Abstract Introduction: Varicella zoster virus primary infection during pregnancy is rare in Portugal as a result of the very high immunity rates of women of reproductive age. It is associated with higher risks of maternal complications, as well as significant fetal morbimortality, particularly if the mother acquires the infection during the first 20 weeks of gestation weeks or in the peripartum. Case description: We report a case of a 31-year-old pregnant Russian patient, G2P1, with pregnancy managed by her family doctor and an obstetrician. At 27 weeks of gestation, she had a walk-in appointment with her family doctor reporting significant contact with varicella. At the time, she did not have symptoms or significant changes at the physical examination. The patient had no previous history of chickenpox or shingles, and no record of varicella zoster virus immunization. She was referred to the obstetrics emergency department, where she was tested for varicella zoster virus serology. It was confirmed that the patient was not immune to the varicella-zoster virus and was offered immunoglobulin administration. She developed varicella at 29 weeks and two days of gestation, without associated maternal complications or ultrasound findings suggesting the development of fetal varicella syndrome. She delivered a healthy infant at 41 weeks and two days of gestation. Comments: This case report aims to emphasize the importance of primary care physicians’ knowledge on the guidance of pregnant women who report significant varicella contact and/or develop varicella. In addition, this report highlights the importance of varicella immunity assessment at preconception counselling and care appointments to identify and manage non-immune women.

Resumo Introdução: A varicela na gravidez é uma patologia pouco frequente em Portugal devido à alta taxa de imunidade da população em idade fértil. Associa-se a risco mais elevado de complicações maternas assim como a morbimortalidade fetal significativa, particularmente quando a infeção ocorre até às 20 semanas de gestação ou no período periparto. Descrição do caso: Mulher de 31 anos, natural da Rússia, grávida, 2G1P, vigiada na Unidade de Saúde Familiar e consulta de obstetrícia. Recorreu à consulta aberta da sua Unidade de Saúde Familiar às 27 semanas de gestação por contacto significativo com caso de varicela. Encontrava-se assintomática e não apresentava alterações ao exame objetivo. Desconhecia história prévia de varicela ou zona e não tinha registo de vacinação contra o vírus varicela zoster. Foi orientada para o serviço de urgên-cia de obstetrícia, onde colheu serologias. Foi confirmada ausência de imunidade para o vírus varicela zoster, pelo que realizou profilaxia com imunoglobulina. Desenvolveu varicela às 29 semanas e dois dias de gestação, não tendo sido registadas complicações maternas associadas à varicela ou detetados sinais ecográficos de síndroma de varicela fetal. A gravidez decorreu sem outras intercorrências e terminou às 41 semanas e dois dias de gestação. O recém-nascido não apresentava alterações sugestivas de síndroma de varicela fetal. Comentários: O caso clínico descrito pretende enfatizar a necessidade do conhecimento do médico de família da abordagem das grávidas com contacto com varicela ou que desenvolvam a doença. Para além disso, tem como objetivo alertar para a importância da avaliação do estado de imunidade em idade fértil para a identificação de mulheres potencialmente não imunes e a sua atempada orientação.

Abstract This case aims to highlight the importance of not neglecting anamnesis through pandemic times and to recognize the symptoms of a probable antidepressant withdrawal. A 41-year-old woman with a history of depressive syndrome and hyperthyroidism. Medicated daily with paroxetine 20 mg, bisoprolol 2.5 mg and thiamazole 5 mg. By self-initiative, she abruptly suspended paroxetine, which she was taking for 3 years. After 3 days, she presented with dizziness, dyspnea, tiredness, abdominal pain and diarrhea. Given the contact with SARS-CoV-2 infection cases in the workplace, a laboratory test for SARS-CoV-2 was requested and the result was negative. In TraceCOVID-19 surveillance, the patient reported the suspension of paroxetine and was indicated immediate resumption, with consequent total complaints regression. The case described mimics the clinic of a COVID-19 infection, thus emphasizing the complexity of diagnosing paroxetine withdrawal syndrome.

