Instituto Superior de Espinho

Respiratory parameters are often neglected in the assessment of Guillain-Barré syndrome (GBS), yet they may influence other health domains and hinder effective rehabilitation strategies. We aimed to characterize the respiratory function and functional status and explore correlations among them in people with GBS upon admission to inpatient rehabilitation. This retrospective cohort study included adults with GBS admitted between 2018 and 2024. Demographic and clinical characteristics, including pulmonary function (Forced vital capacity-FVC%pred), respiratory (maximal inspiratory and expiratory pressures-MIP and MEP; Peak Cough Flow-PCF) and functional status [peripheral muscle strength (Medical Research Council-MRC and Functional Independence Measure-FIM)], were described. Correlations were explored with Pearson’s correlation. Ninety-five GBS individuals (56 men, 58±13 years) were admitted to rehabilitation 42±25.2 days after diagnosis with demyelinating (n=55; 58%) and axonal variants (n=38; 40%). Their FVC was 82±19%pred, MIP=63±28cm/H2O, MEP=68±29cm/H2O, PCF=330±132L/min, MRC=42±11points and FIM=80±20points. Moderate and positive correlations among respiratory measures (r=0.49-0.61, p<.001) were found. Weak-to-moderate positive correlations between respiratory and functional measures (r=0.27-0.38, p<.05) were found. GBS patients exhibited moderate respiratory and functional impairment at inpatient rehabilitation admission. Correlations between respiratory and functional status indicate that these domains influence each other and should, therefore, be considered in a comprehensive assessment of these patients to optimize rehabilitation outcomes.

Cesarean birth (CB) rates are increasing globally, with a current prevalence of 21.1% and a projected prevalence of 28.5% by 2030. Conversely, assisted vaginal birth (AVB) rates are declining, with reported rates of less than 10% in low- and middle-income countries (LMICs) and 10%-15% in high-income countries (HICs). In some African countries, AVB rates are as low as <1%. Declining AVB rates are attributable to lack of appropriate skills, equipment, and trained personnel, especially in LMICs, fear of litigation, and misconceptions that CB is safer, paucity of local guidelines and policies encouraging AVB, and increasingly accessible, acceptable, and safer CB techniques, amongst others. Optimizing appropriate care and decision making around CB and mode of birth is now a public health priority, especially given the significantly higher morbidity and mortality associated with CB compared to vaginal birth. Increasing AVB rates can potentially reduce CB rates, therefore improving maternity safety. This paper reviews the current best evidence on AVB and makes recommendations for good practice, including indications and prerequisites for AVB, who to determine who is suitable for AVB, choice of instrument, sequential application of instrument, when to abandon AVB, analgesia, antibiotic prophylaxis and episiotomy for AVB, special situations such as fetal macrosomia, maternal viral infections, previous CB, and risks and benefits of AVB versus second stage CB. An AVB safety checklist is included to reduce the risk of complications. We conclude by recommending that all maternity care providers and skilled birth attendants, including obstetricians, obstetric trainees/residents, interns, and midwives, should be trained and competent to perform AVB, to potentially reduce the current CB epidemic and its associated higher mortality and morbidity.

Cutaneous squamous cell carcinoma (CSCC) is a common skin malignancy with a subset of cases presenting as locally advanced or metastatic disease, often in elderly or comorbid patients. Cemiplimab, an anti-PD-1 antibody, has emerged as a standard treatment for advanced CSCC. This case series presents real-world outcomes of four patients (aged 75 to 83) with advanced CSCC treated with cemiplimab. Two patients had previous disease progression on first-line chemotherapy treatment. All four achieved complete responses, with time to response ranging from 6 to 24 months. Immune-related adverse events occurred in two cases, but were effectively managed. Cemiplimab was discontinued in all patients after sustained responses. Only one patient presented with a local relapse within 2 years after stopping treatment, after which cemiplimab was rechallenged with subsequent disease control. This case series highlights the significant and lasting responses that can be achieved with cemiplimab in advanced CSCC, even in older patients with comorbidities or prior treatment failure. Sustained disease control after treatment discontinuation favors time-limited immunotherapy and, in selected patients, cemiplimab rechallenge may represent a viable therapeutic option upon relapse.

