ABSTRACT Introduction: ANCA associated vasculitis commonly affects the kidneys. The intense inflammatory damage disrupts the glomerular architecture. Induction immunosuppressive therapy is responsible for a large part of the morbidity and mortality of these patients, due to infectious complications. This highlights the importance of defining risk factors associated with a worse renal prognosis in order to select the patients who would benefit the most from immunosuppressive therapy when it comes to renal limited vasculitis. Methods: Retrospective collection of data from patients admitted to the Coimbra’s University Hospital Nephrology Department with the diagnosis of de novo ANCA vasculitis, between 01-06-2009 and 01-06-2019. Data were analysed with SPSS v26® using parametric and nonparametric tests, Kaplan Meyer survival and ROC curve analysis. Results: There were 81 cases of de novo vasculitis, mainly due to anti-MPO antibody associated vasculitis (N=69; 85.2%). Mean age at diagnosis was 67.4 ± 15.7 years and most patients were male (N=47; 58%). At admission, patients had a mean serum creatinine (sCr) of 6.8 ± 4.0 mg/dL. Dialysis was required in 23 (28.4%) patients at admission and 44.4% were dependent on renal replacement therapy at discharge. Among dialysis-dependent patients at discharge treated with immunosuppression for at least 3 months (N=15) we observed partial kidney recovery in 2 (13.3%). Deaths were mostly (N=8/11; 72.7%) caused by infections. Discussion: Our results call into question the need for aggressive induction treatment in dialysis-dependent patients without extrarenal manifestations.

ABSTRACT Eosinophilic granulomatosis with polyangiitis is an ANCA vasculitis characterized by asthma, rhinosinusitis and peripheral eosinophilia. The kidney is infrequently involved, usually in the form of necrotizing crescentic glomerulonephritis. We present the case of a 60-year-old man who presented with painless sudden loss of visual acuity, purpuric exanthem in his legs, asthenia and myalgia. CT-scan ruled out acute vascular and intracranial space occupant lesions. Optical coherence tomography showed signs of left central retinal artery occlusion and perfusion deficits in the right arterial retinal blood supply. Complementary study showed prominent peripheral eosinophilia (24.500 cel/uL), increased serum IgE (1260U/L) and increased C-reactive protein (10.6mg/dl). During admission, the patient presented with acute kidney failure (serum creatinine of 4.7mg/dl) and an exceptionally high p-ANCA MPO titer (>600U/L). Eosinophilic granulomatosis with polyangiitis was diagnosed and plasmapheresis, pulse steroid therapy and intravenous cyclophosphamide were provided. Kidney biopsy showed interstitial nephritis with high eosinophil content while the glomerulus was relatively spared, with only mild endocapillary proliferation. The patient didn’t require dialysis. Kidney function was normal at discharge, although the visual deficit did not improve.

Resumo Em Portugal, os médicos de família trabalham com uma lista bem definida de utentes, aos quais prestam cuidados de saúde ao longo da vida. Vários estudos mostraram que as dimensões maiores das listas estão associadas a piores resultados de saúde comprometedoras da qualidade do atendimento prestado. Devido ao contexto socioeconómico português desfavorável e à falta de médicos de família, tem-se verificado um aumento significativo da dimensão média das listas de utentes atribuídas aos médicos de família nos últimos anos. A Associação Portuguesa de Medicina Geral e Familiar (APMGF) desenvolveu, em 2017, uma investigação técnico-científica que acabou por tipificar diferentes contextos do exercício clínico. Este trabalho considerou as características geográficas e socioeconómicas, bem como um conjunto de indicadores demográficos, visando ajustar a dimensão das listas de acordo com as necessidades específicas da população. Com os ajustamentos propostos na gestão da dimensão das listas de utentes, será possível prestar serviços de saúde com mais qualidade, segurança, eficácia e obter ganhos decorrentes da maior personalização na prestação de cuidados. Neste artigo uma breve revisão é feita sobre este tópico, direcionando o enfoque para os resultados do trabalho desenvolvido pela APMGF.

Abstract In Portugal, family doctors work with a well-defined list of patients to whom they provide healthcare throughout their lives. Several studies showed that larger list sizes are associa- ted with poorer health outcomes and compromise the quality of care. A significant increase in the average list size has been observed in recent years due to the Portuguese unfavorable socioeconomic context and the lack of family doctors. In 2017, the Portuguese Association of General and Fa- mily Medicine (APMGF) developed technical and scientific research that ultimately typified a set of different clinical practice contexts. It considers the geographic and socioeconomic characteristics and a set of population-based indicators, adjusting the list size according to the population’s specific needs. Such adjustments ensure health care services with better quality, safety, efficacy, and personalized to their features. In this paper, a brief review is made on this topic, focusing on the work developed by APMGF and its main results.

Resumo Em Portugal, os médicos de família trabalham com uma lista bem definida de utentes, aos quais prestam cuidados de saúde ao longo da vida. Vários estudos mostraram que as dimensões maiores das listas estão associadas a piores resultados de saúde comprometedoras da qualidade do atendimento prestado. Devido ao contexto socioeconómico português desfavorável e à falta de médicos de família, tem-se verificado um aumento significativo da dimensão média das listas de utentes atribuídas aos médicos de família nos últimos anos. A Associação Portuguesa de Medicina Geral e Familiar (APMGF) desenvolveu, em 2017, uma investigação técnico-científica que acabou por tipificar diferentes contextos do exercício clínico. Este trabalho considerou as características geográficas e socioeconómicas, bem como um conjunto de indicadores demográficos, visando ajustar a dimensão das listas de acordo com as necessidades específicas da população. Com os ajustamentos propostos na gestão da dimensão das listas de utentes, será possível prestar serviços de saúde com mais qualidade, segurança, eficácia e obter ganhos decorrentes da maior personalização na prestação de cuidados. Neste artigo uma breve revisão é feita sobre este tópico, direcionando o enfoque para os resultados do trabalho desenvolvido pela APMGF.

