Cumulative Risk Exposure and Social Isolation as Correlates of Carer and Child Mental Health During the COVID-19 Pandemic: An Online Study with Families from Various Europeans Countries.

This study adopted a cumulative risk approach to examine the relations between various domains of risk factors (i.e., social isolation and home confinement, other pandemic-related risk factors, and pre-existing psychosocial risk factors) and carers' and children's mental health during the first wave of the COVID-19 pandemic in Europe. The sample consisted of 1475 carers of 6- to 16-year-old children and adolescents residing in five European countries (Portugal, United Kingdom, Romania, Spain, and The Netherlands) who completed an online survey. The results showed that each of the three domains of adversity accounted for unique variation in carers' and children's mental health outcomes. Also, the results indicated that pre-existing psychosocial risk factors moderated the relationship between pandemic-related risk factors and children and carers' anxiety and between social isolation and confinement and carers' well-being. Simple slopes analysis suggested a stronger relationship between these domains of adversities and mental health outcomes in already more vulnerable families. It is important to consider the implications of social isolation measures and confinement for families' mental health, paying special attention to families with pre-existing psychosocial vulnerabilities.

Happiness, quality of life and their determinants among people with systemic sclerosis: a structural equation modelling approach.

BACKGROUND: Patients' objectives and experiences must be core to the study and management of chronic diseases, such as SSc. Although patient-reported outcomes are attracting increasing attention, evaluation of the impact of disease on the overall subjective well-being, equivalent to 'happiness', is remarkably lacking. OBJECTIVES: To examine the determinants of happiness and quality of life in patients with SSc, with emphasis on disease features and personality traits. METHODS: Observational, cross-sectional multicentre study, including 142 patients, with complete data regarding disease activity, disease impact, personality, health-related quality of life (HR-QoL) and happiness. Structural equation modelling was used to evaluate the association between the variables. RESULTS: The results indicated an acceptable fit of the model to the data. Perceived disease impact had a significant negative direct relation with HR-QoL (ß = -0.79, P < 0.001) and with happiness (ß = -0.52, P < 0.001). Positive personality traits had a positive relation with happiness (ß = 0.36, P = 0.002) and an important indirect association upon QoL (ß = 0.43) and happiness (ß = 0.23). Perceived disease impact is influenced by body image, fatigue and SSc-related disability to a higher degree (ß = 0.6-0.7) than by disease activity (ß = 0.28) or form (ß = 0.17). Impact of disease had a much stronger relation with HR-QoL than with happiness. CONCLUSIONS: The results suggest that treatment strategies targeting not only disease control but also the mitigation of relevant domains of disease impact (body image, fatigue, global disability) may be important to improve patients' experience of the disease. The reinforcement of resilience factors, such as positive psychological traits, may also play a contributory role towards better patient outcomes.

Flexibility between immersion and distancing: A dynamic pattern with effect on depressive symptoms.

Objective: Recent studies on immersion (first-person perspective) and distancing (third-person perspective) in psychotherapy have shown the potential of both perspectives in the treatment of depression. High levels of change were associated with transitions between immersion and distancing, suggesting that a dynamic pattern between them may result in a more adaptive view of reality. This study aimed to assess if higher flexibility between these perspectives, during clients reflection on negative experiences in the intermediate phase, is associated with lower levels of depressive symptoms at the end of treatment. Method: We analyzed the flexibility through frequency and magnitude of transitions between immersion and distancing, in representative sessions of the intermediate phase of therapy in 17 cases with depression. Results: The results showed that the higher frequency and lower magnitude in the intermediate phase predicted lower levels of depressive symptoms at the end of treatment. Conclusion: Immersion and distancing seem to work as dynamic processes, and greater flexibility between them in intermediate phase of therapy, characterized by frequent and fast transitions between the two perspectives, may be an adaptive pattern due to its effect on post treatment depressive symptoms.

Genome-wide identification of genes involved in the positive and negative regulation of acetic acid-induced programmed cell death in Saccharomyces cerevisiae.

