Pregnancy, pandemic, anxiety 

Dr. André Galvão de Castro, Psychologist – Master’s Degree in Psychology | Grupo HPA Saude – Gambelas Hospital 

Pregnancy is considered one of the most vulnerable stages in a woman's life cycle, due to all the changes that take place, leaving her more fragile from a physiological and emotional point of view.

This period is deeply marked due to several biological, psychological and social changes, which all have a direct impact on the woman's daily routine, leading to necessary reorganization due to her new role as a future mother. This adaptation brings with it other limitations, in terms of the women’s autonomy and daily life that will invariably have to change. All these alterations, together with a natural concern for the foetus, all the social pressure of having to make sure everything runs perfectly, which often falls upon the woman, together with the feeling that she might fail at some point, does sometimes not correspond to the ideal situation  idealized by women. This may interfere temporarily with the women’s well-being, mood, self-esteem and self-image, and can therefore generate some anxiety and stress.

At the same time, due to the constant information supplied by the media, attention is being directed to the problem of the current pandemic. The worsening situation or the daily increase in the number of cases raises concerns, doubts and uncertainties about the future, can also become a stress triggering factor, which may thus help to exacerbate anxiety.

Anxiety during pregnancy and in the postpartum period is often undervalued and underdiagnosed, affecting many women at a stage in their lives, which they had idealized as being one of the happiest. The help of the spouse during this period becomes paramount, to support the woman in her decisions, to encourage and to transmit security.

It should be noted that this disorder, in addition to preventing many women and new-born infants from enjoying some of the most emotional moments of their lives, can simultaneously enhance anxiety in future adults.

It is now known that a history of anxiety in pregnancy is one of the risk factors for the development of postpartum depression, with significant consequences for the baby and the mother.

It is therefore imperative that women learn to take care of their emotional health, seeking specialized help, during pregnancy. 

Information: Continuity of medical care, in suspected or diagnosed cases of COVID-19 infection.

None of the HPA Health Group hospitals or units is a “COVID-19 unit”.
However, we have defined referral protocols on decisions to be followed related to referrals in suspected cases or positive patients:

• i) All patients who visit any of the Units of the HPA Health Group are screened by means of an epidemiological survey, and their body temperature is also measured;
• ii) Patients with scheduled appointments or examinations (non aerosol generators). When the epidemiological screening of cough, fever, difficulty breathing, or other symptoms associated with SARS-CoV-2 (COVID-19) are negative - the patient follows his normal circuit. If screening is positive, the patient is placed in the Isolation Area of the Emergency Unit for evaluation, if he so wishes.
• iii) Patients in need of transfer from the Emergency Unit to the In-Patients Unit with a negative epidemiological screening result, are admitted to the preventive isolation unit and tested for COVID-19. If the test is positive, patients are referred to the 2 reference hospitals in the area; Faro and Portimão Public Hospitals.
• iiii) Patients in need of transfer from the Emergency Unit to the In-Patients Unit with a positive epidemiological screening result, are admitted to the preventive isolation unit, placed in the quarantine area and submitted to two COVID-19 tests. If any of the tests are positive, patients are referred to the 2 reference hospitals in the area; Faro and Portimão Public Hospitals.
• iiiii) All patients with scheduled surgeries and/or scheduled aerosol-generating exams are previously tested for COVID-19. In case the result is positive, the surgeries and / or exams are subject to multidisciplinary risk/benefit analysis to decide whether to perform or reschedule the surgery and/or exam. 

The impact of the new coronavirus on the cancer patient

Oncology Day Care Hospital, Hospital Particular da Madeira

Person-to-person transmission of SARS-CoV-2 or COVID-19 can occur through respiratory droplets, produced when an infected person coughs or sneezes. These small droplets can be inhaled, or come in contact with the oral or ocular mucosa, transmitting the virus to people who are less than 2 meters away. The same droplets can be deposited on surfaces and hands and subsequently transported to the mouth, nose or eyes, transmitting the disease.

