Centro Hospitalar Tondela-Viseu

Ultrasonography, due to its numerous advantages, has become an indispensable tool in the daily work of physicians. However, there remains a limited body of knowledge regarding the current methods of ultrasound education among medical professionals. A survey was conducted among physicians to assess their previous training in Point-of-Care Ultrasound (POCUS) and their expectations regarding the timing and structure of such education. The survey was randomly administered to a group of 500 practicing physicians from Poland, Austria, Spain, and Portugal. The questionnaire consisted of 10 items addressing the perceived usefulness of ultrasound in daily clinical practice, the respondents’ ability to perform ultrasound examinations and interventional procedures under ultrasound guidance, as well as their previous exposure to ultrasound training and expectations regarding the ideal time to initiate education in this area. The survey revealed that current POCUS education during undergraduate and postgraduate internship training is inadequate. A total of 76.4% of respondents reported that their medical studies did not adequately prepare them to use ultrasound in clinical practice, and only 9.2% indicated that ultrasound training was a mandatory component of their university curriculum. The vast majority reported acquiring POCUS skills through self-initiated courses outside of their residency programs. Notably, 53.8% of respondents expressed a need for ultrasound education to begin during medical school, while 96.6% stated that the ability to perform ultrasound examinations would significantly improve their clinical work. There is a strong and clearly expressed demand for POCUS education to be introduced at an early stage of medical training. Ultrasound should be integrated as a mandatory component of the medical curriculum, as it greatly facilitates clinical decision-making and enhances the quality of patient care.

This study explored the relationship between fecal calprotectin (FCAL) and C-reactive protein (CRP) trajectory classes and composite outcomes (COs) in Crohn's Disease (CD) patients under infliximab (IFX). COs reflected disease progression, including surgery, hospitalizations, new fistulas, abscesses, strictures, and treatment escalation. The DIRECT study was a multicenter, prospective investigation (2016-2019), including moderate-severe CD patients on IFX. Latent Class Mixed Models (LCMMs) were used to identify subgroups based on longitudinal FCAL and CRP trajectories. FCAL trajectory analysis identified four clusters; CRP analysis revealed three. Patients in the U-shaped FCAL trajectory (Class 1) were more likely to achieve the global CO [odd ratio (OR) 3.263, 95% confidence intervals (CI) 1.050-10.144, p = 0.041] and the CO without symptoms and IFX adjustments compared to those in the sub-threshold decline (Class 4) (OR 9.639, 95%CI 1.147-81.025, p = 0.037). In CRP trajectories, patients in the upward trend (Class C) had higher odds of achieving the global CO compared to the flat trajectory (Class B) (OR 2.171, 95%CI 1.059-4.449, p = 0.034). In multivariable regression models, class membership improved composite outcome discrimination. Patients under IFX therapy with near or above-threshold FCAL levels or a history of high CRP were more likely to experience adverse outcomes. Regression analyses demonstrated that class membership provided additional prognostic value beyond baseline variables alone. These findings highlight the clinical relevance of trajectory-based monitoring for optimizing treatment strategies and underscore the importance of controlling inflammation early to prevent disease progression in CD.

IntroductionAccurate localization of accessory pathways (APs) is essential for effective ablation therapy. The EASY-WPW algorithm, published in 2023, is designed to help clinicians predict AP locations based on baseline ECGs, potentially enhancing procedural efficiency. However, external validation of the algorithm's accuracy and generalizability remains limited.AimThis study aimed to assess the sensitivity and accuracy of the EASY-WPW algorithm in a cohort of patients who underwent successful AP ablation at a tertiary center in Portugal.MethodsWe conducted a retrospective analysis of patients who underwent successful AP ablation from 2021 to 2024. Baseline characteristics and procedural data were collected. Two electrophysiology department members, including a cardiology resident and an electrophysiologist (EP), independently assessed baseline ECGs using the EASY-WPW algorithm. Additionally, an accessible artificial intelligence (AI)-based tool (ChatGPT) was utilized to apply the algorithm to ECGs. The algorithm's sensitivity and positive predictive value (PPV) were calculated based on results from electrophysiological (EP) studies.ResultsA total of 154 patients (72.5% male, n=111) with a mean age of 33.9 ± 18.5 years were included. The mean body mass index (BMI) was 24.3 ± 5.4 kg/m², and the mean heart rate was 75.0 ± 17.3 bpm. Among the cohort, 27.1% were under 18 years old. The algorithm correctly identified AP location in 59% of cases, yielding a PPV of 57.8% and a sensitivity of 55.7%. PPVs for right-sided, left-sided, septal, and lateral pathways were 55.6%, 62.5%, 58.3%, and 56.8%, respectively, with no significant differences between them. No significant differences in algorithm accuracy were found based on patient age (t=0.73, p=0.23), BMI (t=-10.16, p=0.311), or heart rate (t=-1.38, p=0.16). Similarly, clinician experience (resident vs. electrophysiologist) did not significantly affect accuracy, with good agreement between resident and EP (55.8% vs. 59%; kappa=0.76; p=0.001). ChatGPT’s performance in predicting AP locations was significantly lower compared to clinicians (26.5% vs. 59%).ConclusionIn this cohort, the EASY-WPW algorithm showed moderate accuracy, correctly localizing APs in 59% of cases. Patient age, BMI, heart rate, and clinician experience did not significantly impact algorithm performance. Our findings suggest that clinicians, especially those new to electrophysiology, should exercise caution when applying simplified algorithms across diverse populations. Furthermore, while the use of ChatGPT may be tempting, it is currently not advisable for this purpose given its lower accuracy in predicting AP locations.

