Estimating excess mortality and economic burden of Clostridioides difficile infections and recurrences during 2015-2019: The RECUR England study

OBJECTIVES

To generate real-world evidence on all-cause mortality and economic burden of Clostridioides difficile infections (CDIs) and recurrences (rCDIs) in England.

METHODS

We conducted a cohort study using retrospective data from Clinical Practice Research Datalink linked to Hospital Episode Statistics. Patients diagnosed with CDI in hospital and community settings during 2015-2018 were included and followed for ≥1 year. All-cause mortality was described at 6, 12, and 24 months. Healthcare resource usage (HCRU) and associated costs were assessed at 12 months of follow-up. A cohort of non-CDI patients, matched by demographic and clinical characteristics including Charlson Comorbidity Index score, was used to assess excess mortality and incremental costs of HCRU.

RESULTS

All-cause mortality among CDI patients at 6, 12, and 24 months was 15.87%, 20.37%, and 27.03%, respectively. A higher proportion of rCDI patients died at any point during follow-up. Compared with matched non-CDI patients, excess mortality was highest at 6 months with 1.81 and 2.53 deaths per 100 patient-months among CDI and ≥1 rCDI patients. Hospitalizations were the main drivers of costs, with an incremental cost of £1209.21 per CDI patient. HCRU and costs increased with rCDIs.

CONCLUSION

CDI poses a substantial mortality and economic burden, further amplified by rCDIs.

Clostridioides difficile infections, recurrences, and clinical outcomes in real-world settings from 2015 to 2019: The RECUR England study

OBJECTIVE

To estimate the epidemiological and clinical burden of Clostridioides difficile infections (CDIs) and recurrences (rCDIs) in England.

METHODS

This retrospective study included adult patients diagnosed with CDI (community or hospital settings) over 2015-2019 from Clinical Practice Research Datalink and Hospital Episode Statistics databases. Incidences of CDI and rCDI were determined annually. Time to subsequent rCDI was estimated by Kaplan-Meier method. Rates of complications were assessed within 12 months from index episode. Association of risk factors with complications was evaluated using a Cox regression model.

RESULTS

A total of 52,443 CDI episodes were recorded among 36,913 patients. Of these, 75% were aged ≥65 years, 59% were women; 73% were treated in community settings. CDI incidence remained stable (111 episodes per 100,000 patients in 2019). Around 21% of patients had ≥1 rCDI. Sepsis (12%) was the most common complication, followed by colectomy and ulcerative colitis. Age, gender, comorbidities, rCDI, preindex medical procedures, hospitalizations and consultations, and CDI treatment in hospital, were found to increase the risk of complication.

CONCLUSIONS

CDI remains a concern in England. The study highlights the importance of managing primary and rCDI episodes via effective and improved therapies to prevent fatal complications.

Economic impact of reducing treatment gaps in depression

BACKGROUND

Major depressive disorder (MDD) is highly prevalent across Europe. While evidence-based treatments exist, many people with MDD have their condition undetected and/or untreated. This study aimed to assess the cost-effectiveness of reducing treatment gaps using a modeling approach.

METHODS

A decision-tree model covering a 27-month time horizon was used. This followed a care pathway where MDD could be detected or not, and where different forms of treatment could be provided. Expected costs pertaining to Germany, Hungary, Italy, Portugal, Sweden, and the UK were calculated and quality-adjusted life years (QALYs) were estimated. The incremental costs per QALY of reducing detection and treatment gaps were estimated.

RESULTS

The expected costs with a detection gap of 69% and treatment gap of 50% were €1236 in Germany, €476 in Hungary, €1413 in Italy, €938 in Portugal, €2093 in Sweden, and €1496 in the UK. The incremental costs per QALY of reducing the detection gap to 50% ranged from €2429 in Hungary to €10,686 in Sweden. The figures for reducing the treatment gap to 25% ranged from €3146 in Hungary to €13,843 in Sweden.

CONCLUSIONS

Reducing detection and treatment gaps, and maintaining current patterns of care, is likely to increase healthcare costs in the short term. However, outcomes are improved, and reducing these gaps to 50 and 25%, respectively, appears to be a cost-effective use of resources.

Height benefit of GnRH agonists after age 8 in a Portuguese cohort of central precocious puberty

OBJECTIVE

Idiopathic central precocious puberty (iCPP) is common in paediatric endocrinology. Gonadotropin-releasing hormone agonists (GnRHa) are safe, but the effect on final height and the ideal timing for treatment remains controversial. This study aims to assess the effectiveness of GnRHa on growth outcomes in girls with iCPP treated before and after the age of 8 years old.

DESIGN AND PATIENTS

This retrospective longitudinal study evaluated data from Portuguese girls with iCPP who completed treatment between 2010 and 2021.

MEASUREMENTS

Auxological and clinical characteristics were compared according to age at treatment onset.

RESULTS

A cohort of 134 girls with iCPP, was divided into early treatment (ET) (<8 years, n = 48) and later treatment (LT) groups (≥8 years, n = 86). In both groups, most children presented with Tanner II and III. Tanner IV was more frequent in LT group (p = .003). At the end of treatment, predicted adult height increased in both groups (ET p = .032; LT p = .04) and bone age significantly slowed down in all participants (p = .008, p = .034). The height gain was greater in the ET group, but without significant differences (p = .065).

CONCLUSIONS

Treatment with GnRHa improved final height in all girls with iCPP, even when initiated after 8 years. To achieve better outcomes, treatment should be provided promptly after diagnosis.

10th antibody industrial symposium: new developments in antibody and adoptive cell therapies

The annual "Antibody Industrial Symposium", co-organized by LabEx MAbImprove and MabDesign, held its 10th anniversary edition in Montpellier, France, on June 28-29, 2022. The meeting focused on new results and concepts in antibody engineering (naked, mono- or multi-specific, conjugated to drugs or radioelements) and also on new cell-based therapies, such as chimeric antigenic receptor (CAR)-T cells. The symposium, which brought together scientists from academia and industry, also addressed issues concerning the production of these molecules and cells, and the necessary steps to ensure a strong intellectual property protection of these new molecules and approaches. These two days of exchanges allowed a rich discussion among the various actors in the field of therapeutic antibodies.

