Poverty,social exclusion and health in Portugal

People in Portugal have never been so healthy. Nevertheless, there are great differences in health status between social groups and regions. In 1994, Portugal was the country with the second worst level of inequality in terms of income distribution and with the highest level of poverty in the European Union (EU). Poverty in Portugal affects mainly the elderly and women (especially in single parent families). Beyond these groups, there are the children, the ethnic minorities and the homeless. Substance abusers, the unemployed, and ex-prisoners are also strongly affected by situations of social exclusion and poverty. Although poverty has been an important issue on the political agenda in Portugal, it shows a worrying tendency to resist traditional Social Security interventions. In the late 1990s, however, welfare coverage rates appear to have risen. To what extent can poverty cause a worsening of health status? Is there any sustainable positive association between welfare and improved health status? How, to whom and when should actions to improve the health status of the disadvantaged be addressed, without subverting the health status of the rest of the population. It is also necessary to reveal the consequences of poor health to individuals, families and communities in terms of income, social empowerment and the ability to fulfil other needs. Finally, reflection on the role and effectiveness of traditional social security models is necessary, in order to improve the impact and adequacy of its interventions. The goal of this paper is to contribute to the knowledge about disadvantage, the current health situation of the most vulnerable groups in Portuguese society-those affected by poverty, deprivation and social exclusion-and to detect the constraints on access to health and health care.     

The hypersensitivity pneumonitis diagnostic index: use of non-invasive testing to diagnose hypersensitivity pneumonitis in metalworkers

BACKGROUND: Since 1993, several outbreaks of hypersensitivity pneumonitis (HP) have been reported in metalworkers. We report the largest outbreak of HP in metalworkers yet known. It occurred in a Connecticut factory that produces precision parts for the aerospace industry. The workers typically presented with systemic and respiratory problems ("sick fatigue," myalgias, cough, dyspnea, wheezing, and chest tightness). They had variable findings on clinical tests, which complicated diagnosis. An HP diagnostic index was developed to help reduce the uncertainties in case identification. METHODS: Data from 16 biopsy-confirmed cases and 14 non-HP patients were compared, and the HP diagnostic index was derived using variables that best discriminated between the two groups. The index is based on (a) work-related symptoms, (b) dry crackles on auscultation, (c) restrictive spirometry, (d) decreased diffusion capacity and/or increased A-a oxygen gradient, (e) elevated erythrocyte sedimentation rate, (f) abnormal radiographic images, and (g) abnormal gallium scans. We then applied the HP diagnostic index and, for comparison, the "Kenosha epidemiological case criteria" (developed during a recent HP outbreak in an automobile factory) to our data set. RESULTS: The HP diagnostic index and the Kenosha criteria confirmed HP in overlapping sets of 36 and 34 patients, respectively, that were both in good agreement with the clinical diagnoses. CONCLUSIONS: The HP diagnostic index relies less heavily on symptoms, subjective evaluations, and invasive tests than the Kenosha criteria, but both identified similar subsets of the 61 patients as having HP. The HP diagnostic index could provide a useful tool in future HP outbreaks, which are increasingly being recognized in metalworking facilities.     

Aggregate data meta-analysis with time-to-event outcomes

In a meta-analysis of randomized controlled trials with time-to-event outcomes, an aggregate data approach may be required for some or all included studies. Variation in the reporting of survival analyses in journals suggests that no single method for extracting the log(hazard ratio) estimate will suffice. Methods are described which improve upon a previously proposed method for estimating the log(HR) from survival curves. These methods extend to life-tables. In the situation where the treatment effect varies over time and the trials in the meta-analysis have different lengths of follow-up, heterogeneity may be evident. In order to assess whether the hazard ratio changes with time, several tests are proposed and compared. A cohort study comparing life expectancy of males and females with cerebral palsy and a systematic review of five trials comparing two anti-epileptic drugs, carbamazepine and sodium valproate, are used for illustration.     

Health promotion in active-duty military women with children

The purpose of this study was to determine the extent to which selected demographic characteristics, definition of health, perceived health status, perceived self-efficacy, and resources are related to the health promoting behaviors of active-duty women with children and to describe qualitatively the experience of being an active-duty mother. Grounded in Pender's (1996) Health Promotion Model, this study used methodological triangulation to test a hypothesized model. A sample of 141 active-duty women with children using military health services participated. Resource availability and commitment were key components of being successful at balancing home and work demands.     