BACKGROUND: Acetic acid is mostly known as a toxic by-product of alcoholic fermentation carried out by Saccharomyces cerevisiae, which it frequently impairs. The more recent finding that acetic acid triggers apoptotic programmed cell death (PCD) in yeast sparked an interest to develop strategies to modulate this process, to improve several biotechnological applications, but also for biomedical research. Indeed, acetate can trigger apoptosis in cancer cells, suggesting its exploitation as an anticancer compound. Therefore, we aimed to identify genes involved in the positive and negative regulation of acetic acid-induced PCD by optimizing a functional analysis of a yeast Euroscarf knock-out mutant collection. RESULTS: The screen consisted of exposing the mutant strains to acetic acid in YPD medium, pH 3.0, in 96-well plates, and subsequently evaluating the presence of culturable cells at different time points. Several functional categories emerged as greatly relevant for modulation of acetic acid-induced PCD (e.g.: mitochondrial function, transcription of glucose-repressed genes, protein synthesis and modifications, and vesicular traffic for protection, or amino acid transport and biosynthesis, oxidative stress response, cell growth and differentiation, protein phosphorylation and histone deacetylation for its execution). Known pro-apoptotic and anti-apoptotic genes were found, validating the approach developed. Metabolism stood out as a main regulator of this process, since impairment of major carbohydrate metabolic pathways conferred resistance to acetic acid-induced PCD. Among these, lipid catabolism arose as one of the most significant new functions identified. The results also showed that many of the cellular and metabolic features that constitute hallmarks of tumour cells (such as higher glycolytic energetic dependence, lower mitochondrial functionality, increased cell division and metabolite synthesis) confer sensitivity to acetic acid-induced PCD, potentially explaining why tumour cells are more susceptible to acetate than untransformed cells and reinforcing the interest in exploiting this acid in cancer therapy. Furthermore, our results clearly establish a connection between cell proliferation and cell death regulation, evidencing a conserved developmental role of programmed cell death in unicellular eukaryotes. CONCLUSIONS: This work advanced the characterization of acetic acid-induced PCD, providing a wealth of new information on putative molecular targets for its control with impact both in biotechnology and biomedicine.

Patient-defined flares and disease activity worsening in 222 patients with psoriatic arthritis from 14 countries.

OBJECTIVES: To explore patient-defined flares in psoriatic arthritis (PsA), compared to an increase in disease activity in psoriatic arthritis (DAPSA) and to analyze the validity of a patient-reported flare question. METHODS: ReFlap (NCT03119805) was a longitudinal study in 14 countries of consecutive patients with definite PsA. Patients were seen twice in the context of usual care, 4.5±2.2 months apart. Flares were reported by patients and physicians at the second visit using a single question. DAPSA worsening was defined as a change to a higher DAPSA category. Agreement between the definitions of worsening was calculated by prevalence adjusted bias adjusted kappa (PABAK). Validity of patient-reported flare was assessed by comparing patients with versus without flare and transition to flares. RESULTS: In 222 patients, mean disease duration 10.8±8.3 years, 127 (58.8%) males: disease activity was low (mean DAPSA 11.5±14.0); 63.3% received a bDMARD. Patient-reported flares between the 2 visits were seen in 27% patients (for these patients, mean 2.2±3.7 flares per patient, mean duration 12.6±21.0 days per flare). Physician- reported flares were seen in 17.6% and worsening in DAPSA in 40.1% of patients. Agreement between definitions was moderate (PABAK=0.32-0.59). Patients in flare had significantly more active disease than patients not in flare for all outcomes (all P<0.001). At the patient-level, transition to flare state was associated to a worsening in disease activity and impact outcomes. CONCLUSIONS: Patient flares were frequent and were associated with active and symptomatic disease. These findings provide preliminary validation for patient-reported flares in PsA.

Predictors of cardiac involvement in idiopathic inflammatory myopathies.

