frequently asked questions

  • Clinical analysis

    • Urinary Tract Infections

      • 1. Causes of Urinary Tract Infections


        Urinary infections are caused by bacteria normally found in the vagina and intestine. They are more common in women than in men. In the female body, the anus is very close to the opening of the urethra, the tube which carries urine out of the body. The proximity of these two apertures facilitates the passage of bacteria from the anus to the vagina and urethra and from then onto the bladder. They can also be carried to the bladder during intercourse, because of the movement.

      • 2. How common are they?

        Some studies say that about 43% of women between the ages of 14 and 61 will have at least one urinary tract infection. These infections are more common in sexually active women between 20 and 50 years old or in those with diabetes or other diseases that lead to decreased immunity.

      • 3. Does the urinary system protect us from infections?

        The urinary system rids the body of some toxins produced daily. The urine is filtered by the kidney, moves on into the ureters and then on to the bladder and the urethra. The wellbeing of the urinary tract is essential in women of all ages to prevent infection and enable intercourse.

        Spermicides and diaphragms can increase the risk of urinary tract infection. If you use any of these methods, talk to your doctor about the possibility of using other types of birth control.

      • 4. What are the symptoms of a urinary tract infection?

        The most common symptoms of a urinary tract infection include:

        • Sudden urge to urinate;
        • Need to urinate more frequently than usual;
        • Burning sensation, cramps or uncomfortable pain when urinating or immediately afterwards;


        Urinary tract infections, particularly in older women, often affect the lower urinary tract; these are called bladder infections or cystitis. Urinary incontinence can also be a symptom.

      • 5. How serious are urinary tract infections?

        In most cases, urinary tract infections are easily and quickly treated. However, an untreated infection can become a serious situation when the kidney becomes involved. As such, women with recurrent urinary infections (i.e., more than three episodes per year) should take antibiotics for longer periods of time or may require intravenous antibiotics.

      • 6. Should I seek medical attention?

        You should seek a doctor to perform a correct diagnosis and treatment of the disease. Several diseases, namely sexually transmitted diseases, may present symptoms similar to urinary tract infections but require different treatments. A urine test (microbiological examination of urine) may be necessary to confirm if there is infection or to analyze which microorganism is responsible.  If the infection is infrequent or rare, this may not be necessary.

      • 7. Which is the most appropriate antibiotic?

        In general, the best antibiotic for a urinary tract infection is one that heals and has few side effects. The decision to choose one antibiotic over another depends on several factors, including the effectiveness of the antibiotic, side effects, price and bacterial resistance.

        Your doctor will likely ask you several things before prescribing it, specifically:

        • Are you on the pill?
        • Are you trying to get pregnant?
        • Are you pregnant or nursing?
        • Are you allergic to penicillin or other drugs?
        • Have you experienced side effects from antibiotics in the past?
        • Have you ever taken an antibiotic that was not effective?
        • Are you taking any other medication?
        • Do you have other coexisting medical conditions (namely kidney, liver or lung issues)?
      • 8. Will I experience side effects?

        Like any other drug, antibiotics produce side effects, although they are rare and short-lived. The most common are nausea, headache, dizziness and light sensitivity. Antibiotics can unbalance the level of bacteria that we usually have in the body, causing diarrhea or infections, for example, or fungi. It is important that you notify your physician of any side effects that may arise and discuss the problem with them.

      • 9. Do I have to take all the medication?

        In isolated or sporadic infections the physician prescribes one to three days of therapy and in more frequent infections the oral antibiotic therapy may be prescribed for two weeks or more, depending on the type of drug selected. The treatment is carried out for eight weeks to six months, when prophylaxis of new urinary infections is done. You should drink plenty of fluids during the treatment. Check if the antibiotic should be taken with food or on an empty stomach and do not stop the medication before the end of the treatment, even if you feel better after a few days, as the infection may not be totally quelled and you may develop another.

      • 10. How to prevent urinary tract infection.

        Here are some suggestions for preventing urinary infections:

        • Drink at least eight cups of water per day, to dilute the concentration of bacteria in the urinary tract (this is particularly important for women who work outside the home and tend to restrict fluid intake during the day);
        • Urinate often (every 2 or 3 hours) or whenever you feel the need;
        • Avoid using tight clothes and use cotton underwear;
        • Maintain a sound daily hygiene: clean the area around the vagina and anus after urination and defecation, taking care to wipe from front to back to avoid contamination;
        • If you are going through menopause ask your doctor about estrogen treatments for vaginal and urethral atrophy, in an effort to reduce the risk of urinary infections. Sexually active women should take some precautions: wash your hands and pubic area before sex and urinate afterwards.
      • 11. How is the urine sample collected for microbiological examination?

        While it is best if the sample collected is from the first urine of the morning, it may be collected at any time.

        Due to the possibility of contaminating the urine with bacteria and skin cells from the surrounding areas during collection (particularly in women), it is important to first clean the genitals. As you start to urinate, let some urine fall into the toilet (this first portion of the flow washes by dragging most of the impurities in the urethra), then collect the middle portion of urine in the sterile container provided (the middle portion represents the bladder´s flora), and reject the rest into the toilet. This type of sampling is known as midstream specimen.

      • 12. The lab called to inform me they need a new urine sample, because the first one was contaminated. What happened?


        If the skin and genital area are not cleaned thoroughly before the collection, the urine culture may develop three or more different types of bacteria, which is assumed to be contamination. The culture will be rejected because it is not possible to determine if the bacteria originated in the urinary tract or outside. A contaminated sample can be avoided by following the instructions to clean thoroughly before sampling and collect the urine through the midstream specimen technique.

      • 13. My doctor said I had symptoms of a urinary tract infection and prescribed antibiotics without doing a urine culture. Why?

        The reason for this is that most urinary tract infections are caused by bacteria known as Escherichia coli (E. coli). This microorganism is usually sensitive to a range of antibiotics such as trimethoprim/sulfamethoxazole, ciprofloxacin, and nitrofurantoin. In most patients with uncomplicated urinary tract infections, this will be resolved after empiric therapy with one of these antibiotics.

    • Thyroid Diseases

      • 1. What is the Thyroid?

        The thyroid is a small gland, about five centimetres in diameter, located in the neck underneath the skin and below the Adam's apple. Its shape resembles a butterfly and it is made up of two lobes, right and left, joined by a central portion called the isthmus. Each lobe is about 4 cm long and 1 to 2 cm wide.

      • 2. What does the thyroid do?

        This gland has a very important role, since it controls the body's metabolism, i.e. the rate at which the body uses energy.

        This is accomplished through the synthesis of thyroid hormones, Thyroxin (T4), mainly, and Triiodothyronine (T3), which travel through the bloodstream to all parts of the body.

        In addition, also the thyroid gland synthesizes calcitonin, a hormone that helps to regulate calcium levels in the blood by inhibiting bone resorption and increasing calcium excretion through the kidneys.

      • 3. What is the role of the thyroid hormones?

        Thyroid hormones are essential to life and have a major role in the regulation of body function. They have various effects on the metabolism, growth and development of the organism. They contribute to the regulation of body temperature, heart rate, blood pressure, intestinal function, weight control and mood, among other functions. The blood carries them through the bloodstream to all body cells where they attach themselves to receptors located in the cells on which they act, triggering a response from them and influencing their metabolism.

        Thyroid diseases result from changes in gland function, i.e., when hormones are produced in inadequate quantity. We may be dealing with Hyperthyroidism when there is an increased gland activity, seeing as Hypothyroidism is characterized by decreased thyroid function.

      • 4. What are the end products of the thyroid gland synthesis?

        The T4 (Thyroxin) is the main hormonal product of the thyroid gland. Most of the T4 is stored within the thyroid, connected to a protein called thyroglobulin. When needs grow, the thyroid synthesizes more T4 and/or releases part of which is in store into the bloodstream.

        The T4 has a half-life of approximately 2-3 days and is converted to T3 in the peripheral tissues. Approximately 20% of the T3 is formed in the thyroid gland, but about 80% of it is produced by conversion from the T4 in the peripheral tissues (especially in the liver and kidney). The T3 has a half-life of approximately 1 day. Once produced, the T3 enters the core of the cells of the target tissues.


      • 5. How are the thyroid hormones transported in the bloodstream?

        Once formed and secreted, thyroid hormones bind themselves to three proteins in the bloodstream:75% to the thyroxin-binding globulin (TBG), 15% to the transthyretin (TTR, previously known as thyroxine-binding prealbumin) and 10% to the albumin.

        Changes in the carrier proteins (as occurs in pregnancy and liver disease) affect the levels of total thyroid hormones in the blood and result in abnormal numbers.

        Thyroid hormones circulate in the blood as either protein-bound forms or as free forms. Usually, 0.02% of the T4 and 0.3% of the T3 are free. There is a dynamic balance in place between these two forms. Tissue activity of thyroid hormones is mainly due to the free hormone, although any bound hormone is also available for use. In most tissues, the circulating free T3 (FT3) is chiefly responsible for the biological effect and speed control of body functions.

      • 6. How is the thyroid regulated?

        The body has a complex regulatory system in the background to control the amount of T4 and T3 in the blood. When the concentration levels of thyroid hormones in the blood decline, the hypothalamus (organ located in the brain) releases TRH (thyrotropin-releasing hormone), which in turn acts upon the hypophysis (a small gland located below the hypothalamus, the base of the brain and nearly in the centre of the head) causing the release of TSH (thyrotropin or thyroid-stimulating hormone). The TSH stimulates the thyroid to produce and release more thyroid hormones. When the levels of thyroid hormones are elevated, the hypothalamus and the hypophysis decrease the release of TRH and TSH respectively, in order to reduce the thyroid’s production of T3 and T4.

        The hypophysis and the hypothalamus are thus a kind of sensor, sensitive to the levels of thyroid hormones in circulation. Under normal circumstances, the TSH controls the thyroid gland activity. The hypophysis responds to the need for additional thyroid hormones, secreting TSH which stimulates the production and secretion of thyroid hormones. Excessive amounts of T4 and T3 suppress the secretion of TSH.

        As a result, primary hyperthyroidism is characterized by high levels of thyroid hormones and suppressed TSH, while primary hypothyroidism is characterized by inverse changes. Secondary hypothyroidism (hypothalamic or hypophysial disease) is characterized by subnormal concentrations of thyroid hormones and subnormal or inappropriately normal levels of TSH. Secondary hyperthyroidism is characterized by high levels of thyroid hormones and high or inappropriately normal levels of TSH.

      • 7. What are thyroid diseases and how do they occur?

        Thyroid diseases are the result of changes in the gland function that cause the production of hormones in inadequate quantity.

        The main thyroid disorders are functional. They include hypothyroidism, in which there is an insufficient synthesis of thyroid hormones, which leads to a slowing down of the body's functions, and hyperthyroidism, when the thyroid produces too many thyroid hormones, and wherein there is an acceleration of all body functions.

        Structural disorders include changes that cause the thyroid volume to increase, a situation known as goitre. The presence of nodules makes it advisable to carry out medical examinations that enable the identification of those which, being malignant, require special attention.

      • 8. What are the signs and symptoms?

        In general, Hypothyroidism shows no symptoms and it can only be diagnosed through analysis. In more pronounced cases the warning signs are:

        • Struggling to think;
        • Increased sensitivity to cold;
        • Fatigue;
        • Tiring easily;
        • Dry skin, thin and brittle hair;
        • Weight gain;
        • Swollen eyelids and tongue;
        • Constipation;
        • Irregular menstrual periods (in women);

        In children, hypothyroidism can cause a delay in growth and normal sexual development, as well as mental retardation. That is why this disease is part of the neonatal screening, since there is an effective treatment and early detection minimizes complications.

         Hyperthyroidism is characterized by:

        • Palpitations, nervousness, anxiety, irritability, insomnia;
        • Increased heart rate (> 100 per minute);
        • Trembling hands;
        • Weight loss despite increased appetite;
        • Excessive sweating and heat intolerance;
        • Hair loss, thin skin and nail changes;
        • Diarrhoea;
        • Irritation and swelling around the eyes;
        • Bright and fixed gaze and/or prominent eyes (bulging eyes);
        • Sensitivity to light or visual changes.
      • 9. Are there any risk factors?

        Thyroid diseases are very common, but they are more frequent in women and tend to increase with age.