As is the case with the elderly and people with chronic diseases, the cancer patient with active disease or under immunosuppressive antineoplastic treatment, usually has a weakened immune system. Despite the scarce evidence available on the behavior of COVID-19 infection in this pathology, this fact represents an important risk factor for infection and serious complications, as well as for any other infection by another agent.

There is, understandably, fear and anxiety about this new reality.

Even in this pandemic phase, in the case of urgent health treatments, the patient must begin / continue his treatment, without prejudice to his clinical situation. There will be occasional situations, in which the oncological disease is stationary or well controlled, and according to the risk of contact / infection by COVID-19, it may be possible to consider postponing the treatment.

Mitigation measures were implemented, resulting in stringent screening and control of all patients and health professionals in order to minimize the risk of contagion at the Day Care Hospital, according to the specifications of the Hospital Contingency Plan.

The main object is to reduce as much as possible the risk of a possible exposure to infection by COVID-19, minimizing the risk of  decreasing the patient’s immunosuppression system. Therefore, we need to promote the communication between the patient and the physician by remote communication instead of face-to-face consultations (via telephone / video or email, namely for routine consultations of patients that are not on active cancer treatment).

The Oncology Unit of the Hospital Particular da Madeira therefore will continue to provide the necessary treatment to the cancer patient.

The measures widely recommended and publicized by different media, must be strictly observed: respiratory etiquette, frequent hand sanitizing, avoid touching the face with the hands and sharing personal objects, as well as prophylactic social isolation. For the cancer patients under active and immunosuppressive treatment, the use of a surgical mask is recommended due to the risk of infection with COVID-19 and other agents. Its correct placement and removal must be respected.

Protect yourself and others. Combating this threat is in the hands of us all.

There are more diseases beyond Covid-19…
The importance of maintaining the vaccination program and pediatric consultations during this pandemic 

Dr. Luís Gonçalves, Director of the Pediatric and Neonatology Units of the HPA in Gambelas

We are going through a period of pandemic, of a new coronavirus, called “SARS-CoV-2”, which causes COVID-19 disease. As it is a new virus, with which we have not had previous contact, we do not as yet have immunity.

Immunity for the entire population will only be possible once the majority of the world population has been infected or has had the disease, or ideally only when there is a vaccine.

Several scientists worldwide are working hard to develop a vaccine, but it is a complex process that can take several months.

The current pandemic situation of COVID-19 has highlighted the importance of vaccines and, of course, complying with the national vaccination program (PNV - Programa Nacional de Vacinação), is essential. Likewise, in addition to vaccines, which should not be postponed, especially in the younger age groups, follow-up appointments (routine consultations) should also not be postponed.

Thus, the Department of Pediatrics and Neonatology, of the HPA Health Group, according to  the rules in force at the Gambelas Hospital treats all children, including the most vulnerable, such as newborns and children with known pathologies, maintains its routine consultations, also to update vaccines (of the PNV or extra PNV, as I will be mentioned later on in this article).

VACCINATION PROGRAM OF THE PNV

The National Vaccination Program, is a universal program which is cost free whose object is to protect the population against diseases that can potentially present a threat to the health of individuals and to the public in general as is the case with the present COVID-19 virus.

Diseases such as measles, polio, whooping cough, hepatitis B, meningitis caused by various agents, tetanus and many others, are covered by the PNV.  

It is essential to maintain protection against diseases for which a vaccine already exists.  

Portugal is a model country for the whole world due to its vaccination program. Even so, several cases of measles have already been registered in our country this year and the reason the outbreak was not extensive is due to the fact that most of the Portuguese population is vaccinated. For this reason there was a rapid control of all possible transmission. The same may not happen, if children stop being vaccinated. The vaccination rate dropped during the past months of March and April, due to fear of the coronavirus and having to go to the various institutions for vaccines.

It is essential for children to be vaccinated during the COVID-19 pandemic. If not, we run the risk of having new epidemics, particularly of whooping cough and measles, as well as other infections that are preventable by vaccination.

