Métodos construtivos de edifícios – comparação entre pré-fabricação e construção tradicional em betão armado

Em Portugal, a temática da Construção Pré-fabricada, enquanto método construtivo, ainda não se encontra desenvolvida de forma muito aprofundada. Na sua grande maioria, os trabalhos e estudos efetuados centram-se em aspetos de projeto e dimensionamento de determinados componentes préfabricados. Elementos estruturais pré-fabricados são já frequentemente utilizados, por exemplo, em vias de comunicação, pontes, viadutos, passagens inferiores e superiores. No entanto, no âmbito dos edifícios, esta tecnologia ainda não está totalmente explorada, exceção feita a naves industriais. A definição de construção pré-fabricada ainda não é consensual e as dúvidas subsistem, tanto por parte da população em geral, como dos próprios intervenientes no setor da construção. Dadas as suas potencialidades, pretende-se estudar a construção pré-fabricada, no setor dos edifícios, enquanto metodologia construtiva e compará-la com a metodologia de construção tradicional. Numa primeira fase, o trabalho irá consistir em explorar um conjunto de conceitos, métodos, tecnologias e materiais utilizados em alguns países com maior grau de aplicação destas técnicas. Posteriormente, será feita uma comparação entre construção pré-fabricada e construção tradicional, no que diz respeito a planeamento, prazos, custos, sustentabilidade, segurança ou qualidade, com base em estudos comparativos já realizados a nível internacional. Atendendo à informação recolhida, será realizado um trabalho onde são referidos processos, que poderão ajudar a compreender melhor o que é a construção pré-fabricada enquanto método construtivo inovador – quais as suas vantagens, implicações e condicionantes – e avaliar a sua viabilidade enquanto solução construtiva.

SURVIVAL CAPACITY OF Arcobacter butzleri INOCULATED IN POULTRY MEAT AT TWO DIFFERENT REFRIGERATION TEMPERATURES

Arcobacter spp. are emerging enteropathogens and potential zoonotic agents that can be transmitted by food and water, being considered a public health risk. The high isolation rate of these bacteria from poultry products suggests that it may be a major source of human infections. One hallmark for differentiating the genus Arcobacter fromCampylobacter includes their growing capacity at low temperatures (15-30 °C) under aerobic conditions. However, little is known about the population density variation of these bacteria at different refrigeration temperatures. The aim of this study was to determine the survival behavior of two different Arcobacter butzleri concentrations (104 CFU/mL and 107 CFU/mL) inoculated on chicken legs and held at two different refrigeration temperatures (4 and 10 °C) throughout storage time. Results have shown that A. butzleri had growing capacity both at 4 and 10 °C. No statistical difference between the survival trends was found for both bacterial concentrations and temperatures tested. This study shows that A. butzleri is a robust species with regard to storage temperature, and represents a potential health risk for poultry meat consumers.

Territorial Strategic Planning as a support instrument for Regional and Local Development : a comparative analysis between Lisbon and Barcelona metropolitan areas - a first approach

Trabalho de Projecto apresentado para cumprimento dos requisitos necessários à obtenção do grau de Mestre em Metropolização, Planeamento Estratégico e Sustentabilidade.

Modelling resilience in supply chain

Dissertação para obtenção do Grau de Doutor em Engenharia Industrial

Safe reuse of treated urban wastewater in Praia, Cape Verde: a case study

Dissertação para a obtenção do Grau de Mestre em Engenharia e Gestão da Água

Territorial Strategic Planning as a support instrument for Regional and Local Development: a comparative analysis between Lisbon and Barcelona Metropolitan Areas

MARQUES, B.P. (2011) "Territorial Strategic Planning as a support instrument for Regional and Local Development: a comparative analysis between Lisbon and Barcelona Metropolitan Areas", in Atas do 17.º Congresso da APDR, do 5.º Congresso de Gestão e Conservação da Natureza e do Congresso Internacional da APDR/AECR, Bragança e Zamora, pp. 1265-1272, ISBN 978-989-96353-2-6.

