The impact of the COVID-19 pandemic in the clinical assistance to breast cancer patients

PURPOSE

We aimed to disclose the impact of the pandemic on breast cancer patients in a specialized breast cancer center (BCC).

METHODS

A total of 501 breast cancer patients with a first appointment in the BCC from April 1st, 2019 to March 31st, 2021 were divided into four consecutive periods of 6 months. Data from the homologous semesters was compared. Patients with an appointment in the BCC during the study period were eligible for the secondary aim of our study (BCC workload).

RESULTS

After the pandemic declaration (period 3), we found a decrease in the referral by screening programs (p = 0.002) and a reduction in the waiting time between the primary care referral and the first BCC appointment (p < 0.001). There were higher rates of palpable axillary nodes (p = 0.001), an increase in N stage 2 and 3 (p = 0.050), and a trend for primary endocrine therapy as the first treatment (p = 0.021) associated with higher rates of complete axillary node dissection (p = 0.030). In period 4, there were more outward diagnoses (p = 0.003) and a higher rate of surgery as the first treatment (p = 0.013).

CONCLUSION

COVID-19 pandemic implied a more advanced nodal stage, which may be related to the delay in breast cancer screening.

Omission of axillary lymph node dissection in breast cancer patients with micrometastasis or isolated tumor cells in sentinel lymph nodes: a 12-year experience in a tertiary breast unit

INTRODUCTION

After the IBCSG 23-01 trial, our breast center no longer performed axillary lymph node dissection (ALND) after detection of isolated tumor cells (ITC) or micrometastasis in the sentinel lymph nodes (SLN). A recent study suggested that up to half of the patients with micrometastasis in the SLN could benefit from ALND in terms of disease-free survival (DFS) and overall survival (OS).

METHODS

This retrospective, unicentric, study analyzed 261 consecutive cT1-3 cN0 breast cancer patients with ITC or micrometastasis in their SLN. Primary objective was comparison of ALND vs. SLN biopsy (SLNB) with regard to DFS and OS. Secondary objectives included analysis of factors associated with an increased rate of locoregional recurrence (LRR), distant metastasis (DM) and metachronous contralateral breast cancer (MCBC).

RESULTS

DFS events occurred in 19 patients (7.3%) and 14 patients died (5.4%). Median follow-up time was 78 months. 251 patients (96.2%) had micrometastasis in their SLN. There was no difference in the OS or DFS of ALND vs. SLNB patients. History of previous contralateral breast cancer and WBI were associated with an increased and decreased rate of LRR, respectively. Larger tumor size was associated with an increased rate of DM. Non-ductal histological types were associated with an increased rate of MCBC.

DISCUSSION

Avoiding ALND may be safe in pN1mi/pN0(i+) patients. Besides, we strongly encourage clinicians to develop their own follow-up protocols based on the best available evidence, to rapidly identify and treat breast cancer recurrence.

Chest wall perforator flaps for partial breast reconstruction after conservative surgery: Prospective analysis of safety and reliability

INTRODUCTION

Breast-conserving surgery associated with adjuvant radiotherapy is the state of the art in the surgical treatment of breast cancer. Oncoplastic surgery through dermo-adipose flaps based in perforating arteries (muscle sparing flaps) for partial reconstruction is increasingly used as a good option for avoiding musculocutaneous flaps. In this study we evaluate the outcomes of the use of chest wall perforator flaps in the replacement of partial breast volume.

METHODS

A prospective cohort study of female patients that underwent a conservative oncoplastic surgery procedure with partial breast reconstruction using a dermo-adipose flap of perforating arteries of the chest wall was conducted between November 2020 and March 2022 at our centre. Primary outcomes were surgical morbidity, positive margins and reoperation rates. Characteristics associated with the occurrence of complications were further identified.

RESULTS

Forty-five patients underwent the procedure of interest during the study period. The mean age was 55 years. The median larger dimension of the tumor was 23 mm. Lateral intercostal artery perforator (LICAP), lateral thoracic artery perforator (LTAP), a combined flap and Anterior Intercostal Artery Perforator/Medial Intercostal Artery Perforator (AICAP)/(MICAP) were performed in 22, 16, 2 and 5 patients, respectively. The mean operative time was 126 min. A total of 9 (20.0%) patients required a reoperation after definitive diagnosis, 4 due to positive margins and 5 due to immediate/early surgical morbidity.

CONCLUSIONS

Local perforator flaps in oncoplastic breast-conserving surgery are a good option for immediate reconstruction after conservative surgery, showing low morbidity and favourable outcomes.

A comprehensive study on surveillance outcomes of a male population followed at a hereditary breast cancer high-risk consultation at a Portuguese tertiary hospital

INTRODUCTION

Men born with pathogenic/likely pathogenic variants in genes associated with the Hereditary Breast and Ovarian Cancer Syndrome have a higher risk to develop breast cancer and other cancers (such as prostate cancer) and should undergo adequate surveillance protocols in highly specialized Centers.

METHODS

A retrospective study was conducted to assess these genetic variants' epidemiological and phenotypical manifestations in male carriers, as well as the efficacy of the surveillance protocol and compliance toward it through a survey. During follow-up, a genetic panel for testing was implemented, the starting age for surveillance was delayed, and the six-month screening interval was extended to annual.

RESULTS

A total of 104 men from a tertiary hospital's High-Risk Consultation were included, 102 with positive genetic testing for BRCA1 (n = 31), BRCA2 (n = 55), both BRCA2 and another gene (n = 5), CDH1 (n = 2), CHEK2 (n = 4), NF1 (n = 1), RAD51C (n = 4), and an additional two men with no actionable genetic variant identified. The follow-up period ranged from 1 to 13 years, and only one man developed cancer. Survey responses from 48 men in active surveillance showed that more than half recognizes their carrier status and consequent surveillance impact on their life, including the risk of transmission to offspring, fear of future cancer, meaningful distress, and feeling of injustice. Biannual surveillance was not actively detecting more cancer disease cases, confirming the adequacy of the currently implemented protocol CONCLUSION: With support of Genetics to fulfill the current gaps in high-risk management, the proposed redefinition of surveillance protocol would adapt it to the population needs and concerns.

Surveillance of surgical site infection after colorectal surgery: comprehensiveness and impact of risk factors

OBJECTIVE

The incidence of surgical site infection (SSI) is highest after colorectal surgery. We assessed the impact of risk factors for SSI using the population attributable fraction (PAF).

DESIGN

Retrospective cohort study.

SETTING

Portuguese hospitals performing regular surveillance.

PATIENTS

We identified patients who underwent colorectal procedures in hospitals that reported colorectal surgeries every year between 2015 and 2019. Among 42 reporting hospitals, 18 hospitals were included.

METHODS

Risk-factor incidence was estimated using the National Epidemiological Surveillance platform from 2015 to 2019. This platform follows the methodology recommended by the European Centre for Disease Prevention and Control. American Society of Anaesthesiologists (ASA) physical classification, wound classification, open surgery, urgent operation, antibiotic prophylaxis, operation time, and male sex were included as risk factors. Measures of association were retrieved from published meta-analyses. PAFs were calculated using the Levin formula. To account for interaction between risk factors, communality of risk factors was used in a weighted-sum approach, providing a combined value that serves as a measure of the comprehensiveness of surveillance.

RESULTS

Among 11,219 reported procedures, the cumulative SSI incidence was 16.8%. The proportion of SSI attributed to all risk factors was 61%. Modifiable variables accounted for 31% of procedures; the highest was laparotomy (16.8%), and urgent operations (2.7%) had the lowest value. Nonmodifiable factors accounted for 28.7%; the highest was wound classification (14.3%).

CONCLUSIONS

A relevant proportion (39%) of SSI remains unaccounted for by current surveillance. Almost one-third of SSI cases have potentially modifiable factors. Interventions focusing on shorter, less invasive procedures may be optimally effective in reducing the SSI incidence.

Differences among a Portuguese cohort of BRCA pathogenic/likely pathogenic variants carriers choosing risk-reducing mastectomy or intensive breast surveillance

PURPOSE

Women with BRCA1 and BRCA2 (BRCA1/2) pathogenic/likely pathogenic (P/LP) variants have a higher risk to develop breast and ovarian cancer. In structured high-risk clinics, risk-reducing measures are adopted. This study aimed at characterizing these women and identify factors that may have influenced their choice between risk reduction mastectomy (RRM) and intensive breast surveillance (IBS).

