Abstract Introduction: Kidney transplant (KT) recipients have a high risk for adverse outcomes from infections, such as COVID-19. Methods: We have retrospectively reviewed all KT recipients with documented COVID-19 between March 1, 2020, and March 15, 2021, and analyzed patients’ characteristics, clinical course, treatment, and outcomes. Results: We identified 123 patients, 72% were male, with a mean age of 54.5±13.0 years. Twenty percent were asymptomatic, 7% had a nosocomial transmission, and 36% of the remainder required hospitalization. Almost all admitted patients received oxygen, 30% required invasive mechanical ventilation (IMV), more than a half had acute kidney injury, with 10% requiring dialysis, and 20% died. Incidence was comparable to that of the Portuguese population, but the mortality rate was almost four times higher (SMR of 3.768 (95% CI:1.723-7.154). Higher body mass index (OR 1.275, P=0.001), lower baseline graft function (OR 0.968, P=0.015), and nosocomial transmission (OR 13.836, P=0.019) were associated with oxygen demand, whereas female gender (OR 3.801, P=0.031) and lower baseline kidney graft function (OR 0.955, P=0.005), but not body mass index, were associated with IMV and/or death. Conclusion: Mortality rate in KT patients was higher than in the general population and lower baseline kidney function was the most consistent marker for adverse outcomes.

Resumo Introdução: Os receptores de transplante renal (TR) apresentam um alto risco para desfechos adversos de infecções, tais como a COVID-19. Métodos: Revisamos retrospectivamente todos os receptores de TR com COVID-19 documentada entre 1º de Março de 2020 e 15 de Março de 2021, e analisamos as características, curso clínico, tratamento e desfechos dos pacientes. Resultados: Identificamos 123 pacientes, 72% do sexo masculino, com uma média de idade de 54,5±13,0 anos. Vinte por cento eram assintomáticos, 7% apresentaram transmissão nosocomial, e 36% do restante necessitaram de internação. Quase todos os pacientes internados receberam oxigênio, 30% necessitaram de ventilação mecânica invasiva (VMI), mais da metade apresentou lesão renal aguda, com 10% necessitando de diálise, e 20% foram a óbito. A incidência foi comparável à da população portuguesa, mas a taxa de mortalidade foi quase quatro vezes superior (TMP de 3,768 (IC 95%: 1,723-7,154). Maior índice de massa corporal (OR 1,275; P=0,001), menor função do enxerto basal (OR 0,968; P=0,015), e transmissão nosocomial (OR 13,836; P=0,019) foram associados à demanda de oxigênio, enquanto sexo feminino (OR 3,801; P=0,031) e menor função do enxerto renal basal (OR 0,955; P=0,005), mas não índice de massa corporal, foram associados à VMI e/ou óbito. Conclusão: A taxa de mortalidade em pacientes com TR foi mais elevada do que na população em geral e a função renal basal mais baixa foi o marcador mais consistente para desfechos adversos.

Abstract Introduction: Potassium (K+) is the main intracellular cation and is crucial for normal cellular function, especially during children’s development and growth course. Changes in the homeostatic mechanisms of potassium regulation can lead to hypokalemia or hyperkalemia. Objective: This study aimed to provide a narrative review of this common, yet complex, condition of the clinical practice. Development/Conclusion: A comprehensive knowledge of the physiology of potassium metabolism is required to diagnose and treat its disturbances. Nearly 98% of potassium is intracellular, with the concentration gradient maintained by the sodium (Na+)/K+ ATPase pump located in the plasma membrane of cells. Several mechanisms, as β-adrenergic tone, insulin, and acid-base status, interfere with potassium intracellular distribution, but it is the kidney that has the key role in determining the total body potassium content, as it is responsible for approximately 80% of its excretion. The causes of hypokalemia are a mirror of hyperkalemia. Although these are two different entities, both require prompt intervention. The rate of correction depends on the severity of symptoms, presence of changes in electrocardiogram, and time of development of the disorder.