Adaptation as a part of system resilience. insights from fish producers organizations in Portugal

Complex problems of globalized society challenge its adaptive capacity. However, it is precisely the nature of these human induced problems that provide enough evidence to show that adaptability may not be on a resilient path. This thesis explores the ambiguity of the idea of adaptation (and its practice) and illustrates the ways in which adaptability contributes to resilience of social ecological systems. The thesis combines a case study and grounded theory approach and develops an analytical framework to study adaptability in resource users’ organizations: from what it depends on and what the key challenges are for resource management and system resilience. It does so for the specific case of fish producers’ organizations (POs) in Portugal. The findings suggest that while ecological and market context, including the type of crisis, may influence the character of fishers’ adaptation within POs (i.e. anticipatory, maladaptive and reactively adaptive), it does not determine it. Instead, it makes agency even more crucial (i.e. leadership, trust and agent’s perceptions in terms of their impact on fishers’ motivation to learn from each other). In sum, it was found that internal adaptation can improve POs’ contribution to fishery management and resilience, but it is not a panacea and may, in some cases, increase system vulnerability to change. Continuous maladaptation of some Portuguese POs points at a basic institutional problem (fish market regime), which clearly reduces fisheries resilience as it promotes overfishing. However, structural change may not be sufficient to address other barriers to Portuguese fishers’ (PO members) adaptability, such as history (collective memory) and associated problematic self-perceptions. The agency (people involved in structures and practices) also needs to change. What and how institutional change and agency change build on one another (e.g. comparison of fisheries governance in Portugal and other EU countries) is a topic to be explored in further research.

Determinants of mother-baby relationship evaluated during pregnancy

ABSTRACT Background Mental health promotion is supported by a strong body of knowledge and is a matter of public health with the potential of a large impact on society. Mental health promotion programs should be implemented as soon as possible in life, preferably starting during pregnancy. Programs should focus on malleable determinants, introducing strategies to reduce risk factors or their impact on mother and child, and also on strengthening protective factors to increase resilience. The ambition of early detecting risk situations requires the development and use of tools to assess risk, and the creation of a responsive network of services based in primary health care, especially maternal consultation during pregnancy and the first months of the born child. The number of risk factors and the way they interact and are buffered by protective factors are relevant for the final impact. Maternal-fetal attachment (MFA) is not yet a totally understood and well operationalized concept. Methodological problems limit the comparison of data as many studies used small size samples, had an exploratory character or used different selection criteria and different measures. There is still a lack of studies in high risk populations evaluating the consequences of a weak MFA. Instead, the available studies are not very conclusive, but suggest that social support, anxiety and depression, self-esteem and self-control and sense of coherence are correlated with MFA. MFA is also correlated with health practices during pregnancy, that influence pregnancy and baby outcomes. MFA seems a relevant concept for the future mother baby interaction, but more studies are needed to clarify the concept and its operationalization. Attachment is a strong scientific concept with multiple implications for future child development, personality and relationship with others. Secure attachment is considered an essential basis of good mental health, and promoting mother-baby interaction offers an excellent opportunity to intervention programmes targeted at enhancing mental health and well-being. Understanding the process of attachment and intervening to improve attachment requires a comprehension of more proximal factors, but also a broader approach that assesses the impact of more distal social conditions on attachment and how this social impact is mediated by family functioning and mother-baby interaction. Finally, it is essential to understand how this knowledge could be translated in effective mental health promoting interventions and measures that could reach large populations of pregnant mothers and families. Strengthening emotional availability (EA) seems to be a relevant approach to improve the mother-baby relationship. In this review we have offered evidence suggesting a range of determinants of mother-infant relationship, including age, marital relationship, social disadvantages, migration, parental psychiatric disorders and the situations of abuse or neglect. Based on this theoretical background we constructed a theoretical model that included proximal and distal factors, risk and protective factors, including variables related to the mother, the father, their social support and mother baby interaction from early pregnancy until six months after birth. We selected the Antenatal Psychosocial Health Assessment (ALPHA) for use as an instrument to detect psychosocial risk during pregnancy. Method Ninety two pregnant women were recruited from the Maternal Health Consultation in Primary Health Care (PHC) at Amadora. They had three moments of assessment: at T1 (until 12 weeks of pregnancy) they filed out a questionnaire that included socio-demographic data, ALPHA, Edinburgh post-natal Depression Scale (EDPS), General Health Questionnaire (GHQ) and Sense of Coherence (SOC); at T2 (after the 20th weeks of pregnancy) they answered EDPS, SOC and MFA Scale (MFAS), and finally at T3 (6 months after birth), they repeated EDPS and SOC, and their interaction with their babies was videotaped and later evaluated using EA Scales. A statistical analysis has been done using descriptive statistics, correlation analysis, univariate logistic regression and multiple linear regression. Results The study has increased our knowledge on this particular population living in a multicultural, suburb community. It allow us to identify specific groups with a higher level of psychosocial risk, such as single or divorced women, young couples, mothers with a low level of education and those who are depressed or have a low SOC. The hypothesis that psychosocial risk is directly correlated with MFAS and that MFA is directly correlated with EA was not confirmed, neither the correlation between prenatal psychosocial risk and mother-baby EA. The study identified depression as a relevant risk factor in pregnancy and its higher prevalence in single or divorced women, immigrants and in those who have a higher global psychosocial risk. Depressed women have a poor MFA, and a lower structuring capacity and a higher hostility to their babies. In average, depression seems to reduce among pregnant women in the second part of their pregnancy. The children of immigrant mothers show a lower level of responsiveness to their mothers what could be transmitted through depression, as immigrant mothers have a higher risk of depression in the beginning of pregnancy and six months after birth. Young mothers have a low MFA and are more intrusive. Women who have a higher level of education are more sensitive and their babies showed to be more responsive. Women who are or have been submitted to abuse were found to have a higher level of MFA but their babies are less responsive to them. The study highlights the relevance of SOC as a potential protective factor while it is strongly and negatively related with a wide range of risk factors and mental health outcomes especially depression before, during and after pregnancy. Conclusions ALPHA proved to be a valid, feasible and reliable instrument to Primary Health Care (PHC) that can be used as a total sum score. We could not prove the association between psychosocial risk factors and MFA, neither between MFA and EA, or between psychosocial risk and EA. Depression and SOC seems to have a clear and opposite relevance on this process. Pregnancy can be considered as a maturational process and an opportunity to change, where adaptation processes occur, buffering risk, decreasing depression and increasing SOC. Further research is necessary to better understand interactions between variables and also to clarify a better operationalization of MFA. We recommend the use of ALPHA, SOC and EDPS in early pregnancy as a way of identifying more vulnerable women that will require additional interventions and support in order to decrease risk. At political level we recommend the reinforcement of Immigrant integration and the increment of education in women. We recommend more focus in health care and public health in mental health condition and psychosocial risk of specific groups at high risk. In PHC special attention should be paid to pregnant women who are single or divorced, very young, low educated and to immigrant mothers. This study provides the basis for an intervention programme for this population, that aims to reduce broad spectrum risk factors and to promote Mental Health in women who become pregnant. Health and mental health policies should facilitate the implementation of the suggested measures.