METHODS

This study reviewed retrospectively 187 clinical records of affected and unaffected women with P/LP variants of the BRCA1/2 genes, from 2007 to 2022, of which 50 chose RRM, while 137 chose IBS. The research focused on personal and family history and tumor characteristics and their relation with the preventive option chosen.

RESULTS

Among women with personal history of breast cancer, a higher proportion opted for RRM compared to those asymptomatic (34.2% vs 21.3%, p = 0.049), with younger age determining the option for RRM (38.5 years vs 44.0 years, p < 0.001). Among women with personal history of ovarian cancer, a higher proportion opted for RRM compared to those without that history (62.5% vs 25.1%, p = 0.033), with younger age determining the option for RRM (42.6 years vs 62.7 years, p = 0.009). Women who had bilateral salpingo-oophorectomy were more likely to choose RRM than those who did not (37.3% vs 18.3%, p = 0.003). Family history was not associated with preventive option (33.3% vs 25.3, p = 0.346).

CONCLUSIONS

The decision for the preventive option is multifactorial. In our study, personal history of breast or ovarian cancer, younger age at diagnosis, and previous bilateral salpingo-oophorectomy were associated with the choice of RRM. Family history was not associated with the preventive option.

Pet ownership during the first 5 years after breast cancer diagnosis in the NEON-BC cohort

BACKGROUND

Although human-animal interactions (HAI) have been associated with health benefits, they have not been extensively studied among cancer patients nor which factors may influence HAI during cancer survivorship. Therefore, this study aims to describe pet ownership in a breast cancer cohort within 5 years post-diagnosis and to identify associated factors.

METHODS

Four hundred sixty-six patients from the NEON-BC cohort were evaluated. Four groups of pet ownership over the 5 years were defined: 'never had', 'stopped having', 'started having' and 'always had'. Multinomial logistic regression was used to quantify the association between the patient characteristics and the groups defined (reference: 'never had').

RESULTS

51.7% of patients had pets at diagnosis, which increased to 58.4% at 5 years; dogs and cats were the most common. Women presenting depressive symptoms and poor quality of life were more likely to stop having pets. Older and unpartnered women were less likely to start having pets. Those retired, living outside Porto, having diabetes or having owned animals during adulthood were more likely to start having pets. Women with higher education and unpartnered were less likely to always have pets. Those living in larger households, with other adults or having animals throughout life, were more likely to always have pets. Obese women had lower odds of stopping having dogs/cats. Women submitted to neoadjuvant chemotherapy and longer chemotherapy treatments were more likely to stop having dogs/cats.

CONCLUSIONS

Pet ownership changed over the 5 years and is influenced by sociodemographic, clinical and treatment characteristics, patient-reported outcomes and past pet ownership, reflecting the importance of HAI during cancer survivorship.

Local Antibiotic Delivery Ceramic Bone Substitutes for the Treatment of Infected Bone Cavities and Bone Regeneration: A Systematic Review on What We Have Learned from Animal Models

AIMS

the focus of this study is to evaluate if the combination of an antibiotic with a ceramic biomaterial is effective in treating osteomyelitis in an infected animal model and to define which model and protocol are best suited for in vivo experiments of local bone infection treatment.

METHODS

a systematic review was carried out based on PRISMA statement guidelines. A PubMed search was conducted to find original papers on animal models of bone infections using local antibiotic delivery systems with the characteristics of bone substitutes. Articles without a control group, differing from the experimental group only by the addition of antibiotics to the bone substitute, were excluded.

RESULTS

a total of 1185 records were retrieved, and after a three-step selection, 34 papers were included. Six manuscripts studied the effect of antibiotic-loaded biomaterials on bone infection prevention. Five articles studied infection in the presence of foreign bodies. In all but one, the combination of an antibiotic with bioceramic bone substitutes tended to prevent or cure bone infection while promoting biomaterial osteointegration.

CONCLUSIONS

this systematic review shows that the combination of antibiotics with bioceramic bone substitutes may be appropriate to treat bone infection when applied locally. The variability of the animal models, time to develop an infection, antibiotic used, way of carrying and releasing antibiotics, type of ceramic material, and endpoints limits the conclusions on the ideal therapy, enhancing the need for consistent models and guidelines to develop an adequate combination of material and antimicrobial agent leading to an effective human application.

Hospital context in surgical site infection following colorectal surgery: a multi-level logistic regression analysis

BACKGROUND

Surgical site infections (SSIs) are associated with poor health outcomes. Their incidence is highest after colorectal surgery, with little improvement in recent years. The role of hospital characteristics is undetermined.

AIM

To investigate whether SSI incidence after colorectal surgery varies between hospitals, and whether such variance may be explained by hospital characteristics.

METHODS

Data were retrieved from the electronic platform of the Directorate General of Health, from 2015 to 2019. Hospital characteristics were retrieved from publicly available data on the Portuguese public administration. Analysis considered a two-level hierarchical data structure, with individuals clustered in hospitals. To avoid overfitting, no models were built with more than one hospital characteristic. Cluster-level associations are presented through median odds ratio (MOR) and intraclass cluster coefficient (ICC). Beta coefficients were used to assess the contextual effects.

FINDINGS

A total of 11,219 procedures from 18 hospitals were included. The incidence of SSI was 16.8%. The ICC for the null model was 0.09. Procedural variables explained 25% of the variance, and hospital dimension explained another 17%. More than 50% of SSI variance remains unaccounted for. After adjustment, heterogeneity between hospitals (MOR: 1.51; ICC: 0.05) was still found. No hospital characteristic was significantly associated with SSI.

CONCLUSION

Procedural variables and hospital dimension explain almost half of SSI variance and should be taken into account when implementing prevention strategies. Future research should focus on compliance with preventive bundles and other process indicators in hospitals with significantly less SSI in colorectal surgery.

Total Tumor Load to assist in the decision for additional axillary surgery in the positive sentinel node breast cancer patients

The Total Tumor Load (TTL) concept has been demonstrated to accurately predict the status of the non-sentinel lymph nodes (NSLN) in breast cancer patients. In 2019, our center implemented the TTL cut-off of 30,000 CK19 mRNA copies/μL as sole criterion for deciding on performing ALND. This retrospective, unicentric, study analyzed 87 cT1-3N0 breast cancer patients treated consecutively in a period of two years and aimed to evaluate the performance of this criterion. Secondary objectives included the comparison of the criterion versus our previous Clinical Decision Rule (CDR) versus ACOSOG Z0011 criteria for avoiding an ALND in proportion of patients spared an ALND and in proportion of patients left with a surgically untreated metastasized axilla. An interim analysis revealed new TTL cut-offs for deciding on performing an ALND. The 30,000 CK19 mRNA copies/μL criterion yielded an area under the ROC Curve (AUC) of 0.849, a false positive (FP) rate of 30.1% and a positive predictive value (PPV) of 38.9%. The 30,000 CK19 mRNA copies/μL criterion spared 58.6% of the patients an ALND versus 41.4% with CDR versus 73.6% with Z0011 and left 0.0% patients with a surgically untreated metastasized axilla versus 21.4% with CDR versus 42.9% with Z0011. The new TTL cut-off of 260,000 CK19 mRNA copies/μL for deciding on an ALND yielded an AUC of 0.753, a FP rate of 13.7% and a PPV of 47.4%. This new criterion spared 78.2% of the study sample an ALND and left 35.7% of metastasized axillae surgically untreated. This study emphasizes the need to find a new balance between locoregional control and the morbidity associated with Berg levels I + II axillary lymph node dissection.

Factors associated with self-perceived health status in Portugal: Results from the National Health Survey 2014

Background

Self-perceived health is an important indicator of illness and mortality. This study aims at identifying a wide range of factors that can influence self-perceived health status among a representative sample in Portugal.

