Sex differences in axial spondyloarthritis: data from a Portuguese spondyloarthritis cohort.

BACKGROUND: Axial spondyloarthritis (axSpA), particularly ankylosing spondylitis was historically considered a male's disease and has been under-recognized in women. Emerging evidence reveals sex differences in pathophysiology, disease presentation and therapeutic efficacy. OBJECTIVE: To identify differences between sexes in a Portuguese cohort of patients with axSpA regarding clinical manifestations, disease activity, functional capacity, patient related outcomes and presence of sacroiliitis on x-ray or magnetic resonance imaging. METHODS: Patients with ≥18 years fulfilling the ASAS- Assessment of Spondyloarthritis International Society classification criteria for axSpA registered in the electronic Rheumatic Diseases Portuguese Register (Reuma.pt) were included in this multicentric cross-sectional study. Sociodemographic data, clinical features and imaging were collected from the first record in Reuma.pt. These variables were compared between sexes using Mann-Whitney test and Chi-Square test. Variables with a significant association with variable sex were considered in the multiple variable analysis to adjust the sex effect on the outcome variables. Statistical analysis was performed with R version 4.0.2 and p <0.05 was considered statistically significant. RESULTS: A total of 1995 patients were included, 1114 (55.9%) men and 881 (44.1%) women. Men had an earlier disease onset (25.1 vs 28.4, p <0.001), were younger at diagnosis (26.9 vs 30.4, p<0.001) and were more frequently smokers (32.1% vs 15.7%, p <0.001). Comparing to women, men had worse Bath Ankylosing Spondylitis Metrological Index scores (4.0 vs 3.4, p<0.001), higher levels of C-Reactive Protein (10.5 vs 6.9 mg/L, p <0.001) and were more often Human Leukocyte Antigen-B27 positive (67.8% vs 54%, p <0.001). In contrast, women more frequently had inflammatory bowel disease (8.8% vs 4.9%, p =0.004), higher levels of erythrocyte sedimentation rate (25.0 vs 21.0mm/h, p=0.003) and worse patient-related outcomes- Bath Ankylosing Spondylitis Disease Activity Index (5.7 vs 4.5, p<0.001), Patient Global Assessment (60.0 vs 50.0, p <0.001) and fatigue (6.2 vs 5.0, p <0.001). DISCUSSION: In this large multicentric study from a Portuguese axSpA cohort, we confirmed sex differences in patients with axSpA. This work brings awareness to these differences, resulting in less underdiagnosis and misdiagnosis, optimizing treatment strategies, and improving outcomes in axSpA.

Development and usability evaluation of an application for patients with glaucoma.

INTRODUCTION: Glaucoma is a progressive optic neuropathy that requires continuous monitoring. The purpose of the study was to develop and evaluate the usability of a mobile application, for iOS and Android platforms, containing functionalities to improve patients' knowledge about glaucoma and facilitate their treatment. METHODS: The application was developed by a multidisciplinary team using an adapted version of a co-design methodology. Volunteers were selected, among patients and patients' relatives, from the Instituto Cearense de Oftalmologia, chosen by rational choice sampling, to answer the system usability scale after having prior orientation. The results extracted from the questionnaire were analyzed quantitatively. After grouping by age, a proportions test (z-test) was performed. RESULTS: It was possible to develop an application for mobile devices named "GlaucoCheck." Of the 36 interviewees, the average age was 51 (22-69) years old, 56% were women, and 30.5% had a university degree. The average APP score for usability in the SUS questionnaire was 75.6 (95% CI 74.1-77.2). CONCLUSION: There was an appropriate acceptance of patients to the "GlaucoCheck", as it was considered easy to handle, exhibiting interactive and uncomplicated layout. It was possible to develop an application and to register a positive acceptance by the users, encompassing functions that permits better adherence to treatments and additional knowledge about glaucoma.

Report of simultaneous measles outbreaks in two different health regions in Portugal, February to May 2017: lessons learnt and upcoming challenges.

