O doente com patologia múltipla em medicina geral e familiar: comorbilidade de 4 doenças crónicas

RESUMO: A tese de doutoramento visa demonstrar duas proposições: a comorbilidade de 4 situações de doença prevalentes, hipertensão arterial (HTA), diabetes (DM), doença cardíaca isquémica (DCI) e asma é um assunto importante em Medicina Geral e Familiar e o seu estudo tem diversas implicações na forma como os cuidados de saúde são prestados, na sua organização e no ensino-aprendizagem da disciplina. O documento encontra-se dividido em 4 partes: 1) justificação do interesse do tema e finalidades da dissertação; 2) revisão sistemática de literatura publicada entre 1992 e 2002; 3) apresentação de dois trabalhos de investigação, descritivos e exploratórios que se debruçam sobre a mesma população de estudo, o primeiro intitulado “Comorbilidade de quatro doenças crónicas e sua relação com factores sócio demográficos” e o segundo, “Diferenças entre doentes, por médico e por sub-região, na comorbilidade de 4 doenças crónicas”; 4) conclusões e implicações dos resultados dos estudos na gestão da prática clínica, nos serviços, no ensino da disciplina da MGF e no desenvolvimento posterior de uma linha de investigação nesta área. O primeiro estudo tem como objectivos: descrever a prevalência da comorbilidade entre as 4 doenças-índice; verificar se existe relação entre o tempo da primeira doença e o tempo decorrido até ao aparecimento da 2ª e da 3ª doença, nas 4 doenças; determinar a comorbilidade associada às 4 doenças; identificar eventuais agrupamentos de doenças e verificar se existe relação entre comorbilidade e factores sociais e demográficos. O segundo estudo pretende verificar se existem diferenças na comorbilidade a nível local, por médico, e por Sub-Região de Saúde. O trabalho empírico é descritivo e exploratório. A população é constituída pelos doentes, com pelo menos uma das 4 doenças crónicas índice, das listas de utentes de 12 Médicos de Família a trabalharem em Centros de Saúde urbanos, suburbanos e rurais dos distritos de Lisboa e Beja. Os dados foram colhidos durante um ano através dos registos médicos. As variáveis sócio demográficas estudadas são: sexo, idade, etnia/raça, escolaridade, situação profissional, estado civil, tipo de família, funcionalidade familiar, condições de habitação. A comorbilidade é definida pela presença de duas ou mais doenças e estudada pelo número de doenças coexistentes. O tempo de duração da doença é definido como o número de anos decorridos entre o ano de diagnóstico e 2003. Os problemas de saúde crónicos são classificados pela ICPC2. Nas comparações efectuadas aplicaram-se os testes de Mann-Whitney e de Friedman, de homogeneidade e de análise de resíduos. A Análise Classificatória Hierárquica foi utilizada para determinar o agrupamento de doenças e a Análise de Regressão Categórica e Análise de Correspondências na relação entre as características sócio demográficas e a comorbilidade. Identificaram-se 3998 doentes. A idade média é de 64,3 anos (DP=15,70). Há uma correlação positiva significativa (r =0,350 r=0) entre “anos com a primeira doença”e “idade dos doentes” em todos os indivíduos (homens r=0,129 mulheres r=0,231). A comorbilidade entre as quatro doenças crónicas índice está presente em 1/3 da população. As associações mais prevalentes são HTA+DM (14,3%) e HTA+DCI (6,25%). Existe correlação positiva, expressiva, entre a duração da primeira doença, quando esta é a HTA ou a DM, e o intervalo de tempo até ao aparecimento da 2ª e da 3ª doenças. Identificaram-se 18 655 problemas crónicos de saúde que se traduziram em 244 códigos da ICPC2. O número médio de problemas foi de 5,94 (DP=3,04). A idade, a actividade profissional, a funcionalidade familiar e a escolaridade foram as variáveis que mais contribuíram para diferenciar os indivíduos quanto à comorbilidade. Foram encontradas diferenças significativas entre médicos(c2=1165,368 r=0) e entre os agrupamentos de doentes por Sub-Região de Saúde (c2= 157,108 r=0) no respeitante à comorbilidade. Na partição por Lisboa o número médio de problemas é de 6,45 e em Beja de 5,35. Deste trabalho ressaltam várias consequências para os profissionais, para os serviços, para o ensino e para a procura de mais saber nesta área. Os médicos, numa gestão eficiente de cuidados são chamados a desempenhar um papel de gestores da complexidade e de coordenadores assim como a trabalhar num modelo organizativo apoiado numa colaboração em equipa. Por sua vez os serviços de saúde têm que desenvolver medidas de avaliação de cuidados que integrem a comorbilidade como medida de risco. O contexto social da cronicidade e da comorbilidade deverá ser incluído como área de ensino. A concluir analisa-se o impacto do estudo nos colaboradores e o possível desenvolvimento da investigação nesta área.