Resumo Introdução: O potássio (K+) é o principal catião intracelular, sendo um elemento essencial para o normal funcionamento das células, especialmente em crianças, que se encontram numa fase de desenvolvimento e crescimento. Alterações nos mecanismos fisiológicos que regulam a homeostasia do potássio podem levar a hipocalémia ou hipercalémia. Objetivo: Este estudo pretendeu efetuar uma revisão narrativa deste tema tão comum mas complexo da prática clínica. Desenvolvimento/Conclusão: O reconhecimento da fisiopatologia subjacente ao metabolismo do potássio é essencial para estabelecer o diagnóstico e tratar os seus distúrbios. A enzima sódio (Na+)/K+-ATPase, localizada na membrana celular, é a principal responsável pela manutenção do potássio dentro das células. Vários mecanismos interferem com a distribuição intracelular de potássio, nomeadamente a atividade β-adrenérgica, a insulina e o equilíbrio ácido-base, mas é o rim que tem o principal papel na determinação da quantidade corporal total de potássio, sendo responsável por aproximadamente 80% da sua excreção. As causas de hipocalémia são um espelho das causas de hipercalémia e, embora sejam entidades opostas, ambas requerem intervenção imediata. A rapidez da correção depende da gravidade dos sintomas, das alterações eletrocardiográficas e do tempo de instalação do distúrbio.

Resumo Introdução: a síndrome de Bartter inclui um grupo heterogéneo de tubulopatias hereditárias perdedoras de sal. Existem duas formas de apresentação clínica: clássica e neonatal, a forma mais grave. Os tipo I e II representam a maioria dos casos neonatais. Os tipos III e V são geralmente menos graves. Caracteristicamente, a síndrome de Bartter tipo IV é uma nefropatia perdedora de sal com sintomas neonatais ligeiros a graves, com um aspeto especí- fico - surdez neurossensorial. A síndrome de Bartter tipo IV é o tipo menos comum das formas recessivas da doença. Descrição: relatamos o primeiro caso de uma criança portuguesa, com surdez neurossensorial, poliúria, polidipsia e restrição de crescimento, nascida prematuramente devido a polihidrâmnios grave, homozigótica para a mutação G47R do gene BSND, responsável pela síndrome de Bartter tipo IV. Discussão: são raros os casos publicados sobre síndrome de Bartter tipo IV atribuída a esta mutação, e a maioria referem-se a diagnósticos mais tardios, com manifestações clínicas ligeiras. A fraca correlação fenótipo-genótipo combinada com a raridade desta síndrome tornam o diagnóstico pré-natal desafiante. Perante um caso de polihidrâmnios grave em um feto sem malformações aparentes, cariótipo normal e após exclusão de patologia materna, as doenças autossómicas recessivas, incluindo as tubulopatias, devem ser sempre consideradas.

Abstract Introduction: Bartter’s syndrome comprises a heterogeneous group of inherited salt-losing tubulopathies. There are two forms of clinical presentation: classical and neonatal, the most severe type. Types I and II account for most of the neonatal cases. Types III and V are usually less severe. Characteristically Bartter’s syndrome type IV is a saltlosing nephropathy with mild to severe neonatal symptoms, with a specific feature - sensorineural deafness. Bartter’s syndrome type IV is the least common of all recessive types of the disease. Description: the first reported case of a Portuguese child with neurosensorial deafness, polyuria, polydipsia and failure to thrive, born prematurely due to severe polyhydramnios, with the G47R mutation in the BSND gene that causes Bartter’s syndrome type IV. Discussion: there are few published cases of BS type IV due to this mutation and those reported mostly have moderate clinical manifestations which begin later in life. The poor phenotype-genotype relationship combined with the rarity of this syndrome usually precludes an antenatal diagnosis. In the presence of a severe polyhydramnios case, with no fetal malformation detected, normal karyotype and after maternal disease exclusion, autosomal recessive diseases, including tubulopathies, should always be suspected.