The rising global rate of cesarean section (CS) has prompted renewed focus on vaginal birth after cesarean (VBAC) as a safe and effective alternative to repeat CS in properly selected women. The FIGO good practice recommendations provide evidence‐based recommendations to guide VBAC care. Success rates for VBAC range from 60% to 80%, with the highest likelihood in women with prior vaginal birth, non‐recurrent CS indications, interbirth intervals ≥18 months, BMI <30 kg/m2, and spontaneous labor onset. While uterine rupture is the primary concern, its risk remains low at approximately 0.3%–0.7% for women with one prior low transverse CS. Comparisons show that VBAC generally results in similar or better maternal and neonatal outcomes than planned repeat CS, including lower maternal mortality, fewer infections, and shorter hospital stays. This article emphasizes appropriate patient counseling, facility readiness for emergency CS, and continuous fetal monitoring during labor. With proper implementation, VBAC offers a valuable strategy to reduce unnecessary repeat surgeries, improve outcomes, and support informed maternal choice.

Tophaceous gout can present with aggressive tophi causing destruction of the soft tissues, joints, and bones (1,2). A 68-year-old male presented with intense pain in the upper and lower limbs persisting for several weeks. He reported no limb weakness or history of trauma. The patient's medical history included severe tophaceous gout, chronic renal insufficiency, and heart failure. The patient had a poor social condition. On physical examination, he exhibited poor hygiene, cachexia, and dehydration. Active drainage of gout tophi was observed. The normal anatomy of the hand was lost due to joint destruction and fusion of the interdigital spaces (see figure 1 - panel A). Also, a giant tophus can be observed in the first finger of the left hand as well. The patient displayed limited range of motion in the wrists, fingers, and elbows, with hindered mobilization of knees, ankles, and feet due to pain. Subsequent blood tests revealed anemia, leucocytosis with neutrophilia, serum creatinine of 2.68 mg/dL, blood urea nitrogen of 147 mg/dL, and C-reactive protein (CRP) of 15.4 mg/dL. X-rays of the hands (figure 2), elbows, and feet revealed multiple "punched-out" erosions with sclerotic margins, indicative of massive bone and joint destruction. Appropriate wound dressing was provided, and the patient was initiated on antibiotics, corticosteroids, and urate-lowering therapy. While CRP and anemia showed slight improvement, patient began to refuse nutrition, his renal function declined, and he died 10 days after admission. To the best of our knowledge, this represents an extremely rare case of joint fusion resulting from tophaceous gout, attributed to untreated aggressive disease and challenging social circumstances. In such instances, a multidisciplinary approach that includes healthcare professionals, social workers, and mental health experts is essential.

BackgroundTuberculosis (TB) remains a significant global health challenge despite ongoing control efforts, particularly in the context of drug-resistant TB (DR-TB), where treatment success rates remain low, underscoring the need for new therapeutic options. This review synthesises current evidence, since the publication of the World Health Organization guidelines in 2022, on the safety and efficacy of existing and new regimens for drug-susceptible TB (DS-TB) and DR-TB in adults and children.MethodsA comprehensive search was performed across three databases for studies published between January 2022 and February 2024, focusing on current and new TB treatment regimens. Additional backward and forward citation searches were conducted to identify relevant literature.Results35 studies were included, evaluating the efficacy, safety and economic impact of new oral regimens for DS-TB and DR-TB. Regimens based on bedaquiline or delamanid demonstrated high success rates and good tolerability. The BPaLM (bedaquiline, pretomanid, linezolid and moxifloxacin) regimen was more effective and safer than the standard care, while shorter DR-TB regimens reduced costs and increased success rates. However, shorter regimens for DS-TB were associated with increased drug costs. Though limited, paediatric studies suggest that shorter, safer regimens may benefit children.ConclusionEvidence supports the adoption of shorter treatment regimens for both DR-TB and DS-TB to improve safety, effectiveness and cost-effectiveness, particularly in resource-limited settings.