----------------------------------------ABSTRACT: The PhD Thesis has two propositions, co-morbidity of four chronic conditions (hypertension, asthma, diabetes, cardiac ischaemic disease) is a prevalent and complex issue and its study has several implications in the way care is provided and organised as well as in the learning and teaching of the discipline of General Practice. In the first part of the document arguments of different nature are given in order to sustain the dissertation aims; the second part describes a systematic study of literature review from 1992 to 2002; the third presents two research studies "Comorbidity of four chronic diseases and its relation with socio demographic factors” and “Differences between patients among GPs at local and regional level”; implications of study results for practice management, teaching and research are presented in the last part. The prevalence of the four chronic diseases co-morbidity, the relation of the first disease duration with the time of diagnose of the next index condition, the burden of co-morbidity in the four chronic diseases, the clustering of those diseases, the relation between demographic and social characteristics and co-morbidity, are the objectives of the first study. The second intends to verify differences in comorbidity between patients at local and regional level of practice. Research studies were descriptive and exploratory. The population under study were patients enlisted in 12 GPs working in urban and rural health centres, in Lisbon and Beja districts, with at least one of the four mentioned diseases. Data were collected through medical records during one year (2003) and 3998 patients were identified. The social demographic variables were: sex, age, ethnicity/race, education, profession, marriage status, family status, family functionality, home living conditions. Co-morbidity is defined by the presence of two or more diseases, and studied by the number of co-existing diseases. The time duration of the disease is defined by the number of years between the diagnostic year and 2003. The chronic disease problems are classified in accord with ICPC2. The characterization of population is descriptive. The effected comparisons applied the Mann-Whitney, Friedman, homogeneity and analysis of residuals tests. The Classificatory Hierarchy Analysis was utilized to determine the grouping of diseases and the Regression Categorization and Correspondences Analysis was used to study the relation of socio-demographic and co-morbidity. The median age of the population under study is 64,3 (SD= 15,70). There is a significant positive correlation (r =0,350 r=0)between “years with the first disease” and “patient age” for all individuals (men r=0,129 women r=0,231). Co-morbidity of the four index diseases is present in 1/3 of the studied population. The most prevalent associations for the four diseases are HTA+DM (14,03%) and HTA+IHD (6,25%). Expressive positive correlation between the duration of the first disease and the second and the third index disease interval is found. For the 3988 patients, 18 655 chronic health problems, translated in 244 ICPC2 codes, were identified. The mean number of problems is 5,94 (SD=3,04). Age, professional activity, family functionality and education level are the socio demographic characteristics that most contribute to differentiate individuals concerning the overall co-morbidity. Significant differences in co-morbidity between GP patients at local (c2=1165,368 r=0) and regional level (c2= 157,108 r=0) are found. This study has several consequences for professionals, for services, for the teaching and learning of General Practice and for the pursuit of knowledge in this area. New competences and performances have to be implemented. General Practitioners, assuming a role of co-ordination, have to perform the role of complexity managers in patient's care, working in practices supported by a strong team in collaboration with other specialists. In order to assess provided care, services have to develop tools where co-morbidity is included as a risk measure. The social context of comorbidity and chronicity has to be included in the curricula of General Practice learning and teaching areas. The dissertation ends describing the added value to participant's performance for their participation in the research and an agenda for further research, in this area, based on a community of practice.