Integrated care approaches and skills mix policies in Europe

ABSTRACT - Background: Integration of health care services is emerging as a central challenge of health care delivery, particularly for patients with elderly and complex chronic conditions. In 2003, the World Health Organization (WHO) already began to identify it as one of the key pathways to improve primary care. In 2005, the European Commission declared integrated care as vital for the sustainability of social protection systems in Europe. Nowadays, it is recognized as a core component of health and social care reforms across European countries. Implementing integrated care requires coordination between settings, organizations, providers and professionals. In order to address the challenge of integration in such complex scenario, an effective workforce is required capable of working across interdependent settings. The World Health Report 2006 noted that governments should prepare their workforce and explore what tasks the different levels of health workers are trained to do and are capable of performing (skills mix). Comparatively to other European countries, Portugal is at an early stage in what integrated care is concerned facing a growing elderly population and the subsequent increase in the pressure on institutions and professionals to provide social and medical care in the most cost-effective way. In 2006 the Portuguese government created the Portuguese Network for Integrated Care Development (PNICD) to solve the existing long-term gap in social support and healthcare. On what concerns health workforce, the Portuguese government already recognized the importance of redefine careers keeping professional motivation and satisfaction. Aim of the study: This study aims to contribute new evidence to the debate surrounding integrated care and skills mix policies in Europe. It also seeks to provide the first evidence that incorporates both the current dynamics of implementing integrated care in Portugal and the developments of international literature. The first ambition of our study is to contribute to the growing interest in integrated care and to the ongoing research in this area by identifying its different approaches and retrieve a number of experiences in some European countries. Our second goal of this research is to produce an update on the knowledge developed on skills mix to the international healthcare management community and to policy makers involved in reforming healthcare systems and organizations. To better inform Portuguese health policies makers in a third stage we explore the current dynamics of implementing integrated care in Portugal and contextualize them with the developments reported in the international literature. Methodology: This is essentially an exploratory and descriptive study using qualitative methodology. In order to identify integrated care approaches in Europe, a systematic literature review was undertaken which resulted in a paper published in the Journal of Management and Marketing in Health care titled: Approaches to developing integrated care in Europe: a systematic literature review. This article was recommended and included into a list of references identified by The King's Fund Library. A second systematic literature review was undertaken which resulted in a paper published in the International Journal of Healthcare Management titled: Skills mix in healthcare: An international update for the management debate. Semi-structured interviews were performed on experts representing the regional coordination teams of the Portuguese Network for Integrated Care Development. In a last stage a questionnaire survey was developed based on the findings of both systematic literature reviews and semi-structured interviews. Conclusions: Even though integrated care is a worldwide trend in health care reforms, there is no unique definition. Definitions can be grouped according to their sectorial focus: community-based care, combined health and social care, combined acute and primary care, the integration of providers, and in a more comprehensive approach the whole health system. Indeed, models that seek to apply the principles of integrated care have a similar background and are continually evolving and depend on the different initiatives taken at national level. . Despite the fact that we cannot argue that there is one single set typology of models for integrated care, it is possible to identify and categorize some of the basic approaches that have been taken in attempts to implement integrated care according to: changes in organizational structure, workforce reconfiguring, and changes in the financing system. The systematic literature review on skills mix showed that despite the widely acknowledged interest on skills mix initiatives there is a lack of evidence on skills mix implications, constraints, outcomes, and quality impact that would allow policy makers to take sustained and evidence-based decisions. Within the Portuguese health system, the integrated care approach is rather organizational and financial, whereas little attention is given to workforce integration. On what concerns workforce planning Portugal it is still in the stage of analyzing the acceptability of health workforce skills mix. In line with the international approaches, integration of health and social services and bridging primary and acute care are the main goals of the national government strategy. The findings from our interviews clarify perceptions which show no discrepancy with the related literature but are rather scarce comparing to international experience. Informants hold a realistic but narrow view of integrated care related issues. They seem to be limited to the regional context, requiring a more comprehensive perspective. The questionnaire developed in this thesis is an instrument which, when applied, will allow policy makers to understand the basic set of concepts and managerial motivations behind national and regional integrated care programs. The instrument developed can foster evidence on the three essential components of integrated care policies: organizational, financial, and human resources development, and can give additional input on the context in which integrated care is being developed, the type of providers and organizations involved, barriers and constraints, and the workforce skills mix planning related strategies. The thesis was successful in recognizing differences between countries and interventions and the instrument developed will allow a better comprehension of the international options available and how to address the vital components of integrated care programs.

Sustainable urban planning: parameters to the operational process

In modern society, energy consumption and respect for the environment have become essential aspects of urban planning. The rising demand for alternative sources of energy, coupled with the decline in the construction sector and material usage, gives the idea that the thinking on modern cities, where attention is given to reduced energy consumption, savings, waste recycling and respect for the surrounding environment, is being put into practice. If we examine development of the city over recent centuries, by means of the theories of the most famous and influential urban planners, it is possible to identify the major problems caused by this type of planning. For this reason, in recent urban planning the use of systems of indicators that evaluate and certify land environmentally and energetically guides the master plan toward a more efficient city model. In addition the indicators are targeted on key factors determined by the commissioner or the opportunities the territory itself provides. Due the complexity of the environmental mechanics, the process of design and urban planning has become a challenging issue. The introduction of the indicators system has made it possible to register the life of the process, with a spiral route that allows the design itself to be refined. The aim of this study, built around the creation of a system of urban sustainability indicators that will evaluate highly eco-friendly cities, is to develop a certification system for cities or portions of them. The system will be upgradeable and objective, will employ real data and will be concerned with energy production and consumption.