Abstract Background Myocardial infarction remains a main cause of death in western countries. Clinical trials that supply scientific evidence behind the guidelines usually exclude the elderly and underrepresent female patients. Furthermore, new studies suggest that these patients are less likely to receive guideline-oriented treatment and therefore are at higher risk of adverse events during hospitalization. Purpose Compare gender differences in the initial management of older patients presenting with ST elevation myocardial infarction (STEMI) and non ST elevation myocardial infarction (NSTEMI). Methods Enrolled patients with the age of 65 or older, admitted in the cardiology department with the diagnosis STEMI and NSTEMI during 2007 and 2015. Excluded patients who underwent thrombolysis. Patients were divided in two groups: STEMI group and NSTEMI group. In each group, comparison between genders was made in terms of percutaneous coronary intervention (PCI) versus conservative approach, timing of PCI (urgent versus delayed), and in-hospital cardiovascular outcomes (cardiovascular death and heart failure). For statistical analysis, the two groups were compared using Person’s Chi-Square test and odds-ratio chances, considering p values <0.05 to be statistically significant. Results The study cohort was composed 382 patients in the STEMI group, and 621 patients for NSTEMI group. In the STEMI group, 36.4% of the patients were female. Female patients were older than male patients (mean age of 78.2 years vs 75.8 years), and cardiovascular risk factors were prevalent in the former. There was no difference in the choice of conservative treatment (17.3% females vs 16% males, p=0.78) and in the timing of PCI (delayed PCI in 16.5% females vs 15.2% males, p=0.75). In terms of adverse events, no difference between genders in in-hospital mortality or heart failure. In the NSTEMI group, 37.5% of the patients were female. Female patients were older than male patients (mean age of 79 years vs 76.2 years), and arterial hypertension, dyslipidemia and obesity were prevalent in the former. Female patients were 1.48 times more likely to receive conservative treatment vs male patients (45.4% females vs 36% males, p=0,02). However, there was no difference between genders in in-hospital mortality or heart failure, even in the conservative approach subgroup. There was no difference in the timing of PCI (delayed PCI in 94.1% females vs 94.4% males, p=0,91). DISCUSSION There was no difference in the initial management of STEMI elderly patients, regardless of gender. Although female elderly patients presenting with NSTEMI were more likely to receive conservative treatment, there was no difference in adverse outcomes during hospitalization.

Background: European countries have included healthcare workers (HCWs) among priority groups for COVID-19 vaccination. We established a multi-country hospital network to measure the SARS-CoV-2 incidence and effectiveness of COVID-19 vaccines among HCWs against laboratory-confirmed SARS-CoV-2 infection. Methods: HCWs from 19 hospitals in 10 countries participated in a dynamic prospective cohort study, providing samples for SARS-CoV-2 testing at enrolment and during weekly/fortnightly follow-up. We measured the incidence during pre-Delta (2 May–6 September 2021), Delta (7 September–14 December 2021), and Omicron (15 December 2021–2 May 2023) waves. Using Cox regression, we measured the relative vaccine effectiveness (rVE) of the first COVID-19 booster dose versus primary course alone during Delta and Omicron waves. Results: We included a total of 3015 HCWs. Participants were mostly female (2306; 79%), with a clinical role (2047; 68%), and had a median age of 44 years. The overall incidence of SARS-CoV-2 infection was 3.01/10,000 person-days during pre-Delta, 4.21/10,000 during Delta, and 23.20/10,000 during Omicron waves. rVE was 59% (95% CI: −25; 86) during Delta and 22% (1; 39) during Omicron waves. rVE was 51% (30; 65) 7–90 days after the first booster dose during the Omicron wave. Conclusions: The incidence of SARS-CoV-2 infection among HCWs was higher during the Omicron circulation period. The first COVID-19 vaccine booster provided additional protection against SARS-CoV-2 infection compared to primary course vaccination when recently vaccinated <90 days. This multi-country HCW cohort study addressing infection as the main outcome is crucial for informing public health interventions for HCWs.