        The prevalence of hyperthyroidism in women is approximately 1.3%, increasing to about 4 to 5% in elderly women.

        Graves’ disease is a variant of hyperthyroidism, resulting from an autoimmune disease, and it is more common in young women. On the contrary, toxic multinodular goiter (with hyperthyroidism) is more common in elderly women.

        As for hypothyroidism, it is in 5 to 8 times more common in women than in men.

        Iodine deficiency, common during pregnancy and childhood, can cause thyroid disease.

      • 10. What are the most common thyroid diseases?

        The most common thyroid diseases are:

        Graves’ disease – This is the most common cause of hyperthyroidism. Graves’ disease is a chronic autoimmune disorder in which the immune system of the affected person fails to recognize itself and starts producing antibodies that attack the thyroid, causing inflammation, damage, and the production of excessive amounts of thyroid hormones.

        Hashimoto's Thyroiditis - This is the most common cause of hypothyroidism. Much like Graves’ disease, Hashimoto's Thyroiditis is a chronic autoimmune disorder in which the organism's defences fail to recognize the thyroid as part of the body and attack it as if it were a foreign entity. However, in Hashimoto's Thyroiditis, as the thyroid is being damaged, it loses the ability to release hormones in sufficient quantity, creating the hypothyroidism.

        Thyroid Nodules - A thyroid nodule is a small lump in the thyroid gland that may be solid or a cyst filled with fluid. They are very frequent injuries and can be diagnosed through cervical palpation or by ultrasound. At least about 4% of women and 1% of men will have at least one thyroid nodule throughout their life; most of them are benign. However, on some occasions, thyroid nodules can be cancerous. The differential diagnosis of these can only be performed through fine-needle aspiration biopsy and cytology.

        Thyroiditis - These form a group of clinical conditions characterized by the inflammation of the thyroid and may be associated with both hypothyroidism and hyperthyroidism. They often cause pain in the neck, but it may not happen. Its main causes are: autoimmune, infection, exposure to chemicals toxic to the thyroid, or other unknown reasons. Depending on the cause, it may be acute, transient or chronic.

        Thyroid Cancer - Thyroid Cancer is very uncommon, affecting 1 in 1,000 people. There are basically four types of thyroid cancer:

        • Papillary thyroid cancer - Comprises about 60-70% of all thyroid cancers. This type of cancer is more common in women than in men, especially in young people;
        • Follicular thyroid cancer - Responsible for approximately 15% of all cases. It is the most aggressive form, which usually affects women in old age.
        • Anaplastic thyroid cancer - Also primarily affects women in old age. It represents 5% of thyroid cancers. It is a very aggressive form of cancer and treatment is difficult.
        • Medullary thyroid cancer (MTC) - It is a neuroendocrine tumour of the parafollicular cells, or C cells, and represents 4% of thyroid carcinomas. One of the features of these tumours is the production of calcitonin. MTC can be found along with other endocrine carcinomas in a syndrome called Multiple Endocrine Neoplasia (MEN).
      • 11. How common is Hypothyroidism?

        Hypothyroidism is relatively common, affecting 2-3% in the general population. The average age at diagnosis is approximately 55 years old. Hypothyroidism is much more common in women; the ratio of female to male subjects is 10:1. Postpartum hypothyroidism, a transitional hypothyroid phase after pregnancy, is found in 5-10% of women.

      • 12. What is subclinical hypothyroidism?

        Subclinical hypothyroidism is a mild and more frequent form of hypothyroidism, usually with few to no symptoms. Up to 10-20% of women over 50 have subclinical hypothyroidism. There is an association with hypercholesterolemia and subtle cardiac abnormalities. From the biochemical point of view, the total thyroxin (total T4) and free T4 levels are normal, whereas the TSH levels are slightly elevated.

        When treated with thyroxin, patients start to feel better, and the cardiac and lipid abnormalities disappear. Anti-thyroid antibodies, one of the indicators of thyroid autoimmune disease, may help predict which patients will progress to clinical hypothyroidism; it is recommended that patients with minimally elevated levels of TSH are subjected to testing. 

      • 13. What can cause hypothyroidism?

        Hypothyroidism can be caused by several disorders. The two most common causes are chronic lymphocytic thyroiditis (Hashimoto's disease), an autoimmune form of thyroid destruction, and radioiodine induced hypothyroidism, after treatment of Grave's disease (autoimmune hyperthyroidism). Postpartum thyroiditis occurs in approximately 10% of women; two-thirds of which undergo a transitional hypothyroid phase (6-12 months) which requires treatment.

        Other less common causes of hypothyroidism include: subacute thyroiditis, external irradiation of the neck, medications (anti-thyroid drugs, amiodarone, interferon), infiltrative diseases, central hypothyroidism (hypophysial / hypothalamic), birth defects and endemic goitre (iodine deficiency).

      • 14. What are the best tests to confirm a hypothyroidism diagnosis?

        There are several thyroid function tests available to doctors, including TSH, Total T4, Total T3, Free T4 and Free T3 determinations.

        In an outpatient setting, only one test is generally necessary: TSH evaluation. TSH, synthesized and secreted by the anterior pituitary, is the most sensitive indicator of thyroid functioning. Essentially, one can say: if the TSH is normal, the patient is euthyroid; if the TSH is elevated, the patient has primary thyroid insufficiency.

        The physician should have some caution when interpreting total T4 levels. Many conditions not related to thyroid disease lead to the emergence of low or high levels of total T4, as more than 99% of the T4 is attached to proteins, and total T4 levels depend on the amount of proteins carrying thyroid hormones which are subject to a large variation

      • 15. How is hypothyroidism treated?

        Hypothyroidism is treated through administrating thyroid hormone in the form of Levothyroxin (LT4), to provide the organism with the amount of hormones that it has become unable to produce.

        Other thyroid hormone preparations include triiodothyronine (LT3) which is reserved for special cases, due to its potency and its short half-life.
      • 16. Follow up

        Most cases of hypothyroidism are final, there is no cure.

        However, as long as the treatment is well done, the patient will not have any symptoms. The proper dosage of LT4 (Levothyroxin) can vary over time within the same person, which requires continued monitoring, so that the dosage can be adjusted. Young and otherwise healthy patients can start the medication with total doses of LT4 replacement (1.6 µg/kg). Elderly patients and those with known or suspected heart disease should start medication in low doses of LT4, which will gradually increase every 2-3 months until the TSH is normal.
      • 17. Which thyroid disorders are most often associated with hyperthyroidism?

        It is important to establish the difference between primary and secondary forms of hyperthyroidism. Primary hyperthyroidism is due to the hyperactivity of the thyroid gland and comprises the vast majority of cases. Secondary hyperthyroidism is a less common problem, which, on rare occasions, may result from a pituitary tumour secreting a thyroid stimulating hormone, or excessive thyroid hormone supplementation.

        Three forms of primary hyperthyroidism account for the vast majority of cases:

        1. Graves’ disease
        2. Toxic multinodular goiter
        3. Solitary Toxic Nodule
      • 18. How is primary hyperthyroidism diagnosed?

        Since primary hyperthyroidism results from the hypersecretion of thyroid hormones, thyroxin (T4) and/or triiodothyronine (T3) levels are high. Moreover, suppression of the pituitary leads to a low or undetectable level of TSH in the blood.
        Subsequently, other tests may be required to know and differentiate the causes: determination of antibodies, thyroid scintigraphy or ultrasound.
        With thyroid scintigraphy and in the case of Graves' disease, the distribution of the tracer is uniform throughout the gland, whereas in the multinodular goitre the distribution is heterogeneous and almost completely restricted to a node in patients with toxic solitary nodule.
      • 19. How is hyperthyroidism treated?

        There are three types of treatment and your doctor can explain the risks and benefits of each one. The goal is to stop the excessive production of thyroid hormones.

        1. Antithyroid drugs:
          In Portugal there are drugs that can decrease the production of thyroid hormones. Some patients may achieve a remission with prolonged treatment (12-18 months), although others can only reach a temporary control. There may be some side effects (skin reactions, liver abnormalities, reduced white blood cells) and its intake should be monitored and controlled by an endocrinologist.
        2. Radioactive iodine:
          This results in a final resolution of hyperthyroidism. It is administered orally (usually in capsules) and destroys the thyroid cells as it infiltrates them. Its maximum effect is observed 3-6 months after the administration. Occasionally hyperthyroidism remains and a second dose is required. More often it results in hypothyroidism (less active gland) and a thyroid hormone replacement is necessary. It is difficult to calculate the exact dose of iodine necessary to achieve a normal thyroid function. This method has been used for a long time and does not have any major complications.
        3. Surgical treatment:
          In some cases it is necessary to surgically remove part of (toxic nodule) or the entire gland (Graves' disease or toxic multinodular goiter). If it is completely removed, hypothyroidism arises and it is necessary to take a thyroid hormone for the rest of your life. 
      • 20. What are some of the characteristics of antithyroid drugs?

        Most types of hyperthyroidism, including Graves’ disease, can be effectively treated with antithyroid drugs of the thyonamide group. These drugs inhibit the synthesis of thyroid hormones. Approximately 20-50% of patients achieve remission with these drugs.
        Severe side effects are rare, but granulocytopenia, skin rashes and liver toxicity are possible. In order to reduce these complications, it is important to monitor liver function tests periodically and alert the patient to seek medical attention if they present new skin rashes or any sign of infection. Moreover, we think it is necessary to perform a complete blood count with differential white cell count, every 2-4 weeks, during the administration of antithyroid drugs. A gradual decline in the number of white blood cells may indicate the beginning of granulocytopenia.
      • 21. How important are radioactive iodine and surgery in the treatment of hyperthyroidism?

        The most common treatment of Graves’ disease is radioactive iodine. The desired outcome of this therapy is hypothyroidism, due to the complete destruction of the gland, which usually occurs within 2-3 months. It is important to monitor thyroid function tests and provide additional L-thyroxine, since the gland is completely destroyed, hypothyroidism comes to light.

        Radioactive iodine is generally well tolerated, but there may be severe signs and symptoms of thyrotoxicosis 1-2 weeks after therapy.

        Surgery is not usually indicated for Graves’ disease, but it may be appropriate in the presence of a thyroid nodule if the physician suspects that it is a carcinoma.

      • 22. What is subacute thyroiditis?

        Subacute thyroiditis is an inflammation of the thyroid gland which often occurs in association with upper respiratory tract infections. Patients typically have a painful gland of increased size. In the natural history of this disorder, an early stage of hyperthyroidism, due to the release of thyroid hormones from the damaged thyrocytes, is followed by a hypothyroidism phase and, finally, by a return to euthyroid and the restoration of normal glandular function. Not all patients manifest this phase. The disease usually completes its course in 2-3 months. The symptomatic treatment of the hyperthyroidism and hypothyroidism phases is advisable.

      • 23. What is the natural history of subacute thyroiditis?

        Subacute thyroiditis is likely of viral origin. Although clinical recovery usually occurs, serum thyroglobulin levels remain high, and intrathyroid iodine content remains low for several months. Patients are also more susceptible to iodine-induced hypothyroidism, subsequently. These findings suggest the persistence of subclinical abnormalities after an episode of subacute thyroiditis.

      • 24. What is postpartum thyroiditis?

        Postpartum thyroiditis disorder is often seen in women (about 5-10%) after delivery. Its cause is unknown. Its course, like subacute thyroiditis, consists of three phases: an initial stage of hyperthyroidism, followed by an intermediate stage of hypothyroidism and, subsequently, euthyroid. This disorder is usually resolved within 1 year or less after delivery. However, as in the case of subacute thyroiditis, recurrent episodes can result in permanent hypothyroidism.
        Postpartum thyroiditis is common, occurring in about 5-10% of women during the postpartum period. It may present itself as depression, and should be differentiated from postpartum depression. Many other signs and symptoms wrongly attributed the birth and care of the baby may be related to abnormalities in thyroid function.
      • 25. How common is postpartum thyroiditis?

        After delivery, 5-10% of women develop biochemical evidence of thyroid dysfunction. About one-third of affected women develops symptoms (usually hypothyroidism) and is treated with L-thyroxine for a period of 6 to 12 months.

      • 26. What are the differences between subacute thyroiditis and postpartum thyroiditis?