VACCINES THAT TAKE PRIORITY

Due to all that I have already mentioned, ALL stages of the PNV must be carried out in all its programmed stages and therefore ALL vaccines must be taken. However, due to the severity of the diseases that are protected by vaccines, (such as meningitis) or the importance of group immunity (such as measles) or because they are the primary vaccination, I will highlight those which should never be postponed, even in a pandemic situation.

The PNV begins in pregnancy, with the future mother being vaccinated to protect the newborn infant against whooping cough. Then, throughout one´s lifetime, it is very important to comply with the vaccination program. If this is not observed, it is not only the individual himself who is at risk, but also all those with whom he has a daily relationship.

During the child’s first year of life, in addition to the whooping cough vaccine, diphtheria, tetanus, polio, the invasive disease hemophilic influenza b, measles and meningococcal C meningitis, are very important and are all administered at the age of  12 months.

OTHER VACCINES NOT INCLUDED IN THE PNV

In addition to vaccines of the PNV, there are others that may be recommended by your attending physician / pediatrician. This is because there are diseases that may not be significant in representing a danger to the population in general, but that risk may be important for the individual.

During the pediatric age, these recommendations are released by the Vaccines Commission of the DGS (National Health Board) and are part of the Pediatric Infectious Society of the Portuguese Pediatric Society.

This group of vaccines include vaccine against Rotavirus (causes acute gastroenteritis), Meningococcus B and ACWY (causes meningitis / septicemia).

At the HPA Health Group, we maintain the administration of the vaccines not included in the  PNV , according to the medical recommendations, of our pediatrician.

VACCINATION AND PEDIATRIC CONSULTATIONS DURING THE PANDEMIC

Although many exams and consultations are being reorganized during the current pandemic, it is essential not to stop or delay vaccines which have been booked for your child, as they protect against many potentially serious illnesses.

Contact the HPA Health Group and the Department of Pediatrics and Neonatology, in the Out-Patients Unit, and plan your trip to the hospital. Each child can only be accompanied by a single parent and the social distancing rules must be observed, hand hygiene and respiratory etiquette referred to in the guidelines of the National Health Board, must be complied with. The use of a mask is mandatory, and can be provided at the entrance of the hospital for those who do not have one.

Check-Up consultations for newborn babies and children, recommended by the National Child and Youth Health Program, should also be maintained during this pandemic period.

Thus, the Department of Pediatrics and Neonatology maintains, despite the constraints caused by the COVID-19 pandemic, pediatric consultations at the following ages:

• 7-10 days after birth;
• 1 month;
• 2 months;
• 4 months;
• 6 months;
• 9 months;
• 12 months;
• 18-24 months;
• 5 years of age.

In some cases, such as with chronic diseases, there may be a need for extra consultations, depending on the assistant pediatrician, which must be respected.

All urgent situations must be attended to in the Pediatric Emergency Unit.

Whenever non-urgent matters arise and parents need assistance with questions (such as finding out test results or renewal of prescriptions, for example) the Pediatric Unit can be contacted, either by phone or email, thus avoiding unnecessary trips to the hospital on:

282 420 400 or rpediatriahpaf@grupohpa.com

Recommendations for asthmatic patients or with other types of respiratory allergies

Dr. Pedro Morais Silva, Immunoallergologist

On the 5th of May this year we celebrate World Asthma Day.  We are going to take this opportunity to answer some queries regarding the relationship between allergic diseases and COVID-19 infection.

The data currently available (and it must be noted that there is much we still do not know) does not seem to indicate an increased risk of becoming ill, either by asthmatic patients or other allergic diseases. However, from a theoretical point of view it makes sense that an uncontrolled asthma could be a risk factor for suffering a more serious COVID-19 infection, so extra care is recommended to maintain the disease under control.

It is therefore very important that regular treatment is maintained, without fail. If your asthma is well controlled with your daily medication, you should continue the treatment. If you have recently noticed symptoms of asthma such as wheezing, coughing, chest tightness or shortness of breath, you may need to adjust your daily medication. If your treatment plan calls for an adjustment of your medication when symptoms worsen, you should put that adjustment into action. If you are not sure how to adjust your medication in the event of a worsening condition, we recommend that you speak to your doctor.