--------RÉSUMÉ:Cette thèse de doctorat prétend démontrer deux postulats : le premier, que la comorbidité de quatre maladies fréquentes, hypertension artérielle (HTA), diabète (DM), maladie cardiaque ischémique (DCI) et asthme, est un thème important en Médecine Générale et Familiale et que son étude a plusieurs implications au niveau de l'approche pour dispenser les soins, de leur organisation et de l'enseignement/apprentissage de la discipline. Le document comprend quatre parties distinctes : 1) justification de l'intérêt du sujet et objectifs de la dissertation ; 2) étude systématique de publications éditées entre 1992 et 2002 ; 3) présentation de deux travaux de recherche, descriptifs et exploratoires, un premier intitulée « Comorbidité de quatre maladies chroniques et leur relation avec des facteurs sociodémographiques » et un deuxième « Différences entre malades, selon le médecin et la sous région, dans la comorbilité de quatre maladies chroniques» ; 4) conclusions et conséquences des résultats des études dans la gestion de la pratique clinique, dans les services, dans l'enseignement de la discipline de MGF et dans le développement postérieur de la recherche dans ce domaine. Les objectifs de la première étude sont les suivants : décrire la prévalence de la comorbidité entre les quatre maladies chroniques, vérifier s'il existe une relation entre temps de durée de la première maladie et l'espace de temps jusqu'à le diagnostic de la 2ème ou 3ème maladie; déterminer la comorbidité entre les 4 maladies ; identifier d'éventuelles groupements de maladies et vérifier s'il existe une relation entre comorbidité et facteurs sociodémographiques. La deuxième étude prétend vérifier s'il existe des différences de comorbidité entre médecins et par groupement régional. Le travail empirique est descriptif et exploratoire. La population est composée des malades ayant au moins une des quatre maladies chroniques parmi les listes de malades de douze Médecins de Famille qui travaillent dans des Centres de Santé urbains, suburbains et ruraux (Districts de Lisbonne et Beja). Les données ont été extraites pendant l'année 2003 des registres des médecins. Les variables sociodémographiques étudiées sont : le sexe, l'âge, l'ethnie/race, la scolarité, la situation professionnelle, l'état civil, le type de famille, sa fonctionnalité, les conditions de logement. La comorbidité est définie lorsqu'il existe deux ou plusieurs maladies et est étudiée d'après le nombre de maladies coexistantes. La durée de la maladie est établie en comptant le nombre d'années écoulées entre le diagnostique et 2003. Les problèmes de santé chroniques sont classés par l'ICPC 2. Pour les comparaisons les tests de Mann-Whitney et Friedman, de homogénéité et analyse de résidues ont été appliqués. L'Analyse de Classification Hiérarchique a été utilisée pour procéder au regroupement des maladies et l'Analyse de Régression Catégorique et l'Analyse de Correspondances pour étudier la relation entre les caractéristiques sociodémographiques et la comorbilité. Les principaux résultats sont les suivants : les 3998 malades identifiés ont 64,3 ans d'âge moyen (DP=15,70). Il existe une corrélation positive significative (r =0,350 r=0) entre « les années avec la première maladie » et « l'âge des malades », chez tous les individus (hommes r=0,129 femmes r=0,231). La comorbidité entre les quatre maladies chroniques est une réalité chez 1/3 des patients. Les associations les plus fréquentes sont HTA+DM (14%) et HTA+DCI (6,25%). Il existe une corrélation positive significative entre la durée de la première maladie, HTA ou DM, et l'écart jusqu'à l'apparition de la deuxième et de la troisième maladie. Chez les malades, 18.655 problèmes chroniques de santé ont été identifiés et traduits en 244 codes de l'ICPC2. La moyenne des problèmes a été de 5,94 (DP=3,04). L'âge, l'activité professionnelle, la fonctionnalité familiale et la scolarité sont les variables qui ont le plus contribué à différencier les individus face à la comorbilité. Des différences notoires ont été trouvées entre médecins (c2=1165,368 r=0) et entre les groupements régionaux (c2=157,108 r=0) en ce qui concerne la comorbidité. Dans le groupe de patients de Lisbonne, le chiffre moyen de problèmes est de 6,45 et à Beja il est de 5,35. Cette étude met en évidence plusieurs conséquences pour les professionnels, les services, l'enseignement et l'élargissement du savoir dans ce domaine. Les médecins, soucieux de gérer efficacement les soins sont appelés à jouer un rôle de gestionnaires de la complexité et de coordinateurs, de même qu'à travailler dans un modèle d'organisation soutenus par un travail d'équipe. D'autre part, les services de santé doivent eux aussi développer des mesures d'évaluation des soins qui intègrent la comorbidité comme mesure de risque. Le contexte social de la chronicité et de la comorbidité devra être inclus comme domaines à étudier. La fin de cette thèse décrit l'impact de cette étude sur les collaborateurs et le développement futur de la recherche dans ce domaine.