Resumo Este caso pretende realçar a importância de não descurar a anamnese em tempos de pandemia e a familiarização com os sintomas sugestivos de abstinência de antidepressivos. Mulher, 41 anos, com antecedentes de síndrome depressiva e hipertiroidismo. Medicada diariamente com paroxetina 20 mg, bisoprolol 2,5 mg e tiamazol 5 mg. Por autoiniciativa, suspendeu de forma abrupta a paroxetina, que cumpria há 3 anos. Passados 3 dias, iniciou quadro de tonturas, dispneia, cansaço, dor abdominal e diarreia. Dado o contexto de casos de infeção por SARS-CoV-2 no local de trabalho, foi pedido o teste laboratorial para SARS-CoV-2 cujo resultado foi negativo. No âmbito da vigilância TraceCOVID-19, a utente referiu a suspensão da paroxetina tendo tido indicação para retoma imediata, com consequente regressão total das queixas. O caso descrito mimetiza a clínica de uma infeção COVID-19, enfatizando, assim, a complexidade do diagnóstico da síndrome de abstinência de paroxetina.

ABSTRACT End stage kidney disease (ESKD) is a prevalent health issue across the world and it is well established that kidney transplantation (KT), specifically from a living donor, is currently the best value-based treatment method. Ergo, it is crucial to invest heavily in making this care strategy the best possible option for the majority of eligible patients. Barriers to the kidney transplant process are mainly related to education and accessibility: awareness of the clinical and societal relevance of the therapy must be promoted at the level of patients, clinicians and health providers. A health-literacy-focused website has been developed as part of this, aiming to provide the general population, particularly potential organ receptors and donors, with better access to trustworthy information and data. This was meant to be the effective expression of knowledge diffusion and innovation as a result of an academic master thesis. This communication-focused digital resource is designed to combat these obstacles and to create a long-lasting, positive and significant impact.

ABSTRACT In Portugal, as well as in Europe, peritoneal dialysis (PD) use remains low. Reorganization of PD units including a well‑structured peritoneal access management protocol are fundamental to improve the take‑up of this therapy. We analyzed the procedure and outcomes in a PD unit, addressing two key quality questions: at which level of estimated glomerular filtration rate (eGFR) were patients referred to peritoneal cateter placement and whether if it was timely placed. We retrospectively evaluated all patients submitted to catheter placement between 2017 and June 2020. We analyzed the patient journey from Kidney Replacement Therapies (KRT) Option Appointment, until PD start, as well as demographic and clinical variables, including eGFR at four time points (KRT Options Appointment, PD unit evaluation, catheter placement, and PD start). To explore the adequacy of cateter placement schedule, we compared the characteristics of the patients who started PD within 90 days of catheter placement (Early group), and of those who started after the first 90 days (Late group). We analyzed 48 patients in the Early and 27 in the Late group. The Early group presented a lower eGFR on KRT Options Appointment, with timely intervention: eGFR at catheter placement averaged 8.0 ± 2.1 mL/min/1,72m2. PD start occurred at 7.0 ± 1.9 and 8.0 ± 2.4 mL/min/1.72m2, in the Early and Late group, respectively. None of the patients suffered an urgent transition to HD by CVC. Four patients started PD less than 15 days after catheter placement, all of them without complications. PD patients’ admission involves specific tasks. Administrative tools or indicators to evaluate those processes are lacking. A peritoneal access clinic would allow the formalization of this circuit, allowing a quality and equitable approach to dialysis access. We suggest a structured pathway for peritoneal access management.

ABSTRACT Peritoneal dialysis (PD) relies on adequate function of PD catheter. Mechanical complications are a major cause of dropout among PD patients. A prompt timing and an appropriate intervention may overcome these problems with catheter salvage, without interrupting PD treatment. Many Portuguese centers still lack a proper articulation between nephrology and surgical departments. We describe current available surgical approaches in the implantation of PD catheters, management of mechanical complications, exit‑site infections and other abdominal surgical procedures. Our aim is to reinforce the need for an established protocol of action between these departments as occurs with vascular access in hemodialysis.

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.

