Luiz Miguel Santiago

Prevalence of multimorbidity in the adult population attending primary care in Portugal: a cross-sectional study

Objectives To determine the prevalence of multimorbidity in the adult population attending primary care in Portugal, to identify associated sociodemographic factors, and to reveal combinations of chronic health problems. Design Cross-sectional, analytical study. Setting Primary Care Centres in mainland Portugal across the five Portuguese Healthcare Administrative Regions. Participants 1279 women and 714 men agreed to participate. The mean age was 56.3 years (59.0 years for men; 54.8 years for women). The most frequent marital status was married/cohabiting (69.5%). The most predominant living arrangement was living as a couple (57.2%). A considerable proportion consisted of pensioners/retirees (41.5%) and adults with a low educational level (48.7%). Sufficient monthly income was reported in 54.4% of the cases. Primary outcome measures For each patient, multimorbidity was measured either by the presence of ≥2 or ≥3 chronic health problems, from a list of 147 chronic health problems. Clinical data were collected using the general practitioners knowledge of the patients history, patients self-report and medical records. Cluster analyses were performed to reveal distinct patterns of multimorbidity. Secondary outcome measures Patient social and demographic data (sex, age, residence area, current marital status, number of years of formal education, living arrangements, professional status and self-perceived economic status). Logistic regression analyses were performed to determine the association between sociodemographic factors and multimorbidity. Results Multimorbidity (2 or more chronic health problems) was present in 72.7%. When a cut-off of three or more was used, an expressive percentage of multimorbidity (57.2%) remained present. The likelihood of having multimorbidity increased significantly with age. Pensioners/retirees and adults with low levels of education were significantly more likely to suffer from multimorbidity. Cardiometabolic and mental disorders were the most common chronic health problems. Six multimorbidity clusters have been identified. Conclusions Multimorbidity was found to be a common occurrence in the Portuguese primary care users. Future primary healthcare policies should take multimorbidity into consideration.

Multimorbidity in primary care in Portugal (MM-PT): a cross-sectional three-phase observational study protocol

Introduction Multimorbidity is defined as the co-occurrence of more than one chronic disease in one person without assigning an index disease. This rapidly increasing phenomenon markedly influences patients’ overall health, has major implications for effective provision of healthcare services and has a significant economic toll on individuals and society. Since Portugal is a country with a growing ageing population, a better understanding of the role of multimorbidity should be assessed. The aim of this study is to further the knowledge of the epidemiological factors associated with multimorbidity in Portugal, chiefly its prevalence and the health and social implications. Methods and analysis This study protocol describes a primary care nationwide three-phase study. The first phase is drawn to access the prevalence and patterns of multimorbidity. In the second phase, individual parameters are assessed, such as patients’ health-related quality of life, perceived family support and unmet health needs of patients with multimorbidity. The third and last phase of this study aims to characterise general practitioners’ knowledge, awareness and practices related to multimorbidity management. Ethics and dissemination The study will be conducted in accordance with the principles expressed in the Declaration of Helsinki. It has full approval from the Ethics Committee of the Faculty of Health Sciences, University of Beira Interior, and the Ethics Committee of the Central Health Region of Portugal. Study results will be published in peer-reviewed journals and presented at national and international conferences.

Epidemiology of injuries in senior male rugby union sevens: a systematic review

ABSTRACT Objectives: In 2016 the Rugby Union variant of sevens will enter the official Olympic Programme. Until now, most of injury surveillance studies in Rugby Union focus on elite 15-a-side cohorts, with reported injury incidence rates reaching 96 per 1000 player-match-hours, and mean severity set at 20 days. Sparse data is available regarding rugby sevens. The aim of this study was to systematically review available data regarding the epidemiology of injuries in senior male rugby sevens. Methods: Electronic databases (Pubmed, Google Scholar, SCOPUS, Scielo and IndexRMP) were searched in September 2015, complemented by manual searches of bibliographies and relevant “grey literature”. Results: Seven prospective cohort original articles addressing injuries in senior male rugby sevens players were included in this review. Overall injury incidence rates in elite rugby sevens tournaments ranged 101.5 to 119.8 per 1000 player-match-hours. Mean severity was greater than 34.1 days. Lower limb and joint/ligament injuries were the most frequent in elite players. The only study on amateur players revealed a lower injury incidence rate (74.7 per 1000 player-match-hours), and a higher proportion of muscle/tendon (37.5 %) injuries. Conclusion: Injury incidence rates in rugby sevens are higher than those reported for the 15-a-side variant, at the same level of competition. Injuries are also more severe, resulting in longer absence periods. This might result from the fact that rugby sevens is played with greater speed, leading to an increase in energy transfers during tackles, more running and turning manoeuvers, that can possibly cause more severe injuries.