Emery-Dreifuss muscular dystrophy type 2 (EDMD2) is a rare autosomal dominant neuromuscular disorder caused by LMNA gene mutations and characterized by progressive skeletal muscle weakness and significant cardiac involvement.We report the case of a 45-year-old woman who presented with sudden-onset, left-sided hemiparesis and dysarthria. Initial imaging was unremarkable, and symptoms transiently improved, suggesting a transient ischemic attack. However recurrent deficits led to the identification of right middle cerebral artery occlusion and new-onset atrial fibrillation. Mechanical thrombectomy was successfully performed.Subsequent cardiac evaluation revealed dilated cardiomyopathy with moderately depressed systolic function and segmental wall motion abnormalities, although coronary arteries were normal. Cardiac magnetic resonance imaging demonstrated myocardial fibrosis with late gadolinium enhancement in the subendocardial and mid-wall regions, suggestive of genetic cardiomyopathy.A neurological examination noted lordotic posture, waddling gait, positive Gowers' sign, generalized proximal muscle atrophy, and flaccid hyporeflexic tetraparesis. Electromyography confirmed a proximal myopathy. The patient reported limb weakness since her twenties. Family history was significant for similar neuromuscular and cardiac symptoms.Genetic testing identified a heterozygous LMNA missense variant (ClinVar ID: 804298), confirming the diagnosis of EDMD2. Despite the implantation of a cardiac resynchronization therapy defibrillator and optimal medical management, she experienced recurrent ventricular tachyarrhythmias, necessitating listing for heart transplantation.This case highlights the diagnostic challenges of EDMD2, particularly when the initial presentation is ischemic stroke, a rare manifestation of this genetic myopathy. It underscores the importance of a multidisciplinary approach for early diagnosis and management to improve the outcomes of this rare but impactful disorder.

Introduction: Hemorrhagic cystitis (HC) is a common complication after allogeneic hematopoietic stem cell transplantation (HSCT), characterized by inflammation and bleeding of the bladder. Hyperbaric oxygen therapy (HBOT) has been shown to be effective in the treatment of radiation-induced HC. However, the optimal treatment for HC after allogeneic HSCT has not yet been established. Furthermore, limited research has been conducted on the use of HBOT in this setting. This study aimed to evaluate the effectiveness and safety of HBOT in patients with late-onset HC after allogeneic HSCT. Methods: Twenty-five-year (1998–2022) retrospective analysis performed in all consecutive patients with confirmed late-onset HC after allogeneic HSCT treated with HBOT at two centers in Portugal. Medical records were reviewed for clinical and laboratory features, primary indications for allogeneic HSCT, conditioning regimen, and treatment strategies for HC. Patients received 100% oxygen at 2.1–2.5 atmosphere absolute pressure (ATA) for 70–90-minute periods, once daily, five times per week. Complete clinical response was defined as the absence of macroscopic hematuria sustained for at least 2 weeks, and partial response was described as a downgrading in the severity of HC. Statistical significance was considered for values of p < 0.05. Results: The sample included 61 patients with a mean age of 28.0 (SD 14.2) years, 33 males. Complete response was achieved in 72.1% (n = 44) of patients and partial response in 14.8% (n = 9). Concerning patients with a complete response, the median number of HBOT sessions was 15.5 sessions (IQR 10.0-26.8). Patients treated with 10 or more sessions of HBOT had a higher rate of complete or partial response (OR 12.5, 95%CI 1.9–83.2, p-value < 0.05). There was no response in 8 (13.1%) patients, and 6 interrupted the treatments early. Only 2 patients suspended the HBOT due to a lack of clinical benefit. Conclusion: Our study supports using of HBOT as an adjunctive treatment for late-onset HC after allogeneic HSCT. Furthermore, 10 or more HBOT sessions delivered seem to impact the rate of HC resolution. Prospective, randomized, and well-controlled trials are needed to establish HBOT’s definitive efficacy and safety.