        Patients with subacute thyroiditis exhibit pain in the thyroid region, high erythrocyte sedimentation rate and a transient increase in thyroid antibodies. Most of it is positive for the HLA-B35 antigen and histological examination shows the presence of giant cells and granulomas in the thyroid.
        In the post-partum condition there is no pain, the erythrocyte sedimentation rate is normal, and thyroid antibodies are positive both before and after the episode. The prevalence of HLA-DR3 and HLA-DR5 antigens is increased and histological examination shows lymphocytic infiltration of the thyroid gland.
      • 27. Why do some women develop postpartum thyroiditis?

        It is believed that women who develop postpartum thyroiditis are carriers of underlying asymptomatic autoimmune thyroiditis. During pregnancy, the maternal immune system is partially suppressed, and there is a dramatic increase in thyroid antibodies after birth. Although it is not believed that antimicrosomal antibodies are cytotoxic, they are currently the most reliable marker of susceptibility to postpartum illness.

      • 28. In patients carrying postpartum thyroiditis, does the thyroid function return to normal, like in subacute thyroiditis?

        Not always. Approximately 20% of women suffer permanently from hypothyroidism, and an equal amount shows slight persistent abnormalities.

      • 29. Which lab tests are essential for thyroid disorders?

        It depends on the type of disorder.

        The most sensitive thyroid dysfunction test is TSH. Because of the existent log/linear relationship between TSH and FT4, we should not expect an abnormal FT4, unless the TSH is >10 mIU/L or <0.05 mIU/L.

        Anti-TPO antibodies are the most sensitive indicator for autoimmune thyroid.

        The T3 is used in some cases, when it is necessary to determine the etiology of hyperthyroidism [the ratio of T3/T4 is high (>20:1) in the case of Graves’ hyperthyroidism].

        TSH and anti-TPO antibodies are important in the evaluation of thyroid dysfunction during preconception and pregnancy.

        Thyroglobulin is used as a tumour marker for thyroid cancer.

    • Vitamin D

      • 1. What is Vitamin D and how does it operate in our body?

        Vitamin D is a general name given to a group of liposoluble compounds that are essential for maintaining the mineral balance in the body. It is also known as calciferol. Its main forms are known as:

        • Vitamin D3 (cholecalciferol: of animal origin), formed by the action of ultraviolet light in the vitamin D precursors in the skin;
        • Vitamin D2 (ergocalciferol: of vegetable origin) less potent than D3.

        Vitamin D is metabolized in the liver to form 25-hydroxyvitamin D or 25(OH)D; this is the most abundant metabolite in the circulation and serves as an indicator of the amount of vitamin D.

        In the kidney, 25(OH)D is converted to 1,25-dihydroxyvitamin D or 1,25(OH)2D or Calcitriol, which is the hormonal form of vitamin D. Its secretion is stimulated by a decreased amount of serum calcium or the increase of the parathyroid hormone (PTH).

        The main function of 1,25(OH)2D is to maintain the calcium homeostasis, promoting bone mineralization, by increasing the calcium and phosphorus from the diet, at an intestinal level, and mobilizing calcium from bones.

        Recent studies show that apart from kidney cells, many others have the enzyme that synthesizes 1,25(OH)2D.

        Many of these cells also possess vitamin D receptors, which facilitates the action of the active hormone. 

        In the extrarenal system, calcitriol controls the expression of over 200 genes involved in cellular differentiation, replication and immunity. These features of vitamin D are currently being actively researched. 

      • 2. What are the sources of vitamin D?

        The largest source of vitamin D in the human body is endogenous production through exposure to sunlight. Exposing your arms and legs to sunlight for 5 to 30 minutes between 10 a.m. and 3 p.m., twice a week, is often enough. Sunscreen, so important for protection against skin cancer, blocks the formation of this vitamin.

        Other natural sources rich in vitamin D are fish liver oils and saltwater fish such as sardines, herring, salmon and Atlantic bonito.

        Eggs, meat, milk and butter also contain small amounts.

        Plants are weak sources and fruit and nuts have no vitamin D.

        The amount of vitamin D in human milk is insufficient to meet the children's needs.

      • 3. What is the amount of vitamin D needed?

        Currently, the proposed levels of Total 25-hydroxyvitamin D measured in the serum are:

        Deficiency <10 ng/ml (0-25 nmol/L)

        Insufficiency 10-30 ng/ml (25-75 nmol/L)

        Sufficiency 30-100 ng/ml (75-250 nmol/L)

        Toxicity >100 ng/ml (>250 nmol/L)


        It is estimated that one billion people worldwide do not reach the optimal minimum concentration of 30 ng/ml.

        However, experts believe that the population of all age groups may need more vitamin D than current guidelines recommend.

      • 4. Who is at risk of Vitamin D deficiency?

        • People with limited sun exposure;
        • People with dark skin;
        • Adults over 50;
        • People with conditions that cause fat malabsorption, such as pancreatitis, cystic fibrosis, celiac disease, and resection of the gall bladder;
        • People with liver or kidney disorders  and enzyme deficiencies;
        • People living in Nordic climates during the winter;
        • Obese people
      • 5. It is true that maintaining sufficient levels of Vitamin D helps prevent certain diseases and maintain good general health?

        The role of vitamin D in regulating circulating levels of calcium and phosphorus to ensure bone mineralization is well known.

        The diseases classically associated with vitamin D deficiency are rickets (in children) and osteomalacia (in adults).

        Currently, we known that vitamin D is important for the normal functioning of many types of cells, but the needs of each tissue and response to vitamin D vary.

        The various effects of vitamin D are mediated by receptors regulating over 200 genes. In addition to the receptors in the intestine and bone, there were also identified vitamin D receptors in the brain, prostate, breast, colon, immune system cells, smooth muscle and cardiomyocytes.

        An increasingly large number of studies associate vitamin D deficiency with an increased risk of developing several diseases, namely:

        • Type 1 diabetes;

        • Breast cancer and other cancers (in postmenopausal women);

        • Fractures in the elderly, as a complication of osteoporosis;

        • Cardiovascular disease, hypertension, and death from myocardial infarction and stroke;

        • Multiple sclerosis and, eventually, other autoimmune diseases.

      • 6. What are the recommendations for Vitamin D dosing?

        This test is recommended for those at risk of Vitamin D deficiency who, should their levels be below 30 ng/ml (75 nmol/L), should take vitamin supplements.

        It is recommended that the dosage of 25(OH)D lasts at least 3 months after beginning treatment with supplements (to reach stable levels).

        Experts also recommend the use of a test that determines both 25(OH)D and 25(OH)D3, i.e., a test taht measures the Total 25-hydroxyvitamin D, especially in countries where both forms of vitamin D are available in dietary supplements.

    • What you need to know about Hepatitis B

      • 1. What is Hepatitis B?

        Hepatitis B is a liver disease caused by a virus.
        This disease causes the liver to become inflamed and it ceases to function properly. This organ performs many important tasks, such as fighting against infections and bleeding or removing medication, drugs and other toxic substances from the bloodstream. It is also responsible for energy storage, progressively releasing it between meals or when needed.
      • 2. What causes Hepatitis B?

        Hepatitis B is caused by the Hepatitis B Virus (HBV), discovered in 1965.

        It is the most dangerous type of hepatitis and it is one of the most common diseases in the world; there are an estimated 350 million chronic carriers of the virus. These carriers can develop serious liver disorders, such as cirrhosis and liver cancer, diseases responsible for the death of a million people a year across the globe; however, it is possible to prevent this virus through the hepatitis B vaccine, which has an efficiency of 95 percent.

        The virus causes acute hepatitis in a third of those affected, and one in every thousand infected may fall victim of fulminant hepatitis. In less than ten percent of cases in which the infection occurs in adulthood, the disease becomes chronic, a situation more common in men. In Portugal there are an estimated 150 thousand chronic carriers of HBV.

      • 3. How can I contract hepatitis B?

        The virus is transmitted through contact with blood, semen and bodily fluids of an infect person, much like the human immunodeficiency virus (HIV), which causes Aids, only the Hepatitis B virus is 50 to 100 times more infectious than HIV.
        There is also the possibility of mother to child transmission at birth, a particularly severe form of contagion, given the high tendency of evolution to chronicity. This is very common in hyperendemic areas of developing countries, where most of those infected contracts the virus during childhood. In industrialized countries, this age group is the most 'secure', as the vaccine against hepatitis B is part of the national program of vaccination of 116 countries, including Portugal. In the Western world, Europe and North America, the virus is transmitted mainly to young adults through sexual contact and by sharing syringes and other injecting equipment among intravenous drug users.
        In short, hepatitis B can be contracted through:
        • Having unprotected sex with infected people;
        • Sharing syringes with intravenous drug users
        • Getting a tattoo or body piercing with dirty instruments or poorly sterilized ones which were previously used in other people;
        • An accidental prick with a needle contaminated with infected blood (health care personnel can contract hepatitis B this way);
        • Living with someone who has hepatitis B;
        • Sharing personal objects (such as toothbrushes or razors) with an infected person;
        Hepatitis B can’t be contracted through hugging, sitting next to or shaking hands with someone infected.
      • 4. What are the symptoms of Hepatitis B?

        Hepatitis B causes symptoms very similar to influenza, such as: 

        • Fatigue;
        • Nausea;
        • Fever;
        • Loss of appetite;
        • Stomach pain;
        • Diarrhea.

        Some people may also exhibit:

        • Jaundice (skin and eyes present a yellowish colour);
        • Light-coloured faeces;
        • Dark-coloured urine.

        Some people, however, may not present any symptoms.

      • 5. Which tests are done to diagnose Hepatitis B?

        To confirm if you are infected with the hepatitis B virus, the doctor orders lab blood tests. These tests serve not only to verify whether you are infected or not, but also to identify the stage or course that the infection is taking at a given time.

        There are 5 markers of Hepatitis B: 3 anti-bodies and 2 specific antigens. These markers appear in the blood at different times. Usually the first to be detected is HBs antigen (HbsAg or Hepatitis B surface antigen), which persists for one to three months and which reveals the presence of virus in the body. Its positivity is indicative of an acute or chronic active infection, or even that the patient is an asymptomatic carrier, potentially infectious. A bit later (but sometimes simultaneously) the HBe (HBeAg) antigen arises, meaning that the infectious agent is multiplying. The risk of infection is higher at this stage.

        Only after do the antibodies arise and the first to appear is, usually, anti-HBc (an antibody fighting HBcAg). It emerges in acute infections and chronic carriers, and it is an infallible marker of infection, more reliable than the surface antigen; afterwards, if the body's immune defences are operating correctly, anti-HBe arises in response to the HBe antigen. This means that there has been a seroconversion, the multiplication of the virus decreased and, if nothing interferes with the normal course, the HBs antigen disappears and the anti-HBs antibody arises, which remains in the body for a lifetime, and grants immunity. Its presence indicates the resolution of the disease and reflects immunity. It is an indicator of effective vaccination.

        The presence of the HBe antigen, beyond eight weeks, indicates that the hepatitis is moving on to a chronic phase. The permanence of the HBs antigen for more than six months confirms the transition to the chronic stage.

        The meaning and interpretation of these markers depends not only on each of them, but in their joint presence or absence and their relationship with clinical data.

        A liver biopsy may be needed for patients who exhibit evidence of virus presence in the body for more than six months, to assess the severity of liver damage. As chronic HBV infection is a sexually transmitted disease, infected people should be tested to detect the possible presence of HIV.

      • 6. How is Hepatitis B treated?

        Acute hepatitis B is treated with rest and the patient should not to consume alcoholic beverages and foods or drugs that can be toxic to the liver.
        If the hepatitis evolves into a chronic disease, it can be treated with interferon. Pegylated interferon, or peginterferon, has replaced the classic interferon. The treatment with peginterferon lasts, in general, 12 months and has an efficiency of 36-42%, or higher in patients with higher transaminases and lower viral load.
        Alternatively, the treatment can be done with nucleoside analogues, such as lamivudine and adefovir, which interrupt the multiplication of the virus and stimulate the destruction of infected cells, meaning they have a strong antiviral effect but require a more prolonged administration than peginterferon to provide similar response rates.
        As with all medication, treatments for hepatitis B have side effects, so patients should consult with a doctor. If chronic hepatitis leads to cirrhosis and this develops into liver failure, liver transplantation is advisable. However, in the case of hepatitis B the risk of relapse are very high, since there are no effective ways to prevent infection in the new liver. Normally anti-HBs immunoglobulin is administered shortly after harvesting the liver from the body and before inserting the new organ, as to neutralize the virus in blood. The patient should continue to receive anti-HBs immunoglobulin for several years, to prevent HBs antigen from reappearing.
        The patient receiving the new liver should not be over 65 or suffer from a severe disease that affects other organs like the kidneys, lungs and heart.
      • 7. How can I protect myself?