Geographical Distribution of Periodontitis Risk and Prevalence in Portugal Using Multivariable Data Mining and Modeling

We aimed to estimate the geographical distribution of periodontitis prevalence and risk based on sociodemographic and economic data. This study used sociodemographic, economic, and health services data obtained from a regional survey and governmental open data sources. Information was gathered for all 308 Portuguese municipalities and compiled in a large set of 52 variables. We employed principal component analysis (PCA), factor analysis (FA) and clustering techniques to model the Portuguese nationwide geographical distribution of the disease. Estimation of periodontitis risk for each municipality was achieved by calculation of a normalized score, obtained as an adjusted linear combination of six independent factors that were extracted through PCA/FA. The municipalities were also classified according to a quartile-based risk grade in each cluster. Additionally, linear regression was used to estimate the periodontitis prevalence within the peri-urban municipality clusters, accounting for 30.5% of the Portuguese population. A total of nine municipality clusters were obtained with the following characteristics: mainly rural/low populated, including small villages (one), partly rural, including small cities (two), mainly urban/peri-urban, including medium-sized to large cities (4), and urban/large cities (2). Within the clusters, a higher periodontitis risk was identified for municipalities with lower income, older populations. The estimated periodontitis prevalence for the 18 municipalities included in the four peri-urban clusters ranged from 41.2% to 69.0%. Periodontitis prevalence estimates range from 41.2% to 69.0% for the municipalities characterized as peri-urban and mainly urban, most of them located in the Lisbon Metropolitan Area, the tenth largest in Europe.

Access to cardiac rehabilitation programs in patients with acute coronary syndrome: can referral be a step towards improvement? Insights from a multicentre national registry

 

The burden of cardiovascular disease remains on top of society's health problems, and acute coronary syndromes are undoubtedly a major cause. Cardiac rehabilitation programs (CRP) have been demonstrated to be a cost-effective strategy in reducing morbimortality and improving quality of life after an acute event. Despite this evidence and clinical recommendations, CRP are still globally underused. The lack of referral patients to CRP has been appointed as an important impediment to patients' participation.

This study aimed to clarify the main features of referred patients to CRP vs non-referred patients after an acute coronary syndrome (ACS).

The authors performed a retrospective analysis of adult patients with information about CRP destination, included in the Portuguese Registry on Acute Coronary Syndromes (ProACS) between October 2010 and December 2021. Comparison tests for parametric and non-parametric variables were performed. Logistic regression was applied for multivariate analysis. A p-value less than 0.05 was considered statistically significant.

A total of 28809 patients admitted for ACS were analysed, 22896 (79.5%) not referred for CRP (group 1) and 5913 (20.5%) were referred or even had a planned CRP. Table 1 shows the most important baseline characteristics and differences between groups. Table 2 demonstrate the group differences regarding admission diagnosis, complementary study results and in-hospital complications. Multivariate analysis established the following variables as independent factors for non-referral for CRP: age greater than 75 years (OR 0.80, 95% CI [0.72, 0.89]), history of valvular disease (OR 0.76, 95% CI [0.59, 0.97]), history of kidney disease (OR 0.65, 95% CI [0.54, 0.79]), admission diagnosis of unstable angina (UA) (OR 0.37, 95% CI [0.27, 0.50]), multivessel disease (OR 0.73, 95% CI [0.67, 0.80]), left ventricular ejection fraction less than 50% (OR 0.76, 95% CI [0.68, 0.84]), mechanical complication of myocardial infarction (OR 0.26, 95% CI [0.10, 0.67]) and acute heart failure during hospitalization (OR 0.67, 95% CI [0.58, 0.77]).

In conclusion, contrary to international results, women and patients with non-ST-segment elevation myocardial infarction were not negative predictors for referral to CRP. However, we observed that in our country, older patients, those with UA as an admission diagnosis, comorbidities and/or reduced systolic function are less referred to CRP by physicians. Paradoxically, these patients often have greater disease management complexity and poor outcomes. Besides that, the beneficial effects of cardiac rehabilitation in these groups have been demonstrated. Thus, it is extremely important to understand the limitations of referral in our country and implement strategies to overcome them.

Funding Acknowledgement

Type of funding sources: None.

Care pathways for people with major depressive disorder: a European Brain Council Value of Treatment study

Background

Despite well-established guidelines for managing major depressive disorder, its extensive disability burden persists. This Value of Treatment mission from the European Brain Council aimed to elucidate the nature and extent of “gaps” between best-practice and current-practice care, specifically to:Identify current treatment gaps along the care pathway and determine the extent of these gaps in comparison with the stepped-care model and Recommend policies intending to better meet patient needs (i.e., minimize treatment gaps).

Methods

After agreement upon a set of relevant treatment gaps, data pertaining to each gap were gathered and synthesized from several sources across six European countries. Subsequently, a modified Delphi approach was undertaken to attain consensus among an expert panel on proposed recommendations for minimizing treatment gaps.

Results

Four recommendations were made to increase the depression diagnosis rate (from ~50% episodes), aiming to both increase the number of patients seeking help, and the likelihood of a practitioner to correctly detect depression. These should reduce time to treatment (from ~1 to ~8 years after illness onset) and increase rates of treatment; nine further recommendations aimed to increase rates of treatment (from ~25 to ~50% of patients currently treated), mainly focused on targeting the best treatment to each patient. To improve follow-up after treatment initiation (from ~30 to ~65% followed up within 3 months), seven recommendations focused on increasing continuity of care. For those not responding, 10 recommendations focused on ensuring access to more specialist care (currently at rates of ~5–25% of patients).

Conclusions

The treatment gaps in depression care are substantial and concerning, from the proportion of people not entering care pathways to those stagnating in primary care with impairing and persistent illness. A wide range of recommendations can be made to enhance care throughout the pathway.

Establishing Principles for Community-Based Research

Academic health centers and their universities are increasingly encouraged to engage in more community-based and participatory approaches to research. Yet, traditional ethics guidelines and regulations are inadequate for addressing the dynamics of community-campus research partnerships. In this article, the authors share stories from the Community Research Collaborative (CRC), a collective of community leaders and faculty that published guidelines for community-based research (CBR). The CRC offers a case study in how a collaborative process of developing CBR guidelines can create space for partners to wrestle with the historical and present-day harms carried out in indigenous and minoritized communities in the name of science and to imagine alternative ways of working together collectively. This case study highlights the complex power dynamics inherent in community-campus partnerships and how storytelling can play a role in unearthing and addressing them. It positions the work of the CRC as incomplete and evolving while offering a foundation on which other institutions could carry out similar processes in their localities.

Phase III impact of telerehabilitation in patients with coronary heart disease

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiac rehabilitation (CR) in coronary heart disease (CAD) has been shown to improve physical capability and health-related quality of life, reducing morbimortality. However, CR accessibility is still low and patient adherence remains poor. It has been hypothesized that using mobile applications to telemonitor exercise-based CR would increase patient adherence to CR, improving results. Hybrid cardiac telerehabilitation (HCTR) is a new concept that includes center and home interventions.

Objectives

Investigate the effects of HCTR program on improving physical activity, quality of life and reducing cardiovascular risk factors among patients with CAD 1 year after CR phase II.