Methods

We used the 2014 National Health Survey (n = 17,057), whereby participants were required to assess their health status from "Very good," "Good," "Fair," "Poor" to "Very poor." We grouped the answers "Very good" and "Good," and "Poor" and "Very poor," respectively. Multinomial logistic regression was used to compare participants' characteristics across groups by computing odds ratio and corresponding 95% confidence intervals. Models included Socioeconomic/demographic characteristics, objective health status, healthcare use, functional disability, barriers to healthcare services utilization, lifestyle variables, mental health status, social support, and satisfaction with life as potential factors that can affect self-perceived health. Models were adjusted for sex, age, educational level, degree of urbanization, and presence of chronic diseases.

Results

About 45% of participants reported good/very good, 39% reported fair, while ~16% reported poor/very poor health perception. Poor/very poor health was more reported by women when compared to men (19.1 vs. 11.4%, respectively, p < 0.001). A higher prevalence of poor/very poor health status was reported by participants living in thinly populated areas or among older populations. Lower educational levels, lower income, as well as unemployment, were found to increase the risk of reporting poor/very poor health status. Utilizing healthcare services more frequently, experiencing barriers to access healthcare services, having depressive symptoms or activity limitations, or lacking social support were found to be significantly associated with poor/very poor self-perceived health.

Conclusion

Subjects living in Portugal tend to report less good/very good health status and more poor/very poor health when compared to the rest of Europe. This study stresses the importance of socioeconomic factors, chronic illness, barriers to access healthcare services, social isolation, and mental health status in influencing self-perceived health and highlights the urgent need for social-informed policies, strategies, and interventions to reduce health inequalities in Portugal.

Breast cancer patient-reported outcomes on level 1 and level 2 oncoplastic procedures using BREAST-Q®

PURPOSE

In breast cancer management not only mortality and surgical morbidity measurements are important but also patient satisfaction indexes. The authors evaluated the satisfaction and health-related quality of life (HRQOL) using the breast-conserving therapy (BCT) and breast reduction (BR) modules of BREAST-Q^®.

METHODS

This is a cross-sectional study that analyzed breast cancer patients consecutively submitted to breast surgery between January 2011 and April 2018 using two modules of BREAST-Q^®. 968 patients were contacted and 232 answers were gathered: 171 patients submitted to oncoplastic level 1 surgery answered the BCT module and 61 submitted to oncoplastic level 2 surgery answered the BR module. Clinical data were retrieved from patients' medical records.

RESULTS

Among the 232 questionnaires received, the median scores for psychosocial well-being, sexual well-being and (postoperative) satisfaction with breasts for BCT and BR modules were, respectively, 77.0 and 73.5 (p = 0.17); 62.0 and 53.0 (p = 0.14); 72.0 and 66.0 (p = 0.66). The median of adverse effects of radiation in the BCT module was 87.0. The median satisfaction with outcome in the BR module was 86.0. Both groups of patients revealed high scores of satisfaction with care. For the BCT patients, satisfaction with breasts strongly correlated with sexual well-being and was moderately correlated with psychosocial and physical well-being. For the BR patients, the satisfaction with outcome strongly correlated with satisfaction with medical team and moderately correlated with the remaining scales.

CONCLUSION

Both oncoplastic surgery levels yielded similar satisfaction outcomes when assessed using BCT and BR modules of BREAST-Q^®.

Initial experience with targeted axillary dissection after neoadjuvant therapy in breast cancer patients

Background

Targeted axillary dissection (TAD) combines sentinel node biopsy (SNB) with the removal of the previously marked metastatic node. TAD is a promising concept for axillary restaging in node-positive breast cancer patients with pathological complete response (pCR) to neoadjuvant therapy (NAT). We aimed to evaluate TAD feasibility in this context.

Methods

A prospective observational study was conducted in biopsy-confirmed cN1 patients. The removal of the clipped node (CN) was guided by intraoperative ultrasound. SNB used indocyanine green and patent blue V dye. If the CN or sentinel lymph nodes (SLN) had any metastatic foci, or the TAD procedure was unsuccessful, the patient underwent axillary lymph node dissection (ALND).

Results

Thirty-seven patients were included. TAD and SNB identification rates were 97.3%. Every retrieved CN was also a SLN. At the individual level, SNB identification rate was 89.2% with indocyanine green and 85.5% with patent blue V dye. The CN identification rate was 81.1%, being higher when the CN was localized on the intraoperative ultrasound (84.4% vs 60.0%). Nodal pCR was achieved by 54.1% of our patients and was more frequent in HER2-positive and triple-negative tumors (p = 0.039). Nineteen patients were spared from ALND.

Conclusion

TAD with intraoperative ultrasound-guided excision of the CN and SNB with indocyanine green and patent blue V dye is a feasible concept to identify patients without axillary residual disease after NAT, that can be spared from ALND, although the need for marking the biopsied node should be further investigated.

Frailty-Independent Undertreatment Negative Impact on Survival in Older Patients With Breast Cancer

Purpose

The management of older adults with breast cancer (BC) remains controversial. The challenging assessment of aging idiosyncrasies and the scarce evidence of therapeutic guidelines can lead to undertreatment. Our goal was to measure undertreatment and assess its impact on survival.

Methods

Consecutive patients with BC aged 70 years or older were prospectively enrolled in 2014. Three frailty screening tools (G8, fTRST, and GFI) and two functional status scales (Karnofsky performance score and Eastern Cooperative Oncology Group Performance Status) were applied. Disease characteristics, treatment options, and causes of mortality were recorded during a 5-year follow-up. In addition, we defined undertreatment and correlated its survival impact with frailty.

Results

A total of 92 patients were included in the study. The median age was 77 (range 70–94) years. The prevalence of frailty was discordant (G8, 41.9%; fTRST, 74.2%; GFI, 32.3%). Only 47.8% of the patients had a local disease, probably due to a late diagnosis (73.9% based on self-examination). Thirty-three patients (35.6%) died, of which 15 were from BC. We found a considerably high proportion (53.3%) of undertreatment, which had a frailty-independent negative impact on the 5-year survival (hazard ratio [HR], 5.1; 95% confidence interval [CI], 2.1–12.5). Additionally, omission of surgery had a frailty-independent negative impact on overall survival (HR, 3.9; 95% CI, 1.9–7.9).

Conclusion

BC treatment in older adults should be individualized. More importantly, assessing frailty (not to treat) is essential to be aware of the risk-benefit profile and the patient's well-informed willingness to be treated. Undertreatment in daily practice is frequent and might have a negative impact on survival, as we report.

Identifying the profile of Helicobacter pylori negative gastric cancers: a case only analysis within the Stomach cancer Pooling (StoP) Project

BACKGROUND

The prevalence of Helicobacter pylori negative gastric cancer (HpNGC) can be as low as 1%, when infection is assessed using more sensitive tests or considering the presence of gastric atrophy. HpNGC may share a high-risk profile contributing to the occurrence of cancer in the absence of infection. We estimated the proportion of HpNGC, using different criteria to define infection status, and compared HpNGC and positive cases regarding gastric cancer risk factors.

METHODS

Cases from 12 studies from the Stomach cancer Pooling (StoP) Project providing data on H. pylori infection status determined by serological test were included. HpNGC was reclassified as positive (eight studies) when cases presented CagA markers (four studies), gastric atrophy (six studies), or advanced stage at diagnosis (three studies), and were compared with positive cases. A two-stage approach (random-effects models) was used to pool study-specific prevalence and adjusted odds ratios (ORs).

RESULTS

Among non-cardia cases, the pooled prevalence of HpNGC was 22.4% (n=166/853) and decreased to 7.0% (n=55) when considering CagA status; estimates for all criteria were 21.8% (n=276/1325) and 6.6% (n=97), respectively. HpNGC had a family history of gastric cancer more often (OR=2.18, 95% confidence interval [CI]:1.03-4.61) and were current smokers (OR=2.16, 95%CI:0.52-9.02).

CONCLUSION

This study found a low prevalence of HpNGC, who are more likely to have a family history of gastric cancer in first-degree relatives.

IMPACT

Our results support that H. pylori infection is present in most non-cardia gastric cancers, and suggest that HpNGC may have distinct patterns of exposure to other risk factors.