        There is a vaccine against hepatitis B available to everyone, but it has no effect on those who are already infected by the virus. It consists of three doses that are administered via intramuscular injections within six months and shows an efficiency of 95 percent. In Portugal, it is included in the National Vaccination Program. Babies, children of mothers carrying the virus, should be vaccinated at birth, after which there is no risk of transmission through breastfeeding.

        It is necessary to get every injection to stay protected. If you are travelling to countries with a high incidence of hepatitis B, be sure to receive all injections before travelling.

        Immunity appears to be lasting although limited in time, with no need for reinforcement, at least in the first five to ten years of vaccination.
        Here are a few other measures against hepatitis B that you can take, to protect yourself and other people with whom you interact

        • Use condoms during sexual intercourse;

        • Do not share used needles and syringes, sharp and piercing objects, or instruments used for the preparation of injectable drugs;

        • Wear glove and protective gear if you must be in contact with another person's blood;

        • Do not use someone else’s personal items of hygiene, which may contain traces of blood;

        • Ensure that instruments used in tattoos, piercings or bodily perforations are clean and properly sterilized.

    • What you need to know about Hepatitis C

      • 1. What is Hepatitis C?

        Hepatitis C is a liver inflammation caused by a virus (hepatitis C virus or HCV), that when chronic can lead to cirrhosis, liver failure and cancer.
        It is known as the 'silent' epidemic due to the increased number of chronically infected people worldwide and the fact that the infected may not show any symptoms for 10 or 20 years, and feel perfectly healthy.
        It is estimated that there are 170 million chronic carriers (about three percent of the world's population), nine of which are European millions, which makes HCV a much more common virus than HIV, responsible for AIDS. According to the World Health Organization, it is possible that every year three to four million new cases arise on the planet. The prevalence of the virus differs depending on geographical region; while in Europe and North America infection rates are around two percent, in Africa, Southeast Asia, the Western Pacific and Eastern Mediterranean prevalence rates are higher.
        In the western world, users of injectable and inhalable drugs and people who have undergone blood transfusions and derivatives and/or surgery before 1992 are the most affected. With the discovery of the human immunodeficiency virus - responsible for AIDS - in the 80s of the last century, new preventive measures were adopted and, today, the possibility of HCV infection through blood transfusion or during surgery in hospitals is practically null. This security is not guaranteed in some medical facilities and hospitals in developing countries.
        In Portugal, chronic hepatitis C is already a major cause of cirrhosis and hepatocellular carcinoma; there are an estimated 150,000 people infected, although the vast majority are undiagnosed.
        According to a study by the European Monitoring Centre for Drugs and Drug Addiction, Portugal is one of the European countries with the highest rates of this virus’ infection, which affects 60 to 80 percent of drug addicts.
        About 20 to 30 percent of individuals infected with HCV recover spontaneously after an acute infection from HCV, but the remaining 70 to 80 percent progress to chronic hepatitis, often without even realizing it. In 20 percent of patients, chronic hepatitis C can lead to cirrhosis and/or liver cancer. Some patients may develop cirrhosis within a few years, while others may take decades. Among the possible explanations is the age at which the person was contaminated (the later it was, the more serious the evolution of infection may be), hormonal differences (more common in males) and alcohol consumption (which stimulates the multiplication of the virus and decreases immune defences). This type of hepatitis only exceptionally presents itself as fulminant hepatitis.
      • 2. What causes Hepatitis C?

        Hepatitis C is caused by a virus, more specifically the hepatitis C virus or HCV. This virus was only identified in 1989 and accounts for about 90% of so-called hepatitis non-A and non-B.
        The incubation period is an average of six to seven weeks. (two to 26 weeks). About 85% of individuals who have contracted HCV become chronically infected. Of these, about 70% develop chronic hepatitis. About 20% to 25% of chronic hepatitis caused by HCV progress to liver cirrhosis, and in cirrhotic patients about 1-5% develop primary liver cancer. The mortality rate from chronic HCV hepatitis is estimated to be between 1% and 5%.
        Important factors in aggravation and acceleration of lesions in chronic hepatitis:
        • Consuming alcoholic beverages;
        • Coinfection with other viruses (HIV, HAV, HBV);
        • Previous or concomitant liver disease.
      • 3. How can I contract Hepatitis C?

        Hepatitis C is transmitted primarily through contact with the blood of an infected person, and, with much less efficiency, through body fluids. The virus has also been detected in saliva, urine, semen and bile, but with a low potential risk of transmission.

        Therefore, HCV is essentially spread through contaminated blood. 

        Risk situations, with different contagion potentials: 

        • Sharing syringes and other instruments used in the preparation of injecting and inhaling drugs;
        • Blood exposure from cutting or perforating materials of collective use improperly sterilized or disposable, used in procedures such as body piercing, tattoos, acupuncture, manicures/pedicures, barbers and hairdressers, etc.;
        • Social or familial contact with personal items (toothbrushes, razors, shavers, scissors, etc.);
        • Healthcare professionals’ occupational exposure to blood (needles, needlestick injuries);
        • Not using condoms during sexual intercourse when there are multiple partners. However, as the sexual transmission is infrequent, its use in relations between spouses is not usually required;
        • Newborns from HCV positive mothers;
        • Hemodialysis.

        In the absence of a vaccine against hepatitis C, it is best to focus on prevention, avoiding, above all, contact with contaminated blood.

      • 4. What are the symptoms of Hepatitis C?

        In most cases this disease is asymptomatic, which further complicates its control and facilitates its spread in the community. The diagnosis is generally accidental, being made during serological screening in blood donations, or to assess the possible cause of altered transaminases, evidenced in routine examinations.
        Only 25 to 30 percent of those infected exhibit, in the acute phase, symptoms of illness, which can manifest itself through unspecific complaints such as lethargy, malaise, fever, concentration problems; gastrointestinal complaints such as loss of appetite, nausea, alcohol intolerance, liver pain, or the more specific symptom, jaundice. Often, the symptoms are unclear, and may resemble the flu. The chronic carrier of the virus may not have any symptoms, feeling healthy, while developing cirrhosis or liver cancer.
      • 5. Which tests are done to diagnose Hepatitis C?

        Hepatitis C infects and damages the liver. In response to exposure to the virus, our organism produces antibodies against HCV proteins. The most common test for HCV surveys these antibodies in our blood. Other available tests detect the presence of viral RNA, the amount of RNA present, or determine the specific subtype of the virus.

        Each test has a slightly different purpose:

        • Anti-HCV Tests detect the presence of antibodies against proteins of the virus, indicating exposure to HCV. These tests do not distinguish whether the tested subject still has an acute or chronic active viral infection, or whether it is a serological scar that has simply been exposed to the virus in the past. Generally, the test is reported as positive or negative. There is some evidence that if the test is weakly positive, it may not mean previous exposure to HCV. The weakly positive results should be confirmed with the next test.
        • HCV RIBA Test (immunoblotting) is an additional test to confirm the presence of antibodies against the virus. In most cases, it can tell us if the positive anti-HCV test was due to exposure to HCV (positive RIBA) or it represents a false signal (negative RIBA). In a few cases, the results fail to answer this question (Undetermined RIBA). Like the anti-HCV test, the RIBA cannot tell us if the subject is currently infected, only that there was an exposure to the virus.
        • HCV-RNA Testing is carried out by polymerase chain reaction (PCR) and detects the RNA of the Hepatitis C virus, indicating whether there is an active HCV infection. The result of the HCV-RNA is considered positive if a viral RNA is detected; otherwise the result is negative. In addition to its application as a confirmation test, the Qualitative HCV-RNA can also be used to control treatment response, verifying if the virus was eliminated from the body after treatment.
        • Viral Load or Quantitative HCV-RNA tests measure the amount of viral RNA particles in the blood. Viral load tests are often used before and during treatment to help determine response to the therapy, by comparing the amount of virus before and after the treatment (typically 3 months).
        • Viral genotyping is used to determine the type, or genotype, of the virus. There are 6 major HCV types; the most common (genotype 1) has a worse response to treatment than genotypes 2 and 3 and usually requires longer therapy (12 months versus 6 months for genotypes 2 and 3). Determining the HCV genotype is, therefore, useful to define a treatment strategy, being solicited before starting treatment to assess its success and required duration.
      • 6. What does the test result mean?

        If the result of the Anti-HCV test is positive, it means that you were likely infected with Hepatitis C virus, even if the infection has been so faint that you were not even aware of it.

        A positive anti-HCV test should be confirmed by an HCV RIBA test, especially if the result is weakly positive. A positive RIBA confirms that you have been exposed to the virus, while a negative RIBA indicates that your first test was probably a false positive and you have never been infected with HCV.

        An HCV RNA Qualitative test is often used when the antibody test is positive, to verify whether the infection is still present. A positive HCV-RNA means that you are currently infected with HCV.

        Currently, the RIBA tests have been receiving increasingly restricted indications in clinical practice, since when faced with a positive anti-HCV result, through enzyme immunoassay testing, the most favourable procedure from the standpoint of cost-effectiveness appears to be Qualitative HCV-RNA survey, which not only confirms the positivity of the antibody, but also determines the presence of current viremia.
      • 7. Can I be vaccinated against HCV?

        No. There is currently no vaccine available.

        Developing a vaccine has been difficult because the virus displays several different molecular configurations that are constantly changing. In addition, antibodies raised by HCV infection are not neutralizing, meaning they do not prevent reinfection or grant immunity. The difficulty in the development of the vaccine against the virus stems mainly from this behaviour of the immune system when faced with HCV infection.

      • 8. Is there a treatment for Hepatitis C?

        Yes, there are currently certain drugs that can be used in the treatment of HCV infection. The most commonly used are a combination of two drugs (pegylated interferon associated with ribavirin).

        Meanwhile, the effectiveness of the treatment depends on various factors such as age, the virus' genotype and the viral load exhibited by the HCV, and the degree of liver damage. Healing probabilities can therefore vary from very low to as high as 80%.

    • Helicobacter pylori and Peptic ulcer

      • 1. What is a peptic ulcer?

        A peptic ulcer is a wound in the stomach lining, or duodenum, which is the beginning of the small intestine. Peptic ulcers are common: One in every 10 Americans develops an ulcer at some point in their life.

        Most gastric ulcers and duodenal ulcers (peptic ulcers) are caused by a bacteria, Helicobacter Pylori, but some ulcers are caused by prolonged use of nonsteroidal anti-inflammatory drug (NSAID), such as aspirin (acetylsalicylic acid) and ibuprofen.

      • 2. What causes these ulcers?

        Until the eighties of the twentieth century, peptic ulcers were considered to be the result of acid hypersecretion produced by a disorder in the specialized gastric cells. However, in 1983, scientists identified a bacteria, Helicobacter pylori (H. pylori), that colonizes the gastric mucosa and has since been associated with gastroduodenal pathology (gastritis, peptic ulcer, especially duodenal ulcers, and gastric carcinoma).

        Although we believed that spiced food, spices, acid, and stress were the main causes of ulcers, we now know that nine out of ten ulcers are caused by H. pylori. Medications that reduce stomach acid can make you feel better by relieving the symptoms, but they will not cure the ulcer.

        The good news is - since most ulcers are caused by this bacterial infection, they may then be cured with the right antibiotics.

      • 3. What are the symptoms of an ulcer?

        The most common symptom is pain with a burning sensation or burning in the abdomen between the sternum and the navel.

        The pain often occurs when the stomach is empty, between meals and in the early hours of the day, but can occur at any other time. It may last from a few minutes to several hours and may be relieved by eating or by taking antacids.

        Less common symptoms may include:

        • Nausea;
        • Vomiting;
        • Loss of appetite.

         Sometimes ulcers bleed. If the bleeding goes on for an extended period, it can lead to anemia, weakness and fatigue. If the bleeding is heavy, blood can be found in vomit or evacuation of bloody or black stools.