RESUMO Introdução: A taxa estimada de filtração glomerular (TFGe) com base na cistatina-C sérica (Cis-C) parece ser tão precisa quanto aquela baseada na creatinina sérica (Cr), mas cis-C parece ser um melhor preditor de resultados adversos. Nosso objetivo foi avaliar se a cis-C poderia ser uma ferramenta confiável para a previsão de desfechos adversos em pacientes idosos com doença renal crônica grave (DRC). Métodos: Um grupo de 348 pacientes idosos com DRC em estágio não terminal (estágios 1-4, de acordo com TFGe-EPI Cr e/ou Cis-C), encaminhados para nossa unidade de consulta durante 2016, foi estudado retrospectivamente e dividido em quatro categorias exclusivas: DRC_estágio 4 nenhum (TFGe-Cr≥30mL/min; TFGe -Cis-C≥30mL/min), DRC_estágio 4_Cr apenas (TFGe-Cr <30mL/min), DRC_estágio 4 _Cis-C_apenas (TFGe-Cis-C <30 mL/min), DRC_estágio4_combinado (TFGe-Cis-C <30mL/min. TFGe-Cr <30mL/min). Características basais, preditores de óbito e eventos clínicos (eventos cardiovasculares e internações por doenças cardiovasculares, lesão renal aguda ou eventos infecciosos) foram explorados até dezembro de 2018. Resultados: Uma coorte de 77 ± 7,4 anos, com índice de comorbidade de Charlson modificado (mCCI) de 3 (IQR: 1-4), foi acompanhada durante 29 (IQR: 26-33) meses. Não houve diferenças significativas entre as características dos grupos no estágio 4. A análise de sobrevida foi estratificada pelo acompanhamento aos 12 meses, sendo que no primeiro ano, as curvas de sobrevida dos grupos DRC_estágio4_Cis-C_apenas e DRC_estágio4_ combinado foram significativamente inferiores quando comparadas com os restantes grupos (p = 0,028). Ajustando para idade, sexo e mCCI, DRC_estágio4_Cis-C_apenas, ao contrário do grupo DRC_estágio4_Cr_apenas, teve maiores taxas de eventos clínicos (p <0,05) do que o grupo DRC_estágio4_nenhum. Conclusão: Em pacientes idosos com estadiamento discordante da DRC, a TFGe baseada na Cis-C parece ser um melhor preditor de resultados adversos do que a TFGe baseada na Cr. Pacientes com DRC em estágio 4, definida apenas por Cr, parecem se comportar de forma semelhante àqueles com DRC menos grave.

ABSTRACT Introduction: Estimated glomerular filtration rate (eGFR) based on serum cystatin-C (sCys) seems as accurate as when based on serum creatinine (sCr), but sCys seems a better predictor of adverse outcomes. We aimed to study whether sCys could be a reliable tool for the prediction of adverse outcomes in elderly patients with severe chronic kidney disease (CKD). Methods: A group of 348 elderly patients with non-end-stage CKD (stages 1-4, according to eGFR-EPI sCr and/or sCys), referred to our consultation unit during 2016, was retrospectively studied and divided into four exclusive categories: CKD_stage4_neither (eGFR-sCr≥30mL/min; eGFR-sCys≥30mL/min), CKD_stage4_sCr_only (eGFR-sCr<30mL/min), CKD_stage4_sCys_only (eGFR-sCys<30mL/min) and CKD_stage4_combined (eGFRsCr<30mL/min; eGFR-sCys<30mL/min). Baseline characteristics, predictors of death, and clinical events (cardiovascular events and admissions for cardiovascular, acute kidney injury or infectious events) were explored until December 2018. Results: A 77±7.4 year-old cohort, with a modified Charlson Comorbidty Index (mCCI) of 3 (IQR:1-4), was followed-up during 29 (IQR: 26-33) months. There were no significant differences between the characteristics of the stage 4 groups. Survival analysis was stratified by follow-up at 12 months, and in the first year, survival curves of CKD_stage4_sCys_only and CKD_stage4_combined groups were significantly lower than the other groups (p=0.028). Adjusting for age, sex, and mCCI, CKD_stage4_sCys_only, conversely to CKD_stage4_sCr_only, had higher rates of clinical events (p<0.05) than CKD_stage4_neither group. Conclusion: In elderly patients with discordant CKD staging, sCys-based eGFR seems to be a better predictor of adverse outcomes than sCr-based eGFR. Patients with stage 4 CKD defined by sCr alone seem to behave similar to those with less severe CKD.