None of the drugs commonly used to control asthma or allergic rhinitis appears to interfere with the body's ability to prevent or fight infection caused by the new coronavirus. Inhalers or nasal corticosteroids are safe and should be used to control an allergic respiratory disease.

There is currently no reliable information to suggest that any specific medication, supplement or food has a beneficial or preventive effect to avoid becoming ill. There are also no specific vaccines to prevent this infection. Existing vaccines to prevent other infections (for example pneumonia or flu) should be taken according to the usual recommendations. There is no recommendation as to the need of reinforcing or anticipating the administration of the normal annual flu vaccine.

To prevent becoming infected, you should follow the recommendations of the General Health Department - restrict social contact and stay at home, if possible; wash your hands frequently, scrubbing  them well for at least 20 seconds; use a mask wherever it is recommended; do not touch the eyes, nose and mouth. The latter can be more challenging for allergic patients, especially if there are symptoms such as itching or discomfort. Talk to your doctor if you have these complaints, as there are several medications that can help.

If you have an asthma attack and need to go to an Emergency Unit, remember to take your medication plan with you, as well as, if prescribed, your expansion chamber.

Several patients suffer from allergies during the spring season. The symptoms caused by an allergy are different from those of a common colds, flu and COVID-19, as shown in the following table:  

The Immunoallergology Consultation is operational and fully available to help its patients. Stay safe. Take care of yourself and, if you can, those that are in need.

Recommendations for patients with Autoimmune Diseases undergoing biological and/or non-biological treatment 

Dr. Carlos Carneiro, Internal Medicine Specialist and responsible for the Autoimmune Diseases Out-Patients Consultation  

My first words are of trust and hope.

Trust in a better world with changing habits as a result of this pandemic and hope that we will overcome this pandemic.

However, it is very important that we realize that this is not a sprint, but a marathon, in which our resilience, respect for others, social distancing and individual protection are keys for success.

Social distancing is not synonymous with isolation. Protect yourself, but keep a regular follow-up with your doctor, because ONLY TOGETHER WILL WE WIN!

Patients with autoimmune diseases undergoing biological/non-biological therapy are not at a greater risk of being infected with SARS-CoV-2 (COVID-19). In the absence of scientific evidence, it is assumed that they may have a higher risk of complications and mortality from infection, essentially the elderly, when certain other co-morbidities are present (cardiovascular disease, diabetes, chronic respiratory disease, hypertension, cancer).

In the majority of cases, it is not advisable to suspend preventative biological/non-biological treatment, as suspending therapy may lead to worsening of the autoimmune disease, and will not guarantee a reduced risk of contagion.

Patients suspected or confirmed of COVID-19, with symptoms of infection/respiratory disease - cough, fever, difficulty breathing - or close contact with people suffering from these symptoms, should suspend biological /non-biological therapy until the situation is clarified.

It is therefore essential to reduce exposure to COVID-19 in order to reduce the risk of infection.

Recommendations:

• Wash hands frequently with soap and water for at least 20 seconds especially in public spaces.
• Avoid touching the eyes, nose and mouth with unwashed hands
• Use protection masks
• Avoid high-risk situations such as places with a high concentration of people or close contact with people with symptoms of respiratory disease/infection. 

The diabetic patient and diet during social isolation

Marina Augusto Estêvão - Nutritionist

In these difficult times for all of us, it is very important that diabetics maintain good eating habits, in order to control their blood sugar levels, keeping their diabetes compensated.

Daily routines have certainly changed in recent weeks due to the fact that we are at home and do not perform the tasks that would normally occupy our daily lives; going to work, water aerobics class, walking with friends, or even daily shopping trips.

Even so, being diabetic one should continue to maintain a healthy and adequate diet and try to stay active, even when at home. 