Pacientes com hipertensão arterial em ambiente de medicina geral e familiar: análise comparativa entre controlados e não controlados

OBJECTIVE To study the differences between controlled and uncontrolled hypertensive patients. METHODS This was a cross-sectional observational study of the hypertensive population on the lists of three general practitioners in the district of Coimbra in central Portugal in 2013, with a margin of error of 6% and 95% confidence interval in each sample, organized in ascending order of health care user numbers. Data were gathered electronically by the investigators after approval by the Regional Health Authoritys ethics committee. RESULTS A sample of 201 individuals was studied, of whom 104 (51.7%) were male and 86 (42.8%) were aged under 65 (p=0.127 for gender and age-group). Hypertension was controlled in 130 (64.7%). We found significant differences in target organ damage, more frequent in those with controlled hypertension (33.1% vs. 19.7%, p=0.031), in hypertension control, better in those taking at least one anti-hypertensive drug at night (56.9% vs. 29.6%, p<0.001), and in prescription of non-steroidal anti-inflammatory drugs, more frequent in those with uncontrolled hypertension (11.3% vs. 3.8%, p=0.043). CONCLUSION Hypertension control is significantly associated with target organ damage, taking at least one anti-hypertensive drug at night and not taking non-steroidal anti-inflammatory drugs simultaneously.

Pressão arterial periférica por Dinamap e pressão arterial central por tonometria planar de absorção no ambulatório de Medicina Geral e Familiar

INTRODUCTION Central blood pressure (CBP) is the pressure exerted by the blood column at any given moment on the aortic and carotid artery walls, which is a close proxy for the blood pressure inside the brain and the heart, and is thus a better marker of cardiovascular morbidity and mortality than peripheral blood pressure (PBP). OBJECTIVE To assess how the augmentation index (AI), peripheral pulse pressure (pPP), central pulse pressure (cPP) and subendocardial viability ratio (SEVR) vary in hypertensive patients according to level of control of CBP and PBP. METHODS We performed an observational, cross-sectional study in a convenience sample from a general practice in Central Portugal over a period of four days in May 2010. Measurements were taken after a four-minute resting period. The following values were considered to reflect controlled pressures: PBP <140/90 mmHg, CBP <130/80 mmHg, pPP <55 mmHg and cPP <45 mmHg. RESULTS The sample included 92 patients, 38 male (41.3%), mean age 62.3±11.1 years, with no significant difference in gender distribution. PBP was controlled in 55 (59.8%), and CBP in 53 (57.6%). Both PBP and CBP were controlled in 50 patients (54.3%) and neither was controlled in 34 (37.9%). pPP and cPP were significantly lower in those with controlled PBP (p<0.001) and CBP (p<0.001). AI was non-significantly lower in those with controlled PBP (78±9 vs. 80.7) and those with controlled CBP (78±9 vs.81±7) (p=0.02). SEVR was within the desirable range in 92 patients (92.2%). 78.4% of individuals were taking drugs acting on the renin angiotensin aldosterone system (RAAS). CONCLUSIONS In a convenience sample of 92 patients, PBP and CBP were controlled in 59.8% and 57.6%, respectively. Those with controlled PBP had significantly better peripheral systolic and diastolic blood pressure, CBP, pPP and cPP; the same was true of those with controlled CBP, who also had a significantly better AI. The percentage of the cardiac cycle in diastole had a desirable value for 92,2% of the subjects.