Assistimos nas últimas décadas a uma crescente atenção sobre os idosos e os seus cuidadores, formais e informais. Com a organização das respostas, urge acompanhar os técnicos, as suas perceções e indicadores de satisfação, como stress e burnout podem dar indicações úteis para a melhoria das instituições. Existindo ainda escassos estudos sobre esta temática, o presente trabalho visa descrever e analisar a satisfação laboral e o burnout entre assistentes geriátricos, explorando, especificamente o papel de variáveis pessoais e profissionais. Foram recolhidos dados junto de uma amostra de 197 assistentes geriátricos de instituições no norte do País, com recurso a um questionário sociodemográfico, um questionário de satisfação no trabalho e o Oldenburg Burnout Inventory para avaliar o burnout. Dos resultados, destaca-se a maior satisfação com a formação profissional, com o local de trabalho e com os colegas, e menor satisfação com o salário e oportunidades de promoção laboral. No burnout, os valores encontram-se dentro da média teórica sendo superior a exaustão. Os dados permitem ainda perceber uma relação negativa entre o burnout e as habilitações literárias, e positiva entre a experiência profissional e a exaustão. Também na satisfação laboral, algumas dimensões apareceram relacionadas com as habilitações académicas e experiência profissional. A satisfação profissional apareceu como um preditor significativo do burnout, explicando 21,6% da exaustão e 34,8% do distanciamento. Entendendo a satisfação profissional como um indicador do funcionamento das instituições, os dados apresentados podem ser importantes para uma compreensão mais abrangente destas organizações e novas medidas para promover a sua qualidade.

Over the last decades e have witnessed increasing attention on the elderly and their caregivers, both formal and informal. With the organization of the institutions, it is imperative to follow the technicians, their perceptions and indicators of satisfaction, as stress and burnout can give useful indications for the improvement of institutions. Given the few studies on this subject, the present work aims to describe and analyse job satisfaction and burnout among geriatric assistants, specifically exploring the role of personal and professional variables. Data were collected from a sample of 197 geriatric assistants from institutions in the north of the country, using a sociodemographic questionnaire, a job satisfaction questionnaire and the Oldenburg Burnout Inventory to assess burnout. Among the results, we highlight the greater satisfaction with vocational training, with the workplace and with colleagues, and less satisfaction with salary and job promotion opportunities. In the burnout, the values are within the theoretical average being higher in exhaustion. The data also allow us to perceive a negative relationship between burnout and qualifications, and a positive relationship between professional experience and exhaustion. Also, in job satisfaction, some dimensions appeared related to academic qualifications and professional experience. Professional satisfaction appeared as a significant predictor of burnout, accounting for 21.6% of exhaustion and 34.8% of disengagement. Understanding professional satisfaction as an indicator of the functioning of institutions, the data presented may be important for a more comprehensive understanding of these organizations and new measures to promote their quality.

Chronic kidney disease (CKD) has a high clinical and socioeconomic impact and is often associated with multimorbidity. Improved treatment has allowed an increase in patient survival, but patient life expectancy remainslimited. The disease course has a continuum of lesion, stage and treatment transitions. The focus is often placed on treatment modality, disregarding the course of a CKD patient’s disease. In addition, patient management in transitions of modalities of renal replacement therapy (RRT) can also be a vector for improving clinical outcomes. The transition between different types of CKD treatment and the transition of care from paediatric to adult team are critical processes throughout the life of a CKD patient. In the therapeutic transition, there is the need to identify better predictors of success in allocating patients with stage 5 CKD to their first dialytic modality in. There is a risk of early mortality in the induction period of dialysis, particularly of the elderly in extracorporeal dialysis regimens. Doubt remains in decision making about the ideal timing to establish the transition to renal replacement therapy and its most appropriate type. Transfer between dialytic modalities also calls for opportune and integrated policies protecting vascular resources. Renal transplantation is considered the optimal renal replacement therapy; however, transplant failure or the side effects of immunosuppression are threats to consider, which may redirect these patients back to dialysis and involves a re-evaluation of the patient’s status. Also, end-of-life care and decision making between initiating renal replacement therapy or maintaining conservative management are a challenge in the elderly. This review identifies the main challenges in these transitional processes, raising awareness of areas in need of improvement in patient care. The aim should be to achieve a more comprehensive and appropriate health management than a limited focus on CKD modality treatment.