Materials and methods

Longitudinal retrospective study with patients who attended phase 2 CR program (CRP) at a hospital center between august 2018-november 2020. They were divided in 2 groups: group 1 completed conventional CRP (CCRP), 12 weeks of monitored hospital physical exercise and educational sessions; group 2 participated on HCTR program (CCRP associated to a tele-monitorization platform consisting of a mobile application, MOVIDA.eros, with medical prescription of physical exercise and remote interaction). Group 2 maintained use of MOVIDA.eros on phase 3. Evaluations were performed on T0 – phase 2 onset, T1 – end of phase 2, T2 – 1 year after T1, with registration of age, gender, occupation, body mass index (BMI), exercise stress testing, echocardiogram (evaluation of left ventricular ejection fraction [LVEF]), LDL, HDL cholesterol, triglycerides, NTproBNP levels, and application of EuroQol-5D questionnaire (EQ5D), International Physical Activity Questionnaire – Short Form (IPAQ).

Statistical analysis was completed through software SPSS v28. p-values &lt;0.05 were considered statistically significant.

Results

We analyzed 68 patients, 46 on group 1 and 22 on group 2. Variable analysis revealed similar group characteristics, except for age (p=0.011) and LVEF (p=0.005). There was an association between HCTR adherence and occupation (p=0.002; greater proportion of intellectual professionals on group 2). We observed a significant IPAQ (p=0.018) and EQ-5D index (p=0.034) improvement between T0 to T1 in both groups, but only in group 2 persisted till T2. In exercise stress testing, both groups revealed an increase in METs at T1 and decrease at T2, without significant differences between them. Regarding lipid profile, HbA1c, NTproBNP and BMI, both groups improved from T0 to T1 maintaining it till T2 with no differences between them, however in group 2 HDL cholesterol levels were greater and HbA1c levels were lower than group 1. In both groups, LVEF increased from T0 to T1 and from T1 to T2 in both groups, with faster and higher improvement in group 2.

Conclusions

HCTR outperformed CCRP improving physical activity, patient quality of life, HDL cholesterol and faster improvement of LVEF. These findings encourage the use of a mobile platform in CR.

The Microencapsulation of Tung Oil with a Natural Hydrocolloid Emulsifier for Extrinsic Self-Healing Applications

In this work, tung oil was utilised as a catalyst-free self-healing agent, and an in-situ polymerization process was applied to encapsulate the tung oil core with a poly(urea-formaldehyde) (PUF) shell. The conventional poly(ethylene-alt-maleic-anhydride) (PEMA) polymer was compared to a more naturally abundant gelatin (GEL) emulsifier to compare the microcapsules’ barrier, morphological, thermal, and chemical properties, and the crystalline nature of the shell material. GEL emulsifiers produced microcapsules with a higher payload (96.5%), yield (28.9%), and encapsulation efficiency (61.7%) compared to PEMA (90.8%, 28.6% and 52.6%, respectively). Optical and electron microscopy imaging indicated a more uniform morphology for the GEL samples. The thermal decomposition measurements indicated that GEL decomposed to a value 7% lower than that of PEMA, which was suggested to be attributed to the much thinner shell materials that the GEL samples produced. An innovative and novel focused ion beam (FIB) milling method was exerted on the GEL sample, confirming the storage and release of the active tung oil material upon rupturing. The samples with GEL conveyed a higher healing efficiency of 91%, compared to PEMA’s 63%, and the GEL samples also conveyed higher levels of corrosion resistance.

Multilayer Regulation of Neisseria meningitidis NHBA at Physiologically Relevant Temperatures

Neisseria meningitidis colonizes the nasopharynx of humans, and pathogenic strains can disseminate into the bloodstream, causing septicemia and meningitis. NHBA is a surface-exposed lipoprotein expressed by all N. meningitidis strains in different isoforms. Diverse roles have been reported for NHBA in heparin-mediated serum resistance, biofilm formation, and adherence to host tissues. We determined that temperature controls the expression of NHBA in all strains tested, with increased levels at 30−32 °C compared to 37 °C. Higher NHBA expression at lower temperatures was measurable both at mRNA and protein levels, resulting in higher surface exposure. Detailed molecular analysis indicated that multiple molecular mechanisms are responsible for the thermoregulated NHBA expression. The comparison of mRNA steady-state levels and half-lives at 30 °C and 37 °C demonstrated an increased mRNA stability/translatability at lower temperatures. Protein stability was also impacted, resulting in higher NHBA stability at lower temperatures. Ultimately, increased NHBA expression resulted in higher susceptibility to complement-mediated killing. We propose that NHBA regulation in response to temperature downshift might be physiologically relevant during transmission and the initial step(s) of interaction within the host nasopharynx. Together these data describe the importance of NHBA both as a virulence factor and as a vaccine antigen during neisserial colonization and invasion.

Postpartum Eosinophilic Ascites: A Case Report

Eosinophilic gastrointestinal diseases (EGID) are a group of conditions characterized by histopathologic eosinophilic infiltrates in one or more segments of the gastrointestinal (GI) tract. It occurs in the absence of known causes for eosinophilia. It can affect every part of the gastrointestinal tract, but eosinophilic ascites (EA) is uncommon. There is a clinical overlap between EGID and GI involvement of hypereosinophilic syndrome (HES), so distinguishing them may not be easy. We report a case of eosinophilic gastroenteritis in a 26-year-old-woman with the uncommon presentation of eosinophilic ascites after delivery. It is vital to maintain a high grade of suspicion to diagnose these disorders and exclude the secondary causes since treatment varies. In addition, the occurrence of this postpartum syndrome has been described, so it is essential to recognize this entity in this period.

Do GnRH Agonists Really Increase Body Weight Gain? Evaluation of a Multicentric Portuguese Cohort of Patients With Central Precocious Puberty

INTRODUCTION

There are several concerns associated with gonadotropin-releasing hormone agonist (GnRHa) treatment for central precocious puberty (CPP), such as obesity and changes in body mass index (BMI). We aimed to investigate whether any anthropometric differences exist and if they persist over time.

METHODS

We conducted an observational study of Portuguese children (both sexes) diagnosed with CPP between January 2000 and December 2017, using a digital platform, in order to analyze the influence of GnRHa treatment on BMI-SD score (BMI-SDS).

RESULTS

Of the 241 patients diagnosed with CPP, we assessed 92 patients (8% boys) in this study. At baseline, 39% of the patients were overweight. BMI-SDS increased with treatment for girls but then diminished 1 year after stopping GnRHa therapy (p = 0.018). BMI-SDS variation at the end of treatment was negatively correlated with BMI-SDS at baseline (p < 0.001). Boys grew taller and faster during treatment than did girls (p < 0.001), and therefore, their BMI-SDS trajectory might be different.

CONCLUSIONS

This study showed an increase of body weight gain during GnRHa treatment only in girls, which reversed just 1 year after stopping treatment. The overall gain in BMI-SDS with treatment is associated with baseline BMI-SDS.

Emergency department and hospital utilisation and expenditures in the last year of life: retrospective chronic diseases cohort study

OBJECTIVES

We aimed to examine the influence of chronic diseases in emergency department (ED) and inpatient utilisation and expenditures in the 12 months before death.

METHODS

Retrospective cohort study of ED and inpatient database. Adults deceased at a hospital in Portugal in 2013 were included. We tested the influence of chronic diseases on the number of ED visits, hospital admissions and expenditures using generalised linear models.