Objectives: Idiopathic inflammatory myopathies (IIM) are a group of rare disorders that can affect the heart. This work aimed to find predictors of cardiac involvement in IIM. Methods: Multicenter, open cohort study, including patients registered in the IIM module of the Rheumatic Diseases Portuguese Register (Reuma.pt/Myositis) until January 2022. Patients without cardiac involvement information were excluded. Myo(peri)carditis, dilated cardiomyopathy, conduction abnormalities, and/or premature coronary artery disease were considered. Results: 230 patients were included, 163 (70.9%) of whom were females. Thirteen patients (5.7%) had cardiac involvement. Compared with IIM patients without cardiac involvement, these patients had a lower bilateral manual muscle testing score (MMT) at the peak of muscle weakness [108.0 ± 55.0 vs 147.5 ± 22.0, p=0.008] and more frequently had oesophageal [6/12 (50.0%) vs 33/207 (15.9%), p=0.009] and lung [10/13 (76.9%) vs 68/216 (31.5%), p=0.001] involvements. Anti-SRP antibodies were more commonly identified in patients with cardiac involvement [3/11 (27.3%) vs 9/174 (5.2%), p=0.026]. In the multivariate analysis, positivity for anti-SRP antibodies (OR 104.3, 95% CI: 2.5-4277.8, p=0.014) was a predictor of cardiac involvement, regardless of sex, ethnicity, age at diagnosis, and lung involvement. Sensitivity analysis confirmed these results. Conclusion: Anti-SRP antibodies were predictors of cardiac involvement in our cohort of IIM patients, irrespective of demographical characteristics and lung involvement. We suggest considering frequent screening for heart involvement in anti-SRP-positive IIM patients.

The idiopathic inflammatory myopathies module of the Rheumatic Diseases Portuguese Register.

AIMS: To characterise the idiopathic inflammatory myopathies (IIM) module of the Rheumatic Diseases Portuguese Register (Reuma.pt/myositis) and the patients in its cohort. METHODS: Reuma.pt is a web-based system with standardised patient files gathered in a registry. This was a multicentre open cohort study, including patients registered in Reuma.pt/myositis up to January 2022. RESULTS: Reuma.pt/myositis was designed to record all relevant data in clinical practice and includes disease-specific diagnosis and classification criteria, clinical manifestations, immunological data, and disease activity scores. Two hundred eighty patients were included, 71.4% female, 89.4% Caucasian, with a median age at diagnosis and disease duration of 48.9 (33.6-59.3) and 5.3 (3.0-9.8) years. Patients were classified as having definite (N=57/118, 48.3%), likely (N=23/118, 19.5%), or possible (N=2/118, 1.7%) IIM by 2017 EULAR/ACR criteria. The most common disease subtypes were dermatomyositis (DM, N=122/280, 43.6%), polymyositis (N=59/280, 21.1%), and myositis in overlap syndromes (N=41/280, 14.6%). The most common symptoms were proximal muscle weakness (N=180/215, 83.7%) and arthralgia (N=127/249, 52.9%), and the most common clinical signs were Gottron's sign (N=75/184, 40.8%) and heliotrope rash (N=101/252, 40.1%). Organ involvement included lung (N=78/230, 33.9%) and heart (N=11/229, 4.8%) involvements. Most patients expressed myositis-specific (MSA, N=158/242, 65.3%) or myositis-associated (MAA, 112/242, 46.3%) antibodies. The most frequent were anti-SSA/SSB (N=70/231, 30.3%), anti-Jo1 (N=56/236, 23.7%), and anti-Mi2 (N=31/212, 14.6%). Most patients had a myopathic pattern on electromyogram (N=101/138, 73.2%), muscle oedema in magnetic resonance (N=33/62, 53.2%), and high CK (N=154/200, 55.0%) and aldolase levels (N=74/135, 54.8%). Cancer was found in 11/127 patients (8.7%), most commonly breast cancer (N=3/11, 27.3%). Most patients with cancer-associated myositis had DM (N=8/11, 72.7%) and expressed MSA (N=6/11) and/or MAA (N=3/11). The most used drugs were glucocorticoids (N=201/280, 71.8%), methotrexate (N=117/280, 41.8%), hydroxychloroquine (N=87/280, 31.1%), azathioprine (N=85/280, 30.4%), and mycophenolate mofetil (N=56/280, 20.0%). At the last follow-up, there was a median MMT8 of 150 (142-150), modified DAS skin of 0 (0-1), global VAS of 10 (0-50) mm, and HAQ of 0.125 (0.000-1.125). CONCLUSIONS: Reuma.pt/myositis adequately captures the main features of inflammatory myopathies' patients, depicting, in this first report, a heterogeneous population with frequent muscle, joint, skin, and lung involvements.