Fostering e-participation sustainability through a BPM-driven semantic model

According to a recent Eurobarometer survey (2014), 68% of Europeans tend not to trust national governments. As the increasing alienation of citizens from politics endangers democracy and welfare, governments, practitioners and researchers look for innovative means to engage citizens in policy matters. One of the measures intended to overcome the so-called democratic deficit is the promotion of civic participation. Digital media proliferation offers a set of novel characteristics related to interactivity, ubiquitous connectivity, social networking and inclusiveness that enable new forms of societal-wide collaboration with a potential impact on leveraging participative democracy. Following this trend, e-Participation is an emerging research area that consists in the use of Information and Communication Technologies to mediate and transform the relations among citizens and governments towards increasing citizens’ participation in public decision-making. However, despite the widespread efforts to implement e-Participation through research programs, new technologies and projects, exhaustive studies on the achieved outcomes reveal that it has not yet been successfully incorporated in institutional politics. Given the problems underlying e-Participation implementation, the present research suggested that, rather than project-oriented efforts, the cornerstone for successfully implementing e-Participation in public institutions as a sustainable added-value activity is a systematic organisational planning, embodying the principles of open-governance and open-engagement. It further suggested that BPM, as a management discipline, can act as a catalyst to enable the desired transformations towards value creation throughout the policy-making cycle, including political, organisational and, ultimately, citizen value. Following these findings, the primary objective of this research was to provide an instrumental model to foster e-Participation sustainability across Government and Public Administration towards a participatory, inclusive, collaborative and deliberative democracy. The developed artefact, consisting in an e-Participation Organisational Semantic Model (ePOSM) underpinned by a BPM-steered approach, introduces this vision. This approach to e-Participation was modelled through a semi-formal lightweight ontology stack structured in four sub-ontologies, namely e-Participation Strategy, Organisational Units, Functions and Roles. The ePOSM facilitates e-Participation sustainability by: (1) Promoting a common and cross-functional understanding of the concepts underlying e-Participation implementation and of their articulation that bridges the gap between technical and non-technical users; (2) Providing an organisational model which allows a centralised and consistent roll-out of strategy-driven e-Participation initiatives, supported by operational units dedicated to the execution of transformation projects and participatory processes; (3) Providing a standardised organisational structure, goals, functions and roles related to e-Participation processes that enhances process-level interoperability among government agencies; (4) Providing a representation usable in software development for business processes’ automation, which allows advanced querying using a reasoner or inference engine to retrieve concrete and specific information about the e-Participation processes in place. An evaluation of the achieved outcomes, as well a comparative analysis with existent models, suggested that this innovative approach tackling the organisational planning dimension can constitute a stepping stone to harness e-Participation value.

Earthen plasters based on illitic soils from Barrocal region of Algarve: contributions for building performance and sustainability

Clayish earth-based mortars can be considered eco-efficient products for indoor plastering since they can contribute to improve important aspects of building performance and sustainability. Apart from being products with low embodied energy when compared to other types of mortars used for interior plastering, mainly due to the use raw clay as natural binder, earth-based plasters may give a significant contribution for health and comfort of inhabitants. Due to high hygroscopicity of clay minerals, earth-based mortars present a high adsorption and desorption capacity, particularly when compared to other type of mortars for interior plastering. This capacity allows earth-based plasters to act as a moisture buffer, balancing the relative humidity of the indoor environment and, simultaneously, acting as a passive removal material, improving air quality. Therefore, earth-based plasters may also passively promote the energy efficiency of buildings, since they may contribute to decreasing the needs of mechanical ventilation and air conditioning. This study is part of an ongoing research regarding earth-based plasters and focuses on mortars specifically formulated with soils extracted from Portuguese ‘Barrocal’ region, in Algarve sedimentary basin. This region presents high potential for interior plastering due to regional geomorphology, that promote the occurrence of illitic soils characterized by a high adsorption capacity and low expansibility. More specifically, this study aims to assess how clayish earth and sand ratio of mortars formulation can influence the physical and mechanical properties of plasters. For this assessment four mortars were formulated with different volumetric proportions of clayish earth and siliceous sand. The results from the physical and mechanical characterization confirmed the significantly low linear shrinkage of all the four mortars, as well as their extraordinary adsorption-desorption capacity. These results presented a positive correlation with mortars´ clayish earth content and are consistent with the mineralogical analysis, that confirmed illite as the prevalent clay mineral in the clayish earth used for this study. Regarding mechanical resistance, although the promising results of the adhesion test, the flexural and compressive strength results suggest that the mechanical resistance of these mortars should be slightly improved. Considering the present results the mortars mechanical resistance improvement may be achieved through the formulation of mortars with higher clayish earth content, or alternatively, through the addition of natural fibers to mortars formulation, very common in this type of mortars. Both those options will be investigated in future research.