RESULTS

The study included 484 patients (81.8% ≥65 years, median two chronic diseases). Nearly all (91.3%) attended the ED in the 12 months before death. The median number of admissions was 1, median expenditure was €6159. Adjusting for confounders, chronic pulmonary disease increased ED and inpatient utilisation (1.49; 95% CI: 1.22 to 1.83; 95% CI 1.29, 1.09 to 1.51). Increased ED utilisation was observed for patients with renal disease, dementia and metastatic solid tumour (1.40, 95% CI 1.15 to 1.71; 1.39, 95% CI 1.11 to 1.75; 1.31, 95% CI 1.07 to 1.60). Other malignancies showed increased inpatient utilisation (1.24, 95% CI 1.09 to 1.42). The number of chronic conditions had a considerable effect on expenditures (3: 2.08, 95% CI 1.44 to 2.99; ≥4: 4.02, 95% CI 2.51 to 6.45).

CONCLUSION

We found a high use of hospitals at the end of life, particularly EDs. Our findings suggest that people with cancer, renal disease, chronic pulmonary disease and dementia are relevant when developing cost-effective alternatives to hospital care.

Hybrid cardiac telerehabilitation program as a potential strengthening factor in the quality of life in patients with coronary heart disease: a retrospective single-centre analysis

 

Cardiac rehabilitation (CR) has well known beneficial effects on physical capacity, health-related quality of life, morbidity and mortality in patients with coronary artery disease (CAD). However, underuse of CR and not sustained improvements have been noted. It has been proposed that telemonitored exercise-based CR, by the use of mobile applications, can improve patient adherence to CR programs providing better outcomes.

The aim of this study was to investigate the effects of telemonitored cardiac rehabilitation on physical capacity, health-related quality of life and control of cardiovascular risk factors among patients with CAD on phase 2 of the Cardiac Rehabilitation Program (CRP).

A retrospective study was conducted and patients in CRP between 2017 and 2020 were included. Patient selection and information collection were obtained through medical records. Outcomes were Body Mass Index, Hospital Anxiety and Depression Scale (HADS), EuroQol-5D score (EQ-5D), International Physical Activity Questionnaire (IPAQ), estimated functional capacity in cardiac stress test, lipid panel and glycated hemoglobin. Patients were divided into two groups: group 1 followed the conventional strategy and group 2 followed a hybrid telemonitored CRP, with the use of MOVIDA mobile application. Variables were analysed in the beginning (T0) and in the end (T1) of the phase 2, around 3 months after. Group comparisons tests and multivariate logistic regression were performed. A p-value less than 0.05 is statistically significant. Statistical analysis was performed using SPSS software v25.0.

We analysed 107 patients, which 93 of these were assiduous and 69 concluded the phase 2 of CRP: 44 patients in group 1 and 25 patients in group 2. Two groups have similar baseline characteristics, except for age (p=0.02). It appears that participation in the PRC led to an improvement in physical capacity, mental well-being, and in lipid panel, regardless of the strategy. The improvement in quality of life, quantified by EQ-5D, was significant only in group 2 (p=0.03). There is also no correlation between age and the differences recorded in EQ-5D (p=0.86).

We hypothesise that, when compared to conventional CRP, cardiac telemonitored exercise using modern communication methods and on-demand coaching will result in an improved behavioural change, which translates to higher quality of life. Further studies including more patients and the phase 3 of CRP are needed to confirm these results.

Funding Acknowledgement

Type of funding sources: None.

Follow-up of infants born to mothers with Graves' disease

INTRODUCTION

The prevalence of neonatal hyperthyroidism (HN) due to maternal Graves Disease (GD) ranges from 0.1 to 2.7%. It may occur in pregnant women with the following: active DG, after treatment with radioactive iodine, anti-thyroid or thyroidectomy or with a previous child with hyperthyroidism. The aim of our observational study was to evaluate the follow-up of infants born to mothers with GD at a Tertiary Hospital prior to the implementation of a follow-up protocol.

METHODS

This was a retrospective observational study using data from the medical records of mothers with a diagnosis of GD and their newborns from January 2013 until May 2018. Newborns were divided into two groups: high and low risk for NH according to maternal TRAb, third trimester treatment and signs of fetal hyperthyroidism.

RESULTS

We identified 31 newborns, 58% female; 87% high risk. In none of the newborns was umbilical cord blood collected. In the high risk group, 22% had thyroid function evaluation at day-1, one patient presented with hyperthyroidism and 82% were asymptomatic. Considering the cases with an insufficient blood sample for analysis, 9 consultations would have been spared. We found a significant delay in obtaining the high-risk group results which would have spared 10 appointments. A positive correlation was found between age at outpatient clinic discharge and the number of appointments and the maternal TRAb titer.

CONCLUSION

The correct surveillance of pregnancy and newborns with identification of those at high risk is essential to avoid unnecessary consultations and blood analyses that increase parental anxiety and hospital costs. Consequently, a multidisciplinary protocol was created to standardize the approach.

Expression of HLA-DR in Cytotoxic T Lymphocytes: A Validated Predictive Biomarker and a Potential Therapeutic Strategy in Breast Cancer

Simple Summary

More than 50% of breast cancer (BC) patients selected for neoadjuvant chemotherapy (NACT) are subjected to at least a 6-month regimen of this treatment without a clear benefit, probably delaying more effective therapeutic strategies and being exposed to potential treatment-associated toxicity. Thus, it is urgent to implement reliable predictive biomarkers, as well as novel treatments for NACT non-responder patients. This study validates that the HLA-DR level in cytotoxic T lymphocytes (CTLs) is an independent and robust predictive factor of BC patients’ response to NACT, as previously proposed. Hence, a predictive probability model of response was developed as a new tool to improve treatment decisions. HLA-DR level in CTLs also have a general prognostic value, which might be relevant for long-term BC management. In addition, our results suggest that increasing the expression of HLA-DR in CTLs of non-responders could be a promising therapeutic strategy to ameliorate BC response to NACT.

Abstract

Neoadjuvant chemotherapy (NACT) is common in breast cancer (BC) treatment, though more than half of the patients lack an effective response. Therefore, new predictive biomarkers and alternative therapies are crucial. Previously, we proposed HLA-DR-expressing cytotoxic T lymphocytes (CTLs) as a potential biomarker of the response to NACT. To validate this observation and further investigate these cells, 202 BC patients were enrolled. Flow cytometry analyses were performed in 61 biopsies and 41 blood samples pre-NACT and 100 non-NACT tumor samples. All the patients were followed up for 34 months. Blood-isolated immune cells were cultured with BC cell lines in a 3D system. We confirmed that HLA-DR level in CTLs is a highly sensitive, specific, and independent biomarker to predict response to NACT and developed a predictive probability model. This biomarker was also associated with progression-free survival, regardless of the treatment. The clinical observations are substantiated by the anti-tumor properties of HLA-DR-expressing CTLs. Intriguingly, HLA-DR level in CTLs can be modulated ex vivo, boosting their capacity to kill tumor cells synergistically with doxorubicin. Thus, HLA-DR expression in CTLs is a validated tool to select patients that will actually benefit from NACT, and its stimulation might be a novel therapeutic approach for BC.