Clinical characterisation of a multicentre nationwide cohort of patients with antisynthetase syndrome.

BACKGROUND: Antisynthetase syndrome (ASyS) is characterised by the association of inflammatory myopathy, interstitial lung disease (ILD), arthritis, Raynaud's phenomenon (RP) or mechanic's hands (MH), with the presence of anti-aminoacyl-tRNA-synthetase antibodies (anti-ARS). It has been suggested that different anti-ARS may be associated with distinct clinical pictures. OBJECTIVE: To characterise the clinical and immunological features of a multicentric nationwide cohort of ASyS patients. METHODS: This is a multicentre retrospective cohort study including patients with ASyS from nine Portuguese rheumatology centres. Data on patients' demographics, signs and symptoms, laboratory results, pulmonary imaging findings and treatment with immunomodulators were collected. Comparison between patients with different anti-ARS antibodies was made using the Chi-square test for categorical variables and Student's t-test or Man-Whitney test for continuous variables, considering anti-Jo1 positive patients as the reference group. RESULTS: Seventy patients were included (70% female) with a median age in years at disease onset of 52 (15-75) years and median follow-up time of 3 years (range 0-32). The three most common clinical manifestations were ILD (n=53, 75.7%), followed by arthritis (n=43, 61.4%) and myositis (n=37, 52.9%). Forty-three patients were positive for anti-Jo1 (61.4%), 11 for anti-PL12 (15.7%), 10 for anti-PL7 (14.3%), 4 for anti-EJ (5.7%), and 2 for anti-OJ (2.9%) antibodies. Antibody co-positivity with anti-Ro52 antibodies was found in 15 patients (21.4%) and was more prevalent in anti-Jo1 patients. ILD prevalence was similar in the different anti-ARS subgroups, without statistically significant differences. Patients positive for anti-PL7 antibodies had significantly lower risk of presenting arthritis (p =< 0.05) and those positive for anti-PL-12 antibodies had a significantly lower risk of presenting myositis than the reference group of anti-Jo1 positive patients (p =< 0.05). RP was more frequently found in patients positive for anti-PL-12 than in anti-Jo1-positive patients (p =< 0.05). Malignancies were reported in four (5.7%) patients, none of whom were anti-Ro52-positive, and one of such patients had a double malignancy. Only three deaths were reported. Corticosteroids were the most frequently prescribed therapy and the use of immunosuppressive drugs was decided according to the type of predominant clinical manifestation. CONCLUSION: The three most common clinical manifestations were ILD, followed by arthritis and myositis. Patients positive for anti-PL7 antibodies had significantly lower risk of presenting arthritis and those positive for anti-PL-12 antibodies had a significantly lower risk of presenting myositis than the reference group of anti-Jo1 positive patients. RP was more frequently found in patients positive for anti-PL-12 than in anti-Jo1-positive patients. Corticosteroids were the most frequently prescribed therapy. These results are generally concordant with data retrieved from international cohorts.

Risk Factors for Infection, Predictors of Severe Disease, and Antibody Response to COVID-19 in Patients With Inflammatory Rheumatic Diseases in Portugal-A Multicenter, Nationwide Study.