Here are some tips:

•  Avoid numerous trips to the supermarket and try to buy food that lasts longer. For example, apples and pears, frozen fish, canned sardines, mackerel or tuna, frozen vegetables, dried fruits;
• Prefer brown or whole wheat bread that can be frozen  when still fresh so that it can be eaten later (if you usually weigh your portion, be sure to let it thaw completely before weighing it so that the quantity you want to eat is the correct one);
• Instead of buying fresh or cream cheese to put on bread, use  olive oil with chopped garlic, tomatoes and oregano,  accompany it with an infusion of herbs;
• Between meals, avoid frequent biscuit snacks. Being at home for long periods of time can increase one’s desire to eat frequently. Cut carrots, cucumber or peppers into sticks and make a hummus sauce (1 jar chick peas + chopped parsley  + juice of 1 lemon + 1-2 cloves of garlic + little water + 1 tablespoon of tahini ; grind  in a processor and you're done), use about 3 tablespoons of this sauce with the vegetable sticks for a morning or afternoon snack;
• Another snack option is 2 tablespoons of lupines (previously rinsed to remove excess salt) with 1 small apple, or  ½ handful of unsalted nuts (almonds, walnuts, peanuts, hazelnuts) ;
• Soups should be rich in vegetable avoiding potatoes (eg courgette, carrot, onion, mushrooms, broccoli, add a drizzle of olive oil once cooked, avoiding excess salt and add  parsley, coriander or mint for additional flavor);
• Eat peas, beans, chick peas, lentils or broad beans for carbohydrates. Avoid using pasta, rice potatoes too often (ideally ¼ of the plate o peas etc, with large quantity of vegetables, fish meat  or egg);
• Don't forget to stay hydrated. If you are used to having your water bottle at work, maintain that habit at home also, drinking at least 1.5l / day. If you have difficulty drinking that amount of water, add mint, a cinnamon stick and slices of orange to add flavor;
• Stay active. Play music that you like and dance either on your own or with your partner.  Do some gardening, climb up and down stairs, skip, walk around the house a little or practice some gym in the lounge. 

The Cancer Patient

Oncologist Dr André Andraz Cruz explains the impact of the new coronavirus on the cancer patient  

The coronavírus (COVID-19) is a respiratory disease caused by a new coronavírus, which was identified for the first time in the province of Wuhan, in China, in December 2019. In the majority of cases it causes minor effects similar to those of a cold or flu.

However, it may cause a more severe form of the disease, similar to that of Severe Accute Respiratory Syndrome (SARS), known as SARS-CoV-2, with a mortality rate proportional to age and other diseases. 

It is a highly contagious disease, through respiratory droplets and through contact with contaminated surfaces with subsequent contact of the hands with the eyes, nose and mouth.

In addition to elderly patients with chronic diseases, cancer patients with active disease or undergoing immunosuppressive cancer treatment generally have a weakened immune system. Despite the scant evidence concerning the behavior of COVID-19 infection in this pathology, the above fact constitutes an important risk factor for infection and serious complications, as well as for any other infection by another agent.

There is, understandably, fear and anxiety of patients in the face of this new reality.

Even in this pandemic phase, in the event of urgent health care treatment being necessary, the cancer patient will start / continue his treatment, without prejudice to his clinical situation. There will be occasional situations, in which the oncological disease is indolent or is well controlled, and weighing the risk of contact / infection by COVID-19, it will be possible to consider postponing the treatment.

Naturally, there is now a rigorous screening and control of all patients according to the Contingency Plan of the Hospital, in order to minimize the risk of infection in the Day Care Hospital, be it to other patients, or to the Health professional.

Another important necessity is to minimize hospital visits; ideally only for treatment ideally favoring Teleconsultations whenever possible (namely routine consultations of patients not undergoing cancer treatment). 

The measures widely recommended and widespread in the media must be strictly observed - respiratory etiquette, washing hands frequently, avoid touching the face with the hands and sharing personal objects, as well as prophylactic social isolation. In cancer patients under active and immunosuppressive treatment, the use of a mask is recommended due to the risk of infection with COVID-19 and other agents. However, placing and removal of the mask must be done correctly.

The Cancer Units of the Day Care Hospitals of Alvor and Gambelas – will continue to provide the treatment necessary to cancer patients.  

