Implementation of Orthogeriatrics in Portugal.

INTRODUCTION: Orthogeriatrics is the subspecialty of geriatrics that is dedicated to the care of elderly patients with fragility fractures. The Orthogeriatrics Unit of the Vila Nova de Gaia Hospital Centre was the first unit created in Portugal in October 2015, in a co-management model. METHODS: Patients older than 65 years and with femur fractures were admitted to the unit after surgery. The department was run by internists with differentiation in geriatrics, and multidisciplinary support from orthopaedics, physiatrists, physiotherapists, nutritionists, and social workers, as well as rehabilitation nursing. A comprehensive multidisciplinary assessment was performed upon admission, including comprehensive geriatric assessment as well as postoperative monitoring of complications, investigation of fall mechanisms, functional rehabilitation, and outpatient orientation. Analysed variables included demographics, comorbidities, prior level of functionality, delay of orthopaedic surgery, complications, time of hospitalization, functional prognosis, and destination after discharge. Follow-up was maintained to assess short- and medium-term mortality. Kaplan-Meier curves and Cox regression were used for the statistical analysis of mortality. RESULTS: In four years of activity with 444 admissions, the typical patients were women (80.7%), with an average age of 84 years, coming from home (92%) after an accidental fall resulting in a proximal femur fracture. About half (54%) were previously autonomous, but with a high index of comorbidities (mean Charlson Index of 4.85), the most relevant of which were arterial hypertension (71%), malnutrition (46%), heart failure (35%), hyperlipidaemia (34%), osteoporosis (32%), and dementia (16%). During hospitalization, most patients had medical complications (86.3%), the most frequent ones being anaemia (45%), infections (35%), namely, urinary, respiratory, and surgical wound infections, acute heart failure (15%), and acute kidney injury (11%). Prevalent geriatric syndromes were also identified and corrected through protocols for delirium, urinary incontinence, pressure ulcers, and constipation. The mean length of stay was 12.49 days. At discharge, 75% presented a modified Rankin Scale score lower than 3 and 73% of patients were able to return home, with a low referral rate to long-term care facilities (5.9%). The in-hospital mortality rate was 2.65%. It was possible to maintain follow-up protocol after discharge in 343 patients, and the mortality at 12 months was 19.23% and at three years, it was 25.52%, with a risk of death almost doubled for patients discharged with a high degree of dependence (modified Rankin Scale score ≥ 3; OR: 2.19; p < 0.001). CONCLUSION: We demonstrated reduced in-hospital mortality despite an elderly, frail population, with multiple previous comorbidities and a high number of inpatient intercurrences evidencing the importance of a good in-hospital co-management between internal medicine and orthopaedics, demonstrating the benefit of orthogeriatric units in patients with fragility fractures of the femur.

Chylous Ascites due to Mantle Cell Lymphoma.

Chylous ascites is rare and results in accumulation of lymph in the abdominal cavity, due to several mechanisms. The ascitic liquid is milky because of the high concentration of triglycerides (>200 mg/dl). The higher incidence compared to the past is explained by increased survival of patients with cancer and more aggressive surgery. We describe the case of an 87-year-old man admitted to the geriatric ward due to general oedema, chylous ascites and loss of weight, explained by mantle cell lymphoma. LEARNING POINTS: Chylous ascites is more frequent in trauma, but in some cases may be related to obstruction of the thoracic duct by retroperitoneal fibrosis, pancreatitis or neoplasms.It is a progressive, difficult to manage condition, with a spectrum of treatment ranging from a special diet to surgery.Its prognosis depends fundamentally on the predisposing condition.

Unexplained lymphadenopathies: autoimmune lymphoproliferative syndrome in an adult patient.

Autoimmune lymphoproliferative syndrome (ALPS) is characterised by massive enlargement of the lymphoid organs, autoimmune cytopenias and a predisposition to develop lymphoid malignancies. The basic defect is a disturbance of the lymphocyte apoptosis, and a high number of circulating TCRab CD3+CD4-CD8- T-cells (double-negative T cells (DNT cells)). We describe a case of a 41-year-old man with fever, hepatosplenomegaly, multiple lymphadenopathy, autoimmune haemolytic anaemia and severe thrombocytopenia. Peripheral blood immunophenotyping revealed elevation of the characteristic DNT cells in 8% and high levels of interleukin 10. Histopathological analysis of lymph nodes showed lymphadenitis with paracortical hyperplasia. It was assumed as a probable diagnosis of ALPS, and the procedure was to medicate the patient with steroids. As a result, a significant clinical improvement was achieved, and he has been in remission for 2 years. To our knowledge, this is the first case reported in a Portuguese adult patient.

[Whipple's Disease: retrospective analysis of twelve cases and review of the literature]. / Doença de Whipple: análisis retrospectivo de doce casos e revisión de la literature.