ABSTRACT Introduction: Ammonia is a resultant molecule from the protein metabolism that can be neurotoxic when present in high concentrations, causing brain edema and encephalopathy. Extracorporeal blood purification technique (EBPT) can play a role in reducing both ammonia and urea blood levels. However, there are no specific guidelines for its use in hyperammonemia, due to its low incidence and scarce literature on this subject, particularly in adults. Case report: The authors describe a case of a 22‑year‑old previously healthy woman. She presented with polyuria, polydipsia, anorexia, vomiting and significant (>10%) weight loss over a month. Laboratory data revealed hypoglycemia and a high anion gap metabolic acidosis with severe acidemia with normal lactate, serum creatinine of 1.12 mg/dl and 260 (reference value 26‑74)umol/l of ammonia. Urine analysis showed ketone bodies. She evolved with progressive encephalopathy and neurological deterioration. The hypothesis of hyperammonemic encephalopathy secondary to a hereditary metabolic disease was suspected. Medical supportive therapy was initiated. An EBPT for ammonia removal and acid‑base correction was initiated using continuous venovenous hemodiafiltration (CVVHDF) with a drastic neurologic improvement. A fatty acid beta‑oxidation deficit was discovered. The patient was discharged with no neurological changes, with a strict diet free of fat, animal protein and high‑protein vegetables, plus supplementation with benzoate, carnitine, riboflavin, maltodextrine and essential amino acids. Discussion and conclusion: In adults, hyperammonemia related to metabolic disorders is rare, and in the presence of encephalopathy, ECDT should be considered. Ammonia is easily dialysable either by intermittent or continuous techniques. CVVHDF provides a continuous clearance with less rebound effect.

Incremental dialysis is increasingly recognized as a safe and beneficial method of initiating dialysis. Different centers use distinct prescription methods. We discuss the advantages of incremental hemodialysis and the potential benefit of preserving residual renal function as we present our experience. We reviewed the data from 20 incident patients, with a mean follow-up of 9.5 months, who started dialysis with our prescription method, using hemofiltration as the preferred depurative technique. All patients tolerated treatment well; no major complications were reported. Dialysis adequacy targets were achieved. While data are clearly limited, we raise the hypothesis that convective techniques could bring additional benefit in preserving residual renal function in incident patients, and that this strategy should be studied and compared with others.

Background: In December 2019, a new form of coronavirus was identified (COVID-19) and quickly became a worldwide pandemic. Previous data reported a more severe disease in older patients, with high comorbidities, which are common features in hemodialysis patients. Scarce data is available about the clinical presentation and outcomes in this population. For this reason, we aim to report the characteristics of COVID-19 disease in hemodialysis patients admitted to our center. Methods: We retrospectively reviewed all patients on chronic hemodialysis admitted with a laboratory-confirmed COVID-19 infection from March 2nd to May 20th of 2020. Baseline characteristics, clinical, laboratory and radiological presentation were registered and treatment and outcomes Results: Fourteen patients were included, 57% female, with a median age of 81 years old and a high number of comorbidities. Cough and fever were the most common symptoms and lymphocytopenia, increased inflammatory parameters and coagulation dysregulation were frequently registered. Ground-glass opacities were present in each thorax computerized tomography performed. Five patients developed respiratory insufficiency, but none needed invasive ventilation or ICU admission. In a significant proportion, discharge was postponed due to the impossibility of ensuring social isolation. Median viral shedding was 38 days. Discussion and conclusion: Hemodialysis patients who required hospitalization were very old and had multiple comorbidities. Even so, the impaired immune response of this population seems to cause a less severe course of the disease and a longer time of viral shedding. HD units have required a reformulation of their circuits in order to avoid disease spreading.