In Portugal, measles vaccination coverage and population immunity are high, and no endemic measles cases had been reported since 2004. The World Health Organization classified measles as eliminated in the country in 2015 and 2016, based on data from the previous 3 years. However, in a context of increasing incidence in several European countries in 2016 and 2017, Portugal experienced two simultaneous measles outbreaks with a total of 27 laboratory-confirmed cases (0.3 cases/100,000 population) in two health regions between February and May 2017. Nineteen cases (70.1%) were adults, of whom 12 were healthcare workers. Overall, 17 cases (63.0%) were not vaccinated, of whom five were infants younger than 12 months of age. One unvaccinated teenager died. Genotype B3 was identified in 14 cases from both regions. Measles virus sequencing identified different possible origins of the virus in each region affected. Although measles transmission was stopped in less than 2 months from the first case being notified, these outbreaks represent an opportunity to reinforce awareness of measles diagnosis. We highlight the intensity of the control measures taken and their impact on the rapid control of the outbreaks and also the fact that high vaccination coverage was crucial to stop transmission.

Challenging measles case definition: three measles outbreaks in three Health Regions of Portugal, February to April 2018.

We report three simultaneous measles outbreaks with 112 confirmed cases in three Health Regions of Portugal, from February to April 2018. The mean age of cases was 30 years, 79% worked in a healthcare setting and 87% were vaccinated. Genotype B3 was identified in 84 cases from the three outbreaks. Primary cases in each outbreak were imported. Several cases presented with modified measles, highlighting the importance of rethinking the measles case definition for vaccinated cases.

Portuguese recommendations for the use of biological therapies in patients with axial spondyloarthritis - 2016 update.

OBJECTIVE: To update the recommendations for the treatment of axial spondyloarthritis (axSpA) with biological therapies, endorsed by the Portuguese Society of Rheumatology. METHODS: These treatment recommendations were formulated by Portuguese rheumatologists based on literature evidence and consensus opinion. At a national meeting, the 7 recommendations included in this document were discussed and updated. A draft of the full text of the recommendations was then circulated and suggestions were incorporated. A final version was again circulated before publication and the level of agreement among Portuguese Rheumatologists was anonymously assessed using an online survey. RESULTS: A consensus was achieved regarding the initiation, assessment of response and switching of biological therapies in patients with axSpA. In total, seven recommendations were produced. The first recommendation is a general statement indicating that biological therapy is not a first-line drug treatment option and should only be used after conventional treatment has failed. The second recommendation is also a general statement about the broad concept of axSpA adopted by these recommendations that includes both non-radiographic and radiographic axSpA. Recommendations 3 to 7 deal with the definition of active disease (including the recommended threshold of 2.1 for the Ankylosing Spondylitis Disease Activity Score [ASDAS] or the threshold of 4 [0-10 scale] for the Bath Ankylosing Spondylitis Disease Activity Index [BASDAI]), conventional treatment failure (nonsteroidal anti-inflammatory drugs being the first-line drug treatment), assessment of response to treatment (based on an ASDAS improvement  of at least 1.1 units or a BASDAI improvement of at least 2 units [0-10 scale] or at least 50%), and strategy in the presence of an inadequate response (where switching is recommended) or in the presence of long-term remission (where a process of biological therapy optimization can be considered, either a gradual increase in the interval between doses or a decrease of each dose of the biological therapy). CONCLUSION: These recommendations may be used for guidance in deciding which patients with axSpA should be treated with biological therapies. They cover a rapidly evolving area of therapeutic intervention. As more evidence becomes available and more biological therapies are licensed, these recommendations will have to be updated.

Measles outbreak after 12 years without endemic transmission, Portugal, February to May 2017.

We report a measles outbreak in two Portuguese health regions (Algarve and Lisbon and the Tagus Valley) since February 2017, and which by 31 May resulted in 28 confirmed cases, of which 16 were unvaccinated. Thirteen cases were healthcare workers. One unvaccinated teenager died. Genotype B3 was identified in 14 cases from both regions. This outbreak occurs after 12 years without endemic measles transmission, and in a context of high measles vaccination coverage and immunity.

Portuguese Recommendations for the use of biological therapies in patients with rheumatoid arthritis- 2016 update.