Pulmonary function and aerobic capacity in asymptomatic bariatric candidates with very severe morbid obesity

PURPOSE: Aerobic capacity and respiratory function may be compromised in obesity, but few studies have been done in highly obese bariatric candidates. In a prospective study, these variables were documented in the preoperative period, aiming to define possible physiologic limitations in a apparently healthy and asymptomatic population. METHOD: Forty-six consecutively enrolled adults (age 39.6 ± 8.4 years, 87.0% females, body mass index /BMI 49.6 ± 6.3 kg/m² ) were analyzed. Ventilatory variables were investigated by automated spirometry, aerobic capacity was estimated by a modified Bruce test in an ergometric treadmill, and body composition was determined by bioimpedance analysis. RESULTS: Total fat was greatly increased (46.4 ± 4.6% of body weight) and body water reduced (47.3 ± 4.6 % body weight), as expected for such obese group. Spirometric findings including forced vital capacity of 3.3 ± 0.8 L and forced expiratory volume-1 second of 2.6 ± 0.6 L were usually acceptable for age and gender, but mild restrictive pulmonary insufficiency was diagnosed in 20.9%. Aerobic capacity was more markedly diminished, as reflected by very modest maximal time (4.5 ± 1.1 min) and distance (322 ±142 m) along with proportionally elevated maximal oxygen consumption (23.4 ± 9.5 mL/kg/min) achieved by these subjects during test exercise. CONCLUSIONS: 1) Cardiopulmonary evaluation was feasible and well-tolerated in this severely obese population; 2) Mean spirometric variables were not diminished in this study, but part of the population displayed mild restrictive changes; 3) Exercise tolerance was very negatively influenced by obesity, resulting in reduced endurance and excessive metabolic cost for the treadmill run; 4) More attention to fitness and aerobic capacity is recommended for seriously obese bariatric candidates;

The burden of chronic low back pain in the adult Portuguese population : an epidemiological population-based study under the scope of Epireumapt