Background: Many patients with end-stage renal disease start renal replacement therapy in an unplanned manner. The vast majority initiate hemodialysis by a central venous catheter, since its use is more widespread and available. This technique is associated with a high risk of infection and damage of the vascular patrimony associated with the use of central veins. Urgent-start peritoneal dialysis comes as an alternative treatment for selected patients. Case report: A 55-year-old woman with focal segmental glomerulosclerosis presented with a rapid decline of renal function and was given renal replacement therapy counselling and opted for peritoneal dialysis. Her chosen modality was postponed for one month due to early uremic symptoms, followed by hemodialysis start through a central venous catheter. During this period a sepsis due to central venous catheter infection occurred, implying four weeks of intravenous antibiotics. Discussion and Conclusion: Although there has been an increase in the number of publications on urgent-start peritoneal dialysis, showing that this technique has comparable results either to urgent-start hemodialysis and planned-start peritoneal dialysis, there still is some resistance to the use of this modality. Given the importance of this subject, this review aims to describe and summarize the available evidence on urgent-start peritoneal dialysis outcomes. Moreover, specific barriers are addressed. Its use is encouraged in hospitals where peritoneal dialysis is available, as an opportunity to improve chronic kidney disease patient management and transition to dialysis.

RESUMO Introdução: Tem sido sugerido que os níveis de cistatina C são modificados pela obesidade e inflamação. Além disso, a cistatina C tem sido associada a eventos cardiovasculares e desfechos de mortalidade. Objetivo: Estudar a associação da cistatina C com o perfil metabólico e doença cardiovascular de pacientes em diálise peritoneal. Métodos: Os dados coletados incluíram avaliação clínica, laboratorial e de bioimpedância múltipla de 52 pacientes estáveis em diálise peritoneal. A função renal residual mínima foi definida como > 2mL/min/1,73m2. Resultados: A cistatina C sérica não esteve significativamente associada à excreção peritoneal ou urinária. A correlação negativa da cistatina C com a taxa catabólica protéica normalizada (rho -0,33, p = 0,02) e uma tendência de correlação positiva com a gordura corporal relativa (rho 0,27, p = 0,05) não foram independentes da função renal residual. A cistatina C não se associou significativamente à doença cardiovascular (p = 0,28), nem com hemoglobina glicada (p = 0,19) ou proteína C reativa (p = 0,56). No modelo multivariado, idade e diabetes foram os mais fortes preditores de doença cardiovascular (razões de probabilidade 1,09, p = 0,029 e 29,95, p = 0,016, respectivamente) enquanto a gordura corporal relativa se associou negativamente à doença cardiovascular (p = 0,038). A cistatina C não se associou significativamente com doença cardiovascular (p = 0,096), tampouco a função residual mínima (p = 0,756). Conclusão: Neste grupo de pacientes em diálise peritoneal, a cistatina C não se correlacionou com o estado metabólico ou inflamatório, nem com doença cardiovascular, após ajuste para função renal residual.

ABSTRACT Introduction: It has been suggested that cystatin C levels are modified by obesity and inflammation. Furthermore, cystatin C has been associated with cardiovascular events and mortality outcomes. Aim: To study the association of cystatin C with the metabolic profile and cardiovascular disease of peritoneal dialysis patients. Methods: Data collected included clinical, laboratorial, and multifrequency bioimpedance assessment of 52 stable peritoneal dialysis patients. Minimal residual renal function was defined as > 2mL/min/1.73m2. Results: Serum cystatin C was not significantly associated with peritoneal or urinary cystatin C excretion. Negative correlation of cystatin C with normalized protein catabolic rate (rho -0.33, p = 0.02) and a trend towards positive correlation with relative body fat (rho 0.27, p = 0.05) were not independent from residual renal function. Cystatin C was not significantly associated with cardiovascular disease (p = 0.28), nor with glycated hemoglobin (p = 0.19) or c-reactive protein (p = 0.56). In the multivariate model, both age and diabetes were the strongest predictors of cardiovascular disease (odds ratio 1.09, p = 0.029 and odds ratio 29.95, p = 0.016, respectively), while relative body fat was negatively associated with cardiovascular disease (p = 0.038); neither cystatin C (p = 0.096) nor minimal residual renal function (p = 0.756) reached a significant association with cardiovascular disease. Conclusions: In this group of peritoneal dialysis patients, cystatin C did not correlate with the metabolic or inflammatory status, nor cardiovascular disease, after adjustment for residual renal function.