BACKGROUND: Whipple's disease is a rare and chronic bacterial disease with multiorganic involvement. Although there is no valid estimate of its actual prevalence, only about 1,000 cases have been reported. OBJECTIVE: To describe the demographic, clinical, laboratory, endoscopic and pathologic features, type of treatment used, its duration and response. METHODS: Based on the duodenal histology, we identified twelve cases of Whipple's disease in the Hospital Centre of Vila Nova de Gaia, between 1997 and 2010. RESULTS. Nine patients (75%) were male and the mean age at diagnosis was 58 years. All patients experienced at least one gastrointestinal and general symptom. Arthralgia were reported in four patients (33%) and occurred on average six years before the onset of gastrointestinal and general symptoms. In 10 patients the initial treatment was trimethoprim-sulfamethoxazole. The initial treatment duration was one year in 8 cases (80%). Seven patients (70%) had a symptomatic resolution between the third and sixth months of antibiotic therapy, as well as an endoscopic and histological improvement. Even in these patients, there was maintenance of periodic acid-Schiff positive macrophages, although in small number and with a more diffuse distribution. Gastrointestinal symptoms predominated in cases of clinical relapse. CONCLUSIONS: The gastrointestinal and general symptoms as well as the arthralgia were the predominant manifestations. The majority of patients showed clinical and endoscopic improvement in response to treatment with trimethoprim-sulfamethoxazole. However, in these cases periodic acid-Schiff positive macrophages can remain for years. Thus, in the absence of clinical deterioration, the presence of these structures is not indicative ofactive disease.

Inpatients' opinions on a hospital in Portugal.

BACKGROUND: Little is known about the relationship between the opinions of inpatients and the degree to which hospitals are improving in performance over time. The aim of this study was to determine the personal assessment level of inpatients or their representatives regarding aspects of health care in an internal medicine ward. METHODS: We carried out a questionnaire in September 2011 with 284 discharged patients and patient representatives, focusing on their opinions about the department, health professionals and amenities, with response options ranging from 1 (very bad) to 5 (very good). The relationships between domains from the questionnaire and socio-demographic factors were examined using a t-test and one-way ANOVA. RESULTS: The response rate was 78%. The patients showed a slightly higher mean score (m) for factors in the medical care domain than did the patient representatives (m = 4.51 vs. m = 4.27; p = 0.014). The mean score of all the items in all domains was 4.24; this allowed us to determine the difference from the overall mean (DIFM) for medical care (DIFM = 0.18; p = 0.000), foods (DIFM = -0.31; p = 0.000), diagnostic tests (DIFM = -0.15; p = 0.036) and transport (DIFM = -0.41; p = 0.000). Respondents with a medium or higher educational level gave lower scores to the domains food (m = 3.74; p = 0.004), diagnostic tests (m = 3.72; p = 0.04) and transport (m = 3.62; p = 0.025) than those with lower educational levels. The domains facilities (m = 2.4; p = 0.04) and diagnostic tests (m = 3.63; p = 0.009) were given lower scores by those aged <50 years compared with older respondents. CONCLUSIONS: Our findings suggest that the evaluation of the responders will allow the hospital management to make improvements in the quality of care.

[Hyperusers and emergency]. / Hiper utilizadores e urgência.

INTRODUCTION: The emergency service is the source of medical assistance for users in need of other medical care. The hyperusers make substantial part of the emergency services and their impact on the health system is unknown. OBJECTIVE: To know the pattern of the emergency unit (UU) of Espinho's Hospital used by frequent visitors and compare them with infrequent visitors. MATERIALS AND METHODS: In a retrospective study of cases and controls in the year 2006, were evaluated episodes of the emergency unit, defining hyperusers who attended UU in four or more occasions. The UU works twenty four hours a day, with a staff of two general physicians and in front of it functions the centre of primary care, twelve hours a day in five days a week. The variables analyzed were: sex, age, cause of admission administrative, time of admission and discharge, destination and procedures. RESULTS: The number of attendances was 36715 made by 19525 patients. The hyperusers represented 9.7% of all patients and accounted for 33.2% of visits to the unit. Infrequent UU users were younger (36,7 vs. 45,2 years p < 0.001) than frequent users to urgent care and search more times for traumatic disease (23,5% vs. 12,1% p < 0.001).The determinants associated with the hyperusers were hospitalization (OR = 3.38, CI = 2.89 to 3.95), the old age group (OR = 2.44, CI = 2.32 to 2.57) and medical disease (OR = 2.23, CI = 2.09 to 2.30). CONCLUSIONS: The profile of hyperuser of UU is the elderly in need of hospitalization because of medical illness. It's important to these patients an effective communication and coordination of care between UU and primary care settings, that can improve the continuity of care.

[Basic emergency]. / Urgência básica.

The increasing demand of health care and lack of its accessibility, in the scope of the National Health Service, are the most determining factors for the use of emergency departments. These facts are reproducible in the town of Espinho in spite of its two emergency consultations working at the same time, open consultation in the primary cares and hospital unit for emergency consultation, twenty meters distant from each other. This study attempt to investigate the reasons why the inhabitants of Espinho choose the institution, based on the opinion survey performed during the first fortnight of July 2002. The purpose of the study was to verify whether the different perception of the illness severity was related to the choice of the institution by the inhabitants of Espinho. In general, the results have shown that the inhabitants of Espinho knew how both consultations work and their choice was a consequence of their expectation at the moment. The patient s self-evaluation of his health condition has proved to be a very important predictor in the choice made. Thus, the open consultation in the primary cares is adjusted to give assistance to the chronic disease, while the emergency unit is prepared for the acute disease. The patients were more pleased with the performance of the emergency unit, which may be used in interventions to improve some aspects of health services and care and concerning the resources of health professionals.