RESUMO: Nos países desenvolvidos a lombalgia é a condição músculo-­‐esquelética mais prevalente. Quando evolui para um quadro crónico é responsável por um encargo económico bastante considerável, não só em relação aos indivíduos, mas também para a sociedade. A lombalgia crónica é por isso uma das principais causas de perda de produtividade e de perda de independência económica, nomeadamente através do absenteísmo (ausência do trabalho), do presenteísmo (perda de produtividade no trabalho, devido à capacidade diminuída provocada pela lombalgia) e da incapacidade para trabalhar (invalidez permanente, total ou parcial). Até à data, em Portugal, a prevalência e carga social da lombalgia crónica eram desconhecidas. Até agora não existiam estudos populacionais de grande dimensão sobre este tema. O objetivo principal desta tese foi determinar a prevalência de lombalgia crónica, e também avaliar a carga social que esta tem na população adulta Portuguesa. O trabalho de investigação foi desenvolvido no âmbito do Estudo Epidemiológico de Doenças Reumáticas em Portugal (EpiReumaPt). Este foi o primeiro estudo de larga escala e de base populacional, que determinou a prevalência de doenças reumáticas e músculo-­‐ esqueléticas na população adulta portuguesa. Foi realizado numa amostra aleatória e representativa, de 10.661 indivíduos do Continente, da Região Autónoma dos Açores e da Região Autónoma da Madeira, entre Setembro de 2011 e Dezembro de 2013. Esta tese foi dividida em duas secções. A primeira secção incluiu o detalhe das questões relativas ao desenvolvimento e gestão do EpiReumaPt, constituindo-­‐se como um guia prático sobre como realizar um estudo de base populacional de larga escala, em Portugal. A metodologia detalhada do EpiReumaPt foi também descrita nesta secção e incluiu os objectivos, o desenho do estudo, as características de recrutamento e a preparação de dados para análise. Nesta secção foram ainda descritos os principais resultados do EpiReumaPt. Estes evidenciaram que a lombalgia foi a condição músculo-­‐esquelética com maior prevalência na população adulta portuguesa.A segunda secção desta tese estimou a prevalência da lombalgia crónica ativa na população adulta Portuguesa, e avaliou a carga social esta condição. A lombalgia ativa foi definida com base na dor auto-­‐relatada no dia da entrevista e que persistia há pelo menos 90 dias (independentemente da causa). A lombalgia foi definida como dor na área definida entre a margem inferior das décimas segundas costelas até às pregas glúteas inferiores, com ou sem dor nos membros inferiores. A carga social foi medida tendo em conta os seguintes parâmetros: qualidade de vida, função, consumo de recursos de saúde, consumo de analgésicos e outros fármacos usados no alívio da dor, sintomas de ansiedade e sintomas de depressão. Os resultados mostraram que o consumo de recursos em saúde e a carga social da lombalgia crónica na população adulta Português é significativa. Também a incapacidade causada pela lombalgia crónica,nos indivíduos com idade ativa, é responsável por elevadas taxas de absenteísmo e má qualidade de vida, aos quais acresce o consequente ónus socioeconómico. Esta tese também concluiu que o consumo de analgésicos e outros medicamentos para alívio da dor, na população adulta portuguesa com lombalgia crónica ativa, é relativamente baixa. A maioria destes indivíduos não tomava nenhum medicamento analgésico, independentemente da intensidade da dor. Mesmo os indivíduos que reportaram dor intensa, apenas 4.0% estavam no primeiro degrau da escada analgésica da Organização Mundial de Saúde; 2.3% usavam opióides fracos e 0.03% usavam opióides fortes para controlar a dor (segundo e terceiro degrau da escada analgésica da Organização Mundial da Saúde). O trabalho de investigação também confirmou que a prevalência de sintomas de ansiedade e depressão entre os indivíduos adultos portugueses com lombalgia crónica ativa é elevada. Nestes indivíduos, registou-­‐se um consumo mais elevado de analgésicos e outros medicamentos para alívio da dor, quando comparados com os indivíduos com lombalgia crónica activa sem esses sintomas psicológicos. Os grupos terapêuticos mais utilizados foram os ansiolíticos, sedativos e hipnóticos, os antidepressivos e os anti-­‐inflamatórios não esteróides. A intensidade média da dor reportada foi também maior entre os indivíduos com lombalgia ativa e sintomas de ansiedade e/ou depressão. Também nestes, foi reportada pior função e pior estado de saúde. Em relação ao consumo de recursos de saúde foram encontradas diferenças significativas entre as duas populações: os indivíduos com lombalgia ativa e sintomas psicológicos concomitantes registaram maior número de consultas de psiquiatria de outras especialidades médicas, assim como precisaram de mais apoio domiciliário nos 12 meses prévios à entrevista do EpiReumaPt. Foram também identificados os fatores associados a sintomas isolados de ansiedade, a sintomas isolados de depressão e a sintomas de ansiedade e depressão. Resumindo,esta tese permitiu concluir que a lombalgia crónica é um problema de saúde comum na população adulta portuguesa, contribuindo para um elevado grau de incapacidade e que consequentemente afeta o desempenho laboral e o bem-­‐estar dos indivíduos. A lombalgia crónica é também responsável por um consumo considerável de recursos de saúde. Acresce ainda que os sintomas de ansiedade e depressão são comuns, entre os indivíduos com lombalgia crónica, contribuindo com uma carga social adicional.