Between parent and child: negotiating cancer treatment in adolescents

Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital, founded the Kenneth B. Schwartz Center. The Schwartz Center is a non-profit organization dedicated to supporting and advancing compassionate health care delivery, which provides hope to the patient, support to caregivers, and sustenance to the healing process. The center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, their families, and their caregivers, and gain insight and support from fellow staff members. Cancer in adolescents presents an extra dynamic of psychosocial complexity. The case of a 19-year-old woman with acute myelocytic leukemia is discussed. Her disease was refractory to allogeneic transplantation, and she died with severe graft-versus-host disease. Ms. P and her mother established very different relationships with the team which supported them through the transitions in her care, and Ms. P was able to die at home, with hospice care. The personal connection with the team enabled a degree of positive adjustment through the nightmare of loss. The epidemiology of cancer in adolescents and paradigms of care are reviewed. Psychosocial aspects of adolescence, opportunities for personal growth and support, and the challenge of end-of-life care are discussed.     

Intravaginal surface EMG probe design test for urinary incontinence patients

Pelvic floor training is a well-established treatment for female urinary stress incontinence The purpose of this study was to test four different intravaginal surface electromyography (EMG) probes for biofeedback exercise and measurements. The study design was a comparison test. The study was accomplished in a referral on outpatient clinic. Participants were 9 urinary incontinent patients sent to physiotherapist for pelvic floor muscle exercise and 2 asymptomatic volunteers. The participants were asked to do pelvic floor contractions in supine position. The EMG activity of pelvic floor muscles was measured with four different types of intravaginal probes, and rectal pressure was measured simultaneously with a microtip catheter for controlling the pelvic floor muscle contraction force levels. Main outcome measure was the electrical activity of pelvic floor muscle contractions. The intraprobe correlation coefficients for comparing subsequent measurements ranged from 0.84-0.97, indicating adequate reliability. The results were affected by the location of the measuring electrodes, and the shape and size of the probes. No statistically significant differences were found between different probes. The compliance was best with L- shaped probe B and it gave highest mean EMG values so it was chosen for M- further development as a biofeedback-based home training system.     

Phase I study of pegylated liposomal doxorubicin and gemcitabine in patients with advanced malignancies

BACKGROUND: Pegylated liposomal doxorubicin (PEG-LD) and gemcitabine have single-agent activity in breast and ovarian carcinoma patients. We conducted a Phase I trial to evaluate the maximum tolerated dose (MTD) and toxicities of this combination in patients with advanced malignancies. METHODS: Twenty-six patients with refractory or recurrent malignancies were enrolled in this dose escalation trial. Dose escalation proceeded from a starting level of PEG-LD 20 mg/m(2) and gemcitabine 1000 mg/m(2) administered on Days 1 and 15 of a 28-day cycle. RESULTS: The MTD was PEG-LD 20 mg/m(2) and gemcitabine 2000 mg/m(2) administered on Days 1 and 15 of a 28-day cycle. Dose-limiting toxicity, a Grade 3 rash, was observed in one patient during Cycle 1 and Grade 3 stomatitis and a rash were observed in a second patient during Cycle 2 after administration of PEG-LD 25 mg/m(2) and gemcitabine 2000 mg/m(2). Other side effects included palmar-plantar erythrodysesthesia, nausea, and fatigue. One complete and two partial responses were observed. CONCLUSIONS: The recommended Phase II dose is PEG-LD 20 mg/m(2) with gemcitabine 2000 mg/m(2) on Days 1 and 15 of a 28-day cycle. A trial with this combination is currently ongoing at this institution comprising patients with refractory ovarian carcinoma.     

Kidney stones,carbonic anhydrase inhibitors,and the ketogenic diet

PURPOSE: Because carbonic anhydrase inhibitors and the ketogenic diet are each known risk factors for kidney stones, simultaneous use of these therapies has been discouraged. The objective of this study was to establish the prevalence of nephrolithiasis in children in this combination-therapy population. METHODS: Since 1996, 301 children have been started on the ketogenic diet at our institution. A retrospective cohort study of renal calculi in ketogenic diet patients was performed to evaluate the increased risk with combined use of a carbonic anhydrase inhibitor. RESULTS: In 15 (6.7%) of 221 children on the ketogenic diet without the use of carbonic anhydrase inhibitors, stones developed. In five (6.3%) of the 80 children on the diet in combination with topiramate or zonisamide, stones developed. There was no difference between these two groups (p = 0.82). No child was treated with either acetazolamide or more than one carbonic anhydrase inhibitor simultaneously. Prior ketogenic diet duration was shorter (10.4 vs. 22.4 months; p = 0.03), and more children had either a family history of renal stones or significant urologic abnormalities (80 vs. 27%; p = 0.04) in the combination-therapy group. CONCLUSIONS: The combined use of carbonic anhydrase inhibitors and the ketogenic diet does not increase the risk of kidney stones. We recommend that all patients treated with combination therapy should be treated with increased hydration. Urine alkalinization should be considered for children with previous renal abnormalities, family histories of kidney stones, hematuria, or elevated urine calcium-to-creatinine ratios. If renal stones are found, we advocate discontinuation of the carbonic anhydrase inhibitor.