Mots(dits) écrits:formes et valeurs de la diffusion des idées au 18ème siècle, au Portugal

Les rapports complexes entre les différentes façons de faire circuler les idées et les informations ne datent pas de nos jours. A toutes les époques, les messages qui circulent emploient toutes sortes de véhicules et de langages, très souvent complémentaires. Ces véhicules et ces langages n'ont peut-être rien d'extraordinaire. Ils appartiennent au monde des gestes de tous les jours, des gestes qui se répètent et dont la répétition est elle-même importante pour la construction du sens de chaque message. Ces gestes qui sont répétés, qui sont attendus et qui sont reconnus incluent des sons, des images, des comportements, des mots, ou des citations. Il y a donc un rapport qui s'y établit entre répétition et nouveauté, rapport dans lequel la répétition fournit chaque fois une nouvelle information, même si elle est déjà attendue, tandis que leur absence peut représenter l'anxiété, ou même le scandale.

Héraldique des sceaux du clergé séculier portugais au Moyen Âge

Ce n’est que dans les dernières années que l’héraldique au Portugal a entamé le processus de rénovation qui, en France, a commencé il y a déjà quelques décennies. Dans ce processus, l’étude de l’héraldique médiévale a été peu contemplé, restant pratiquement à faire, en bonne partir dû à l’absence d’armoriaux antérieurs au XVe siècle qui permettent de connaître les armes utilisées par les familles et les diverses entités portugaises. Pour cette raison, les sceaux portant des représentations héraldiques ont une importance extrême, car ils constituent très fréquemment la seule source pour l’étude des armoiries, ayant en plus l’avantage d’être datés avec précision et liées à des personnages ou entités qui sont connues. Cependant, la sigillographie portugaise se trouve aussi dans une phase de son évolution qui, n’étant plus embryonnaire, est encore une phase de formation. Il nous manque des catalogues, des dépouillages systématiques, des études approfondies qui permettent aux héraldistes de faire leurs recherches. C’est dans ce contexte qui est née ce partenariat entre deux médiévalistes très intéressés à la sigillographie et un spécialiste d’héraldique, qui ensemble ont décidé d’entamer l’étude des origines des représentations héraldiques dans les sceaux portugais, en commençant par les sceaux du clergé séculier, qui constitue le sujet par excellence de la recherche des deux historiens. Dans ce vaste univers sigillaire, qui concerne des personnes d’une grande variété d’origines sociales, y compris la noblesse et la riche bourgeoisie urbaine, les éléments héraldiques semblent avoir émergé seulement à partir de la fin du XIIIe siècle, et d’une façon timide. Le XIVe siècle assiste à sa diffusion dans les sceaux d’évêques, dignités et chanoines, mais ce n’est qu’au XVe siècle que l’héraldique s’impose, gagnant même une place primordiale dans quelques représentations sigillographiques. Le but de cette communication sera donc l’analyse du processus d’héraldisation des sceaux du clergé séculier portugais, entre les dernières décennies du XIIIe et le XVe siècle, pour évaluer comme s’est procédé, dans le cas portugais, le phénomène d’«acculturation héraldique» de l’emblématique épiscopale et cléricale.

Notes sur la géologie et la paléontologie du Miocène de Lisbonne. XXI Primeira caracterização de dinoflagelados dos níveis mais baixos da série miocénica de Lisboa

This is the first report on Dinoflagellata from lowermost Miocene beds in Portugal (Tagus basin, Lisbon region, exposure at Benfica). Some general data about Dinoflagellata are presented. Descriptions are provided for some forms: Gonyaulacysta tenuitabulata, Spiniferites ramosus, Achomosphaera sp., Hystrichokolpoma rigaudae, Homotriblium cf. pallidum, Cordosphaeridium sp, and Lingulodinium machaerophorum. Lithostratigraphical study of an important section along Circular highway at Benfica has shown that there is a hitherto unknown sedimentary cycle in Lisbon's lowermost Miocene (upper Oligocene?). Pollen and Ostracoda point out to an Lower Aquitanian or even Upper Chattian age for the first Neogene marine transgression in Portugal, previously considered as Upper Aquitanian or Lower Burdigalian.