The Knowledge, Awareness, and Practices of Portuguese General Practitioners Regarding Multimorbidity and its Management: Qualitative Perspectives from Open-Ended Questions

Multimorbidity’s high prevalence and negative impact has made it a subject of worldwide interest. The main aim of this study was to access the Portuguese knowledge, awareness, and practices of general practitioners (GPs) regarding multimorbidity and its management, in order to aid in the development of interventions for improving outcomes in multimorbid patients in primary care. A web-based qualitative descriptive study was carried out in the first trimester of 2016 with primary care physicians working in two districts of the Centre region of Portugal. Open-ended questions were analysed via inductive thematic content analysis. GPs pointed out several difficulties and challenges while managing multimorbidity. Extrinsic factors were associated with the healthcare system logistics’ management (consultation time, organization of care teams, clinical information) and society (media pressure, social/family support). Intrinsic factors related to the GP, patient, and physician-patient relationship were also stated. The most significant conclusion to emerge from this study is that although GPs perceived difficulties and challenges towards multimorbidity, they also have the tools to deal with them: the fundamental characteristics of family medicine. Also, the complex care required by multimorbid patients needs adequate consultation time, multidisciplinary teamwork, and more education/training.

Epidemiology of Time-Loss Injuries in Senior and Under-18 Portuguese Male Rugby Players

Abstract Rugby union has one of the highest injury incidence rates in team sports, however, most of the available data focus on the epidemiology of injuries in countries where rugby is popular. We aimed to report the incidence rate and relevant epidemiological aspects of injuries occurred in a group of Portuguese male rugby players. A prospective cohort study was conducted with a group of 45 senior and 32 under-18 male players (total of 77 players). Outcome measures included injury incidence, position, type, location and severity of injuries. The match injury incidence for all players was 55.84 per 1000 player match-hours (66.66 for seniors, 42.85 for under-18), while mean time-loss for injury was 20.79 days. No statistical differences were found between groups. Lower limb injuries accounted for 60.5% of all injuries, while joint/ligament injuries were the most prevalent type. Contact events were responsible for 65.1% of injuries. Despite the limitations, the obtained data are consistent with the literature. Time-loss injuries seem highly prevalent in rugby union and the incidence rates found in this Portuguese-based study were lower than the reported for international and senior men’s professional rugby union, but higher than those occurring in community rugby in tier-1 countries. The authors believe these data reinforce the need to develop and implement effective injury surveillance and prevention programs.

Letter to the Editor About the Article “Predatory Publishing: An Industry that Is Threatening”

Revista Científica da Ordem dos Médicos www.actamedicaportuguesa.com C A R TA S A O ED TO R Ruben DUARTE FERREIRA1, Sara SILVA1, Isabel CARRAPATOSO2, Frederico REGATEIRO2, Natacha SANTOS3, Diana SILVA3, Filipa SOUSA4, Susana OLIVEIRA4, Miguel PAIVA5, José TORRES DA COSTA3, Rita CÂMARA4, Emília FARIA2, Susana LOPES DA SILVA1, Grupo de Interesse de Imunodeficiências Primárias da Sociedade Portuguesa de Alergologia e Imunologia Clínica 1. Centro de Imunodeficiências Primárias. Serviço de Imunoalergologia. Centro Hospitalar de Lisboa Norte. Centro Académico de Medicina de Lisboa. Lisboa. Portugal. 2. Serviço de Imunoalergologia. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal. 3. Serviço de Imunoalergologia. Hospital de São João. Centro Hospitalar de São João. Porto. Portugal. 4. Unidade de Imunoalergologia. Hospital Dr. Nélio Mendonça. SESARAM. Funchal. Portugal. 5. Serviço de Imunoalergologia. Hospital Dona Estefânia. Centro Hospitalar de Lisboa Central. Lisboa. Portugal. Autor correspondente: Susana Lopes da Silva. susanasilva@medicina.ulisboa.pt Recebido: 30 de março de 2018 Aceite: 03 de abril de 2018 | Copyright

Promoting players’ safety and welfare through the sharing of scientific knowledge with sports agents: the new reality of Portuguese rugby sevens