OBJECTIVE: To update the recommendations for the treatment of Rheumatoid Arthritis (RA) with biological therapies, endorsed by the Portuguese Society of Rheumatology (SPR). METHODS: These treatment recommendations were formulated by Portuguese rheumatologists based on literature evidence and consensus opinion. At a national meeting the 10 recommendations were discussed and updated. The document resulting from this meeting circulated to all Portuguese rheumatologists, who anonymously voted online on the level of agreement with the recommendations. RESULTS: These recommendations cover general aspects as shared decision, prospective registry in Reuma.pt, assessment of activity and RA impact and treatment objective. Consensus was also achieved regarding specific aspects as initiation of biologic therapy, assessment of response, switching and definition of persistent remission. CONCLUSION: These recommendations may be used for guidance of treatment with biological therapies in patients with RA. As more evidence becomes available and more therapies are licensed, these recommendations will be updated.

In vivo efficacy of a biotherapic and eugenol formulation against Rhipicephalus microplus.

The control of Rhipicephalus microplus is essential to prevent cattle discomfort and economic losses. However, increased resistance and acaricides inefficiency lead producers to adopt strategies that could result in the accumulation of chemical residues in meat and milk with possibilities of poisoning in animals and people. This scenario demonstrates the necessity of research into the identification of novel, effective and environmentally safe therapeutic options for cattle tick control. The objectives of this study were to develop and assess the efficacy of R. microplus biotherapic and of 5% eugenol for the control of R. microplus in artificially infested calves. Eighteen male 6-month-old Holstein calves were divided into three groups of six animals. In Group 1, the animals did not receive medication (control group); in Group 2, the animals received 1 mL of R. microplus biotherapic at dilution 6CH (centesimal Hahnemannian), orally administered twice daily. And in Group 3, they received a single application of eugenol 5% in the pour-on formulation. The median efficacy for biotherapy and eugenol 5% was respectively 10.13 and 13.97%; however, upon analyzing reproductive efficiency, it is noteworthy that the biotherapic had 45.86% efficiency and was superior to the action of eugenol (12.03%) after 37 days of treatment. The ultrastructural study provided information about the effects of R. microplus biotherapic on the ovaries of engorged females and showed disorganization in the deposition of the oocyte exochorion. The results suggest hatchability inhibition of larvae, interference in R. microplus reproduction and future possibilities for eco-friendly control of R. microplus with biotherapic 6CH.

Effectiveness of early adalimumab therapy in psoriatic arthritis patients from Reuma.pt - EARLY PsA.

Objective To compare outcomes in psoriatic arthritis (PsA) patients initiating adalimumab (ADA), with short- and long-term disease duration and to evaluate the potential effect of concomitant conventional synthetic disease-modifying antirheumatic drugs (csDMARD) or glucocorticoids. Methods Analyses included adult PsA patients registered in the Rheumatic Diseases Portuguese Register (Reuma.pt) between June 2008-June 2016 who received ADA for ≥3 months. Psoriatic Arthritis Response Criteria (PsARC) response, tender and swollen joint count, inflammatory parameters, patient (PtGA) and physician global assessment (PhGA), Disease Activity Score-28 joints (DAS28), and Health Assessment Questionnaire Disability Index (HAQ-DI) were compared between patients with <5 years of disease (early PsA) and those with ≥5 years of disease duration (late PsA). Time to achieving PsARC response was estimated using the Kaplan-Meier method. Results Of 135 PsA patients treated with ADA, 126 had information on disease duration (earlyPsA, n=41). PsARC response was achieved by 72.9% of the patients (88.0% early PsA vs 62.2% late PsA; P=0.022) after 3 months and by 85.4% after 24 months (100% early PsA vs 75.9% late PsA; P=0.044). Early PsA patients achieved significantly less painful joints (2.7 vs 6.7, p=0.006), lower mean C-reactive protein (0.5 mg/dL vs 1.3 mg/dL; P=0.011), and PhGA (18.3 vs 28.1; P=0.020) at 3 months. In the long term, early PsA patients also had fewer swollen joints (0.3 vs 1.7; P=0.030) and lower PhGA (6.3 vs 21.9; P<0.001), C-reactive protein (0.4 mg/dL vs 1.0 mg/dL; P=0.026), and DAS28 (2.2 vs 3.2; P=0.030). HAQ-DI decreased in both groups reaching a mean value at 24 months of 0.4 and 0.8 (P=ns) in early and late PsA, respectively. Early PsA patients obtained PsARC response more rapidly than late PsA (3.8 and 7.4 months, respectively; P=0.008). Concomitant csDMARDs showed clinical benefit (2-year PsARC response, 88.3% vs 60.0%; P=0.044). Concomitant glucocorticoids had no effect on PsARC response over 2 years of follow-up. Persistence on ADA was similar in both groups. Conclusion Early PsA patients had a greater chance of improvement after ADA therapy and better functional outcome, and achieved PsARC response more rapidly than late PsA. In this cohort, comedication with csDMARDs was beneficial over 2 years.