---------------------------------- ABSTRACT:Low Back Pain(LBP) is the most prevalent of musculoskeletal condition in developed countries.When it becomes chronic, LBP causesan enormous economic burden on individuals and society -­‐ it is one of the leading causes of loss of productivity and economic independence through absenteeism (time off work), presenteeism (lost productivity because of diminished capacity while at work) and work disability (permanent, partial or complete disablement for work purposes). In Portugal the prevalence and burden of LBP and chronic LBP (CLBP) were poorly defined. Until now no large population-­‐based studies have focused on this. The main aim of this thesis was to determine the prevalence of LBP and CLBP, and also to assess the burden of CLBP in the adult rtuguese population. The research work was developed under the scope of EpiReumaPt (the Portuguese Epidemiologic Study of Rheumatic Diseases). EpiReumaPt was the first national large population-­‐based and prevalence study of rheumatic and musculoskeletal diseases (RMD). It was performed among a randomized and representative sample of 10,661 adult Portuguese subjects recruited in Mainland, Azores and Madeira Islands, from September 2011 to December 2013. The first section of this thesis included detailed issues regarding the development and management of EpiReumaPt, and provided a practical guide on how to set-­‐up a large population-­‐based study in Portugal. The detailed methodology of EpiReumaPt, including its objectives,study design,recruitment features,and data preparation for analyses were also described. The main results from EpiReumaPt study were provided in this section and showed that LBP was the musculoskeletal condition with highest prevalence among Portuguese population. The second section of this thesis estimated the prevalence of active CLBP among adult Portuguese population, and assessed the social burden of this condition. Active CLBP was defined based on self-­‐reported pain on the day of the interview, and for most of the time for at least 90 days (independently from cause). LBP was defined as pain in the back area from the lower margin of the twelfth ribs to he lower gluteal folds, with or without pain referred to the lower limbs. Social burden was measured taking into account the following outcomes: quality of life, function, healthcare resources consumption, analgesic and other pain relief drugs intake, anxiety and depression symptoms. Results showed that the healthcare consumption and social burden of CLBP among adult Portuguese population were enormous, and the disability caused by CLBP among subjects in a working age provides high rates of absenteeism (work loss) and poor quality of life, with a consequent socioeconomic burden. This thesis also concluded that analgesic and other pain relief drugs untake among adult Portuguese population with active CLBP was very low. Most of the subjects with active CLBP did not take any analgesic drug regardless pain severity. Even when subjects self-­‐reported severe pain, only 24.0% were in the 1st step of the analgesic ladder,2.3% used weak analgesic opioids and 0.03% used strong opioids (2nd and 3rd step of WHO analgesic ladder, respectively) to control pain . The research work also confirmed that the prevalence of anxiety and depression symptoms among adult Portuguese subjects with active CLBP was high. Regarding pharmacological therapy, the intake of analgesic and other pain relief drugs was higher among subjects with anxiety and/or depression symptoms, when compared with subjects without these psychological symptoms. Anxiolytics, sedatives and hypnotics, antidepressants and NSAIDs intake had higher usage rates among these subjects. The pain severity mean was also higher among this subjects and function and health status was worse. Regarding healthcare resources consumption,significant differences between the two populations were found. Subjects with ctive CLBP and concomitant psychological symptoms had a higher number of psychiatrist and other physician visits. They also needed more home care in the previous 12 months. Factors associated with isolated symptoms of anxiety, depression,and concomitant anxiety and depression symptoms were also identified. Summarizing, we concluded that CLBP is a common health problem among adult Portuguese population contributing to disability and affecting labor performance, and the well being of subjects. it is also responsible for considerable healthcare resource consumption. Anxiety and depression symptoms are common among subjects with CLBP and provided an additional burden among them.