Objective: To identify risk factors for SARS-CoV-2 infection and for severe/critical COVID-19, and to assess the humoral response after COVID-19 in these patients. Methods: Nationwide study of adult patients with inflammatory RMDs prospectively followed in the Rheumatic Diseases Portuguese Register-Reuma.pt-during the first 6 months of the pandemic. We compared patients with COVID-19 with those who did not develop the disease and patients with mild/moderate disease with those exhibiting severe/critical COVID-19. IgG antibodies against SARS-CoV-2 were measured ≥3 months after infection and results were compared with matched controls. Results: 162 cases of COVID-19 were registered in a total of 6,363 appointments. Patients treated with TNF inhibitors (TNFi; OR = 0.160, 95% CI 0.099-0.260, P < 0.001) and tocilizumab (OR 0.147, 95% CI 0.053-0.408, P < 0.001) had reduced odds of infection. Further, TNFi tended to be protective of severe and critical disease. Older age, major comorbidities, and rituximab were associated with an increased risk of infection and worse prognosis. Most patients with inflammatory RMDs (86.2%) developed a robust antibody response. Seroconversion was associated with symptomatic disease (OR 13.46, 95% CI 2.21-81.85, P = 0.005) and tended to be blunted by TNFi (OR 0.17, 95% CI 0.03-1.05; P = 0.057). Conclusions: TNFi and tocilizumab reduced the risk of infection by SARS-CoV-2. Treatment with TNFi also tended to reduce rates of severe disease and seroconversion. Older age, general comorbidities and rituximab were associated with increased risk for infection and worse prognosis, in line with previous reports. Most patients with RMDs developed a proper antibody response after COVID-19, particularly if they had symptomatic disease.

Patient-Physician discordance in assessment of disease activity in Rheumatoid Arthritis patients.

BACKGROUND: In rheumatoid arthritis (RA), global disease activity is commonly evaluated, from the patient's and the physician's perspective, through a 100mm visual analogue scale (VAS) and plays an important role in the assessment of diseases activity and treatment decisions. Our aim was to determine patient-physician discordance in the assessment of disease activity and to explore its determinants. METHODS: Cross sectional study including RA patients (ACR/EULAR 2010 classification criteria). The discrepancy between patients-physicians (∆PPhGA) was defined as PGA minus PhGA, and a difference > |20mm| was considered as "discordant". Correlation between ∆PPhGA and other variables was assessed through Pearson's correlation and comparison between groups through t-test. Variables with p < 0.05 or considered clinically relevant were included in multivariable linear regression analysis to identify determinants for ∆PPhGA. A p < 0.05 was considered statistically significant. RESULTS: In total, 467 patients with RA were included (81.2% female; mean age 63.9% ± 12.2 years). PGA and PhGA were discordant in 61.7% of the cases. The proportion of concordance increased (p < 0.01) when considering only patients in remission (DAS 28 3V < 2.6). In multivariable analysis (R2adjusted=0.27), VAS-pain-patient (ß 0.74, 95% CI 0.62-0.88, p=0.00) and TJC (ß 0.16, 95% CI 0.45-0.48, p=0.02) remained associated with a higher ∆PPhGA. CONCLUSION: Our study confirmed that a significant discrepancy between patients and physicians in the assessment of global disease activity is frequent in clinical practice, and is probably due to valorization of different parameters by the two groups.

SARS-CoV-2 outbreak in immune-mediated inflammatory diseases: the Euro-COVIMID multicentre cross-sectional study.

BACKGROUND: The COVID-19 pandemic has raised numerous questions among patients with immune-mediated inflammatory diseases regarding potential reciprocal effects of COVID-19 and their underlying disease, and potential effects of immunomodulatory therapy on outcomes related to COVID-19. The seroprevalence of SARS-CoV-2 and factors associated with symptomatic COVID-19 in patients with immune-mediated inflammatory diseases are still unclear. The Euro-COVIMID study aimed to determine the serological and clinical prevalence of COVID-19 among patients with immune-mediated inflammatory diseases, as well as factors associated with COVID-19 occurrence and the impact of the pandemic in its management. METHODS: In this multicentre cross-sectional study, patients aged 18 years or older with a clinical diagnosis of rheumatoid arthritis, axial spondyloarthritis, systemic lupus erythematosus, Sjögren's syndrome, or giant cell arteritis were recruited from six tertiary referral centres in France, Germany, Italy, Portugal, Spain, and the UK. Demographics, comorbidities, treatments, and recent disease flares, as well as information on COVID-19 symptoms, were collected through a questionnaire completed by participants. SARS-CoV-2 serology was systematically tested. The main outcome was the serological and clinical prevalence of COVID-19. Factors associated with symptomatic COVID-19 were assessed by multivariable logistic regression, and incidence of recent disease flares, changes in treatments for underlying disease, and the reasons for treatment changes were also assessed. This study is registered with ClinicalTrials.gov, NCT04397237. FINDINGS: Between June 7 and Dec 8, 2020, 3136 patients with an immune-mediated inflammatory disease answered the questionnaire. 3028 patients (median age 58 years [IQR 46-67]; 2239 [73·9%] women and 789 [26·1%] men) with symptomatic COVID-19, serological data, or both were included in analyses. SARS-CoV-2 antibodies were detected in 166 (5·5% [95% CI 4·7-6·4]) of 3018 patients who had serology tests. Symptomatic COVID-19 occurred in 122 (4·0% [95% CI 3·4-4·8]) of 3028 patients, of whom 24 (19·7%) were admitted to hospital and four (3·3%) died. Factors associated with symptomatic COVID-19 were higher concentrations of C-reactive protein (odds ratio 1·18, 95% CI 1·05-1·33; p=0·0063), and higher numbers of recent disease flares (1·27, 1·02-1·58; p=0·030), whereas use of biological therapy was associated with reduced risk (0·51, 0·32-0·82; p=0·0057). At least one disease flare occurred in 654 (21·6%) of 3028 patients. Over the study period, 519 (20·6%) of 2514 patients had treatment changes, of which 125 (24·1%) were due to the pandemic. INTERPRETATION: This study provides key insights into the epidemiology and risk factors of COVID-19 among patients with immune-mediated inflammatory diseases. Overall, immunosuppressants do not seem to be deleterious in this scenario, and the control of inflammatory activity seems to be key when facing the pandemic. FUNDING: Pfizer, Sanofi, Amgen, Galapagos, and Lilly.