Beyond the operating room: do hospital characteristics have an impact on surgical site infections after colorectal surgery? A systematic review

Background

Hospital characteristics have been recognized as potential risk factors for surgical site infection for over 20 years. However, most research has focused on patient and procedural risk factors. Understanding how structural and process variables influence infection is vital to identify targets for effective interventions and to optimize healthcare services. The aim of this study was to systematically review the association between hospital characteristics and surgical site infection in colorectal surgery.

Main body

A systematic literature search was conducted using PubMed, Scopus and Web of Science databases until the 31st of May, 2021. The search strategy followed the Participants, Exposure/Intervention, Comparison, Outcomes and Study design. The primary outcome of interest was surgical site infection rate after colorectal surgery. Studies were grouped into nine risk factor typologies: hospital size, ownership affiliation, being an oncological hospital, safety-net burden, hospital volume, surgeon caseload, discharge destination and time since implementation of surveillance. The STROBE statement was used for evaluating the methodological quality.

A total of 4703 records were identified, of which 172 were reviewed and 16 were included. Studies were published between 2008 and 2021, and referred to data collected between 1996 and 2016. Surgical site infection incidence ranged from 3.2 to 27.6%. Two out of five studies evaluating hospital size adjusted the analysis to patient and procedure-related risk factors, and showed that larger hospitals were either positively associated or had no association with SSI. Public hospitals did not present significantly different infection rates than private or non-profit ones. Medical school affiliation and higher safety-net burden were associated with higher surgical site infection (crude estimates), while oncological hospitals were associated with higher incidence independently of other variables. Hospital caseload showed mixed results, while surgeon caseload and surveillance time since implementation appear to be associated with fewer infections.

Conclusions

Although there are few studies addressing hospital-level factors on surgical site infection, surgeon experience and the implementation of a surveillance system appear to be associated with better outcomes. For hospitals and services to be efficiently optimized, more studies addressing these variables are needed that take into account the confounding effect of patient case mix.

Quality of life trajectories during the first three years after diagnosis of breast cancer: the NEON-BC study

BACKGROUND

We aimed to identify and characterize quality of life trajectories up to 3 years after breast cancer diagnosis.

METHODS

A total of 460 patients were evaluated at baseline (before treatments), and after 1- and 3-years. Patient-reported outcomes, including quality of life (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, QLQ-C30), anxiety, depression and sleep quality, were assessed in all evaluations. Model-based clustering was used to identify quality of life trajectories.

RESULTS

We identified four trajectories without intersection during 3 years. The two trajectories characterized by better quality of life depicted relatively stable scores; in the other trajectories, quality of life worsened until 1 year, though in one of them the score at 3 years improved. Sociodemographic and clinical characteristics at baseline did not differ between trajectories, except for mastectomy, which was higher in the worst trajectory. Anxiety, depression and poor sleep quality increased from the best to the worst trajectory.

CONCLUSIONS

The type of surgery and the variation of other patient-reported outcomes were associated with the course of quality of life over 3 years. More research to understand the heterogeneity of individual trajectories within these major patterns of variation is needed.

A Scoping Review of Process Indicators for Measuring Quality of Care in Glaucoma

PRCIS

There are no standardized process quality indicators (QIs) in glaucoma care. Although they can be inferred from guidelines and trials, they should be designed and standardized to allow better assessment of the quality of care.

PURPOSE

QIs are crucial for assessing the performance of any health care system. To allow efficiency, effectiveness, and patient-centeredness, there is a need for prompt acquisition of up-to-date information. Among the available QIs, process indicators have the highest sensitivity to frequent changes and could better reflect the implementation outcomes of novel ideas and technology. This study aimed to map the available information regarding process QIs in glaucoma care, identify the current development stage of these indicators, and systematically synthesize them.

MATERIALS AND METHODS

We performed a scoping review of 4 electronic bibliographic databases for studies reporting on process QIs in glaucoma. We retrieved 7502 references and created a domain list reflecting the core idea underlying each indicator.

RESULTS

We summarized information from 18 documents and listed 20 domains. The most mentioned domains were follow-up, optic nerve head assessment, visual field test, and intraocular pressure. Indicators regarding the quality of life assessment, patient assistance, or presence of written protocols were less frequently mentioned.

CONCLUSIONS

There are notable variations among process QIs in glaucoma and significant heterogeneity in their descriptions in published studies. Although novel indicators can be inferred from guidelines and trials, they should be designed and standardized for better assessment of performance in health systems to improve their quality.

Statistical models for analyzing count data: predictors of length of stay among HIV patients in Portugal using a multilevel model

BACKGROUND

This study offers a comprehensive approach to precisely analyze the complexly distributed length of stay among HIV admissions in Portugal.

OBJECTIVE

To provide an illustration of statistical techniques for analysing count data using longitudinal predictors of length of stay among HIV hospitalizations in Portugal.

METHOD

Registered discharges in the Portuguese National Health Service (NHS) facilities Between January 2009 and December 2017, a total of 26,505 classified under Major Diagnostic Category (MDC) created for patients with HIV infection, with HIV/AIDS as a main or secondary cause of admission, were used to predict length of stay among HIV hospitalizations in Portugal. Several strategies were applied to select the best count fit model that includes the Poisson regression model, zero-inflated Poisson, the negative binomial regression model, and zero-inflated negative binomial regression model. A random hospital effects term has been incorporated into the negative binomial model to examine the dependence between observations within the same hospital. A multivariable analysis has been performed to assess the effect of covariates on length of stay.

RESULTS

The median length of stay in our study was 11 days (interquartile range: 6-22). Statistical comparisons among the count models revealed that the random-effects negative binomial models provided the best fit with observed data. Admissions among males or admissions associated with TB infection, pneumocystis, cytomegalovirus, candidiasis, toxoplasmosis, or mycobacterium disease exhibit a highly significant increase in length of stay. Perfect trends were observed in which a higher number of diagnoses or procedures lead to significantly higher length of stay. The random-effects term included in our model and refers to unexplained factors specific to each hospital revealed obvious differences in quality among the hospitals included in our study.

CONCLUSIONS

This study provides a comprehensive approach to address unique problems associated with the prediction of length of stay among HIV patients in Portugal.

Fruits and vegetables intake and gastric cancer risk: A pooled analysis within the Stomach cancer Pooling Project

A low intake of fruits and vegetables is a risk factor for gastric cancer, although there is uncertainty regarding the magnitude of the associations. In our study, the relationship between fruits and vegetables intake and gastric cancer was assessed, complementing a previous work on the association betweenconsumption of citrus fruits and gastric cancer. Data from 25 studies (8456 cases and 21 133 controls) with information on fruits and/or vegetables intake were used. A two-stage approach based on random-effects models was used to pool study-specific adjusted (sex, age and the main known risk factors for gastric cancer) odds ratios (ORs) and the corresponding 95% confidence intervals (CIs). Exposure-response relations, including linear and nonlinear associations, were modeled using one- and two-order fractional polynomials. Gastric cancer risk was lower for a higher intake of fruits (OR: 0.76, 95% CI: 0.64-0.90), noncitrus fruits (OR: 0.86, 95% CI: 0.73-1.02), vegetables (OR: 0.68, 95% CI: 0.56-0.84), and fruits and vegetables (OR: 0.61, 95% CI: 0.49-0.75); results were consistent across sociodemographic and lifestyles categories, as well as study characteristics. Exposure-response analyses showed an increasingly protective effect of portions/day of fruits (OR: 0.64, 95% CI: 0.57-0.73 for six portions), noncitrus fruits (OR: 0.71, 95% CI: 0.61-0.83 for six portions) and vegetables (OR: 0.51, 95% CI: 0.43-0.60 for 10 portions). A protective effect of all fruits, noncitrus fruits and vegetables was confirmed, supporting further dietary recommendations to decrease the burden of gastric cancer.