Notes sur la géologie et la paleontology du Miocène de Lisbonne. XXII - Une Espèce nouvelle Pokornyella Lusitanica (Ostrocoda), dans le Miocène Inférieur du bassin du Tage

A new species, Pokornyella lusitanica (Ostracoda), from the Lower Miocene (Aquitanian) of the Lisbon area, is described. Some palaeoecological data are presented.

Faunes ichthyologiques du Néogène Supérieur d’Angola, leur âge, remarques sur le Pliocène marin en Afrique Australe

This note is concerned with fish remains from Upper Neogene beds at Farol das Lagostas (and nearby quarry of SECIL) and Baía Farta, mainly recovered by the author in 1960, 1961, 1963 and 1967. For further data see ANTUNES, 1964, pp. 213-215. All the forms identified until now (many of them for the first time) are show in «tableau I». Smaller ones are poorly represented. I. benedeni is provisorily accepted as a distinct species, though it may correspond to a dental morphotype that does exist equally in the extant I. oxyrhinchus (see text): therefore I. benedeni from Farol das Lagostas may after all represent only some dental variations that really belong in the form described as I. cf. oxyrhinchus. The presence of Aprionodon and Hypoprion could not be ascertained: Procarcharodon megalodon, Carcharodon carcharias, Isurus benedeni. Galeocerdo cuvieri, and Carcharhinus sp. I and sp. II are specially discussed. The whole fauna does not correspond either to a very shallow and coastal environment, or to deep waters far away from the coast. It clearly points out to warm waters: an acceptable model would be the fauna from the tropical Atlantic between Northern Angola and Senegal-Cape Verde. The age of this fauna was long regarded as Burdigalian. The data formerly presented (ANTUNES, 1963) that allowed us to ascribe a pliocene age to the uppermost Neogene beds of Farol das Lagostas (Neogene III, ANTUNES, 1964) are reviewed and developed in this paper. This view is corroborated by planctonic foraminifera and stratigraphical data which provide further evidence to prove the presence of miocene beds much younger than Burdigalian, and that some deposits previously correlated to this stage have instead a Plio-Pleistocene age. Fish fauna from Farol das Lagostas is very characteristic, with giant P. megalodon in association with C. carcharias (which predominates, and whose stratigraphical distribution is particularly discussed), and with other very advanced forms like the extant tiger shark, G. cuvieri, enormous I. Benedeni, Hemipristis, and Carcharhinus (whose size largely exceeds the maximum observed with miocene material). With the exception of P. megalodon (extinct) all the other forms show very close affinities, or even identity with modern species. Comparisons with very similar faunas from some South African localities that may also have a Pliocene age are also presented.

Contributions à la paleontology du Miocène moyen continental du basin du tage

This study on middle Miocene Charophytes from the Tagus'basin indicates the presence of two species. hitherto undescribed from these strata in Portugal, Correlation diagrams of height and width of gyrogonite demonstrate that the populations of Nitellopsis (Tectochara) etrusca from the localities Póvoa de Santarém and Pêro Filho are identical to that from La Grenatière (Hérault, France), The population of Lychnothamnus duplicicarinatus from Tremês is identical to that already known from Anwill (Switzerland). The age of this flora is therefore suggested as being the upper part of the middle Miocene. The results of Charophyte studies are in accordance with stratigraphical conclusions from previously conducted mammalian studies (Antunes and Mein), A table showing the distribution of species in the three portuguese localities is given.

Contributions à la paleontology du Miocène moyen continental du basin du tage

The lignite-clays of Póvoa de Santarém dated as Upper «Vindobonian» (mammalian zone MN6), fielded abundant remains of animals and plants (spores, pollens, seeds, etc.). The forms identified are indicative of several environments. Plants, either aquatic or belonging to swampy areas are predominant (Nuphar sp., Sparganium sp., Stratiotes kaltennordheimensis, cf. Ranunculus sp.). There are also remains of plants characteristiques of a humid rather than a swampy soil such as Polypodiaceae, Myrica ceriferiformis, Toddalia maii, Spirematospermum wetzeleri. The genera Vitis and Ephedra, although rare, point fowards the existence of drier regions in the neighbourhood. The presence of polens such as Picea indicate the presence at some distance less warm upland forest areas.