Introduction: Vascular access (VA) for hemodialysis (HD) is the lifeline for End Stage Renal Disease (ESRD) patients. Long-term HD patients often have exhaustion of their venous patrimony for an autologous VA construction and, sometimes, even for a central venous catheter (CVC) placement. Case report: We describe the case of a 43-year-old woman with ESRD due to lupus nephritis, on maintenance HD since 2009. She also had secondary antiphospholipid syndrome and was chronically anticoagulated. Nevertheless, the patient had multiorgan thrombotic events (without sequelae) and several episodes of irreversible thrombosis of arteriovenous fistulas. Her HD course was also marked by multiple severe CVC infections, at different locations; a hemoperitoneum during cholecystectomy, and an immediate thrombosis of the renal artery of a kidney transplant. She was admitted to our hospital after an irreversible dysfunction of a right jugular CVC, with documentation of thrombosis of the superior and inferior vena cava. Exhaustion of the venous patrimony for HD was assumed and it was decided to make an arterio-arterial graft (AAG) of early cannulation. The first cannulation of the AAG was performed two days after surgical intervention, with no complications. The patient performed a twelve hour per week HD treatment with good efficiency. Conclusion: AAG is an alternative for HD patients who have exhausted all their venous patrimony and it can be considered prior to the placement of a CVC as their sole remaining vascular access.

Objetivos: Caracterizar os principais motivos para requisição de tomografia computorizada (TC) da coluna lombar na Unidade Local de Saúde (ULS), ao nível dos cuidados de saúde primários (CSP), e intervir de forma a melhorar a qualidade da sua prescrição. Tipo de estudo: Quasi-experimental, pré pós-intervenção. Local: Seis unidades funcionais (UF) da ULS. População: Quarenta e nove médicos especialistas de medicina geral e familiar (MGF). Métodos: Foram analisadas todas as requisições de TC da coluna lombar efetuadas entre 1 de outubro de 2014 e 31 de março de 2015, relativamente ao número de requisições e informação clínica acompanhante, a qual permitiu a classificação de «aceitável» ou «não aceitável» com base na evidência bibliográfica e no protocolo de articulação entre o Agrupamento de Centros de Saúde (ACeS) e o serviço de ortopedia. Em setembro de 2015 foi realizada uma intervenção clínica com a apresentação dos resultados obtidos e a divulgação do protocolo. Globalmente foi acordado um aumento de 20% das requisições «aceitáveis». Foram analisados os pedidos de TC efetuados posteriormente - entre 1 de outubro de 2015 e 31 de março de 2016; a eficácia da intervenção traduzir-se-ia numa diminuição do número absoluto de requisições e num aumento da proporção daquelas classificadas como «aceitáveis». Resultados: Após a intervenção verificou-se uma redução em 39,5% de TC requisitadas (de 387 para 234) e um aumento estatisticamente significativo da proporção de requisições classificadas como «aceitáveis» (de 7,7% para 15,2%, p=0,0091). Contudo, apesar deste aumento, a proporção de requisições consideradas «não aceitáveis» manteve-se elevada (84,8%). Conclusão: A escassez/ininteligibilidade da informação clínica poderá ter levado à subestimação do número de requisições «aceitáveis». Apesar dos resultados favoráveis será necessária uma nova intervenção no sentido de uma redução mais expressiva e sustentada de requisições «não aceitáveis».