In vitro acaricidal efficacy of plant extracts from Brazilian flora and isolated substances against Rhipicephalus microplus (Acari: Ixodidae).

The tick Rhipicephalus microplus causes significant losses in livestock cattle and has developed increasing resistance to the primary acaricides that are used to treat these infections. The objective of this study was to identify new biomolecules or isolated substances showing acaricidal activity from plants. Larval packet tests were conducted to evaluate the effects of 11 species of plants and three isolated substances (betulinic acid, eugenol, and nerolidol) on R. microplus. An adult female immersion test was performed with the substance that showed the highest larvicidal activity, which was evaluated for inhibition of reproduction. Tests using Licania tomentosa, Hymenaea stigonocarpa, Hymenaea courbaril, Stryphnodendron obovatum, Jacaranda cuspidifolia, Jacaranda ulei, Struthanthus polyrhizus, Chrysobalanus icaco, Vernonia phosphorea, Duguetia furfuracea, and Simarouba versicolor extracts as well as the isolated substance betulinic acid indicated lower acaricidal effects on R. microplus larvae. The extract displaying the best larvicidal activity was the ethanolic extract from L. tomentosa at a concentration of 60%, resulting in a mortality rate of 40.3%. However, nerolidol and eugenol showed larvicidal activity, which was highest for eugenol. Nerolidol caused a 96.5% mortality rate in the R. microplus larvae at a high concentration of 30%, and eugenol caused 100% mortality at a concentration of 0.3%. In the adult immersion test, 5% eugenol was identified as a good biomolecule for controlling R. microplus, as demonstrated by its high acaricidal activity and inhibition of oviposition.

2011 Portuguese recommendations for the use of biological therapies in patients with psoriatic arthritis.

OBJECTIVE: To develop recommendations for the treatment of psoriatic arthritis (PsA) with biological therapies, endorsed by the Portuguese Society of Rheumatology. METHODS: These treatment recommendations were formulated by Portuguese rheumatologists based on literature evidence and consensus opinion. A draft of the recommendations was first circulated to all Portuguese rheumatologists and their suggestions were incorporated in the draft. At a national meeting the recommendations were discussed and all attending rheumatologists voted on the level of agreement for each recommendation. A second draft was again circulated before publication. RESULTS: A consensus was achieved regarding the initiation, assessment of response and switching biological therapies in patients with PsA. Specific recommendations were developed for several disease domains: peripheral arthritis, axial disease, enthesitis and dactylitis. CONCLUSION: These recommendations may be used for guidance in deciding which patients with PsA should be treated with biological therapies. They cover a rapidly evolving area of therapeutic intervention. As more evidence becomes available and more biological therapies are licensed, these recommendations will have to be updated.

Portuguese recommendations for the use of biological therapies in patients with axial spondyloarthritis--December 2011 update.

OBJECTIVE: To develop recommendations for the treatment of axial spondyloarthritis with biological therapies, endorsed by the Portuguese Society of Rheumatology. METHODS: These treatment recommendations were formulated by Portuguese rheumatologists based on literature evidence and consensus opinion. A draft of the recommendations and supporting evidence was first circulated to all Portuguese rheumatologists and their suggestions were incorporated in the draft. Secondly, at a national meeting the recommendations were presented, discussed and revised. Finally, the document resulting from this meeting was again circulated to all Portuguese rheumatologists, who anonymously voted online on the level of agreement with the recommendations. RESULTS: A consensus was achieved regarding the initiation, assessment of response and switching biological therapies in patients with axial spondyloarthritis. CONCLUSION: These recommendations may be used for guidance in deciding which patients with axial spondyloarthritis should be treated with biological therapies. They cover a rapidly evolving area of therapeutic intervention. As more evidence becomes available and more biological therapies are licensed, these recommendations will have to be updated.

[Practical guide for the use of biological agents in rheumatoid arthritis - December 2011 update]. / Guia prático de utilização de terapêuticas biotecnológicas na artrite reumatóide - actualização de Dezembro 2011.