Parenting and child mental health during the COVID-19 pandemic: An online study with Portuguese and British Families / Parentalidad y salud mental infantil durante la pandemia de COVID-19: Un estudio online con familias Portuguesas y Británicas

COVID-19 and the subsequent public health response created many additional stresses for families. We examined parental behaviour during the COV-ID-19 pandemic in two European Countries and explored the association between parents’ behaviour and children’s anxiety and quality of life. Caregiv-ers of children and adolescents (N = 442; 86.7% mothers) between 6 and 16 years old (M = 10, SD = 2.85) participated in an online cross-sectionalsurvey in Portugal and the United Kingdom. Results show that higher children’s anxiety and lower quality of life were associated with higher levels ofunrealistic parental demands, lower parental self-care, and higher parental emotional dysregulation. Encouragement of children’s emotion expressionand management of exposure to COVID-19 information was negatively associated with children’s anxiety. Promotion of routines, support of children’semotion modulation and promotion of children’s healthy lifestyles were positively associated with children’s quality of life. The predictors differed accord-ing to country and age group. These results highlight the importance of specific parenting behaviours on children’s mental health during COVID-19. Theneed to moderate unrealistic demands and attend to parental self-care to reduce parental emotional dysregulation is important.(AU)

COVID-19 y lasubsiguiente respuesta de salud pública crearon muchas tensiones adicionales para las familias. Examinamos el comportamiento de los padres durantela pandemia de COVID-19 en dos países europeos y exploramos la asociación entre el comportamiento de los padres y la ansiedad y la calidad de vidadel niño. Cuidadores de niños y adolescentes (N = 442; 86.7% madres) entre 6 y 16 años (M = 10, DT = 2,85) participaran en una online encuesta enPortugal y en el Reino Unido. En los resultados se observa que la mayor ansiedad y una menor calidad de vida de los niños se asociaron con niveles másaltos de demandas parentales poco realistas, menor autocuidado y mayor desregulación emocional de los padres. El estímulo a la expresión de las emo-ciones de los niños y el manejo de la exposición a la información de COVID-19 se asoció negativamente con la ansiedad de los niños. La promoción derutinas, el apoyo a la modulación de las emociones de los niños y la promoción de estilos de vida saludables de los niños se asociaron positivamente conla calidad de vida de los niños. Los predictores difirieron según el país y el grupo de edad. Estos resultados resaltan la importancia de comportamientosparentales específicos en la salud mental de los niños durante el COVID-19. La necesidad de moderar las demandas poco realistas y prestar atenciónal autocuidado de los padres para reducir la desregulación emocional de los padres es importante.(AU)

[The primary care frequent attender profile]. / Perfil do hiperfrequentador nos Cuidados de Saúde Primários.