Aim: To characterize the main reasons for requesting lumbar spine computed tomography (CT) scans at primary care units wi-thin a Local Health Unit (ULS), and to intervene in order to improve the quality of such requests. Type of study: Quasi-experimental, pre- post assessment. Local: Six Functional Units (UF) of ULS. Population: Forty-nine family physicians. Methods: All the lumbar spine CT scans performed between October 1, 2014 and March 31, 2015 were reviewed regarding the number of requests and clinical information, which allowed their classification as “acceptable” or “not acceptable”, accordingly to the current scientific evidence, and to the protocol between ACeS and orthopedics department of ULS. In September 2015, a clinical education session was carried out at each of the participating units, where the results were presented and the protocol disseminated. A 20% increase in the number of ‘acceptable' request was agreed. A second assessment was performed evaluating the CT scans requested by the same family physicians between October 1, 2015 and March 31, 2016. Efficacy of the intervention was defined as a decrease in the absolute number of CT scan requests, and the increase of the proportion of ‘acceptable' requests. Results: After the intervention, a 39.5% reduction in the overall number of CT scans requested was observed (387 vs 234), and a statistically significant increase in the number of requests classified as ‘acceptable' (7.7% vs 15.2%, p=0.0091). However, despite this increase, the proportion of requests classified as ‘not acceptable' remained high (84.8%). Conclusion: The scarcity/unintelligibility of clinical information may have led to the underestimation of the number of ‘acceptable' requests. In spite of the favorable outcomes, a new intervention will be necessary for a more significant and sustained reduction of the proportion of ‘not unacceptable' requests.

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.

O carcinoma de células em anel de sinete é uma forma rara de adenocarcinoma que afeta predominantemente o estômago. A forma primária do íleon é muito rara e apresenta mau prognóstico. Apresentamos um caso de doença de Crohn do íleon cuja forma de apresentação cursou com quadro oclusivo associado a adenocarcinoma de células em anel de sinete do íleon. A doente apresentava história prévia de diarreia crónica e tinha história familiar de doença inflamatória. Foi submetida a ressecção cirúrgica e os achados histopatológicos revelaram a presença de aspetos compatíveis com doença de Crohn do íleon e adenocarcinoma de células em anel de sinete. Foi proposta uma associação com esta forma rara de tumor e inflamação de longa duração, contudo, não existem recomendações estabelecidas de vigilância de neoplasia na doença inflamatória intestinal com atingimento ileal.

Signet ring cell carcinoma is a rare form of adenocarcinoma that predominantly affects the stomach. Signet ring cell carcinoma originated from the ileum is extremely rare and the prognosis is poor. We present a case of small bowel obstruction with features suggesting Crohn disease of the ileum. The symptoms were chronic diarrhea and abdominal pain with a family history of inflammatory bowel disease. The patient underwent surgery and histopathology revealed both aspects of signet ring cell carcinoma and Crohn disease of the ileum. An association between long-standing inflammation and the development of this subtype of tumor has been proposed but there are no established surveillance guidelines for small bowel neoplasm in inflammatory bowel disease.

Resumo Introdução: O maior interesse por tratamentos minimamente invasivos, como os fios de sustentação, com menor risco de complicações, mínimo tempo de afastamento das atividades laborais e eficazes em corrigir a ptose e as rítides características do envelhecimento fez muitos especialistas adotarem essa técnica, porém muitas dúvidas sobre sua segurança e eficácia limitam sua adoção de forma geral. Objetivo: Analisar dados publicados na literatura sobre longevidade dos resultados, sua eficácia, segurança e seu risco de eventos adversos graves associados aos procedimentos com vários tipos de sutura. Método: Revisão de literatura com as palavras-chave thread lift, barbed suture, suture suspension e Aptos. Devido à escassez de literatura, foram também selecionados relatos recentes de rejuvenescimento facial com uso de fios, complementados com trabalhos das referências bibliográficas. Resultado: Os primeiros resultados da suspensão facial com fios com garras permanecem inconclusivos. Os eventos adversos podem ocorrer, embora em sua maioria sejam pequenos, autolimitados e de curta duração. Os dados sobre o efeito máximo da correção, a longevidade dos resultados e as consequências da permanência dos fios em longo prazo não são claros. Conclusão: O interesse pelo lifting com fios está em alta no momento, mas esta revisão sugere que ele não deve ser apresentado como opção a uma ritidoplastia.