Smoking and Helicobacter pylori infection: an individual participant pooled analysis (Stomach Cancer Pooling- StoP Project)

Smoking has been associated with acquisition and increased persistence of Helicobacter pylori infection, as well as with lower effectiveness of its eradication. A greater prevalence of infection among smokers could contribute to the increased risk for gastric cancer. We aimed to estimate the association between smoking and seropositivity to H. pylori through an individual participant data pooled analysis using controls from 14 case-control studies participating in the Stomach Cancer Pooling Project. Summary odds ratios and prevalence ratios (PRs), adjusted for age, sex and social class, and the corresponding 95% confidence intervals (CIs) were estimated through random-effects meta-analysis. Heterogeneity was quantified using the I statistic and publication bias with Egger's test. There was no significant association between smoking (ever vs. never) and H. pylori seropositivity (adjusted odds ratio = 1.08; 95% CI: 0.89-1.32; adjusted PR = 1.01; 95% CI: 0.98-1.05). The strength of the association did not increase with the intensity or duration of smoking; stratified analyses according to sex, age, region or type of sample did not yield a consistent pattern of variation or statistically significant results, except for participants younger than 55 years and who had been smoking for more than 30 years (adjusted PR = 1.08; 95% CI: 1.02-1.15). This is the first collaborative analysis providing pooled estimates for the association between smoking and H. pylori seropositivity, based on detailed and uniform information and adjusting for major covariates. The results do not support an association between smoking and H. pylori infection.

Risk of Readmission Among HIV Patients in Public Portuguese Hospitals: Longitudinal Multilevel Population-Based Study

Background: Thirty-day hospital readmission is receiving growing attention as an indicator of the quality of hospital care. Understanding factors associated with 30-day hospital readmission among HIV patients in Portugal is essential given the high burden cost of HIV hospitalizations in Portugal, a country suffering from financial constrains for almost 10 years. Objectives: We aimed to estimate the 30-day hospital readmission rates among HIV patients in Portugal and to identify its determinants using population-based data for Portuguese public hospitals. Study Design: A multilevel longitudinal population-based study. Methods: Between January 2009 and December 2014, a total of 37,134 registered discharges in the Portuguese National Health Service (NHS) facilities with HIV/AIDS as a main or secondary cause of admission were analyzed. Logistic regression was used to compare 30-day hospital readmission categories by computing odds ratio (OR) and corresponding 95% confidence intervals (95% CIs). A normal random effects model was used to determine unmeasured factors specific to each hospital. Results: A total of 4914 (13.2%, 95% CI: 12.9%-13.6%) hospitalizations had a subsequent 30-day readmission. Hospitalizations that included exit against medical opinion (OR = 1.18, 95% CI: 1.01-1.39), scheduled admissions (OR = 1.71, 95% CI: 1.58-1.85), and tuberculosis infection (OR = 1.20, 95% CI: 1.05-1.38) exhibited a higher risk of hospitalizations with subsequent 30-day readmission. In contrast, hospitalizations that included females (OR = 0.87, 95% CI: 0.81-0.94), a transfer to another facility (OR = 0.78, 95% CI: 0.67-0.91), and having a responsible financial institution (OR = 0.63, 95% CI: 0.55-0.72) exhibited a lower risk of hospitalizations with subsequent 30-day readmission. Hospitalizations associated with higher number of diagnosis, older ages, or hospitalizations during the economic crisis showed an increasing trend of 30-day readmission, whereas an opposite trend was observed for hospitalizations with higher number of procedures. Significant differences exist between hospital quality, adjusting for other factors. Conclusion: This study analyzes the indicators of 30-day hospital readmission among HIV patients in Portugal and provides useful information for enlightening policymakers and health care providers for developing health policies that can reduce costs associated with HIV hospitalizations.

Faecal occult blood test and colonoscopy use in Portugal: Results from the National Health Survey 2014

OBJECTIVES

Given the recent implementation of regional colorectal cancer screening programs in Portugal, understanding patterns of faecal occult blood test and colonoscopy use is essential to improve its control. We aimed to describe the use of both tests and to identify factors associated with its non- and under-use.

METHODS

A sample of 7208 subjects aged 50-74 from the National Health Survey 2014 was examined. Previous experience of faecal occult blood test and colonoscopy was classified as never or ever; ever-users, who had last undergone these tests more than 2 or 10 years before, respectively, were considered under-users. We computed age- and education-adjusted prevalence ratios and corresponding 95% confidence intervals for non- and under-use.

RESULTS

Of the individuals in the screening age range, 36.9% had never undergone either test. The prevalence of non-use was 50.7% and 62.2% for faecal occult blood test and colonoscopy, and 27.4% and 6.0% of subjects under-used each test, respectively. The lowest prevalence of non- and under-use was found in the Norte region. Low socioeconomic status and unhealthy lifestyles were significantly associated with low testing; greater use was observed for those having more recent contact with healthcare services.

CONCLUSIONS

This study identifies patterns of colorectal cancer screening use, with regional disparities that have not yet been reduced by the implementation of organised screening programmes.

Association between the exposure to phthalates and adiposity: A meta-analysis in children and adults

BACKGROUND

Exposure to environmental chemicals has become one of the major concerns in the past decades. Phthalates are a family of synthetic organic chemicals used in the manufacture of plastics, solvents, and personal care products. These compounds are considered as endocrine-disrupting compounds (EDCs) since they may interfere with the endocrine system and disrupt its physiologic function.

AIM

The purpose of this work is to synthesize results from published literature on the association between the exposure to phthalates and adiposity in adults and children.

METHODS

We searched PubMed from inception up to 01 August 2019, to retrieve original papers reporting data on the association between EDCs and adiposity, using the following search expression: (("Endocrine disruptor" OR Endocrine disruptor[mh] OR phthalate) AND (Obesity OR Overweight OR BMI OR "Body fat" OR Adipose tissue[mh] OR Body size[mh] OR "body size" OR "body weight" OR Anthropometry OR "anthropometric measures")) AND (humans[mh]). The study variables and characteristics were collected during data extraction, namely the study design, sample, exposure, outcome, descriptive and association measures. Study quality was assessed using the STROBE template for observational studies. Although studies examined several adiposity measures, Body Mass Index (BMI) and Waist Circumference (WC) were the most commonly used, therefore, we used the beta coefficients regarding BMI and WC, and odds ratios when BMI outcome was categorical to perform the meta-analysis. Data from the studies were combined using fixed effects meta-analyses to compute summary regression coefficients or odds ratios and corresponding 95% confidence intervals (95% CI). Heterogeneity between studies was assessed by the I2 statistic.

RESULTS

In the systematic review we found 29 publications addressing the association between phthalate compounds and adiposity. The vast majority of the included studies reported associations that were not statistically significant. For most of the phthalate compounds there were few studies providing compatible measures and therefore it was not possible to combine the results in a meta-analysis. Both for BMI and WC, the meta-analysis for MiBP, MCPP and MbzP showed negative associations and null association for MBP in children, although none of them was significant. For MEP, positive but not significant associations were found both in children and adults. Conversely, for MEHP a negative association was found also in children and adults although it did not reach statistical significance. Only for MECPP a significant association was found for obesity in adults (OR = 1.67 (95% CI 1.30; 2.16).

CONCLUSION

In general, a positive association between phthalates and adiposity measures was found, especially in adults. However, most of the results did not reach statistical significance and the inconsistencies found between studies did not allow to reach a definitive conclusion. Additionally, we cannot exclude a possible effect of publication bias.

Meat intake and risk of gastric cancer in the Stomach cancer Pooling (StoP) project

The consumption of processed meat has been associated with noncardia gastric cancer, but evidence regarding a possible role of red meat is more limited. Our study aims to quantify the association between meat consumption, namely white, red and processed meat, and the risk of gastric cancer, through individual participant data meta-analysis of studies participating in the "Stomach cancer Pooling (StoP) Project". Data from 22 studies, including 11,443 cases and 28,029 controls, were used. Study-specific odds ratios (ORs) were pooled through a two-stage approach based on random-effects models. An exposure-response relationship was modeled, using one and two-order fractional polynomials, to evaluate the possible nonlinear association between meat intake and gastric cancer. An increased risk of gastric cancer was observed for the consumption of all types of meat (highest vs. lowest tertile), which was statistically significant for red (OR: 1.24; 95% CI: 1.00-1.53), processed (OR: 1.23; 95% CI: 1.06-1.43) and total meat (OR: 1.30; 95% CI: 1.09-1.55). Exposure-response analyses showed an increasing risk of gastric cancer with increasing consumption of both processed and red meat, with the highest OR being observed for an intake of 150 g/day of red meat (OR: 1.85; 95% CI: 1.56-2.20). This work provides robust evidence on the relation between the consumption of different types of meat and gastric cancer. Adherence to dietary recommendations to reduce meat consumption may contribute to a reduction in the burden of gastric cancer.