Les Hipparion du Portugal

This paper is concerned with Hipparion from Ribatejo, Portugal, and with the stratigraphy of the Neogene series of this region. The first two chapters are an introduction and an historical review. Paleontological study includes both a revision of the specimens accounted by ROMAN (1907) and the description of new material. Two forms were recognized, an early H. cf. primigenium, lower Vallesian in age, NM 9 mammal unit (from Archino, Vila Nova da Rainha, Aveiras de Cima), and a more advanced H. primigenium cf. melendezi. Upper Vallesian, NM 10 (possibly lowermost Turolian, NM 11) (at Azambujeira and Marmeleira). A synthesis of Middle and Upper Miocene from Ribatejo is also presented. Levels with H. p. cf. melendezi are somewhat older than «Upper Pontian», as it was previously acknowledged, they attain at the best the lowermost Turolian (approximately corresponding to «Upper Pontian»). Even higher levels may be Turolian in age, though they are not yet accurately dated. Almost all the localities are shown (tableau 11) according to its stratigraphical position; age, correspondance to mammal units from NM 5 to NM 10 (and may be also from NM 11 to NM 12), and correlation with marine formations near Lisbon are also taken in account. The stratigraphical position of localities such as Póvoa de Santarém, Quinta do Marmelal, Pero Filho, Azambujeira (lower levels), and Fonte do Pinheiro was revised; the stratigraphical position of Marmeleira was ascertained. The localities so far known correspond to NM 5 (?), NM 6, NM 8, NM 9, NM 10 and possibly to NM II and NM 12. A new interpretation (M. T. ANTUNES) of localities with oysters from Ribatejo allows a better correlation with vertebrate localities. Relationships with Serravallian transgression seem well established. Only two localities, Vila Nova da Rainha and Foz do Alviela, may possibly be correlated to V-b division of Lisbon (Langhian) with «Hispanotherium fauna». All the other localities are younger than Serravallian oyster beds. Undirect correlation shows that NM 6 localities are somewhat younger than the apogee ef Serravallian transgression (corresponding approximately to Blow's N 11 to N 13 zones based on planctonic foraminifera).

Contribution à l’étude du nannoplacton du leg 12, «sites» 118-119 (Ocean Atlantique)

This paper reports a Scanning Electron Microscopy study of some samples from the leg 12, Deep Sea Drilling Project, sites 118 and 119. The chronostratigraphic distribution, the frequency of the species identified and the datation of the samples studied are presented. In accordance with the calcareous nannofossil zonation proposed by E. MARTINI (1971) the samples from site 118 are ascribed to the Upper Miocene while the samples from site 119 are located between the Lower (NN1) and the Upper Miocene (NN10).

Notes sur la géologie et la paleontology du Miocène de Lisbonne

This note deals with the stratigraphical and paleontological study of the Palença section on the southern bank of the river Tagus, Portugal, and specially with its coccolithophorids. Three main lithostratigraphical units may be recognized: the lowest one does correspond to the upper part of COTTER's division II, the intermediate one to divisions III and IV-a, the third corresponding to pratically the whole division IV-b, However other and higher levels are also represented. Higher beds are also represented in the same sections; they are less well exposed and were not studied in detail. Caracterisation of biozones on the basis of Coccoliths so far found at Palença section is difficultsince MARTINI's zones have been defined mainly by forms of Discoaster and other genera that are wanting. However we can recognize that the richest assemblage (from beds 17-18, the uppermost layers of blue clays IV-a) may correspond to NN4. This is not in opposition to the results of the study of planctonic foraminifera, that are characteristic of BLOW's N7. Coccoliths from lower beds do not allow at present any valid comparisons.