Abstract Introduction: The increased interest in minimally-invasive treatments, such as the thread lifting, with lower risk of complications, minimum length of time away from work and effectiveness in correcting ptosis and aging characteristics has led many specialists to adopt this technique, but many doubts about its safety and effectiveness still limit its overall use. Objective: To analyze data published in the literature on the durability of results, their effectiveness, safety, and risk of serious adverse events associated with procedures using several types of threading sutures. Methods: Literature review using the key words "thread lift", "barbed suture", "suture suspension" and "APTOS". Due to the scarcity of literature, recent reports of facial lifting using threads were also selected, complemented with bibliographical references. Result: The first outcomes of facial lifting with barbed sutures remain inconclusive. Adverse events may occur, although they are mostly minor, self-limiting, and short-lived. The data on the maximum effect of the correction, the durability of results, and the consequences of the long-term suture stay are yet to be clarified. Conclusion: Interest in thread lifting is currently high, but this review suggests that it should not yet be adopted as an alternative to rhytidectomy.

Avaliar o conhecimento dos cuidados paliativos entre anestesiologistas por meio de questionário individual. A amostra teve 95 profissionais, dos quais 65 do sexo masculino e 30 do feminino. Sessenta e dois anestesiologistas informam que "qualidade de vida" é o termo que melhor expressa os cuidados paliativos e 53 consideram a combinação da assistência casa/hospital a mais conveniente para o atendimento do paciente que requer esses cuidados. Observou-se que 83,2% dos pesquisados (n=79) não receberam preparação para lidar com paciente que requer cuidados paliativos e 88,4% comentam com colegas quando um paciente morre (n=84). A maioria dos entrevistados (n=46) discorda da prática de eutanásia. Quanto à autopercepção do conhecimento sobre cuidados paliativos, numa escala de 0 (nenhum conhecimento) a 10 (conhecimento total), a maioria das respostas alcançou média 5 (n=28), o que mostra a necessidade da reflexão acerca do cuidar na área da anestesiologia.

To assess anesthesiologists' knowledge about palliative care through an individual questionnaire. The sample was 95, with 65 male and 30 female. Sixty-two of the anesthesiologists reported quality of life as the term that best expresses the palliative care, and 53 consider the combination of home care/ hospital the most convenient for the treatment of a patient who requires palliative care. It was observed that 83.2% of the interviewed (n = 79) have not been prepared for patients who require palliative care and that 88.4% mention to a colleague when a patient dies (n = 84). Most respondents (n = 46) disagreed with the practice of euthanasia. As for the perception of palliative care on a scale of 0 (no knowledge) to 10 (full knowledge), there was a majority of the average response of 5 (n = 28). It shows the need to reflect about care in the filed of anesthesiology.

Evaluar el conocimiento de los cuidados paliativos entre los anestesiólogos a través de un cuestionario individual. La muestra fue de 95, de los cuales 65 eran del sexo masculino y 30 del femenino. Sesenta y dos de los anestesiólogos informan "la calidad de vida" como el término que mejor expresa los cuidados paliativos y 53 consideran que la combinación de cuidado en el hogar / hospital es más conveniente para el cuidado del paciente que lo requiere. Se observó que el 83,2% de los investigadores (n = 79) no recibieron la preparación para lidiar con el paciente que requiere cuidados paliativos y el 88,4% comentan con sus compañeros cuando un paciente muere (n = 84). La mayoría de los encuestados (n = 46) no estaban de acuerdo con la práctica de la eutanasia. En cuanto a la autopercepción del conocimiento sobre los cuidados paliativos, en una escala de 0 (ningún conocimiento) a 10 (pleno conocimiento), la mayoría de las respuestas alcanzó el promedio de 5 (n = 28). Esto demuestra la necesidad de reflexión acerca del cuidar en el área de anestesiología.