      • 4. What is Helicobacter pylori?

        Helicobacter pylori is a Gram-negative bacterium, approximately 2.5 mm in length and 4 to 6 unipolar flagella which allow the microorganism to move in a helical corkscrew-like movement.

        The very name Helicobacter pylori reflects its helical or spiralled (S-shaped) morphology and the most common site for its isolation, the stomach pylorus. Identified in 1983, H. pylori colonizes the gastric mucosa and has been associated with gastroduodenal pathology, namely chronic gastritis, peptic ulcer disease (especially duodenal ulcers) and also gastric adenocarcinoma and primary gastric lymphoma (MALT). Recently, there have been investigations regarding its association with some extra-gastrointestinal diseases, such as iron deficiency anemia, stunting, or chronic urticaria.

      • 5. How is H. pylori transmitted?

        H. pylori infection typically begins in childhood, as an inflammatory process of the stomach. The acquisition of the bacteria follows a 10% rate in children between two and eight years old, so most teenagers are infected. Although the transmission of the microorganism appears to happen from one person to another, the mode of transmission is not fully known. It is believed that H. pylori is transmitted by the oral-oral or fecal-oral route. Many researchers think that it is transmitted by contaminated food or water. In addition, it is possible that aerophagia and gastroesophageal reflux, higly common in gastritis, enable its fixation in the mouth, making oral contact a means of transmission of infection. The organism has been cultivated in both vomiting and diarrheal stools.

      • 6. What enables the adaptation of H. pylori to the gastric environment?

        Most microorganisms are inactivated by the acid gastric environment. However, H. pylori is well adapted to the acidic environment of the human stomach. A number of special features ensure successful colonization. These include the microorganism’s ability to adhere to the gastric wall, the production of urease, and the presence of flagella that confer mobility. H. pylori typically gathers around the tight intercellular junctions of epithelial cells, below the mucous layer, although 1/5 of the microorganisms are found adhering to the mucosal surface. The dhesion is specific for gastric mucin producing cells. The motility is an important feature that allows microorganisms to penetrate the viscous mucus layer of the stomach and colonize the gastric mucosa.

        H. pylori is the most potent urease producer of all known microbes. (The active urease is present in the cytoplasm as well as on the surface and in the extracellular space of the bacteria). This enzyme hydrolyzes the urea to CO2 and ammonia. The microorganism envelops itself in a cloud of ammonia, which has a significant role in the colonization and adaptation by buffering the gastric acid of the multi-bacterial microenvironment. The elevation of the resulting pH creates a favourable microenvironment for the bacteria.

        Another adaptive mechanism which enables the bacteria to colonize the human gastric tract is the outer membrane, or lipopolysaccharide envelope (LPS). This LPS envelope does not trigger from the host the same vigorous immune response as with other Gram-negative microorganisms. This diminished reactivity may be due to the high concentration of Lewis blood group antigens in LPS, enabling H. pylori to mimic glycoproteins or glycolipids on the surface of the human cells. This molecular mimicry can explain how this microorganism can evade the host’s defence mechanisms and induce the formation of autoantibodies with cross-reactivity, found in some patients. This permanent state of chronic inflammation maintained at a low level, with the concomitant increase of mutations and deregulated apoptosis may also partially lead to most gastric cancers associated with H. pylori.

      • 7. Incidence and implications of H. pylori infection.

        H. pylori infection is very common. It has been postulated that H. pylori infection is the most common chronic infection worldwide. It is estimated that over 50% of the world’s population is infected with this stomach bacteria. In developed countries (USA) approximately 20% of people under 40 and 50% of people over 60 are infected. In developing countries the majority of adults (2/3) is infected.

        The prevalence of the infection increases with age, most likely reflecting the so-called cohort effect, in which the variation in the age at which H. pylori is acquired will influence the risk of peptic ulcer disease. Specifically, the infections acquired early in life increase the risk of distal gastric cancer and gastric ulcer, but decrease the risk of duodenal ulcer. On the contrary, the late acquisition of H. pylori increases the risk of duodenal ulcer but reduces the risk of gastric ulcers and stomach cancer. The socio-economic status varies inversely with the prevalence of infection, with individuals of lower socioeconomic strata showing the highest rates of infection.

        H. pylori can exist for decades in the gastric mucosa without any apparent symptoms or diseases. However, histopathology speaking, all individuals infected with H. pylori exhibit evidence of active chronic gastritis. The gastritis is generally more obvious in the antrum, but can extend to the rest of the body and cardia.

      • 8. What are the consequences of H. pylori infection?

        H. pylori colonization may lead to chronic active gastritis (chronic inflammation of the stomach mucosa), the first stage of development of an ulcer. The transition into ulcer can be facilitated by unhealthy activities and habits like smoking, drinking alcohol and being subjected to stress. H. pylori infection is also associated a 3-12 times increased risk of gastric cancer.

      • 9. Do all patients infected with H. pylori develop the disease associated with this bacteria?

        No. Most people infected do not contract an ulcer. Epidemiological data show that the incidence of diseases associated with H. pylori in infected individuals varies between 1 and 10%.

        The most likely justifications for the selective development of gastritis or peptic ulcer disease in people infected with H. pylori include differences in the virulence of H. pylori strains, genetic differences in human susceptibility and environmental and behavioural factors.

        [Most gastric adenocarcinomas occurring in the gastric body and antrum are due to H. pylori infection, however, less than 1% of those infected will develop adenocarcinoma].

        The diet has also been studied as an environmental co-factor that plays an important role in carcinogenesis related with H. pylori. Salting, smoking and other types of meat preparations are associated with an increased risk of gastric cancer, while fresh fruit and vegetables are protective.

      • 10. Is it important to perform tests to detect H. pylori infection?

        Yes, for several reasons. The diagnosis of H. pylori infection is impossible based exclusively on clinical assessment, as there are no characteristic clinical symptoms associated with this condition. Once detected, H. pylori infection can be effectively treated with antibiotics in double, triple and even quadruple regimens, which pair the use of antibiotics and antisecretory drugs.

        As suggested in the Maastricht 2-2000 Consensus Report, the first line of therapy should be a triple therapy using a proton-pump inhibitor such as Omeprazole (or ranitidine bismuth citrate) combined with Clarithromycin and Amoxicillin or, alternatively, Clarithromycin and Metronidazole, for at least 7 days.

        The importance of detecting and eradicating H. pylori infection is reflected not only in the patient’s healing, but also in the probability of subsequent relapses. It has been shown that H. pylori eradication reduces the relapse rate to only 3%, while the conventional treatment without antibiotics is accompanied by relapse rates of up to 67%.

      • 10.Which tests are available to detect H. pylori infection?

        Helicobacter pylori infection can be detected by invasive and non-invasive methods:

        Invasive Methods

        Based on gastric biopsy during an endoscopic examination. The presence of H. pylori in a biopsy fragment is further confirmed either by direct microscopic examination, by a rapid urease test or by bacteriological culture of the microorganism from the biopsy material.

        [The culture is relatively insensitive for the diagnosis of H. pylori, but may be required to determine antimicrobial sensitivity in patients who do not respond to antibiotic therapy].

        The invasive tests are not without difficulties, as they can be painful, with some risk and discomfort to the patient. They are time consuming and not always sensitive, due to the tendency that H. pylori has to distribute itself in islands or colonies in the gastric mucosa, in its un-colonized areas.

        Non-invasive methods:

        These include the urea breath test and stool antigen test, which can detect the presence of an active infection and are called active testing; and the serological tests, which detect antibodies specific to H. pylori, which are markers of exposure to H. pylori but do not indicate whether there is active infection and are called passive tests.

        Serology (anti-H. Pylori antibodies)

        Serological tests are the main non-invasive tests used in Portugal and are far less accurate than the urea breath test. They rely on the detection of anti-H. pylori IgG antibodies in serum or plasma. Serology enables the quantitative determination of antibodies. The level of antibodies is expressed in arbitrary units, which differ from one mark to another. The immunoenzymatic analysis (ELISA) is the favoured test, as it is sensitive and user friendly. While these tests are relatively inexpensive, they are unable to distinguish an active infection from prior exposure to H. pylori.

        A positive result in serology can mean one of three things: the patient is infected at the time of testing; the patient was once infected, but, at the time of testing, the infection was resolved by either specific therapy or natural course; or the test has detected non-specific crossed antibodies.

        Antibody levels may persist for a long time in the patient’s blood after the eradication of the H. pylori infection, decreasing very slowly over time. Therefore, for the follow-up treatment, serological tests are less useful since it is necessary to compare the titers of antibodies pre and post treatment, separated by a long period of time.

        Nevertheless, several studies in the literature suggest that a decrease in the IgG antibody level over 25% six months after therapy predicts with relative accuracy the successful cure of H. pylori infection.

        Urea breath test

        Helicobacter pylori produces urease an enzyme which hydrolyzes urea into ammonia and carbon dioxide. The microorganism can use the urease activity to regulate the pH in its microenvironment. The urea breath test is based on the principle that there is urease activity in the stomach of patients infected with H. pylori.

        After ingesting a urea solution labelled with 13C, this is then hydrolyzed by the urease produced by the bacteria in the gastric mucosa, releasing ammonia and labelled CO2. The CO2 is then diffused through the gastric mucosa to the epithelial blood vessels and into the general circulation and within a few minutes is eliminated by the exhaled air. The labelled urea is usually given to the patient with a drink, to delay gastric emptying and increase the contact time with the mucosa. 20 minutes after ingesting the urea, exhaled air samples are collected in a tube containing an agent which retains CO2 (hyamine).

        Detection of 13C (which is a non-radioactive isotope from 12C) is performed using costly equipment, such as mass spectrometry.

        Fecal Antigen Test

        This is an enzyme immunoassay test capable of detecting the presence of H. pylori antigens in stool samples. The first available tests used polyclonal antibodies, and have been used in thousands of patients across Europe; it almost as specific (91.2%) and sensitive (92.4%) as the urea breath test. However, some centres have reported a significant variability between different batches.

        Recently, an ELISA test of monoclonal antibodies has shown excellent results and avoids this variability. The monoclonal test currently available has shown to be as accurate as the urea breath test (97.5% sensitivity, 94.7% specificity). While equivalent to the urea breath test in performance, the fecal antigen test is considerably less expensive and less time consuming.

        In contrast to serology, the fecal antigen test is useful for confirming the eradication of the infection 4 weeks after the end of therapy. When compared with the urea breath test, the fecal antigen test is more convenient, particularly in paediatrics, since stool samples can be obtained from children without their active collaboration.

        Stool samples can be stored up to 5 days at room temperature or at -20 °C which does not seem influence the test’s performance.

      • 12. When do antibodies against H. pylori appear, during the infection? Is it important to quantify the antibodies’ levels?

        Generally, antibodies against H. pylori can be detected within 10 to 20 days after the infection has set in and persist all throughout. These antibodies do not provide protection against H. pylori nor do they help eliminate it. Quantification of antibody titers is an important tool because:

        1. The level of antibody titers adequately reflects the severity of H. pylori gastric colonization.
        2. The successful eradication of H. pylori with antibiotic treatment leads to a significant decrease in antibody levels within the following 6 months.
        3. The recurring rise in antibody titers can be a warning sign to consider the possibility of relapse.
      • 12. Testing and treating dyspepsia – which test to choose?

        The recent European guidelines recommend the use of non-invasive tests for the detection of Helicobacter pylori infection in the context of primary health care, in patients with persistent or recurrent, uncomplicated recurrent dyspepsia, and if the test result is positive, administer triple therapy.

        With a policy requiring non-invasive testing and treatment, we need to use a higly accurate test, so that patients receive the correct treatment.

        The Urea Breath Test and Serology were the first non-invasive tests available; the urea breath test is the most accurate, but it has not been widely used in a primary care setting in Portugal, most likely because it is expensive and time consuming as it requires two breath samples, taken 20 minutes apart.

        Serological tests have been the main non-invasive tests performed in Portugal and are less accurate than the urea breath test, although they have the advantage of being significantly cheaper.

        Other non-invasive test currently available and accurate is the fecal antigen test, which detects the presence of H. pylori antigens in stool samples. This test has been widely appraised and it has shown to be as accurate as the urea breath test. It uses similar laboratory methods to serological tests and can be introduced easily into the laboratory’s practice routine. Although equal to the breath test in performance, the fecal antigen test is considerably less expensive and less time consuming.