Abstract In Portugal, family doctors work with a well-defined list of patients to whom they provide healthcare throughout their lives. Several studies showed that larger list sizes are associa- ted with poorer health outcomes and compromise the quality of care. A significant increase in the average list size has been observed in recent years due to the Portuguese unfavorable socioeconomic context and the lack of family doctors. In 2017, the Portuguese Association of General and Fa- mily Medicine (APMGF) developed technical and scientific research that ultimately typified a set of different clinical practice contexts. It considers the geographic and socioeconomic characteristics and a set of population-based indicators, adjusting the list size according to the population’s specific needs. Such adjustments ensure health care services with better quality, safety, efficacy, and personalized to their features. In this paper, a brief review is made on this topic, focusing on the work developed by APMGF and its main results.

Introduction: Central venous stenosis can be the main obstacle to the creation of a vascular access. The Surfacer® device was developed to solve the problem of complete occlusions of the right internal jugular vein, right brachiocephalic vein and superior vena cava, allowing for the placement of a vascular access in this venous axis. Case Report: We present the case of a 77-year-old patient on long-term hemodialysis with a long history of failed vascular accesses and of central vein stenosis, chronically dialyzed using a tunneled catheter placed through the left femoral vein. With use of the Surfacer® device it was possible to recreate, with an inside-out technique, a tract through the fibrous tissue of the completely occluded right brachiocephalic and right internal jugular veins, subsequently placing a tunneled catheter into the right atrium through this later vein. Conclusion: We report the first successful use in Portugal of a new vascular access device that allows us to rescue a previous unusable right central venous axis for the placement of a central venous catheter, thus avoiding the use of less advantageous options such as the femoral veins and preserving venous vascular capital.

Introdução: O diagnóstico de hiperparatiroidismo primário pode ocorrer de forma incidental em fases assintomáticas ou surgir tardiamente em contexto de queixas inespecíficas e prolongadas. Descrição do caso: Doente de 32 anos, sexo feminino, sem antecedentes de relevo. Em fevereiro de 2012 sofre episódio de cólica renal severa, com necessidade de nefrostomia. A investigação complementar identificou litíase renal exuberante, com indicação para cateter duplo J preventivo. Em dezembro de 2012 sofre rutura do tendão do quadricípete após queda. Em março de 2013, nova queda por desequilíbrio com fratura do colo do úmero. Mantém queixas progressivas de lombalgias, dores ósseas, articulares e fraqueza muscular generalizadas, de características mecânicas, sem sinais inflamatórios, acabando por ficar dependente de cadeira de rodas em 2014. É referenciada ao hospital de referência por hipercalcemia grave e elevação da hormona paratiroideia (PTH 4300pg/ml). A ecografia cervical e cintigrafia das paratiroides confirmam suspeitas de hiperparatiroidismo primário por provável adenoma da paratiroide. Submetida a paratiroidectomia esquerda em maio de 2014, complicada por Síndroma do Osso Faminto, com evolução clínica e analítica favorável. Comentário: O caso clínico procura alertar para o hiperparatiroidismo primário como uma hipótese de diagnóstico possível perante um quadro de queixas osteoarticulares inespecífico e arrastado. O médico de família deve estar alerta para este diagnóstico, tendo em conta a prevalência destas queixas na prática clínica e a importância do diagnóstico precoce.

Introduction: The diagnosis of primary hyperparathyroidism may occur incidentally in asymptomatic phases or appear late in the context of nonspecific and prolonged complaints. Case report: We describe the case of a 32-year-old female without relevant previous medical history. In February 2012, she suffered an episode of severe renal colic, requiring nephrostomy. Further investigation identified exuberant renal lithiasis, with indication for a preventive double J catheter. In December 2012, the patient had a rupture of the quadriceps tendon due to a fall, and in March 2013, had a new fall due to imbalance with a resulting fracture of the humeral neck. The patient maintained progressive complaints of back pain, bone and joint pain and generalised muscle weakness, and eventually became wheelchair-dependent in 2014. The patient was referred to the hospital for severe hypercalcemia and raised parathyroid hormone (PTH 4300 pg/ml). Cervical ultrasound and parathyroid scintigraphy confirmed the clinical suspicion of primary hyperparathyroidism due to a parathyroid adenoma. Left parathyroidectomy was performed in May 2014, complicated with a Hungry-Bone syndrome. Clinical and analytical evolution was favorable. Comment: This clinical case seeks to alert to primary hyperparathyroidism as a differential diagnosis when facing non-specific and prolonged osteoarticular complaints. Due to the prevalence of these complaints in clinical practice and the importance of an early diagnosis, the family physician should be alert to this potential diagnosis.

A incidência da doença oncológica no nosso país nos últimos anos tem um aumento regular a uma taxa constante de aproximadamente 3% ao ano, à semelhança do que também se passa no resto da Europa. É fundamental diminuir os cancros evitáveis e os diagnósticos tardios. A prevenção e o diagnóstico precoce são as estratégias possíveis para atenuar o impacto da doença oncológica nas pessoas e nas famílias

In recent years, the incidence of oncological disease in our country has been increasing steadily at an annual rate of 3%, just as in most countries in Europe. It is essential to reduce avoidable cancers and late diagnoses. Prevention and early diagnosis are main possible strategies to mitigate the impact of oncological disease in individuals and families