group, disseminated CL (22%) and simultaneous VL (54%) were common. In autochthonous cases, lesions, mostly papules/nodules (62%), were frequently observed on the head (48%). The approach to treatment was very heterogeneous. ML cases were all autochthonous, were diagnosed primarily in older immunosuppressed individuals, and were generally treated with liposomal amphotericin B. The findings suggest a need for enhanced surveillance and reporting, clinical awareness, and diagnostic capacity of these forms of leishmaniasis to mitigate underdiagnosis and improve patient outcomes. A holistic One Health approach is advocated to address the multifaceted challenges posed by leishmaniases in Portugal and beyond.
- Epidemiological and Clinical Aspects of Cutaneous and Mucosal Leishmaniases in Portugal: Retrospective Analysis of Cases Diagnosed in Public Hospitals and Reported in the Literature between 2010 and 2020Publication . Rocha, R; Conceição, C; Gonçalves, L; Carvalho, AC; Maia, A; Martins, A; Carujo, A; Maio, A; Forra, C; Melita, C; Couto, D; Fernandes, D; Pereira, D; Leal, E; Sarmento, H; Sousa, I; Gonçalves, JP; Marinho, J; Vasconcelos, J; Cunha, J; Rodrigues, J; Silva, JM; Caley, L; Malheiro, L; Santos, L; Garcia, M; Cunha, M; Lima, M; Andrade, MM; Marques, M; Alpalhão, M; Silva, M; Ferraz, R; Soares, R; Fernandes, S; Llobet, S; Cruz, S; Guimarães, T; Branco, T; Robalo-Nunes, T; Almeida, V; Maia, CLeishmania infantum, a zoonotic vector-born parasite, is endemic in the Mediterranean region, presenting mostly as visceral (VL), but also as cutaneous (CL) and mucosal leishmaniasis (ML). This study aimed to describe the epidemiological and clinical aspects of the CL and ML cases diagnosed in mainland Portugal between 2010 and 2020. Collaboration was requested from every hospital of the Portuguese National Health System. Cases were screened through a search of diagnostic discharge codes or positive laboratory results for Leishmania infection. Simultaneously, a comprehensive literature search was performed. Descriptive statistics and hypothesis testing were performed using IBM® SPSS® Statistics. A total of 43 CL and 7 ML cases were identified, with a predominance of autochthonous cases (86%). In CL, immunosuppressed individuals constituted a significant proportion of patients (48%), and in this group, disseminated CL (22%) and simultaneous VL (54%) were common. In autochthonous cases, lesions, mostly papules/nodules (62%), were frequently observed on the head (48%). The approach to treatment was very heterogeneous. ML cases were all autochthonous, were diagnosed primarily in older immunosuppressed individuals, and were generally treated with liposomal amphotericin B. The findings suggest a need for enhanced surveillance and reporting, clinical awareness, and diagnostic capacity of these forms of leishmaniasis to mitigate underdiagnosis and improve patient outcomes. A holistic One Health approach is advocated to address the multifaceted challenges posed by leishmaniases in Portugal and beyond.
- Hospital-Acquired Urinary Tract Infections: Results of a Cohort Study Performed in an Internal Medicine DepartmentPublication . Lobão, MJ; Sousa, PIntroduction: Urinary tract infections are the most frequent healthcare associated infections, being related to both high costs and morbidity. Our intention was to carry out an epidemiological characterization of hospital acquired urinary tract infections that occurred in an internal medicine department of a Portuguese hospital. Material and methods: Retrospective cohort study (historic cohort). Data were analysed from a systematic random sample of 388 patients, representative of the 3492 admissions occurred in 2014 in that department. Results: One in four patients underwent the placement of a bladder catheter [24.7% (n = 96); 95% CI: 20% - 29%], 36.5% (95% CI: 33% - 48%) of which in the absence of clinical criteria for that procedure. The global cumulative incidence rate for nosocomial urinary tract infections was 4.6% (95% CI: 2.5% - 6.7%). Most hospital acquired urinary tract infections (61.1%) were related to bladder catheter use. We quantified 3.06 infections / 1000 patient-days and 14.5 infections / 1000 catheter-days. Catheter associated urinary tract infection occurred at an early stage of hospitalization. The vast majority of patients (66.7%) that developed a catheter associated urinary tract infection were subjected to bladder catheter placement at emergency department. Seventy one per cent of catheter associated urinary tract infection occurred in patients that were subjected to bladder catheter placement without criteria. Discussion: These results point to an excessive and inadequate use of urinary catheters, highlighting the need for judicious use taking into account the formal clinical indications. The incidence of catheter associated urinary tract infection is similar to what we found in other studies. Nevertheless we found a very high incidence density per catheter-days that may foresee a problem probably related to the absence of early withdrawal of the device, and to both bladder catheter placement and maintenance practices. A significant part of catheter associated urinary tract infection occurred in patients that had the bladder catheter placed in the emergency department, before the admission to the internal medicine ward, which highlights the need to assess the urinary catheterization practices in those departments. Conclusion: The high rate of catheter associated urinary tract infection that occurred in the absence of bladder placement indication reinforces the need to implement prevention strategies that contemplate the reduction of its use. Emergency departments should be part of quality improvement projects in this area. Causes for the early onset of catheter associated urinary tract infection in this cohort should be investigated.
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