        For the follow-up treatment, serological tests are less useful since it is necessary to compare the titers of antibodies pre and post-treatment, and their levels decrease very slowly, making it necessary to wait 6 months to confirm healing.

        Testing for healing with the breath test or the fecal antigen test should be done 1 month, and preferably 3 months, after completion of treatment. (earlier tests may not be sufficiently accurate, either because any remaining microorganisms have not reached the sufficient development to be detected, or because the dead or dying microorganisms affect the accuracy of the tests).

        Serology leads to at least four times more false positive results than the urea breath test or the fecal antigen test, with an unnecessary associated treatment and increased risk of antibiotic resistance in other bacterial flora. If the "test and treat” guidelines for dyspepsia are widely implemented in Europe, the number of patients receiving treatment to eradicate H. pylori can easily double.

        The European Group of Helicobacter pylori study and the European guidelines advise using the urea breath test or the fecal antigen test as opposed to serology. Any additional cost to these tests will be largely offset by improved diagnostic accuracy and reduced use of antibiotics. Moreover, as these tests replace serology, it is likely that their prices will fall.

    • Viral Hepatitis

      • 1. What is Hepatitis?

        Hepatitis is an inflammation of the liver that, depending on the agent causing it, can be cured simply with rest, can require prolonged treatments, or even liver transplantation, when severe complications are developed, like of cirrhosis and liver failure, or liver cancer, which can lead to death.

        Viruses are the primary cause but there are other non-viral etiologies such as excessive consumption of alcohol and other toxic products, such as certain medications and chemicals, and certain plants. There are also autoimmune hepatitis resulting from a disturbance of the immune system, which, for unknown reasons, begins to develop autoantibodies that attack the liver cells, rather than protect them. There are six different types of hepatitis viruses (A, B, C, D, E and G). The main difference between the viruses is their means of propagation and their impact on the health. Hepatitis is usually described as acute or chronic. The acute illness has a short duration; whereas the chronic illness has a long duration, sometimes with periods of exacerbation and remission. When hepatitis B lasts longer than six months it is referred to as chronic hepatitis B.

        Each of these pathologies always involves a medical consultation and proper monitoring. In many cases, having hepatitis is hardly a real "headache", since the body has immune defences which , in the presence of the virus, react by producing antibodies, a sort of soldiers fighting against infectious agents and annihilating them. But, in some situations, these antibodies are not enough to stop the invader’s power, making it necessary to resort to antiviral treatments.

        Although there is still much to study in this area, scientific research has come a long way in the fight against the disease, having already developed vaccines against hepatitis A and B (which has significantly reduced its propagation) and discovering substances (such as interferons) that can stop the virus from multiplying and provide hope of prolonging the life of many patients. These treatments, however, are costly and are not always available in developing countries, which are the most affected areas.

        The hepatitis viruses can be transmitted through food and water contaminated with fecal matter (A and E), through contact with contaminated blood (B, C, D and G) and through sexual intercourse (B, C and D). The viruses have different periods of incubation and, in many cases, the patients have no symptoms. Hepatitis A and E do not become chronic, while the transition to the chronic situation is quite high in hepatitis C and common in hepatitis B, D and G, although this last illness is not very severe.

        Unlike with other diseases, patients with chronic hepatitis can lead an almost normal daily life, without needing to remain inactive, isolated from others or meet strict diets, but they should know their limitations and learn to live with hepatitis.

      • 2. How are viral hepatitis A, B or C transmitted?

        Hepatitis A is an infection of fecal-oral transmission, by ingesting food or water contaminated with the virus. Hepatitis B and C are transmitted through parentage, sexual contact, blood transfusion or derivatives, syringes contaminated with the virus, contact with the blood, secretions, urine, tears, etc., of an infected patient.

      • 3. It is possible to clinically differentiate the type of viral hepatitis?

        Hepatitis A, B and C, the most frequent types of hepatitis, are undistinguishable, since they share the same common signs and symptoms: jaundice, asthenia, anorexia, etc. The clinical history of the particular case may point to a possible type of hepatitis, but, nevertheless, it will remain unspecific. A smaller percentage of patients suffer from an asymptomatic anicteric Hepatitis, which accounts for serologic evidence, but not for the medical history of the illness. This variety is more common in the C virus infection (HCV).

      • 4. It is important to carry out the differential and specific diagnosis of the type of Hepatitis?

        Yes, as the evolution and prognosis is differ between Hepatitis A, B, and C. Hepatitis A has a favourable course, although less than 1% of those infected may evolve into fulminant hepatitis with a high mortality rate. Hepatitis B can either be resolved or follow different paths, as approximately 50% of cases turn into potentially contagious asymptomatic carriers. 10% of patients develop chronic hepatitis, cirrhosis and liver failure. Furthermore, the risk of liver cancer is much higher in patients with this infection. Hepatitis C can be asymptomatic in most cases and, regardless of symptomatic course, more than 75% of those infected develop. Just as HBV, HCV can be closely associated with the development of hepatocellular carcinoma. 

    • Everything you need to know about sampling

      • 1. Should I be fasting before the analysis?

         In general, the patient should be fasting for at least 8 hours for their analysis, although some require a more prolonged fasting, of at least 12 hours, particularly for the Cholesterol Total analysis and its fractions, Triglycerides and Lipid Profile.

        There are, however, several analyses that do not require fasting, such as viral, hormonal, bacteriological, allergic or immunological analyses. You should always ask your attending physician or laboratory to explain how you should proceed. If in doubt, and if for some reason you are unable to clarify your doubts, you should always opt for fasting.

      • 2. How much blood is extracted during the sampling?

        The collected blood amount may vary widely depending on the number and the type of analysis requested by the physician. However, the sample is usually about 6 to 9 mL of blood.

      • 3. Is there anything I should tell the technician responsible for the sampling?

        Any and all information is important and useful to the technician, but the most important are: if you ever felt indisposed or even fainted in previous samplings, if you have any health condition that may affect the sample or its analysis, if you are taking any medication that may interfere with the analysis or the blood sampling, particularly anticoagulants, which increase the time it takes to staunch the sting site.

      • 4. Why did I get a bruise after the blood sampling?

        Although it is not very common, sometimes there can be a blood leak under the skin, thus forming the hematoma.

        A hematoma is a collection of blood within a tissue. In other words, when the blood escapes it natural environment - the blood vessels - and gathers significantly between the cells of a particular organ or tissue, a hematoma occurs. When this phenomenon occurs on the skin or in the structures situated immediately below it, it is referred to as ecchymosis, commonly known as ‘bruise’.

        The appearance of a hematoma may be due to several factors, including:

        • Inadequate compression of the puncture site;
        • Extremely thin veins;
        • Difficult sampling;
        • Drug interference.

        Some people are more prone to develop hematomas, often getting a hematoma at the puncture site.

        To prevent bruising, the puncture site should you should be pressed with dry cotton for one to two minutes, and you should avoid exerting your arm in the following minutes.

      • 5. Can I drink water before the sampling?

        Yes, there is no problem in drinking water in moderation before your analysis, as this will not affect the results. You should not, however, drink it in excess, as that could change the result of the urine test. Do not drink, or eat, anything other than water.

      • 6. Can I smoke before my analysis?

        No, you should not smoke before the analysis. Smoking beforehand will affect the results of some tests, therefore you should abstain from smoking for in the hours prior to the blood sampling, just as you do with food.

      • 7. Can I take my usual medication?

        There are several medications that interfere with blood analyses, such as antibiotics, anti-inflammatory drugs, among others. However, you should not stop taking medication without medical advice. You should tell the technician that you are under certain medication, so that he can correctly read analyses, taking this factor into account.

      • 8. Can I do the tests when I’m menstruating?

        Yes, you can. However, the physician should be made aware that you were menstruating at the time of the sample collection, due to hormonal changes and certain serum proteins.
        It is not recommended to do the analysis of urine and vaginal exudates, because the blood will mix with the sample. The samples for these tests should, therefore, only be done when the menstrual period is completely over, unless the sampling is extremely urgent.
      • 9. How long until my analyses are ready?

        At registration, the user is informed of the time it will take until the analyses are ready, taking into account which ones were requested by the physician. Nevertheless, the most common processing time is approximately one week, after which your results will be delivered at your health care centre. However, there are tests whose results are available on the same day and others, highly specific ones, which can take more than eight days.

      • 10. Why are my results late?

        In exceptional cases there may be delays in delivering results. This delay may be due to a number of situations, such as:
        • Insufficient sample;
        • Sampling may have to be repeated, to confirm the results;
        • Sporadic technical problem.
      • 11. I was told I needed to repeat the sampling. Will there be additional costs for me?

        No, if the sample was insufficient, if the sampling was incorrectly performed or if it is necessary to repeat it to confirm the results, there are no additional costs to what you have already paid for at registration.

      • 12. Should I be tested regularly?

        Clinical analyses are complementary diagnostic tests, which, coupled with other tests and the patient’s medical history, serve to confirm or disprove a diagnosis. However, you should not get tested only when you are ill or showing symptoms. You should be tested regularly, at least once or twice every year, as there are diseases that do not show any distinct symptoms at an early or advanced stage.

        Clinical analyses can be requested for different situations, namely for a simple check-ups, to monitor certain diseases (e.g. diabetes), to confirm or disprove a diagnosis and early detection of many diseases, allowing the doctor to treat them early, increasing the possibility of healing them.

      • 13. From which parts of the body can blood be collected for analysis?

        The best spot for blood collection is in the antecubital fossa of the arm, but it can also be done in the forearm or hands. There are also individual cases where it may be necessary to resort to other collection sites, such as the elbow, feet or ankles.

      • 14. My veins are very hard to find. What can I do to facilitate their surfacing?

        It is not always easy for the technician to find superficial veins to puncture, especially in babies or in some people who have undergone aggressive treatments, such as chemotherapy.

        In order to help the veins surface, you can place a warm cloth on your arm or exercise it a bit, by holding a relatively heavy bucket, for example, which will dilate the arm veins due to exercise or heat, facilitating their visibility on the skin.

      • 15. How do I know what I should take with me and if I should be fasting?

        You should always ask your attending physician to explain what you are going to do and how you should prepare for the tests. If that does not happen or if you have any doubts, you should contact Aqualab so that we can explain the conditions and care required to perform the requested analyses.

        Due to the variety of available analyses there are several possible scenarios, however, the most common is that the person should be fasting for a minimum of 12 hours.

      • 16. Can I take a urine sample for home or should I do it at the laboratory?

        Ideally, the sample should be taken at the laboratory. However, for your own comfort, you can bring a sample from home, using a sterile container and suitable for storing urine.

        You should be aware, however, that the sample required is not always from the first urine of the morning (Urine II), but rather a sample of an Aseptic Urine. This implies specific care and should be taken at the laboratory. You can stop by Aqualab, where the container will be provided or you can buy it at a pharmacy near you.

      • 17. What are Type II Urine and Aseptic Urine?

        Type II Urine is used in the morphological, physical and chemical analysis of urine.

        Aseptic Urine is the collection of the urine with all the aseptic precautions, used for the detection of urinary tract infections caused by bacteria.

        For either one, the preferred sample is always the first urine of the morning, as it is at its most concentrated form. However, both samples can be collected at any time of day, but the aseptic urine should be collected at the laboratory.

      • 18. How can you ensure that there are no swaps and how are the samples identified with my data?

        At registration the patient is given a unique identification number in the laboratory,which allows us to access the data provided by the user. Every sample is indentified during the sampling with tags containing the bar code with the ID number previously assigned.

        Due to the wide automation of the laboratory’s equipment, the apparatus reads the bar code while analysing the sample, and assigns the result to the appropriate number, thus ensuring that there are no exchanges between patient’s results.

      • 19. What can happen to make it necessary to perform a new sampling?

        In certain occasional situations the user can be reconvened to perform a new sampling. There are a few situations that can lead to this, the most common is an insufficient blood sample, due to a difficult collection, but there are others:
        • To confirm a result;
        • In prolonged collections, the blood can eventually coagulate, changing the results;
        • In difficult collections hemolysis may occur in the sample, causing some parameters to change;
        • Incorrect sampling (e.g. contamination of an aseptic urine sample).
        Among other, such as human or technical error.
    • HIV

      • 1. When was HIV discovered?