Caracterização da carga da doença arterial periférica dos membros inferiores : contributos para um melhor conhecimento do peso desta doença no internamento hospitalar

RESUMO - A doença arterial periférica (DAP) apresenta uma carga de doença significativa, afetando cerca de 3 a 10% da população em geral e 15 a 20% dos indivíduos com idade superior a 70 anos. A sua prevalência em Portugal foi estimada em cerca de 5,9% no continente; 6,6% na Região Autónoma dos Açores (RAA) e 3,8% na Região Autónoma da Madeira (RAM). Para além da importante carga de doença, quer em termos epidemiológicos, quer económicos, a DAP confere aos seus portadores um risco cardiovascular agravado, sendo que os mesmos apresentam cerca do triplo do risco de mortalidade e de eventos cardiovasculares quando comparados com indivíduos sem DAP. Tratou-se de um estudo observacional, transversal e descritivo tendo como base duas populações de estudo. A primeira é referente aos hospitais do Serviço Nacional de Saúde (SNS) com a valência de cirurgia vascular e a segunda à população portuguesa com episódios de internamento por diagnóstico de DAP dos membros inferiores (MI) nos anos de 2013 e 2014 na totalidade dos hospitais do SNS. Através da análise dos resultados do questionário procedeu-se à descrição de algumas das características dos serviços e unidades de cirurgia vascular de sete hospitais do SNS; através da análise da base de dados dos GDH para os anos de 2013 e 2014 procedeu-se à caracterização do peso do internamento por DAP dos membros inferiores a nível nacional no mesmo período. A DAP tem uma carga significativa e atendendo aos seus fatores de risco e história natural da doença, apresenta uma tendência crescente durante os próximos anos, representando por isso um enorme desafio para os sistemas de saúde. São, no entanto, necessários estudos mais aprofundados sobre o tema que permitam conhecer melhor o peso desta patologia e, de forma global, melhorar o planeamento, tendo por base a caracterização quer do lado da procura (dados epidemiológicos e peso no internamento), quer da oferta (capacidade instalada).