Influence of Pozzolan, Slag and Recycled Aggregates on the Mechanical and Durability Properties of Low Cement Concrete

The sustainability of the construction sector demands the reduction of CO₂ emissions. The optimization of the amount of cement in concrete can be achieved either by partially replacing it by additions or by reducing the binder content. The present work aims at optimizing the properties of concrete used in the production of reinforced concrete poles for electrical distribution lines, combining the maximization of compactness with the partial replacement of cement by fly ash, natural pozzolans, and electric furnace slags. Natural aggregates were also partially replaced by recycled ones in mixtures with fly ash. Two types of concrete were studied: a fresh molded one with a dry consistency and a formwork molded one with a plastic consistency. The following properties were characterized: mechanical properties (flexural, tensile splitting, and compressive strengths, as well as Young's modulus) and durability properties (capillary water absorption, water penetration depth under pressure, resistance to carbonation, chloride migration, and concrete surface resistivity). The service life of structures was estimated, taking the deterioration of reinforcement induced by concrete carbonation or chloride attack into account. Results revealed that mixtures with fly ash exhibit higher mechanical performance and mixtures with fly ash or pozzolans reveal much higher durability results than the full Portland cement-based mixtures.

Hybrid cardiac rehabilitation program as a potential enhancer of adherence to cardiac rehabilitation in smoking patients with coronary heart disease - a retrospective single-centre analysis

Funding Acknowledgements

Type of funding sources: None.

Cardiac rehabilitation (CR) has well known beneficial effects on physical capacity, health-related quality of life, morbidity and mortality following an acute cardiac event. It is also known that smoking status is a powerful predictor of recurrent cardiovascular disease events. However, it has been noted that smoker patients may be less likely to access or complete CR.

The aim of this study was to determine the levels of anxiety and depression and its improvement, depending on the smoking status of patients with coronary artery disease (CAD) on phase 2 of the Cardiac Rehabilitation Program (CRP). Additionally, we intend to investigate the mental health impact on smoker patients" group in conventional CR versus telemonitored CR.

A retrospective study was conducted and patients in CRP between 2017 and 2020 were included. Patient selection and information collection were obtained through medical records. The outcomes of anxiety and depression were evaluated through the Hospital Anxiety and Depression Scale (HADS). Patients were divided into two groups: group 1 for non-smokers or ex-smokers and group 2 for smokers. For group 2 patients, a sub-analysis was performed for patients following the conventional CR versus the telemonitored CR, with the use of MOVIDA mobile application. Variables were analysed in the beginning (T0) and in the end (T1) of phase 2, around 3 months after. Group comparisons tests and statistical analysis were performed using SPSS software v25.0. A p-value less than 0.05 is statistically significant. 

We analysed 107 patients, which 93 of these were assiduous and 69 concluded the phase 2 of CRP: 39 patients in group 1 and 30 patients in group 2. Two groups have similar baseline characteristics, except for the higher presence of diabetes (p = 0.02) in group 1. It was noted an improvement in both anxiety and depression items for group 1 (p &lt; 0.01 for both), but only for anxiety item for group 2 (p = 0.03). In subgroup analysis, we observed no improvement for smoking patients following the conventional CR for both anxiety and depression items (p = 0.60 and p = 0.71, respectably) versus a significant difference in telemonitored CR patients (p = 0.02 and p = 0.04).

We hypothesise that, when compared to conventional CR, cardiac telemonitored exercise using modern communication methods may result in an improved mental health state among smoking patients, which can lead to a better adherence for CRP. Further studies including more patients and phase 3 of CRP are needed to confirm these results.

Factors associated with involuntary psychiatric hospitalization in Portugal

Background

Identifying which factors contribute to involuntary psychiatric hospitalization may support initiatives to reduce its frequency. This study examines the sociodemographic, clinical, and contextual factors associated with involuntary hospitalization of patients from five Portuguese psychiatric departments in 2002, 2007 and 2012.

Methods

Data from all admissions were extracted from clinical files. A Poisson generalized linear model estimated the association between the number of involuntary hospitalizations per patient in one year and sociodemographic, clinical, and contextual factors.

Results

An increment of involuntary hospitalizations was associated with male gender [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.31; 95%CI 1.06–1.62, p < 0.05], having secondary and higher education [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.45; 95%CI 1.05–2.01, p < 0.05, and exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.89; 95%CI 1.38–2.60, p < 0.001, respectively], a psychiatric diagnosis of psychosis [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 2.02; 95%CI 1.59–2.59, p < 0.001], and being admitted in 2007 and in 2012 [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.61; 95%CI 1.21–2.16, p < 0.01, and exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.73; 95%CI 1.31–2.32, p < 0.001, respectively]. A decrease in involuntary hospitalizations was associated with being married/cohabitating [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.74; 95%CI 0.56–0.99, p < 0.05], having experienced a suicide attempt [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.26; 95%CI 0.15–0.42, p < 0.001], and belonging to the catchment area of three of the psychiatric services evaluated [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.65; 95%CI 0.49–0.86, p < 0.01, exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.67; 95%CI 0.49–0.90, p < 0.01, and exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.67; 95%CI 0.46–0.96, p < 0.05 for Hospital de Magalhães Lemos, Centro Hospitalar Psiquiátrico de Lisboa and Unidade Local de Saúde do Baixo Alentejo, respectively].

Conclusions

The findings suggest that involuntary psychiatric hospitalizations in Portugal are associated with several sociodemographic, clinical, and contextual factors. This information may help identify high-risk patients and inform the development of better-targeted preventive interventions to reduce these hospitalizations.

Follow-up of infants born to mothers with Graves' disease

INTRODUCTION

The prevalence of neonatal hyperthyroidism (HN) due to maternal Graves Disease (GD) ranges from 0.1 to 2.7%. It may occur in pregnant women with the following: active DG, after treatment with radioactive iodine, anti-thyroid or thyroidectomy or with a previous child with hyperthyroidism. The aim of our observational study was to evaluate the follow-up of infants born to mothers with GD at a Tertiary Hospital prior to the implementation of a follow-up protocol.

METHODS

This was a retrospective observational study using data from the medical records of mothers with a diagnosis of GD and their newborns from January 2013 until May 2018. Newborns were divided into two groups: high and low risk for NH according to maternal TRAb, third trimester treatment and signs of fetal hyperthyroidism.

RESULTS

We identified 31 newborns, 58% female; 87% high risk. In none of the newborns was umbilical cord blood collected. In the high risk group, 22% had thyroid function evaluation at day-1, one patient presented with hyperthyroidism and 82% were asymptomatic. Considering the cases with an insufficient blood sample for analysis, 9 consultations would have been spared. We found a significant delay in obtaining the high-risk group results which would have spared 10 appointments. A positive correlation was found between age at outpatient clinic discharge and the number of appointments and the maternal TRAb titer.