Background:Spondyloarthritis (SpA) comprise a complex group of inflammatory arthropathies that can involve both axial and peripheral joints, often associated with extra-musculoskeletal manifestations, particularly psoriasis. The distinction between Psoriatic Arthritis (PsA) with axial involvement and axial SpA (axSpA) with concomitant psoriasis has been a topic of debate, potentially influencing clinical decisions.Objectives:To identify clinical and demographic characteristics associated with clinician’s decision to diagnose patients with psoriasis and axial disease as axSpA or as PsA with axial involvement in practical clinical settings.Methods:All adult patients registered in the Rheumatic Portuguese Disease Register (Reuma.pt) with the clinical diagnosis of PsA with axial involvement (axPsA) or axSpA with concomitant psoriasis were included. Bivariate and multivariate analysis were performed to identify clinical and demographic characteristics associated with the clinical diagnosis of axPsA or axSpA.Results:Out of 854 patients, 88.3% (n=754) received a diagnosis of axPsA and 11.7% (n=100) were diagnosed with axSpA with psoriasis.The diagnosis of axPsA included concomitant peripheral involvement in 82.2% of patients (n=620) and exclusive axial involvement in 17.8% (n=134). In axSpA diagnosis, the prevalence of concomitant peripheral involvement was 48% (n=48). Considering the whole cohort, axSpA diagnosis was associated with less peripheral involvement (OR 0.20, 95% CI 0.13-0.31; p<0.001), younger age at diagnosis (axSpA 36.7 ± 9.4 vs axPsA 43.8 ± 13.1; p<0.001) and at symptom onset (axSpA 30.1 ± 9.7 vs axPsA 39.6 ± 12.9; p<0.001) and higher positivity for HLA-B27 (OR 8.95; 95% CI 5.24-15.28; p<0.001) (Table 1). Regarding extra-articular manifestations, uveitis (OR 7.59; 95% CI 4.5-12.81; p<0.001) and inflammatory bowel disease (OR 21.02; 95% CI 8.01-55.18; p<0.001) were associated positively, while dactylitis was associated negatively with axSpA diagnosis (OR 0.13; 95% CI 0.06-0.29; p<0.001). axSpA patients more commonly received bDMARDs (OR 3.82; 2.13-6.84; p<0.001) and had a longer time from symptom onset until start of first bDMARD (axSpA 13.7 ± 9.3 vs axPsA 9.5 ± 9.1; p<0.001). Cardiovascular comorbidities were negatively associated with axSpA (OR 0.53; 95% CI 0.32 - 0.88; p<0.013). Multivariate analysis identified HLA-B27 positivity, younger age at symptom onset, presence of uveitis and inflammatory bowel disease and lower prevalence of dactylitis as independently associated with axSpA diagnosis.When considering patients with exclusive axial involvement (N=186), axSpA diagnosis was associated with a younger age at diagnosis (axSpA 36.4 ± 10.3; vs axPsA 43.9 ± 13.8; p<0.001) and at symptom onset (axSpA 29.3± 10.1 vs axPsA 38.3 ± 13.6; p<0.001), a higher prevalence of HLA-B27 (OR 8.55; 95% CI 3.59-20.4; p<0.001) and uveitis (OR 7.7; 95% CI 3.0-19.2; p<0.001) (Table 2). Regarding treatment, axSpA patients were more frequently treated with bDMARDs (OR 4.59; 95% CI 2.13 - 9.90; p<0.001) and had a longer time from symptom onset until start of first bDMARD (axSpA 14.8 ± 10.2 vs axPsA 8.5 ± 7.9; p<0.001). However, multivariate analysis did not identify any variables independently associated with the diagnosis of axPsA or axSpA.Conclusion:Patients with axPsA diagnosis exhibit more frequently concomitant peripheral involvement, whereas those with axSpA diagnosis have more often exclusive axial involvement, are younger and more frequently HLA-B27 positive. However, when considering patients with exclusive axial involvement, no differences could be identified between axSpA with psoriasis and axPsA diagnosis. In clinical practice, clinicians tend to diagnose patients with psoriasis as axSpA when axial involvement predominates and there are no peripheral manifestations.REFERENCES:NIL.Acknowledgements:NIL.Disclosure of Interests:None declared.