In addition to these measures, stay at home. 

The Elderly 

The impact of social isolation on the elderly  

According to the Psychologists Board during these difficult times we are going through, can give rise to a mixture of emotions difficult to manage, such anxiety, fear, anguish and or frustration. In the polder population these manifestations might have an even greater repercussion. 

With this in mind, the said organization has alerted to some attitudes and behavior to be adopted for those that have family members or even friends in these circumstances:

• Phone regularly and encourage them to also phone you, show interest and available to chat.
• Do the same to other family members or friends, so that everyone feels connected and protected.
• Since the elderly usually find it more difficult to fall asleep, try to also call them during that period.  This will provide greater peace of mind.
• Keep an eye on their state of Health, once or twice a day, questioning on symptoms they might be having. Even usual symptoms might be significantly different during this period. If you have any doubts call (National Health Line) SNS24 or seek a health professional.
• Make sure they are taking their usual medication.
• Advise them to do some physical activity, for exemple, walking around the House, or some simple exercises.
• Question them about their meals, advise on having balanced meals, sugest diferente recipies.
• Sugest that they should play some games that will keep them amused and motivated.
• Show that you are greatfull for their colabotration, responsibility as a responsible citizen during these difficult times.
• Remind them that if they wish to find further information thay need to do so from oficial sources  DGS or OMS.
• Lastly, show your affection verbally, telling them that you love them and that they are loved.  

Interpreting children’s feelings and learning to calm them down during an isolation period

Children tend to assimilate  parents' feelings, so at a time when many parents  feel uncertain and anxious,  it is predictable that the same will happen with the youngsters.

The Portuguese Psychologists Board has issued some recommendations that can help old and young to understand and overcome these anxieties:

• So that the child within its understanding and development can collaborate, explain how important you’re is his help.  As it is equally important to respect the respiratory etiquette and hand washing, the reason why contact with the face, hands and mouth should be avoided.
• Don't underestimate the child’s feelings of anxiety, fear, frustration or annoyance. However, praise a positive attitude.
• Explain that being isolated at home can also be fun: there is more time to play, you can engage in new activities, they can try out video calls and they can even organize a “logbook”, which will serve to later recall how we won this fight against the virus.
• Convey hope and security. Tell the child that this is a passing phase; that we will not be at home forever, but since it must now be so, let us make the best of it.

Being a diabetic patient in times of a COVID-19 pandemic

Dr. Ricardo Louro, Internist and responsible for the Diabetic Out-Patient Consultation.

Due to the current pandemic circumstances associated to SARS-CoV2 (COVID-19) that is also affecting our country (SPD, SPEDM, NEDM/SPMI e APMGF), it recently become necessary for several scientific societies to reach a consensus and to issue recommendations relating to diabetic patients. 

Diabetes Mellitus (DM) makes people more susceptible, not only to the development of infections, but to conditions of greater severity and a worse prognosis.

Among the various recommendations I wish to highlight:

• I will be postponing all my medical activity which is considered not to be of an urgent nature (out-patients consultations and appointments, exams and treatment).
• I will be optimizing the monitoring DM patients without the presence of the patient, preferably by telephone of email. In this way medical prescriptions can be reissued and trips to the hospital to collect prescriptions can be avoided. 
• Comply with social isolation, avoiding social contact whenever possible. If for some reason this is not possible, maintain a distance of at least 1 meter from other people.
• Avoid contact with people that are ill or those with respiratory symptoms.
• Wash hands frequently with soap and water or a disinfectant solution. Avoid sharing food or crockery.
• Keep hydrated, control blood glucose and ketone levels, measure temperature regularly.
• Should symptoms such as temperature, cough or shortness of breath arise, keep isolation at home and contact Helpline - Saúde24.

From my personal point of view, in addition to the above recommendations do not forget that good practices for controlling Diabetes should be maintained; healthy eating habits, the usual daily exercises, at home. Be sure that you have the necessary medication and the testing materials necessary for the following weeks and that you also have the necessary prescription should you run out of medication.

Stay at home, keep safe, keep your Diabetes under control.