CONCLUSION

The correct surveillance of pregnancy and newborns with identification of those at high risk is essential to avoid unnecessary consultations and blood analyses that increase parental anxiety and hospital costs. Consequently, a multidisciplinary protocol was created to standardize the approach.

Data integration for infrastructure asset management in small to medium-sized water utilities

Water utilities collect, store and manage vast data sets using many information systems (IS). For infrastructure asset management (IAM) planning those data need to be processed and transformed into information. However, information management efficiency often falls short of desired results. This happens particularly in municipalities where management is structured according to local government models. Along with the existing IS at the utilities' disposal, engineers and managers take their decisions based on information that is often incomplete, inaccurate or out-of-date. One of the main challenges faced by asset managers is integrating the several, often conflicting, sources of information available on the infrastructure, its condition and performance, and the various predictive analyses that can assist in prioritizing projects or interventions. This paper presents an overview of the IS used by Portuguese water utilities and discusses how data from different IS can be integrated in order to support IAM.

Factors associated with length of stay and readmission in acute psychiatric inpatient services in Portugal

Assessing the factors that influence duration and number of hospitalizations may support mental health services planning and delivery. This study examines the factors associated with length of stay and readmission in Portuguese psychiatric inpatient services during 2002, 2007 and 2012. Data from all admissions were extracted from clinical files. Logistic regression models estimated the association between length of stay (<17 vs ≥17 days) and number of admissions per year (1 vs >1 admission) with sociodemographic, clinical, and contextual factors. Older age, a diagnosis of psychosis, and compulsory admission were associated with higher odds of longer length of stay. Being married, secondary education, suicide attempt, a diagnosis of substance use and "other mental disorders", being admitted in 2012, and two of the psychiatric inpatient services associated with lower odds of longer length of stay. Being retired (or others), a diagnosis of psychosis, compulsory admission, and psychiatric service were associated with increased odds of readmission. Older age, and secondary and higher education were associated with lower odds of readmission. The findings indicate that multiple factors influence length of stay and readmission. Identifying these factors provides useful evidence for clinicians and policy makers to design more targeted and cost-effective interventions.

How did the use of psychotropic drugs change during the Great Recession in Portugal? A follow-up to the National Mental Health Survey

BACKGROUND

Research suggests that economic recessions might be associated with a higher use of psychotropic drugs, but literature is scarce and contradictory in identifying the most vulnerable groups. This study aims to assess possible changes in the use of psychotropic drugs due to the economic recession in Portugal, by comparing self-reported consumption in 2008/09 and 2015/16.

METHODS

Data from the World Mental Health Survey Initiative Portugal (2008/09) and the National Mental Health Survey Follow-Up (2015/16) were used (n = 911). McNemar's tests were performed to estimate changes in consumption of any psychotropic drug and of antidepressants, anxiolytics, and hypnotics/sedatives. Multiple Generalised Estimating Equations models with interaction effects were used to estimate the population odds of consuming psychotropic drugs according to year, gender and age.

RESULTS

An increase of 6.74% was estimated in the consumption of psychotropic drugs from 2008/09 to 2015/16. Population odds of consuming any psychotropic drugs in 2015/16 were estimated to be 1.5 times higher than in 2008/09 (OR = 1.50;95%CI:1.13-2.01), particularly for hypnotics/sedatives (OR = 1.60;95%CI:1.14-2.25). Women and older individuals presented higher odds of consuming any psychotropic drugs (OR = 2.79;95%CI:2.03-3.84, and OR = 1.80;95%CI:1.28-2.54), after adjusting for year of assessment and education. However, when evaluating the interaction effect of the year with gender and age, men and younger individuals reported higher odds of consuming any psychotropic drugs in 2015/16, when compared to 2008/09 (OR = 1.85;95%CI:1.08-3.17, and OR = 1.95;95%CI:1.32-2.90, respectively).

CONCLUSIONS

The findings indicate that the period of economic recession was associated with an increased risk of psychotropic drugs use in Portugal. Consumption of psychotropic drugs remained higher among women and older individuals, but the results suggest that the economic crisis had a disproportionate impact on men and younger individuals. This identification of the most vulnerable population groups is useful to design effective and targeted public health interventions aimed at alleviating the effects of economic recessions.

Resilient Coping and Social Networks in Old Age

Introduction

Both resilient coping strategies and the structural/functional characteristics of personal social networks are considered important factors when facing adversity and the challenges inherent to the aging process.

Objectives

To analyze the association between the configurations of ego-centred networks and different levels of resilient coping in a sample of elderly people.

Methods

Quantitative, cross-sectional study comparing groups, with 512 participants, mostly women (n = 325; 63.5%), married (n = 264; 51.5%), with 76 years old in average (SD ± 7.6), and with basic education (n = 261; 51%). We used a socio-demographic questionnaire, the IARSP-Elderly (personal social network assessment tool) and the Brief Resilient Coping Scale for data collection.

Results

We found different levels of resilient coping in our sample: low (50.4%); medium (38,7%); strong (10.9%). These three levels of coping were associated with the composition of ego-centred networks, namely the proportion of friends and colleagues (P < 0.05), different perceived emotional support, reciprocity and satisfaction with the network (P < 0.05), frequency of contacts and relationships’ durability (P < 0.05).

Conclusions

Higher levels of coping are associated with a larger proportion of friends in the network, whereas the familistic networks are associated with low coping. Although participants in our study revealed mainly kin comprised networks, these results reflect the relevance of resilient coping in the activation of non-kin relationships in old age.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Barriers to mental health services utilisation in Portugal - results from the National Mental Health Survey

Background: The treatment gap for mental disorders remains a challenge worldwide. Identifying reasons for nontreatment may contribute to reducing this gap.Aims: To evaluate sociodemographic and clinical factors associated with use and barriers to treatment in Portugal.Method: Data from the 2009 National Mental Health Survey were used. Participants reported 12-month treatment and reasons for nontreatment. Logistic regression models analysed the association between sociodemographic (education; employment; income; marital status) and clinical variables (mental disorder diagnosis; disability) with treatment and type of barriers (low perceived need; structural; attitudinal).Results: The majority of participants with a mental disorder was not treated. Treatment was more common among participants with mood disorders (OR = 4.19; 95% CI: 2.72-6.46), and disability (OR = 2.43; 95% CI: 1.33-4.46), and less common among single participants (OR = 0.38; 95% CI: 0.20-0.70) and those with basic/secondary education (OR = 0.42; 95% CI: 0.24-0.73). Attitudinal barriers were more likely among participants with none/primary (OR = 2.90; 95% CI: 1.42-5.90) and basic/secondary education (OR = 1.70; 95% CI: 1.01-2.85), and less likely among those with substance use disorders (OR = 0.27; 95% CI: 0.10-0.70). Low perceived need was higher among single people (OR = 1.77; 95% CI: 1.01-3.08), and lower among those with anxiety (OR = 0.50; 95% CI: 0.28-0.90) and mood disorders (OR = 0.16; 95% CI: 0.09-0.30). Unemployed participants had higher odds of reporting structural barriers (OR = 3.76; 95% CI: 1.29-10.92).Conclusions: This study identifies factors associated with nontreatment, providing useful evidence to develop policies and effective interventions.