The authors review the practical aspects of biological therapy use for rheumatoid arthritis patients, commenting safety issues before and after treatment initiation and the best treatment strategies to optimize efficacy.

Systemic sclerosis, a rare case.

Systemic sclerosis (SS) is a rare severe autoimmune disease involving the connective tissue. The pathophysiology is not clearly understood. It is characterized by a remarkable clinical heterogeneity, and virtually all organs can be affected. Concerning diagnosis, the presence of antinuclear antibodies (ANA) can be found in more than 90% of patients, but the diagnosis is made gathering clinical manifestations, autoimmune panel, nailfold capillaroscopy and in some cases biopsy of the organ involved. The disease course is also weakly understood, although some serological patterns can be distinguished. Current therapeutic options target few aspects of pathologic mechanism and clinical management remains a challenge.The authors presented a rare case of a SS ANA negative, which demonstrates the diagnostic challenge of this disease.

Orbital cysticercosis: diagnosis and treatment controversies.

Orbital cysticercosis is a rare condition and its management is controversial. We report 2 cases of orbital cellulitis associated with cysticercosis in which the treatment with antihelminthics was withheld. The 2 children had good evolution with spontaneous progressive resolution. The current literature is reviewed.

[Portugal and Europe are poliomyelitis free]. / Portugal e a Europa livres da poliomielite.

On the 21st of June 2002, in Copenhagen, the Regional Commission for the Certification of Poliomyelitis Eradication, declared the European Region of the World Health Organization (WHO) as polio-free. The last case (not imported) of poliomyelitis in Europe had occurred in November 1998. The health impact is enormous. In Portugal, the last case of poliomyelitis caused by the wild poliovirus, had occurred in December 1986. The path to eradication in Portugal had begun with a vaccination campaign in 1965/1966, with the oral polio vaccine (Sabin). High vaccination coverage has been maintained since then. The Portuguese program to eliminate poliomyelitis follows the strategic recommendations of WHO, with three components: vaccination; surveillance of acute placid paralysis (AFP); laboratory containment of wild polioviruses. Global eradication has not yet been achieved but is likely to happen till 2005. Keeping the high levels of motivation among Portuguese health workers is essential, in order not to loose what has been achieved. High vaccination coverage has to be maintained. Surveillance of AFP has to be improved and the prompt notification of cases by hospital clinicians, sending stool samples to the reference laboratory, is essential for the success of this activity. The laboratory containment programme is important to prevent the accidental reintroduction of poliomyelitis from laboratories.

Enterorrafias em plano aposicional convencionale com adesivo à base de cianoacrilato no cólon descendente de eqüinos / Conventional appositional pattern and cyanoacrylate tissue adhesive in descending colon enterorrhaphy in horses

Em eqüinos, as enterotomias no cólon descendente säo necessárias para remover enterólitos, corpos estranhos e material alimentar compactado que näo podem ser removidos por técnicas conservativas. Este segmento intestinal possui um suprimento sangüíneo pobre, além de predisposiçäo a complicaçöes pós-operatórias relacionadas à contaminaçäo bacteriana. Assim, este estudo foi conduzido com o objetivo de efetuar avaliaçöes clínicas e anatomopatológicas do emprego de adesivo tecidual à base de cianoacrilato no cólon descendente de eqüinos, comparando-o a uma técnica de sutura aposicional convencional. A intervençäo cirúrgica foi realizada em 15 animais posicionados em decúbito lateral direito, através de laparotomia pelo flanco esquerdo, sob anestesia geral inalatória. Após a exteriorizaçäo do cólon descendente, foram realizadas duas enterotomias de cinco centímetros de extensäo cada, distanciadas 20cm uma da outra. Os animais foram aleatoriamente distribuídos em cinco tempos de observaçäo de três animais cada e sacrificados aos três, sete, 14, 35 e 70 dias de pós-operatório. O adesivo butil-2-cianoacrilato e o fio de poliglactina 910 mostraram-se igualmente apropriados para uso em enterorrafias desse órgäo, sendo que o fio de poliglactina 910 provocou inflamaçäo inicial mais intensa que o cianoacrilato e, mais tardiamente, ambos causaram inflamaçäo granulomatosa do tipo corpo estranho observada, primeiramente, junto ao fio de poliglactina 910 (7º dia) e, a partir do 35º dia, ao redor do cianoacrilato