INTRODUCTION: Frequent attenders are believed to represent a problem in Primary Care, with human, economic and social impact. The present study aimed to describe these patients' sociodemographic and pathological characteristics. MATERIAL AND METHODS: A cross-sectional study with analytical component was conducted in the population of frequent attenders in a Portuguese Primary Health Care Practice, between January 2007 and December 2009, allocated to six General Practitioners. Sociodemographic characteristics as well as data related to physical and mental illness were collected from clinical records. Associations between variables were tested with χ-square and t-test. The top quartile of frequent attenders was compared with the remaining population. The adopted significance level was 0.05. RESULTS: Of the 582 individuals evaluated, with a mean age of 55.4 years (men 58.6 and women 54.3; p = 0.006), 85% had chronic physical illness and 42% had chronic psychiatric illness. In the upper quartile of frequent attenders was observed a higher prevalence of chronic psychiatric illness (p < 0.001), as well as multiple pathology (p = 0.01), when compared to the remaining population. Individuals with physical illness were older (mean age: 58.0 years vs 40.1 years; p < 0.001) while those with chronic psychiatric illness were younger (mean age 53.7 years vs 56.6; p = 0.035). DISCUSSION: It was drawn a profile of the frequent attender consistent with international literature, at a time when there are no studies in Portuguese Primary Care settings. Information and selection bias were detected and minimized. In order to discriminate between frequent attenders, the upper quartile was compared with the remaining population. Some features seemed to be more associated with frequent attendance, such as advanced age, low educational level and the presence of chronic psychiatric illness. CONCLUSION: The frequent attender of this Portuguese Primary Care Practice is a female, in the sixth decade of life, with low educational level, married or living as a couple, coming from a nuclear family, and often with chronic illness. Knowledge of these patients may allow the development of strategies that lead to more cost-effective health care services. This study shows some guidelines for studies on this important population.

Abstract available from the publisher.

[Use of valerian in anxiety and sleep disorders: what is the best evidence?]. / Utilização da valeriana nas perturbações de ansiedade e do sono: qual a melhor evidência?

BACKGROUND: Anxiety disorders and sleep problems are common in the general population and are a cause of frequent consultations in primary care. These problems have significant impact on quality of life and functionality of individuals. The extracts of valerian root have been widely used for a long time by the population and physicians, for their sedative effects, hypnotic and anxiolytic. It is therefore urgent to know what are the benefits and the risks of using this substance for the treatment of anxiety and sleep disorders. OBJECTIVE: To investigate the efficacy and safety of valerian for the treatment of anxiety and sleep disorders. METHODS: A research was carried out for clinical practice guidelines, systematic reviews (SR), meta-analysis (MA) and randomized controlled trials (RCT) in Pubmed, sites of evidence-based medicine and Índex das Revistas Médicas Portuguesas using the MeSH terms valerian, anxiety and sleep disorders, and respective DeCS, analyzing articles in English, Spanish, French or Portuguese, published between January 2000 and March 31, 2010. We also reviewed references of relevant articles. We used the Strength of Recommendation Taxonomy (SORT) from American Family Physician to evaluate the level of evidence and assigning the strength of a recommendation. RESULTS: We found 173 articles of which four were selected which met the inclusion criteria: a meta-analysis, a SR and a RCT concerning the use of valerian in sleep disorders, and an SR on the use of valerian in anxiety disorders. The evidence is insufficient regarding the efficacy of valerian in the treatment of anxiety disorders (SOR A). There seems to be some evidence of the effectiveness of valerian for treating insomnia, which is limited by the quality of existing studies (SOR B). Valerian root is well tolerated and safe, with infrequent and benign side effects (SOR A). DISCUSSION: The evidence is currently insufficient to recommend the use of valerian for the treatment of anxiety disorders. The evidence in insomnia is limited by the contradictory results of studies reviewed and their methodological problems, although it seems to have some effect in mild to moderate insomnia. Despite that, valerian is a safe substance. More RCT are needed, with samples of adequate size, with standardization of measures to assess quality of sleep and levels of anxiety and standardization of dose, type of preparation of valerian used and the time for its use.