CYP21A2 Gene Pathogenic Variants: A Multicenter Study on Genotype-Phenotype Correlation from a Portuguese Pediatric Cohort

BACKGROUND

Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21OHD) is an autosomal recessive disorder characterized by 3 overlapping phenotypes: salt-wasting (SW), simple virilizing (SV), and non-classic (NC). We aimed at conducting a nationwide genotype description of the CAH pediatric patients and to establish their genotype-phenotype correlation.

METHODS

CAH patients were recruited from Portuguese pediatric endocrinology centers and classified as SW, SV, or NC. Genetic analysis was performed by polymerase chain reaction (sequence specific primer, restriction fragment length polymorphism) or direct Sanger sequencing. Genotypes were categorized into 4 groups (0, A, B, and C), according to their predicted enzymatic activity. In each group, the expected phenotype was compared to the observed phenotype to assess the genotype-phenotype correlation.

RESULTS

Our cohort comprises 212 unrelated pediatric CAH patients (29% SW, 11% SV, 60% NC). The most common pathogenic variant was p.(Val282Leu; 41.3% of the 424 alleles analyzed). The p.(Val282Leu) variant, together with c.293-13A/C>G, p.(Ile173Asn), p.(Leu308Thr), p.(Gln319*), and large deletions/conversions were responsible for 86.4% of the mutated alleles. Patients' stratification by disease subtype revealed that the most frequent pathogenic variants were c.293-13A/C>G in SW (31.1%), p.(Ile173Asn) in SV (46.9%), and p.(Val282Leu) in NC (69.5%). The most common genotype was homozygosity for p.(Val282Leu; 33.0%). Moreover, we found 2 novel variants: p.(Ile161Thr) and p.(Trp202Arg), in exons 4 and 5, respectively. The global genotype-phenotype correlation was 92.4%. Group B (associated with the SV form) showed the lowest genotype-phenotype correlation (80%).

CONCLUSION

Our cohort has one of the largest NC CAH pediatric populations described. We emphasize the high frequency of the p.(Val282Leu) variant and the very high genotype-phenotype correlation observed.

Long-term Neuropsychiatric and Neuropsychological Sequelae of Endovascularly Treated Aneurysmal Subarachnoid Hemorrhage

INTRODUCTION

There is limited evidence regarding long-term outcomes of aneurysmal subarachnoid hemorrhage survivors. Most follow-up programs are relatively short and focused on physical functions. Endovascular aneurysmal embolization enables recovery of normal vascular architecture. However, there is growing evidence that neuropsychological and behavior sequelae can significantly impact the lives of these patients, even when treatment is successful. In this study, we reviewed cognition, psychiatric and neuropsychological symptoms, global functionality, and health-related quality of life 10 to 12 years after an aneurysmal subarachnoid hemorrhage.

MATERIAL AND METHODS

A cross-sectional observational study was carried out in a university hospital. All cases of aneurysmal subarachnoid hemorrhage admitted between January 2004 and December 2006 and endovascularly treated were reviewed. Participants underwent a neuropsychological evaluation and a clinical interview with a psychiatrist.

RESULTS

Fourteen patients participated in the study. Almost 70% (n = 10) showed cognitive impairment; in more than 40% (n = 6) of the subjects, significant symptoms of anxiety were identified, and 35% (n = 5) were classified as having clinical depression. Relevant posttraumatic symptoms were reported by more than 70% (n = 10) of patients, and almost 30% (n = 4) showed other moderate neuropsychiatric symptoms. Overall, health-related quality of life was impaired, and personality changes were frequently reported by the participants and their relatives.

DISCUSSION

A significant prevalence of ongoing deficits in high-level functioning and reduced health-related quality of life were observed in a sample of young and professionally active individuals that were successfully treated and discharged from follow-up consultations.

CONCLUSION

There is a need for better follow-up strategies, targeting more subtle deficits and psychological symptoms after aneurysmal subarachnoid hemorrhage.

Solutions to tackle the mental health consequences of the economic recession: A qualitative study integrating primary health care users and professionals' perspectives

This qualitative study explores solutions proposed by primary health care users and professionals to address the consequences of the economic recession and austerity measures on populations' mental health and delivery of care in Portugal. Qualitative data were collected in three primary health care centres in the Lisbon Metropolitan Area. Five focus groups with 26 users and semistructured interviews with 27 health professionals were conducted. Interviews were audio-recorded, transcribed verbatim and underwent thematic analysis. Solutions proposed by users focused on improvements in accessibility and management of services, socioeconomic and living conditions, human resources for health, and investment in mental health. Health professionals focused on improvements in integration and articulation of services, infrastructure and structural barriers to primary care, recruitment and retention of human resources, and socioeconomic and living conditions. The themes from both groups were integrated and organized into three axes for action: 1) increasing investment and reversing austerity measures in health and social sectors; 2) coordination and integration of mental health care; and 3) tackling the social determinants of mental health. The findings provide an assessment of the needs and priorities set by primary health care users and professionals, reflecting their contextspecific experiences. These complementary perspectives highlight the need for inter-sectoral efforts in policy-making to improve delivery of care and to mitigate social inequalities in health across the Portuguese population.

Primary care physicians' decision-making processes in the context of multimorbidity: protocol of a systematic review and thematic synthesis of qualitative research

INTRODUCTION

Good patient outcomes correlate with the physicians' capacity for good clinical judgement. Multimorbidity is common and it increases uncertainty and complexity in the clinical encounter. However, healthcare systems and medical education are centred on individual diseases. In consequence, recognition of the patient as the centre of the decision-making process becomes even more difficult. Research in clinical reasoning and medical decision in a real-world context is needed. The aim of the present review is to identify and synthesise available qualitative evidence on primary care physicians' perspectives, views or experiences on decision-making with patients with multimorbidity.

METHODS AND ANALYSIS

This will be a systematic review of qualitative research where PubMed, CINAHL, PsycINFO, Embase and Web of Science will be searched, supplemented with manual searches of reference lists of included studies. Qualitative studies published in Portuguese, Spanish and English language will be included, with no date limit. Studies will be eligible when they evaluate family physicians' perspectives, opinions or perceptions on decision-making for patients with multimorbidity in primary care. The methodological quality of studies selected for retrieval will be assessed by two independent reviewers before inclusion in the review using the Critical Appraisal Skills Programme (CASP) tool. Thematic synthesis will be used to identify key categories and themes from the qualitative data. The Confidence in the Evidence from Reviews of Qualitative research approach will be used to assess how much confidence to place in findings from the qualitative evidence synthesis.