<bold>Introduction:</bold> Tuberculosis (TB) remains a global health concern and the COVID-19 pandemic has impacted the fight against TB, with delays in diagnosis. Timely diagnosis is crucial, with experts suggesting that diagnostic delay reflects the efficacy of TB programs. Despite the advances, diagnosis is often delayed due to clinicians' low suspicion. Our study aims to assess the healthcare diagnostic delay of TB in Portugal, identifying linked factors. <bold>Methods:</bold> Retrospective analysis of TB notifications in Portugal (2008-2017), analyzing socio-demographic and medical data. Patients with missing/incorrect data were excluded. Analysis was performed with R software, employing multiple imputation and studying associated factors through a generalized additive model <bold>Results:</bold> Among 15359 TB notifications, male sex comprised 70.4%, and 45.1% were aged 20-44. Approximately 7% originated in a high TB incidence country, while 84% were Portuguese. The developed model identified significant diagnostic delays in females and those aged>45, contrasting with lower delays in alcohol abusers and residents in community settings. Additionally, shorter delays were associated with higher education levels and social income <bold>Discussion:</bold> Most factors contributing to diagnostic delay overlap with those described in studies from other countries, namely female gender, older age, and shorter delay in groups with higher stigma. To our knowledge, the fact that a higher education level contributes to a shorter healthcare delay has not been previously described <bold>Conclusion:</bold> Our study provides a robust assessment of diagnostic delays in Portugal. Known factors (gender, age, social factors) affect delay, but the novel observation that higher education levels reduce delay suggests a potential target for enhancing TB program performance

Enquadramento: O desenvolvimento da competência no autocuidado à ostomia é impulsionador de uma transição saudável para a vida com o estoma. Estudos sugerem a existência de fatores condicionadores do desenvolvimento da competência no autocuidado à ostomia. Objetivos: Identificar os fatores condicionadores do desenvolvimento da competência de autocuidado na pessoa com ostomia de ventilação. Metodologia: Estudo quantitativo, descritivo e transversal. Técnica de amostragem não probabilística, com 80 participantes. O instrumento de colheita de dados foi o Formulário de Avaliação da Competência de Autocuidado na Pessoa com Ostomia de Ventilação. Resultados: Ser do sexo masculino, ter baixa escolaridade, ter realizado cirurgia de urgência, ter uma ostomia temporária e ter um cuidador, constituem-se como fatores inibidores do desenvolvimento da competência de autocuidado à ostomia de ventilação. O tempo pós-operatório revelou-se como fator facilitador. Conclusão: O reconhecimento da existência de fatores condicionadores do desenvolvimento da competência no autocuidado à ostomia de ventilação permite ao enfermeiro identificar condições de vulnerabilidade nos seus clientes e adequar as intervenções de forma a potenciar a autonomia.

The symptoms of chronic renal disease-related mineral and bone disease improve significantly in patients after successful simultaneous pancreas-kidney transplantation (SPKT); however, bone pathology is still present even after many post-transplant years. The aim of this study was to analyze the bone densitometry in different periods after SPKT. Three-point densitometry was performed with the dual-energy X-ray absorptiometry (DXA) technique. Serum levels of alkaline phosphatase (ALP), total serum calcium, phosphate and parathyroid hormone were analyzed as markers of mineral metabolism. The study population consisted of 48 patients (28 females, 20 males) with a mean age of 35±6years and mean 24±6years of prior diabetes. Mean period of maintenance dialysis was 36±26months. The median time from SPKT and DXA measurement was 0.53, 26.2 and 41.9months, respectively. Based on the DXA technique, 35.4% of patients were categorized as having osteoporosis at the lumbar spine and 39.6% at the femoral neck. Patients with diagnosed osteoporosis had significantly higher levels of ALP (OR=1.5; 95% CI=1.1-2.2; p<0.05 at the lumbar spine; OR=1.4; 95% CI=1.0-1.9; p<0.05 at the femoral neck). In addition, subjects with lumbar osteoporosis were characterized by a significantly lower body mass index (BMI) (OR=0.5; 95% CI=0.3-0.9; p<0.05). In the long-term follow-up, BMD increased significantly at the lumbar spine (T-score -1.86±1.07 to -1.08±0.89) and femoral neck (T-score -2.12±0.78 to -1.63±0.65). A multivariate linear model identified a BMI increase as a significant factor associated with improvement in BMD. Results of our study led us to conclude that, according to three-point densitometry, BMD among patients with functioning kidney and pancreas grafts improved. Increased serum levels of ALP were significantly associated with a decrease in BMD, suggesting a higher risk of osteoporosis. BMI gain was predictive of BMD improvement.