Healthcare Services Utilization Among Migrants in Portugal: Results From the National Health Survey 2014

Migrants' health is attracting substantial global interest. We aimed to identify barriers and differences in healthcare services utilization between migrants and natives in a nationally representative sample using data from the National Health Survey 2014. A total of 18,165 participants providing information on country of birth and nationality were included, and comparison of healthcare services utilization was made by using participants born in Portugal and with Portuguese nationality as the reference group. Migrants reported a lower frequency of medical visits, a higher consumption of medication without a prescription and less use of preventive care services. The main reasons for not attending medical consultations among migrants were the absence of need and financial difficulties. This study illustrates inequalities in healthcare use among migrants in Portugal, and provides useful information for enlightening policymakers and healthcare providers to develop health policies that can address migrants' needs.

Cervical cytology use in Portugal: Results from the National Health Survey 2014

AIM

Given the disparities across regional cervical cancer screening programs implemented in Portugal, understanding the patterns of cervical cytology use is essential to improve cervical cancer control. We aimed to describe the use of cervical cytology and identify factors associated with its non- and underuse.

METHODS

A total of 5884 women aged 25-64 years were evaluated as part of the National Health Survey 2014. Previous use of cervical cytology was classified as never or ever, and ever-users having undergone the latest testing more than 5 years before were considered under-users. We computed age- and education-adjusted prevalence ratios and corresponding 95% confidence intervals for non- and underuse.

RESULTS

Overall, 13.2 and 12.0% of women reported nonuse and underuse of cervical cytology, respectively. The Norte region presented the lowest prevalence of nonuse and R.A. Açores the highest. Low socioeconomic status and unhealthy lifestyles were significantly associated with low cervical cytology use, whereas greater use was observed in those having more recent contact with health services.

CONCLUSIONS

Cervical cytology use was shown to differ according to sociodemographic characteristics and access to/use of healthcare services. Large regional variations persist in Portugal despite organized screening programs that cover most of the country.

[Fluorescence-Guided Sentinel Lymph Node Biopsy in Breast Cancer: Detection Rate and Diagnostic Accuracy]

INTRODUCTION

Sentinel lymph node biopsy is currently the standard surgical procedure for lymph node staging in patients with early stage breast cancer. It is performed using different techniques, such as the injection of vital dyes and / or radioisotopes and, more recently, guided by fluorescence using Indocyanine green. The aim of this study is to assess the detection rate of sentinel lymph node using Indocyanine green in breast cancer patients according to factors related to the patient and the tumor.

MATERIAL AND METHODS

Retrospective study of a random sample of patients with breast cancer, treated and followed at Centro Hospitalar São João, in Porto, between 2012 and 2016.

RESULTS

Indocyanine green detection rate was over 90% and its diagnostic accuracy was similar to other methods described in the presence of metastatic involvement of lymph nodes.

DISCUSSION

There was no statistically significant difference between the three methods in the detection rates in subgroups of older women, with normal weight and in those who underwent previous surgery in breast or axilla or neo-adjuvant chemotherapy.

CONCLUSION

Indocyanine green is a potential alternative method to other sentinel lymph node screening techniques, appearing as a future option for breast cancer centers with no nuclear medicine department. However, it is essential to carry out further research in order to define the ideal patients' profile that maximizes the method's effectiveness.

Factors associated with time to breast cancer diagnosis and treatment in unscreened women in Portugal

Delays in detection, diagnosis and treatment may lead to poorer prognosis in women with breast cancer. We quantified time intervals from first detection (FD) to diagnosis (D) and first treatment (FT) and identified associated factors. We studied 282 patients diagnosed with breast cancer during 2012 at the Breast Clinic of the Portuguese Institute of Oncology in Porto, Portugal using face-to-face interview and medical records. Associations of sociodemographic and clinical characteristics with time intervals was computed using adjusted percentage differences (adjPD) after logarithmic transformation, odds ratios (adjOR) for comparing the highest and lowest thirds of the distribution and 95 percent confidence intervals (CI) for both measures, using linear and logistic regression, respectively. The median times between FD and D and FT were 31 and 44 days, respectively. Significantly longer periods between FD and D were found in symptomatic women (adjPD = 99.5, 95 percent CI: 37.1, 190.0; adjOR = 3.16, 95 percent CI: 1.57, 6.33). More advanced stage was associated with shorter intervals between D and FT (adjPD = -33.8, 95 percent CI: -44.2, -21.5; adjOR = 0.14, 95 percent CI: 0.05, 0.34). Although some differences according to clinical characteristics were observed, they did not seem to translate into inequities in access to public healthcare in this group of women.

The effect of chronic disease family history on the adoption of healthier lifestyles

AIM

To determine the influence of family history (FH) and personal history (PH) of chronic disease (CD) in the adoption of healthy lifestyles.

METHODS

This cross-sectional study was based on the EPIPorto cohort (n = 1588). Participants were grouped taking into account FH and PH of CD, such as diabetes, myocardial infarction, stroke, asthma, and cancer, and if at least one of the first-degree relatives had died from the CD. Age-, sex-, and education-adjusted odds ratios and corresponding 95% confidence intervals were computed using multinomial logistic regression.

RESULTS

Subjects with PH and FH of CD were more likely to follow recommendations regarding salt intake but less likely regarding obesity measures. Overall, similar results were observed when repeating the analyses according to the type of CD, particularly in those with diabetes.

CONCLUSIONS

Recommendations towards healthier lifestyles are not followed by individuals with history of CD, at least in what concerns obesity measures. Our study suggests reducing obesity as a major target for interventions in these groups of individuals.

Alcohol intake and gastric cancer: Meta-analyses of published data versus individual participant data pooled analyses (StoP Project)

BACKGROUND

Individual participant data pooled analyses allow access to non-published data and statistical reanalyses based on more homogeneous criteria than meta-analyses based on systematic reviews. We quantified the impact of publication-related biases and heterogeneity in data analysis and presentation in summary estimates of the association between alcohol drinking and gastric cancer.

METHODS

We compared estimates obtained from conventional meta-analyses, using only data available in published reports from studies that take part in the Stomach Cancer Pooling (StoP) Project, with individual participant data pooled analyses including the same studies.

RESULTS

A total of 22 studies from the StoP Project assessed the relation between alcohol intake and gastric cancer, 19 had specific data for levels of consumption and 18 according to cancer location; published reports addressing these associations were available from 18, 5 and 5 studies, respectively. The summary odds ratios [OR, (95%CI)] estimate obtained with published data for drinkers vs. non-drinkers was 10% higher than the one obtained with individual StoP data [18 vs. 22 studies: 1.21 (1.07-1.36) vs. 1.10 (0.99-1.23)] and more heterogeneous (I²: 63.6% vs 54.4%). In general, published data yielded less precise summary estimates (standard errors up to 2.6 times higher). Funnel plot analysis suggested publication bias.

CONCLUSION

Meta-analyses of the association between alcohol drinking and gastric cancer tended to overestimate the magnitude of the effects, possibly due to publication bias. Additionally, individual participant data pooled analyses yielded more precise estimates for different levels of exposure or cancer subtypes.

Inspiratory muscle training is effective to reduce postoperative pulmonary complications and length of hospital stay: a systematic review and meta-analysis

PURPOSE

This study systematically review and meta-analyse the effectiveness of inspiratory muscle training (IMT) to reduce postoperative pulmonary complications (PPC) and length of hospital stay (LOS), both in the preoperative and/or postoperative periods of cardiac, pulmonary, and abdominal surgical patients. Sensitive analysis was performed to examine which patients benefit more from IMT according to methodological features (quality of studies and sample size), patient's characteristics (pulmonary risk stratification, age, and body mass index), type of surgery, period of training, and training protocols (training doses and level of supervision).

METHODS

The literature search was made in the electronic databases PubMed®, EBSCO, Web of Science^®, PEDro and Scopus^®. Only randomized controlled trials were included. Data extraction, quality assessment and meta-analysis were performed.