As the authors of the recently published article ‘Epidemiology of injuries in senior male rugby union sevens: a systematic review’ [1], we would like to share with you its impact on the Portuguese rugby community and our achievements since then. As we stated in the article, we believe that the medical staff and all other agents (athletes, coaches, and researchers) must work together aiming at creating a safer environment in a sport with such a high injury incidence rate. We also reported that few data were available regarding injuries in non-elite rugby sevens and that more studies were needed in order to broad current knowledge. Following the publication of our article, we were granted the support from the board and the medical department of the Portuguese Rugby Union to hold a Medical Conference to present our research on rugby sports medicine, which took place in Portugal on the 10th of June 2017 [2.] In this scientific event, we were able to sit in the same stage athletes, coaches, directors, physiotherapists, doctors, and researchers from different parts of the country with the single purpose of debating the need to focus on the epidemiology of sevens injuries and the pathways to a deeper knowledge and mitigation of the problem. During the meeting two relevant pieces of data were presented, followed by a rich discussion: the systematic review that we have published in The Physician and Sports Medicine; a set of data collected in the 2015/16 season of the Portuguese National Rugby Sevens Championship by the same authors that we expect to publish in detail soon. Although data from the systematic review had already been published, it still made a significant impact on the delegates, especially on the members of the Rugby Union that agreed on the need of further studies and research. The data from the study conducted during the national championship, which revealed an overall injury incidence rate of 133.9 injuries per 1000 player match-hours caused a significant concern and long discussion. These figures are much higher than those reported by López et al. [3] for amateur rugby competitions, but more surprising, are higher than those reported for international elite sevens [1]. A deeper analysis of the data allowed the authors to present the ‘Portuguese paradox,’ where the injury incidence rate for the group of athletes playing in the lower division was higher (197) than of those in the top division (118 injuries per 1000 player match-hours), unlike what was previously reported for sevens and fifteens Rugby. However, injury severity was inversely related, with top-tier athlete’s average severity being similar to those at elite level (28 days per injury) unlike the injuries of bottomtier athletes (8.63 days). No other relevant differences were found in our data compared to the literature. We tried to deepen our analysis by collecting data regarding competition formats, athlete’s experience, age, height, weight, training load, and warm-up and to relate it to the occurrence of injuries in those athletes. The bottom-tier was contested by seven teams playing in a single 1-day event, 6 weeks after the end of the fifteens season. A direct association between the occurrence of injuries and the decrease in the volume of training (especially resistance training) was identified, as well as an inverse relation between the number of training hours during the sevens season and the severity of injuries. In the top-tier, contested by eight teams in three consecutive weekly 1-day tournaments (four games played in a day), the opposite relation regarding training loads and injuries was identified: a higher training volume during the sevens season was associated with a higher occurrence of injuries. Players who trained sevens and fifteens simultaneously during the year presented a significant increase in the risk of injury. Based on our findings, we presented a number of suggestions of changes to the competition formats and relevance of rugby sevens season in the Portuguese setting, which included: 1 – avoid the decrease of training volume during the sevens season, and increase the focus on individual preparation of athletes; 2 – highlight the relevance of rugby sevens to the sport and its promotion by increasing the duration of the season and the number of tournaments; 3 – implement bye weeks during the season to allow players’ recovery; 4 – increase the duration of the tournaments from 1–2 days, as

Characteristics Associated with Uncontrolled Blood Pressure Among Portuguese Primary Care Patients with Type 2 Diabetes

INTRODUCTION Determine whether socio-demographic, habits and risk factors are associated with a better tensional control in type 2 diabetes in primary care patients in order to identify a specific target population for compensatory interventions improving diabetes control and reducing its morbi-mortality. MATERIAL AND METHODS Cross-sectional study in primary care. Randomized type 2 diabetes patient data collection by their volunteer family doctors, proportionally stratified from the 5 Portuguese continental regions. VARIABLES blood pressure, age, gender, education, diabetes duration, HbA1c, smoking habits, weight, waist circumference, physical activity and adherence to medication. Bivariate and logistic regression analysis to evaluate each measured variables independent association with uncontrolled blood pressure (≥ 140/90). RESULTS 709 patients were included in the study, 60.2% men, mean age 66.12 ± 10.47 years. In logistic regression analysis, the factors independently associated to uncontrolled BP were lower education (p = 0.014), shorter diabetes duration (p = 0.002), higher waist circumference (p < 0.001), higher pulse pressure (p < 0.001), higher physical activity level (p = 0.043) and being a smoker (p < 0.001). DISCUSSION The main limitations are the fact that the sample was not totaly random and included only primary care patients, a possible inter-observer bias and being a cross-sectional study, thus not providing information on temporal relation or causality. CONCLUSION The sub-group of people with diabetes identified to have worse tensional control should have a different and more intensive approach in primary care. We recommend further longitudinal and population based confirmatory research.