        The Human Immunodeficiency Virus (HIV) was discovered in 1981 by American doctors, who documented the appearance of uncommon opportunistic infections in a particular group of patients. These individuals showed immunosuppression without any apparent reason. After some studies, it was found that this syndrome, until then unknown, caused the reduction of CD4+ T lymphocytes in peripheral blood.

        After 3 years of study, there came the discovery of the agent causing the disease, HIV.

      • 2. Can someone die from AIDS?

        Ironically no, people with AIDS do not die because of the virus. They die because their defences are very low, in a state of immunosuppression, and the appearance of opportunistic infections. While these infections do not cause any major complications in healthy people, they kill those infected with the virus.

      • 3. What are the symptoms caused by this disease?

        During the acute stage, which occurs within four weeks after infection, some people exhibit symptoms similar to those of the flu, such as fever, headaches, stomach and muscle pains, sweats, fatigue, and enlarged lymph nodes.

        This acute stage lasts about one to three weeks, and people recover naturally due to the response of the immune system. The symptoms disappear and individuals with HIV show no symptoms for several years.

        Next comes a symptomatic stage of the infection, in which patients begin to show characteristic symptoms of immunosuppression of the immune system. The patient may suffer from night sweats, weight loss, diarrhea, loss of appetite, hair loss, dry skin, among other symptoms.

        The following stage is the Human Immunodeficiency Syndrome (AIDS), in which there is deterioration in immunodeficiency, enabling the appearance of opportunistic infections.

      • 4. How does HIV work?

        HIV is a virus from the Retroviridae family and causes AIDS (Acquired Immunodeficiency Syndrome). Once settled in the organism, this virus develops and reproduces by invading and destroying a certain type of cells from the immune system, the CD4 T lymphocytes, which are primarily responsible for defending the body against pathogens, tumours and infections.

        The virus attaches itself to the receptors in the walls of the T lymphocytes and merges with them. Next, the virus uses the person’s DNA, reproducing their viral DNA, forming new HIVs that are released into the bloodstream and will infect new cells.

        In its the final stage, the disease decreases the organism's ability to resist any sort of infection, even the most simple, making them so severe and difficult to treat, ultimately leading to death.

      • 5. What is the window period for HIV?

        The window period is the period between acquiring the infection and receiving the positive laboratory tests (antibody screening). This period lasts, on average, 3 to 6 weeks. However, since everyone is different, some people may take longer than normal to develop antibodies against the virus.

        The window period for HIV can last between 3 weeks and 3 months. However, doctors recommend repeating the screening after six months of a possible contagion, to make sure that there is no infection.

      • 6. How is HIV transmitted?

        HIV is not transmitted by the normal direct contact with people infected with the virus, nor by air. The virus can only infect through a gateway. HIV is not very resistant outside the human body, it can only survive up to one hour on the outside, once exposed to environmental conditions.

        It can be spread in three ways:

        1. Sexual intercourse;
        2. Contact with infected blood;
        3. From mother to child, during pregnancy, childbirth or breastfeeding.

        HIV can be transmitted through several bodily fluids, such as blood, semen, vaginal fluids and breast milk.

        The virus gateways can be through sharing contaminated syringes, accidental needle stick injuries, unprotected sex, breastfeeding, direct contact with the blood of an infected person with an open wound or the possibility of infecting the fetus at childbirth or during pregnancy.

        Even though the virus can eventually be transmitted through blood or blood products transfusions, this route shows few associated risks, since it is mandatory to screen all donors for these kinds of issues.

      • 7. What can I do to protect myself against HIV?

        Since there is still no cure or vaccine to prevent HIV infection, the best solution is to avoid certain risk behaviours. You should always wear a condom during sexual intercourse, do not share needles or syringes, do not share materials used to prepare injectable drugs and piercing objects, such as the items used in tattooing or body piercing, in hairdressing, in manicures and in acupuncture.

        You should also be aware of objects that have been in contact with blood, semen and vaginal fluids, which may contain the virus.

        There are also other products, not sold in common locations, which can be used for protection during a wide variety sexual practices.

      • 8. Who should get tested for HIV?

        Everyone should be tested for HIV, not just those who engage in risky behaviours. This is a silent disease that only manifests its presence after many years. Just as we should take care to protect ourselves from HIV, we must also take care to prevent others when infected with this disease, so that HIV does not keep spreading to the entire population.

        AIDS has long since surpassed the barriers that mainly encompassed homosexuals and drug addicts. It is now a disease that anyone can contract. There are no longer stated risk groups, only risk behaviours that should be avoided or, knowingly carried out with the utmost caution.

        Protect yourself, protect others, for the great respect we owe to the right of life, to health, to tranquillity. Consult with your conscience; then with your doctor. in

      • 9. What are the potential risk groups for HIV?

        The potential risk groups are drug addicts, due to syringe sharing, sexually promiscuous individuals, due to not using condoms, and health care professionals, who are always subject to accidents, such as needle stick injuries. However, nowadays, there are no risk groups, only risk behaviours that should be avoided or minimized.

      • 10. How is the laboratory diagnosis of HIV done?

        The laboratory diagnosis of HIV is done through tests that screen for the presence of the antibody and/or antigen of the virus in peripheral blood. Nowadays there are already 4th generation tests, which enable early detection of individuals infected with HIV, reducing the window period to a minimum of two weeks by screening for a core antigen in the HIV nucleus, the antigen p24.

        However, the most commonly used tests for screening HIV are the ELISA tests (Enzyme Linked Immuno-Sorbent Assay), detect antibodies in the blood. These 3rd generation tests enable virus detection 3 to 4 weeks after you have been infected with HIV. Still, due to individual differences, there can be no absolute certainty about the negative results in the first three months after infection.

      • 11. How is a positive result confirmed?

        If an HIV screening comes back positive, this result has to be confirmed before the result is delivered to the user. The patient's serum is first confirmed in the laboratory and is then forwarded to the Faculty of Pharmacy, where confirmatory tests are performed. The most common test is the Western Blot, which is a Molecular Biology test.

      • 12. What is the difference between being HIV Positive and having AIDS?

        A person carrying the HIV virus, meaning someone who, through laboratory screening, tested positive for HIV, is called HIV Positive or Seropositive. For a period of 10 to 15 years, depending on the person, the virus continues to replicate, although the person does not exhibit symptoms at this stage, and the organism can replenish the amount of CD4+ T lymphocytes destroyed by the virus.

        When the infected subject is no longer able to restore the balance between the destroyed CD4+ T lymphocytes and those replaced in circulation, the cell count starts to drop, leading to Acquired Immunodeficiency Syndrome (AIDS), where there is a considerable decline in the host’s defences and opportunistic diseases begin to emerge.

        In laboratory terms, it is considered that a healthy individual has between 500 and 1500 CD4+ T lymphocytes per millilitre of blood. Seropositivity becomes AIDS when the CD4+ T lymphocytes fall below 200 per millilitre of blood, leaving the organism unprotected against infections or opportunistic diseases.

      • 13. Which tests are used in the diagnosis and monitoring of HIV?

        There are several kinds of tests to diagnose and monitor HIV. The most commonly used tests for diagnosing HIV are the detection of HIV antibodies and thedetermination of the p24 antigen.
        The tests used for monitoring HIV are viral load testing and quantification of CD4+ T lymphocytes, which determine when to initiate a treatment, monitoring it and the progression of the virus. These tests should be repeated every three months.
      • 14. How can you know if newborn children of HIV positive mothers are also infected?

        In the case of newborn children of HIV positive mothers, testing for antibodies has a peculiarity: since newborns cannot produce them, they receive immunization from the mother’s antibodies. The antibodies are only valid after a period of 18 months, after which the antibodies from the mother disappear.

        Following this period, if the child does not show HIV antibodies, they are not infected. In these cases, it is also possible to test for the presence of genetic material from the virus, which clarifies whether the newborn is infected with HIV.

      • 15. How is it treated?

        Nowadays there is still no real and effective treatment for this disease, moreover, there is no medical treatment for diseases caused by the virus. Ideally we could kill the causative agent, as in the case of infections caused by bacteria.

        In diseases caused by the virus, the medical course of action is to create in the patient specific defences against the disease, through the preventive administration of vaccines, so that, should an infection emerge, the disease does not. At this time, the vaccine for AIDS prevention has not yet been discovered.

        There is however a group of medications that helps reduce the spread of the virus, although it does not cure or destroys the virus, simply slows its development by inhibiting certain enzymes responsible for the virus’ multiplication. These medications help to prolong a person’s life, containing the infection before it reaches the Immunodeficiency Syndrome, in which the patients no longer have any defences against the simplest infections.

      • 16. Can I remain in a Seropositve state, without it evolving into AIDS, if I don't receive the proper treatment?

        No. If you are HIV Positive and do not receive the proper treatment, you will, sooner or later, develop AIDS. HIV infection has its natural evolution before reaching AIDS. This period can last up to 10 years without treatment.
        With currently available treatments it is possible to modify the natural course of the disease, increasing the asymptomatic period of the disease, thus preventing the surfacing of opportunistic infections and tumours that arise with the onset of AIDS.
        In order to increase this period and preserve the quality of life, all HIV-positive individuals should start a course of treatment with the appropriate medical monitoring.
    • Human Papillomavirus and Cervical Cancer

      • 1. What is HPV?

        HPV (human papillomavirus) belongs to a group of viruses that infect the cervix. An HPV infection that does not disappear, meaning it becomes persistent, may increase the risk of developing cervical cancer.

        There are over 100 types of HPV, of which about 40 can infect the genital tract and are sexually transmitted.

        Genital HPV infections are usually asymptomatic and heal themselves spontaneously, in most cases. However, there are some HPV infections that can cause cervical cancer, other cancers and genital warts.

        The types of HPV associated with cancer, are called oncogenic or high-risk types. There are 12 kinds of high-risk HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59) recognized by the International Agency for Research on Cancer (IARC).


      • 2. What is the link between cervical cancer and HPV?

        An HPV infection is the necessary cause, although not sufficient, for the development of cervical cancer.

        Many HPV infections are naturally resolved by the woman's body, especially at a young age. However, about 5-10% of these infections may persist, which increases the risk developing precancerous cervical lesions. If these lesions are not promptly detected and treated, they may progress to cervical cancer.

        In Portugal, cervical cancer is the 3rd most common cancer among women. It has an incidence rate of around 12.2% and a mortality rate of around 3.6%.

        Being informed about the persistence of some types of HPV can be crucial for the risk stratification of women who may develop cervical cancer.

      • 3. When are HPV tests recommended?

        As suggested by the new consensus for HPV infection and intraepithelial lesions of the cervix, vagina and vulva of the Portuguese Society of Gynecology of 2011 HPV testing is advised:
        • For women over 25;
        • After a cytology with ASCUS results.
        • For postmenopausal women with LSIL cytology.
        • In post-colposcopic orientation (monitoring) in women referenced by cytology with AGC or ASC-H results.
      • 4. What kind of results can I expect from HPV tests?

        When testing for HPV we can determine:

        1. The type(s) of HPV present in the body, causing an infection;
        2. If the infection is caused by HR (High-Risk) or LR (Low-Risk) types.
      • 5. How important is it to know what type of HPV causes the infection?

        Distinguishing whether an HPV infection is caused by a high-risk or low-risk type is useful to stratify the risk of a woman developing precancerous lesions. To do this, there must be a persistent infection. To determine if an infection is persistent, we must know which type of HPV is causing it.

        Information on mixed infections, which, depending on the types of HPV, influence the clinical outcome. E.g. immunosuppressed women (e.g. patient HIV-1 positive).

        Post-treatment monitoring: HPV positivity in post-treatment helps predict possible recurrences of CIN2+ and CIN3+ lesions. This can only be achieved through tests that can determine the HPV type present in the lesion.

        Monitoring the effectiveness of HPV vaccines (currently, there are HPV vaccines available for types 16, 18, 6 and 11).

      • 6. Is knowing the type of HPV clinically relevant?

        It is important to have an HPV test with sensitivity and clinically relevant specificities, so that we can effectively detect HPV types in CIN2+ cases or in more severe situations.

        Recent studies compared "CLART HPV" with other HPV tests. It was found that the "CLART HPV" has an excellent performance when compared with HC2 (a test with clinical cutoff settting) and it also enables us to detect various HPV types, in single or mixed infections, in a single test.