RESULTS

We included 17 randomized controlled trials in the systematic review, of which, 12 were included for the PPC meta-analysis and 11 for the LOS meta-analysis. IMT significantly reduced the risk of PPC (Risk Ratio (RR) = 0.50, 95%CI: 0.39, 0.64, I²=0.0%), and a decrease in LOS (Mean Difference = -1.41, 95%CI: -2.07, -0.75, I² = 0.0%).

CONCLUSION

IMT is effective to reduce PPC and LOS in patients undergoing surgery. Implications for Rehabilitation Physiotherapy interventions with inspiratory muscle training (IMT) are effective to reduce postoperative pulmonary complications (PPC) and length of hospital stay (LOS) after major surgery, and should start preoperatively. Rehabilitation with IMT is beneficial at all ages and risk levels, but older and high-risk patients benefit more, as well as pulmonary surgery patients. IMT is more effective if it is supervised, and prescription target at least two-week period, sessions with more than 15 minutes, with imposed load increment, and adding other exercise modes.

Mammography Use in Portugal: National Health Survey 2014

INTRODUCTION

Understanding the patterns of mammography use and monitoring changes in use are essential to improving national health policy for breast cancer control. We aimed to describe the use of mammography in Portugal and to identify the determinants of its nonuse and underuse by examining data from the National Health Survey 2014.

METHODS

We analyzed data on 8,758 women aged 30 years or older. We defined women at an eligible age for mammography as women aged 45 to 69. Women who reported a previous mammography test were classified as ever-users and grouped according to time since the most recent test. We computed the prevalence of mammography use, and we used Poisson regression models to obtain age-adjusted and education-adjusted prevalence ratios and 95% confidence intervals.

RESULTS

The overall prevalence of mammography use was 80.0%, whereas nonuse was 20.0% and underuse 27.3% among users. The prevalence of nonuse and underuse were lower and associations with sociodemographic characteristics, use of health care services, and behavioral factors were stronger among women aged 45 to 69 than among women aged 30 to 44 and women aged 70 or older. The prevalence of mammography use was generally higher in the northern areas of Portugal than in southern areas and varied by marital status, educational level, and household size. A more frequent use of health care services and healthier behaviors were associated with lower prevalences of both nonuse and underuse.

CONCLUSION

This study illustrates inequalities in mammography use and provides useful information for better allocation of resources in breast cancer screening.

Orthodontic camouflage versus orthodontic-orthognathic surgical treatment in class II malocclusion: a systematic review and meta-analysis

This systematic review was performed to compare dental, skeletal, and aesthetic outcomes between orthodontic camouflage and surgical-orthodontic treatment, in patients with a skeletal class II malocclusion and a retrognathic mandible who have already finished their growth period. A literature search was conducted, and a modified Downs and Black checklist was used to assess methodological quality. The meta-analysis was conducted using the DerSimonian-Laird random-effects method to obtain summary estimates of the standardized mean differences and corresponding 95% confidence intervals. Nine articles were included in the qualitative synthesis and seven in the meta-analysis. The difference between treatments was not statistically significant regarding SNA angle, linear measurement of the lower lip to Ricketts' aesthetic line, convexity of the skeletal profile, or the soft tissue profile excluding the nose. In contrast, surgical-orthodontic treatment was more effective with regard to ANB, SNB, and ML/NSL angles and the soft tissue profile including the nose. Different treatment effects on overjet and overbite were found according to the severity of the initial values. These results should be interpreted with caution, due to the limited number of studies included and because they were non-randomized clinical trials. Further studies with larger sample sizes and similar pre-treatment conditions are needed.

Alcohol consumption and gastric cancer risk-A pooled analysis within the StoP project consortium

An association between heavy alcohol drinking and gastric cancer risk has been recently reported, but the issue is still open to discussion and quantification. We investigated the role of alcohol drinking on gastric cancer risk in the "Stomach cancer Pooling (StoP) Project," a consortium of epidemiological studies. A total of 9,669 cases and 25,336 controls from 20 studies from Europe, Asia and North America were included. We estimated summary odds-ratios (ORs) and the corresponding 95% confidence intervals (CIs) by pooling study-specific ORs using random-effects meta-regression models. Compared with abstainers, drinkers of up to 4 drinks/day of alcohol had no increase in gastric cancer risk, while the ORs were 1.26 (95% CI, 1.08-1.48) for heavy (>4 to 6 drinks/day) and 1.48 (95% CI 1.29-1.70) for very heavy (>6 drinks/day) drinkers. The risk for drinkers of >4 drinks/day was higher in never smokers (OR 1.87, 95% CI 1.35-2.58) as compared with current smokers (OR 1.14, 95% CI 0.93-1.40). Somewhat stronger associations emerged with heavy drinking in cardia (OR 1.61, 95% CI 1.11-2.34) than in non-cardia (OR 1.28, 95% CI 1.13-1.45) gastric cancers, and in intestinal-type (OR 1.54, 95% CI 1.20-1.97) than in diffuse-type (OR 1.29, 95% CI 1.05-1.58) cancers. The association was similar in strata of H. pylori infected (OR = 1.52, 95% CI 1.16-2.00) and noninfected subjects (OR = 1.69, 95% CI 0.95-3.01). Our collaborative pooled-analysis provides definite, more precise quantitative evidence than previously available of an association between heavy alcohol drinking and gastric cancer risk.

The effects of physical activity interventions on glycated haemoglobin A1c in non-diabetic populations: a protocol for a systematic review and meta-analysis

INTRODUCTION

Epidemiological evidence suggests that physical activity has a positive effect on reducing glycated haemoglobin A1c (HbA1c) levels not only in diabetics, but also in healthy subjects. Moreover, a positive association of HbA1c levels with cardiovascular disease and mortality in non-diabetic populations has recently been reported. This is a protocol for a systematic review and meta-analysis aiming to estimate the effects of physical activity on glycaemic control measured by HbA1c levels in non-diabetic populations; and to determine which type of physical activity has a greater influence on glycaemic control.

METHODS AND ANALYSIS

The search will be conducted using MEDLINE, EMBASE, the Cochrane Library and Web of Science databases from inception to mid-2017. Randomised controlled trials, non-randomised experimental studies and controlled pre-post studies written in English, Portuguese, French or Spanish will be included. The Cochrane Collaboration's tool and The Quality Assessment Tool for Quantitative Studies will be used to assess the risk of bias for studies included in the systematic review. Standardised pre-post intervention mean differences of HbA1c will be calculated as the primary outcome. Subgroup analyses will be performed based on the characteristics of physical activity intervention and population included in the studies.

ETHICS AND DISSEMINATION

This systematic review will synthesise evidence on the association of physical activity and HbA1c in non-diabetic populations. This study is important from the clinical and public health point because it will estimate the effect of physical activity on the glycemic control, and it will also examine which is the type of physical activity that should be recommended for preventing type 2 diabetes and its complications. The results will be disseminated by publication in a peer-reviewed journal. Ethical approval will not be required because the data used for this systematic review will be obtained from published studies and there will be no concerns about privacy.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42016050991.

Sex-differences in the prevalence of Helicobacter pylori infection in pediatric and adult populations: Systematic review and meta-analysis of 244 studies

BACKGROUND

The main outcome of Helicobacter pylori infection, i.e. gastric cancer, is more frequent in men, but there is no comprehensive synthesis of the evidence on a potential role of sex in the acquisition and/or persistence of infection.

AIMS

To quantify the association between sex and H. pylori infection in pediatric and adult populations, through systematic review and meta-analysis.

METHODS

PubMed^® was searched, from inception to September 2015, to identify population-based studies reporting the prevalence and/or incidence of H. pylori infection in both sexes. Odds ratios (OR) or data to compute them were extracted; adjusted estimates were preferred, whenever available. The DerSimonian and Laird method was used to compute summary estimates and respective 95% confidence intervals (95%CI), separately for children and adults.

RESULTS

Among a total of 244 studies, mostly cross-sectional, male sex was associated with a greater prevalence of H. pylori infection, both in children (102 studies, OR=1.06, 95%CI: 1.01, 1.12, I²=43.7%) and adults (169 studies, OR=1.12, 95%CI: 1.09, 1.15, I²=68.5%). An underrepresentation of studies showing a negative association between male sex and infection was observed (Egger's test: p=0.006).