Contributions à la Paléontologie du Miocène moyen continental du Bassin du Tage. I - Quelques mollusques - Pero Filho, Póvoa de Santarém, Sítio do Mirante

Some land and freshwater mollusks (Gastropoda, Pelecypoda) from three middle Miocene localities: Pêro Filho, Póvoa de Santarém, Sítio do Mirante, all in Ribatejo province, Portugal, are summarily studied. On a systematical viewpoint it has been shown (see also Tableau): - the presence of the genus Janulus, whose species only survive now at Madeira and Canary's islands; - the presence of "Helix" cotteri that may indeed belong in the genus Megalotachea, common in western Europe since "Helvetian" to Messinian times; - Limax, Testacella, Acroloxus and Pseudamnicola are quoted for the first time in portuguese tertiary formations; Ferrisia has been identified for the first time in Iberian Peninsule; - the presence of other forms previously quoted by ANTUNES & ZBYSZEWSKI (1973), is confirmed: Bithynia, Theodoxus, Pisidium. Such faunules are compatible with a middle Miocene age. On a paleobiogeographical viewpoint, some forms suggest mediterranean affinities. Fossil associations do correspond ecologically to either palustrine or stagnant, calm and shallow water conditions (Sítio do Mirante, and essentially also Póvoa de Santarém), or to fluviatile conditions (Pêro Filho).

Contributions à la Paléontologie du Miocène moyen continental du Bassin du Tage. II - Observations sur les dents pharyngiennes de poissons cyprinidés - Póvoa de Santarém.

The study of Cyprinid fish pharyngeal teeth, collected by M. Telles Antunes in continental "Helvetian" sediments from Póvoa de Santarém, makes possible to demonstrate the occurrence of two distinct species. One remains undetermined. The other belongs to the recent genus Leuciscus CUV. Several dental types of this genus are described and figured as Leuciscus antunesi nov. sp. Palaeoclimatical and palaeoecological interpretations are proposed.

Contributions à la Paléontologie du Miocène moyen continental du Bassin du Tage. III - Mammifères - Póvoa de Santarém, Pêro Filho et Chões (Secorio). Conclusions générales

This study on middle Miocene mammalian faunas from Tagus'basin deals particularly with some small mammals hitherto undescribed from Portugal, including a new Glirid (Paraglirulus scalabicensis nov. sp.); it allows an accurate datation by biostratigraphical standards, Megacricetodon crusafonti, Fahlbuschia darocensis, Cricetodon jotae being characteristic of mammalian MN6 unit, thus their age is nearly that of Sansan and Manchones (however the presence of Peridyromys hamadryas and Lagopsis verus do suggest, amidst this biozone, a somewhat later age than Sansan's); it contributes with indirect correlation data with marine formations, as underlying oyster-bearing beds most probably are in correspondance to the apogee of the same transgression that deposed near Lisbon ”schlier" facies from VI-a division (Serravalian, Blow's zones 10-13, Globorotalia meyeri zone); the diversity of mammalian assemblages is surely related to an environement with varied biotopes, whose characterisation becomes easier if account is taken of the preceding papers on mollusks (G. Truc) and Cyprinid fishes (J. Gaudant), and also according to some unpublished paleobotanical data (J. Pais). A table with a synthesis of all paleontological data so far known is presented.

Cheirogaster sp. (O. Testudines, Fam. Testudinidae, Geochelone sl.) du Paléogène de Naia, Tondela et l’âge du gisement

A land tortoise from a new locality at Naia, Tondela, is described. It is to be reported either to an advanced form of the genus Hadrianus or to an archaic representative of Cheirogaster; it may be included in the comprehensive genus Geochelone s.l., excluding however Ergilemys and its descendants. There is a strong possibility in favour of Cheirogaster. Testudo must also be excluded. It is not possible to classify this specimen at species'level. Our specimen does agree best with Upper Eocene Testudinidae and with some Lower Oligocene ones. Its age is certainly not Upper Oligocene or later, nor Lower and Middle Eocene. This datation is not opposed to the age of the fossiliferous clays of Naia as supposed by correlation with another locality - Côja, about 30 km to the South - which yielded an assemblage of mammals whose Ludian (Upper Bartonian s.l.) age seems well established. Naia and Côja's fossil-bearing clays must be nearly synchronous; their origin is well in place among the phenomena related to the surrection of iberian Central Chain during paroxysmal phase of pyrenean orogenesis.