    • Diabetes

      • 1. What is Diabetes?

        Diabetes is a chronic disease characterized by increased levels of sugar (glucose) in the blood. Blood glucose is called glycaemia - when it is increased it is called hyperglycemia and when it is decreased it is called hypoglycemia.

        The disease affects more increasingly young people around the world. Currently, this disease affects both sexes and has a high prevalence among the Portuguese population.

        Diabetes is a disease that results from the human body’s incapacity to use its main source of energy (glucose), which requires insulin. Hyperglycemia occurs due to insufficient production or insufficient insulin action or both, which is most often the case.

      • 2. What types of Diabetes are there?

        The disease is classified into three types:

        Type 1 – This type of Diabetes, rarer than Type 2, is more common in children and young people, although it can affect any age group, and it used to be called Insulin-Dependent Diabetes Mellitus. It is not usually related to weight, so most of the affected patients have normal body weight. It is caused by problems in pancreases that have a deficit in insulin production or cannot produce it in sufficient amounts. People with Type 1 Diabetes need daily insulin shots to control this condition.

        Type 2 - This is the most common type, it is responsible for 90 to 95% of the cases of diabetes, and was previously called Non-Insulin-Dependent Diabetes Mellitus. It usually affects people in adulthood and is closely associated with excess weight, due to poor diet and sedentary lifestyle. It is caused by resistance to the actions of insulin, leading to insufficient compensatory insulin secretion, i.e., the pancreas secretes insulin in normal amounts early in the disease but said insulin is unable to exert its effect as it should, which makes the pancreas produce more and more insulin in an attempt to compensate for this shortcoming. Over the years, the pancreas becomes "tired" and is no longer able to compensate for the insulin resistance, which is when the hyperglycaemia emerges, and is then diagnosed as Type 2 Diabetes.

        Gestational – This type of Diabetes occurs during pregnancy, in pregnant women who did not have Diabetes beforehand and it usually ends with the delivery. However, about half of the people who suffer from this type of disease later end up suffering from Type 2 Diabetes, if they are not properly monitored.

      • 3. What are the Diabetes risk factors?

        Even though Diabetes can affect anyone, there are some cases with higher risk.
        • People who have direct family members with the disease;
        • Obese men and women;
        • People with particularly sedentary lifestyles
        • People with high blood pressure or high blood cholesterol levels;
        • Women who contracted gestational diabetes during pregnancy;
        • Children weighing four kilograms or more at birth;
        • Patients with pancreatic issues or endocrine diseases;
        • The elderly are more likely to develop the disease.
      • 4. What are the symptoms of Diabetes?

        Since diabetes can cause serious complications, it is important that people pay attention to the appearance of signs suggestive of diabetes. Symptoms associated with diabetes are usually discrete and slow, which leads to a late diagnosis.

          Symptoms in children:

        • Frequent Urination;
        • Thirst;
        • Tiredness;
        • Headaches;
        • Nausea and vomiting;
        • Rapid weight loss.

         Symptoms in adults:

        • Frequent Urination;
        • Thirst;
        • Tiredness;
        • Headaches;
        • Possible weight loss;
        • Blurred vision.

        It is important to remember that while the symptoms in children and adolescents are quite clear, the same cannot be said for adults, especially early on in the disease, hence why it can go undetected for some time. With Type 1 Diabetes, the symptoms usually surface faster and can be more severe and bothersome. With Type 2 Diabetes, it is very common for patients to not show any symptoms, especially at an early stage.

        If faced with these symptoms, you should seek your doctor immediately, to test for the presence or absence of diabetes.


      • 5. Can eating too much sugar cause diabetes?

        Contrary to popular belief, eating too much sugar, in and of itself, does not cause diabetes. However, eating too much sugar can lead to excessive weight gain, and obesity is one of the most common causes of diabetes.

      • 6. Should the patient manage the disease?

        Yes, diabetes should be managed daily by the patient through a good diet, exercise and blood tests - by measuring capillary blood glucose (fingerstick) daily and more than once a day. It is important that measurements are made, preferably, at the same times every day and before eating, so that you can compare the data.

        A patient who is not controlled can have serious complications, while a patient who takes the proper precautions and keeps up the daily monitoring can have a perfectly normal life.

      • 7. Is there a cure for Diabetes?

        Diabetes is a chronic disease for which there is currently no cure. However, like many other diseases, it can be treated and controlled. Most people with diabetes can lead a completely healthy and normal life, so long as they maintain their treatment and a proper diet.

      • 8. How is it diagnosed?

        Diabetes is diagnosed using the following parameters:

        • Fasting blood glucose ≥ 126 mg/dl;
        • Classical symptoms plus random blood glucose ≥ 200mg/dl;
        • Glycemia ≥ 200 mg/dl in the 2 hours OGTT with 75g; 
        • Glycated hemoglobin A1c ≥6.5%

        The diagnosis should always be confirmed after 1 to 2 weeks with the same test. Fasting blood glucose levels between 110 and 126 mg/dl and/or figures between 140 and 200 mg/dl after the 2 hours Oral Glucose Tolerance Test indicate an increased risk of Diabetes.

      • 9. What are the normal levels of blood glucose?

        Currently, the following blood glucose levels are considered normal:
        a) Fasting glycemia: 
        Normal between 70 and 110mg/dl  
        Altered between 110 and 126mg/dl  
        Probable Diabetes - above 126mg/dl  
        b) OGTT (after glucose overload of 75g)
        after 2 hours
        Probable Diabetes - 200mg/dl or above 
        Low glucose tolerance- between 140 and 200mg/dl 
      • 10. If my mother and/or father have diabetes, will I be diabetic as well?

        Diabetes can be inherited. This means that an individual with diabetic parents has a higher probability of becoming diabetic. However, that is not certain, provided you lead a healthy lifestyle (balanced diet, regular exercise, normal body weight) you may never develop this disease.

        In other words, having diabetic parents does not mean you will have diabetes, but it is more likely to happen than to an individual who does not have diabetics in the family.

      • 11. Can Diabetes cause infertility?

        Diabetic women who do not control their blood glucose levels are associated with a higher risk of miscarriage in the first three months of pregnancy. In addition, Type 2 diabetic women are often obese or suffering from polycystic ovary syndrome, which hinder conception.

      • 12. Whatis Gestational Diabetes?

        Gestational Diabetes is the hyperglycemia that occurs exclusively in pregnant women who have not previously had diabetes. It usually disappears after the baby is born.

        During pregnancy (approximately around the 24th gestational week) the body produces large amounts of hormones that help the baby to grow and the organism has a greater need of insulin. If the pancreas does not produce the amount of insulin required or if it does not perform its function properly, blood glucose increases (hyperglycemia), leading to gestational Diabetes.

        Hyperglycemia causes the baby to grow in size and produce insulin. But do not worry - most women with gestational Diabetes have healthy babies.

        The gestational Diabetes must, however, be monitored until the baby is born. Maintaining your blood glucose levels as normal as possible prevents complications, for you and your baby.

        Pregnant women who are now faced with diabetes should accept this step without alarmism or unfounded concerns, as most women with gestational diabetes have healthy babies. Simply check your blood sugar levels regularly and follow the directions given by your health care team.

      • 13. Is it important to control Gestational Diabetes? Why?

        It is important to control it so that there are no complications at birth. Currently, the oral glucose tolerance test is mandatory for pregnant women and, fortunately, in most cases of gestational diabetes a high-quality glycemic control can prevent complications for both the baby and the mother.

    • Non-Invasive Prenatal Test - PANORAMA

      • 1. Can I do the PANORAMA test like any normal analysis?

        No, the PANORAMA test is a specific test that requires advance booking, performed at the Central Laboratory in Albufeira.

      • 2. Should I be fasting for the PANORAMA test?

        No, quite the opposite actually. It is essential that the mother has had her breakfast, since the ideal time to collect the samples is from 10 a.m. to 11a.m.

  • Food and Water Analysis

    • Legislation

      • 1. Which Decree-Law ensures the quality of water for human consumption?

        Decree-Law nr. 306/2007 August 27.

    • Water Microbiology

      • What if I have a well at home? Can I drink that water?

        The good quality of drinking water is essential to our health. All private sources of water supply can be a threat to your health, unless they are properly treated and protected. These can easily become contaminated with bacteria, parasites and viruses or other substances.

        Often, people cannot determine whether their water is safe, because contamination may not be evident through the smell, taste or colour of the water. Unlike public supply, many private sources of water supply are not treated to remove contamination. Therefore, if you have a hole or a well full of apparently "good" water, it does not mean that it is safe to drink it.

      • 2. What is the origin of bacteria in drinking water?

        Human and animal fecal contaminations are the primary sources. These sources include grounds where animal droppings are deposited, such as manures and crop land. Other sources are aseptic tanks dishcarge, flooding or seepage.

      • 3. What are fecal coliforms and E. coli?

        Human and animal fecal contaminations are primary sources. These sources include grounds where animal droppings are deposited, such as manures and crop land. Other sources are aseptic tanks dishcarge, flooding or seepage.

      • 4. What are the pathogenic micro-organisms, i.e., likely to cause diseases?

        Polluted water contains numerous microorganisms capable of causing diseases in humans. These are viruses, bacteria, fungi, protozoa, helminths. These microorganisms originate from either infected people or carriers. The latter can cause intestinal infections, dysenteries, hepatitis, typhoid fever, cholera and other diseases. However, these diseases are not limited to organisms existing in water, there are other factors not associated with drinking water. Intestinal infections and dysentery are generally considered minor health problems. They may, however, be fatal for children, elderly and sick.

      • 5. What is Clostridium perfringens?

        Clostridium perfringens is a bacterium used as an indicator of water pollution of remote or intermittent fecal origin, due to the long residence periods and survival conditions of its spores, which are resistant to chlorine disinfection.

      • 6. What do I need to perform a microbiological analysis of a water sample?

        You must acquire a suitable container, i.e., sterilized. For that, you will have to go to the laboratory or to a sample collection unit or contact us and we will send the appropriate containers.

    • Water Chemistry

      • 1. How can I evaluate the hardness of my water?

        Waters are usually classified according to their degree of hardness, as follows:
        Soft Water 0-75 mg/L (CaCO3)
        Moderately hard water 75-150 mg/L (as CaCO3)
        Hard water 150-300 mg/L (CaCO3)
        Very hard water >300 mg/L (CaCO3)
        Water hardness is caused by the presence of metal cations, of which the calcium and magnesium ions are the ones who contribute on a larger scale.
        -Hard waters are, in general, waters that require considerable amounts of soap to foam, and that form scales in boilers and other materials when they are heated.
        -When the water hardness is high, it leads to the formation of bothersome and disturbing deposits. Soft waters can cause corrosion, because they do not form protective carbonate deposits in plumbing.
        -From a sanitary point of view, hard waters do not have any drawbacks. Even though there are some epidemiological studies that seem to show that there may be an inverse relationship between water hardness and heart diseases associated with other social and climatic factors, this has not yet been fully proved, according to World Health Organization (WHO).
      • 2. Why is tap water white sometimes?

        The white colour is due to the presence of dissolved air in the water, caused mainly by manoeuvring in the Distribution Network. This is timely and temporary, but it should be noted that the water is fit for consumption.

        We advise you to let the water stand for a few minutes.

      • 3. What is the volume of water necessary for a physical-chemical analysis for human consumption?

        You should collect about 500 ml of water. See sampling procedure on the menu - SERVICES.

      • 4. How important is chlorine?

        Chlorine is a disinfectant used in water treatment, which aims to ensure its microbiological quality, without causing problems for public health.

      • 5. Which Legislation regulates the treatment of water for human consumption?

        The Legislation for water treatment is the Decree-Law nr 306/2007 of August 27.

      • 6. What is the water pH?

        The pH (hydrogen potential) reflects the acidity or basicity of the water.

        The pH scale comprises numbers between 0 and 14 - a pH of 7.0 indicates a neutral solution; if it is below 7.0, it indicates an acidic solution; and if it is above 7.0, it indicates an alkaline solution.

      • 7. What can influence the water features?

        Age and plumbing conservation status can change the water’s characteristics, namely the taste, smell and colour. The water temperature may also affect its taste. Cool water is more pleasing to the palate.