CONCLUSIONS

Although further research is needed to understand the mechanisms by which sex may influence the acquisition and/or persistence of infection, our results support a small contribution of sex differences in the prevalence of infection to the male predominance of H. pylori-related outcomes, including gastric cancer.

Contemporary migration patterns in the prevalence of Helicobacter pylori infection: A systematic review

BACKGROUND

A rapid growth in the number of international migrants over the past years has occurred with most traveling to more affluent settings. As Helicobacter pylori infects over half of the adult population and its prevalence is higher in developing countries, understanding the prevalence of infection in migrants can provide insight into future trends in the burden and management of infection. We aimed to describe the prevalence of H. pylori among migrants through a systematic literature review.

METHODS

We searched PubMed^® from inception to September 2015 to identify studies reporting the prevalence of H. pylori in international migrants according to country of birth for first-generation, and country of birth and parents' nationality for successive generations. Comparable data from origin and destination populations were obtained from the same studies or, when not present, from a previous systematic review on H. pylori worldwide.

RESULTS

A total of 28 eligible studies were identified with data for 29 origin and 12 destination countries. Two studies that evaluated refugees presented prevalences of infection higher than both the origin and destination countries. Otherwise, the prevalences among migrants were generally similar or below that of the origin and higher than the destination. Second- or more generation had lower prevalences compared to first-generation migrants.

CONCLUSIONS

Our study findings are consistent with what would be expected based on the prevalence of H. pylori worldwide. The results of this review show that migrants are particularly at risk of infection and help to identify gaps in the knowledge of migrants' prevalence of infection globally.

The Effectiveness of Physiotherapy in the Management of Temporomandibular Disorders: A Systematic Review and Meta-analysis

AIMS

To analyze the methodologic quality, summarize the findings, and perform a meta-analysis of the results from randomized controlled trials that assessed the effects of physiotherapy management of temporomandibular disorders.

METHODS

A literature review was performed using the electronic databases PubMed, Science Direct, and EBSCO. Each article was independently assessed by two investigators using the Physiotherapy Evidence Database (PEDro), Jadad scales, and the Cochrane Risk of Bias tool. A meta-analysis was conducted by using the DerSimonian-Laird random-effects method to obtain summary estimates of the standardized mean differences (SMD) and the corresponding 95% confidence intervals (95% CI). Between-study heterogeneity was computed and publication bias was assessed.

RESULTS

Seven articles met the inclusion criteria and were used in the analysis, corresponding to nine estimates of SMD. The meta-analysis showed that for pain reduction, the summary SMD favored physiotherapy (SMD = -0.63; 95% CI: -0.95 to -0.31; number of studies = 8; I² = 0.0%), while for active range of movement (ROM) the differences between the intervention and control groups were not statistically significant (SMD = 0.33; 95% CI: -0.07 to 0.72; number of studies = 9; I² = 61.9%).

CONCLUSION

Physiotherapy seems to lead to decreased pain and may improve active ROM. However, the results are not definitive and further studies and meta-analyses are needed before these results can be considered fully generalizable.

Glycosylated haemoglobin as a predictor of cardiovascular events and mortality: a protocol for a systematic review and meta-analysis

INTRODUCTION

Glycosylated haemoglobin level (HbA1c) is an indicator of the average blood glucose concentrations over the preceding 2-3 months and is used as a convenient and well-known biomarker in clinical practice. Currently, epidemiological evidence suggests that HbA1c level is an independent risk factor for cardiovascular events such as myocardial infarction, stroke, coronary heart disease and heart failure. This protocol aim is to conduct a systematic review and meta-analysis to determine relationships of HbA1c levels with cardiovascular outcomes and cause of death, and to analyse the range of HbA1c levels that is a predictor of cardiovascular disease and/or mortality based on data from published observational studies.

METHODS AND ANALYSIS

The search will be conducted using Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Web of Science databases from their inception. Observational studies written in Portuguese, Spanish or English will be included. The Quality In Prognosis Studies tool will be used to assess the risk of bias for the studies included in the systematic review or meta-analysis. HRs for cardiovascular outcomes and causes of death with 95% CIs will be determined as primary outcomes. Subgroup analyses will be performed based on cardiovascular outcomes, cause of death studied, and type of population included in the studies.

ETHICS AND DISSEMINATION

This systematic review will synthesise evidence on the potential of using HbA1c level as a prognostic marker for cardiovascular disease outcomes and/or mortality. The results will be disseminated by publication in a peer-reviewed journal. Ethics approval will not be needed because the data used for this systematic review will be obtained from published studies and there will be no concerns about privacy.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42015032552.

Worldwide Burden of Gastric Cancer Attributable to Tobacco Smoking in 2012 and Predictions for 2020

BACKGROUND

The heterogeneous patterns and trends in tobacco consumption contribute to regional and gender differences in the burden of gastric cancer attributable to smoking.

AIMS

To estimate the proportion and absolute number of gastric cancer cases that can be attributed to smoking in different countries, in 2012 and 2020.

METHODS

Population attributable fractions (PAFs) were computed for 118 countries, using data of smoking prevalence in 2002 and 2011 and published estimates of the magnitude of the association between smoking and gastric cancer, assuming a time lag of ≈10 years.

RESULTS

For men, the highest PAF estimates in 2012 were observed in Eastern Asia and the lowest in North America, whereas for women the highest were in Western Europe and the lowest in Africa. Very high Human Development Index (HDI) countries presented the lowest median PAF in men (very high vs. high, medium, and low HDI: 17.2 vs. 20.8 %, p = 0.014) and the highest median PAF in women (very high vs. high, medium, and low HDI: 4.3 vs. 1.8 %, p < 0.001). Estimates for 2020 show a decrease in median PAFs, but the estimated absolute number of cases attributable to smoking in the countries analyzed increased for men (≈154,000 vs. ≈160,000) and decreased for women (≈6200 vs. ≈5600).

CONCLUSIONS

Smoking accounts for a larger number of gastric cancer cases among men, and gender differences are expected to increase in the next decade, despite the decrease in PAFs. Intensified efforts to control smoking are needed to further reduce the burden of gastric cancer.

Maternal and child health interventions in Nigeria: a systematic review of published studies from 1990 to 2014

BACKGROUND

Poor maternal and child health indicators have been reported in Nigeria since the 1990s. Many interventions have been instituted to reverse the trend and ensure that Nigeria is on track to achieve the Millennium Development Goals. This systematic review aims at describing and indirectly measuring the effect of the Maternal, Newborn, and Child Health (MNCH) interventions implemented in Nigeria from 1990 to 2014.

METHODS

PubMed and ISI Web of Knowledge were searched from 1990 to April 2014 whereas POPLINE® was searched until 16 February 2015 to identify reports of interventions targeting Maternal, Newborn, and Child Health in Nigeria. Narrative and graphical synthesis was done by integrating the results of extracted studies with trends of maternal mortality ratio (MMR) and under five mortality (U5MR) derived from a joint point regression analysis using Nigeria Demographic and Health Survey data (1990-2013). This was supplemented by document analysis of policies, guidelines and strategies of the Federal Ministry of Health developed for Nigeria during the same period.

RESULTS

We identified 66 eligible studies from 2,662 studies. Three interventions were deployed nationwide and the remainder at the regional level. Multiple study designs were employed in the enrolled studies: pre- and post-intervention or quasi-experimental (n = 40; 61%); clinical trials (n = 6;9%); cohort study or longitudinal evaluation (n = 3;5%); process/output/outcome evaluation (n = 17;26%). The national MMR shows a consistent reduction (Annual Percentage Change (APC) = -3.10%, 95% CI: -5.20 to -1.00 %) with marked decrease in the slope observed in the period with a cluster of published studies (2004-2014). Fifteen intervention studies specifically targeting under-five children were published during the 24 years of observation. A statistically insignificant downward trend in the U5MR was observed (APC = -1.25%, 95% CI: -4.70 to 2.40%) coinciding with publication of most of the studies and development of MNCH policies.

CONCLUSIONS

The development of MNCH policies, implementation and publication of interventions corresponds with the downward trend of maternal and child mortality in Nigeria. This systematic review has also shown that more MNCH intervention research and publications of findings is required to generate local and relevant evidence.