Introdução e Objetivos: A diálise peritoneal (DP) é uma técnica substitutiva da função renal (TSFR) com eficácia semelhante à hemodiálise (HD); no entanto, ainda permanece subutilizada em qualquer idade. Os médicos temem o elevado drop-out da técnica e a sua menor sobrevida, particularmente nos doentes idosos. Os autores pretenderam explorar causas de drop-out e sobrevida da técnica ao longo das últimas três décadas, em diferentes faixas etárias, centrando uma atenção particular no idoso. Métodos: Foram usados dados do registo prospetivo do programa hospitalar de doentes adultos incidentes em DP. Tendo em conta as diferentes épocas, os doentes foram divididos em 6 coortes (5 anos de intervalo) de acordo com o ano de admissão no programa (1985-2014). Usaram-se modelos de regressão tendo em conta a análise de riscos competitivos para identificar potenciais fatores de prognóstico para a morte e transferência para HD (ajustados para a idade, género, diabetes, era, tipo de técnica e primeira modalidade de TSFR). Posteriormente, os doentes foram estudados de acordo com a idade à admissão do programa: A (18-44 anos); B (45-64 anos); C (≥ 65 anos de idade). Foram avaliadas as taxas de transferência para HD usando a análise de Poisson. As taxas de incidência de drop-out foram comparadas em diferentes épocas e entre os grupos etários, focando particular atenção no doente idoso. Resultados: Foram avaliados 525 pacientes: 211 eram do sexo masculino (40,2%), com idade média de 48 ± 15,7 anos, com follow-up mediano de 23 meses (IQR 9-41,5). A maior causa de drop-out da técnica foi a transferência para HD (35,4%), seguida do transplante renal (27,6%) e de morte (21,7%). A probabilidade de falência técnica e transplantação renal aos 2 e aos 5 anos foi 19,2% e 18,1% e 34,2%; 27,4%, respetivamente. A probabilidade de morte aos 2 e aos 5 anos foi 12,7%, e 21,8%, respetivamente. A coorte mais recente associou-se a menor risco de mortalidade e menor transferência para HD. O modelo de regressão Fine & Gray mostrou que a idade avançada se associou a maior mortalidade, contudo não se associou a maior falência técnica. Nos idosos, a taxa de transferência para HD foi 11,2 episódios/100 doentes-ano (em comparação com 15 e 14 episódios/100 doentes-ano nos grupos A e B, respectivamente, p = 0,33). Não houve diferenças significativas nas causas de transferência para HD entre os diferentes grupos etários. As taxas de drop-out por falência de acessos e por falência de ultrafiltração diminuíram no grupo mais velho e na coorte mais recente, contudo as diferenças não foram estatisticamente significativas entre os grupos. Conclusões: O drop-out por falência técnica diminuiu significativamente na década mais recente. A idade de admissão na diálise peritoneal não mostrou ser um fator de comprometimento da sobrevida da técnica

Introduction and Aims: Peritoneal dialysis (PD) is an efficient renal replacement therapy (RRT), but still remains underutilized at any age. Clinicians fear the rate of dropouts and lower technique survival, particularly in elderly patients. The authors aimed to explore such outcomes over the past 3 decades, in different age and era cohorts. Methods: Consecutive incident patients starting PD were identified from an ongoing registry-base prospective study of quality assessment. In order to control for an era effect, patients were assigned to 6 cohorts (5 years interval) according to the admission year between 1985 and 2014. Regression models taking competing risks into account were performed to identify potential prognostic factors for death and transfer to haemodialysis (HD) (adjusted for age, gender, diabetes, cohort era, automated peritoneal dialysis (APD) use, and first treatment modality - PD first, PD after HD, PD after renal transplant (RT). Then the patients were studied according to age at enrolment in the programme: A (18-44 years; n = 193) ; B (45-64 years; n = 176); C (≥ 65 years old; n = 75). The HD transfer rates using Poisson analysis were evaluated. The incidence of dropout rates was compared at different timesand between age groups, focusing particular attention on the elderly. Results: A total of 525 patients were evaluated: 211 male (40.2%), aged 48 ± 15.7 years old, on PD for 23 (IQR 9 - 41.5) months. The major cause of dropout technique was transfer to HD (35.4%), followed by renal transplantation (27.6%)and death (21.7%). The probability of technical failure and renal transplantation at 2 and 5 years was19.2% and 18.1% and 34.2%; 27.4%, respectively. Probability of death at 2 and 5 years was 12.7%, and 21.8%, respectively. The contemporary cohort was associated with a lower risk of mortality and lower risk of transfer to haemodialysis, with greater access to renal transplantation. The regression model Fine & Gray showed that older age was associated with increased mortality, but was not associated with greater technical failure. Transfer to HD occurred in the elderly at a rate of 11epy/100 patient-year (in comparison to 15 and 14 epy/100 patient-year in non-elderly groups A and B, respectively P = 0.33). The proportions of specific causes of technique failure did not change significantly according to age cohort. The dropoutrates due to access-related-infection and ultrafiltration failure decreased in the elderly group in the morecontemporary cohort, despite the differences were not statistically significant. Conclusions: The dropoutby technique failure decreased significantly in the recent decade. Age at admission in peritoneal dialysisdid not show to be a compromising factor of the technique survival