ETHICS AND DISSEMINATION

This review will use published data. No ethical issues are foreseen. The findings will be disseminated to the medical community via journal publication and conference presentation(s).

PROSPERO REGISTRATION NUMBER

ID 91978.

Exploring socioeconomic and mental health trajectories during times of economic recession: a qualitative study with primary health care users and professionals

Background: The 2008 economic recession has been shown to affect populations' mental health due to deterioration of socioeconomic and living conditions. Concurrently, mental health problems may have constituted a vulnerability to wider social inequalities during this period.Aims: To explore perceptions and experiences of primary health care users and professionals regarding the relationship between mental health and socioeconomic position during the economic recession in Portugal.Method: Data were collected in three primary health care centres in Lisbon Metropolitan Area. Focus groups and semi-structured interviews were conducted with users and professionals, respectively. Interviews were audio-recorded, transcribed verbatim and underwent thematic analysis.Results: Two themes were obtained. The first comprised the relationship between changes in socioeconomic conditions (unemployment, precarious work conditions and financial hardship) and poor mental health. The second involved the consequences of experiencing mental health problems during the recession, namely disability, need of sick leave and early retirement.Conclusions: This study provided a comprehensive overview of the bidirectional relationship between socioeconomic conditions and mental health, emphasizing the need to develop policies to address the drivers of poor mental health during times of economic downturn and tackle the barriers faced by people with mental disorders to promote their full social inclusion.

Deep venous thrombosis of lower limbs in adolescents: a study in a tertiary hospital

BACKGROUND

Venous thromboembolism (VTE) - which includes deep venous thrombosis (DVT) and pulmonary embolism (PE) - has been increasingly recognized in the pediatric population. The estimated incidence is 0.07-0.14 cases per 10,000 children. Most cases are associated with two or more risk factors. Medium and long-term complications include recurrence and post-thrombotic syndrome (PTS).

OBJECTIVE

To characterize the adolescent population with the diagnosis of DVT of lower limbs in a tertiary hospital, regarding its clinical presentation, associated risk factors, treatment and outcome.

METHODS

Retrospective analysis of adolescents with the diagnosis of DVT of lower limbs in our hospital for a period of 7 years.

RESULTS

Eight patients were identified; seven were females; median age was 15 years. The main symptoms were local pain and edema. Left lower limb was affected in six patients. PE occurred in two cases. Positive family history of venous thromboembolism was found in five patients. Seven patients had at least two identifiable risk factors. Combined oral contraceptive pill use was the most common (seven patients). Factor V Leiden mutation was found in three patients and protein C deficiency in one. Iliac vein compression syndrome was diagnosed in one patient. The median time for discharge was 8 days. Election treatment was enoxaparin followed by warfarin, for a median period of 10.9 months. Three patients developed PTS.

CONCLUSIONS

Although uncommon, VTE is an emerging reality in adolescents, particularly in females using oral contraceptive pills. Appropriated prevention strategies and treatment are required as most orientations are extrapolated from adults.

Coccidioidomycosis: first cases reported in Pernambuco, Brazil

Coccidioidomycosis is a fungal infection caused by Coccidioides immitis or Coccidioides posadasii. These fungi are known to thrive in desert climate. Fungi produce infectious arthroconidia in soil, they are aerosolized in the air and when inhaled by humans, usually cause infections such as pneumonia. The first cases of coccidioidomycosis in Brazil were reported in 1978. Since then, there have been other reports mainly from desert regions of Northeastern Brazil. The present report describes three cases of coccidioidomycosis on male farmers from Serra Talhada county, Pernambuco State, who developed pneumonia and were subsequently diagnosed with pulmonary coccidioidomycosis. These three farmers were successfully treated with oral fluconazole. They reported having hunted armadillos in a rural and arid area of Pernambuco State. Armadillos are known to be carriers of Coccidioides. This is the first report of infection caused by Coccidioides in Pernambuco State, Brazil.

The effect of socioeconomic position in the experience of disability among people with mental disorders: findings from the World Mental Health Survey Initiative Portugal

BACKGROUND

Mental disorders are a major cause of disability with impacts on daily functioning and quality of life, which has been associated with socioeconomic disadvantage. The present study aims to assess how socioeconomic position is related to the disability reported by people with mental disorders, using data from the World Mental Health Survey (WMHS) Initiative Portugal.

METHODS

Using data from the Portuguese Mental Health Survey, a nationally representative cross-sectional study (n = 3849), several logistic regression models with interaction terms were performed to evaluate the effect of different indicators of socioeconomic position on the disability reported by people with any mental disorder (any 12-month mood or anxiety disorder). Odds ratios were estimated at the specific values of the main effects and interaction terms between the presence of any mental disorder and education, employment status, self-perceived financial deprivation and subjective social status.

RESULTS

The prevalence rate of any mood or anxiety disorder was 21.0% (n = 788), among which 14.7% (n = 115) reported disability. The results show that among people with any 12-month mental disorder, those in the employment category of "retired or others" had two times higher odds of reporting disability (OR = 2.19; 95%CI: 1.06-4.48) when compared to participants categorized as "working". Likewise, individuals with financial deprivation had two times higher odds of reporting disability when compared to those non-financially deprived (OR = 2.36; 95%CI: 1.31-4.24). The odds ratios obtained for the specific years of education evaluated were not statistically significant but seem to suggest an educational gradient.

CONCLUSIONS

The findings of this study indicate that the disability reported by people with mental disorders varies according to socioeconomic position and draw attention to the need to develop policies to address these inequalities.

Reconceptualization innovative moments as a predictor of symptomatology improvement in treatment for depression

OBJECTIVES

In previous studies, reconceptualization innovative moments were associated with successful psychotherapy. Reconceptualization has two components-(a) a positive temporal contrast between the past self and the present self (contrasting self [CS]) and (b) a description of how and/or why this change has occurred (change process [CP])-from the perspective of the client. The aim of this study is to analyse if CS and CP have the same association with outcomes as reconceptualization.

METHOD

Sixteen cases of clients with major depression (305 sessions) were analysed. Longitudinal regression models were used to explore if proportions of CS, CP, and reconceptualization predicted outcome measures and if outcome measures predicted CS, CP, and reconceptualization.

RESULTS

Reconceptualization is less frequent than CS and CP taken separately, but reconceptualization was a better predictor of treatment outcomes than were its separate components. Moreover, symptom improvement did not predict reconceptualization.

CONCLUSION

The construction of new meanings is important in improving depressive symptomatology. Psychotherapists can elicit these new meanings in their regular practice by posing questions that may help clients to conceptualize what is changing in themselves (CS) and questions of how this change is occurring (CP). The construction of an integrative account of these new meanings is associated with psychotherapeutic gains, and thus, reconceptualizing change could improve symptoms of depression.