Daily Activities in European Children and Adolescents During COVID-19 School Closure: A Longitudinal Study Exploring Physical Activity, Use of Screens, and Sleep Patterns

This longitudinal study aimed to analyze the evolution of patterns of daily activities (physical activity time, screen usage time, and sleep hours) in European youth during school closure due to the COVID-19 health crisis. Participants were 624 caregivers of children and adolescents aged 3-18 from Italy, Spain, and Portugal. Evaluations were online, and four time-points were considered: retrospective measurement of daily activities before confinement (T1), and two (T2), five (T3), and eight (T4) weeks after starting the lockdown. Generally accepted international guidelines on physical activity time, screen usage time, and hours of sleep by age group were used to determine whether the pattern might increase the risk for ill health or not. To estimate the evolution of daily activities, generalized estimating equations (GEE) were used. The percentage of children who practiced less than 60 min of daily exercise increased significantly from before home confinement (47.8%) to T2 (86.4%); it slightly decreased at T3 (79.8%), and remained stable at T4 (76.1%). The percentage of children who made excessive use of screens (according to their age group) significantly increased from T1 to T2 and remained stable and high in the rest of the evaluations. The percentage of children who slept fewer or more hours than recommended for their age group remained stable between T1 and T4, although there was a significant increase at T3. In general, results found unhealthier behaviors as confinement was extended. Results are discussed in order to find strategies for promoting healthy daily activities for future pandemics.

Trends in ultra-processed food availability and its association with diet-related non-communicable disease health indicators in the Portuguese population

Broad variations in dietary and physical activity patterns are part of nutritional transition concept. An additional nutritional transition has as main characteristic the change of consumption of processed foods for ultra-processed foods (UPF). This study aims to evaluate trends of UPF availability in Portuguese population and its association with diet-related non-communicable diseases (NCD) health indicators. This ecological study used data from the Household Budget Surveys conducted by the National Statistics Institute each 5 years within a national representative sample of households. The percentage of UPF was calculated based on the total daily amount of food and beverages available per capita (in grams). Data from the years 1990, 1995, 2000 and 2005 were used, which were retrieved from DAFNE-Anemos Software. NCD age-standardised mortality, prevalence and incidence were obtained from the Global Burden of Disease database, for the years 2000, 2005, 2010 and 2015. Between 1990 and 2005, the UPF availability increased from 3·9 % to 13·8 %. Over the years, almost all food and beverages categories increased the UPF availability contribution, mainly noticeable for milk, sugar, cereal and meat products. Positive correlations were observed between UPF availability and digestive diseases both in prevalence (r = 0·062; P = 0·037) and incidence (r = 0·005; P = 0·010) measures. Neoplasms incidence also showed positive correlation with UPF availability (r = 0·002; P = 0·012). Trends in UPF availability in Portugal increased exponentially. At the same time, there is a trend towards a decrease in unprocessed and processed food availability. The Portuguese population should be made aware of the health risks resulting from excessive consumption of UPF.

Molecular characterization and virulence profile of Klebsiella pneumoniae and Klebsiella oxytoca isolated from ill cats and dogs in Portugal

Klebsiella spp. are important pathogens of humans and companion animals such as cats and dogs, capable of causing severe life-threatening diseases. The aim of this study was to characterize the molecular and phenotypic properties of Klebsiella pneumoniae and Klebsiella oxytoca isolated from ill companion animals by whole genome sequencing, followed by in vitro assessment of biofilm formation and in vivo pathogenicity using the Galleria mellonella model. Two LPS O-types were identified for all the K. pneumoniae isolates tested (O3B and O1/O2v2) and only one for K. oxytoca isolates (OL104), and the most common STs found were ST11 and ST266. Furthermore, a high diversity of K-locus types was found for K. pneumoniae (KL102; KL105; KL31, and KL13). Within K. pneumoniae, one specific O/K/ST-types combination (i.e., KL105-ST11-O1/O2v2) showed results that were of concern, as it exhibited a high inflammatory response at 12 h post-infection in G. mellonella with 80% of the larvae dead at 72 h post-infection. This virulence potential, on the other hand, did not appear to be directly related to the biofilm-forming capacity. Also, virulence and resistance scores obtained for this set of strains did surpass score 1. The present study demonstrated that Klebsiella spp. isolated from companion animals belonging to STs that can cause human infections and present virulence on an invertebrate model. Thus, this study underscores the role of dogs and cats as reservoirs of resistant Klebsiella spp. that could potentially be transmitted to humans.

Prevalence of Parental Violent Discipline Toward Children: Findings From A Portuguese Population

Despite recognizing the detrimental impact of parental violence on children's mental and physical health throughout their lives, violence remains an all-too-real part of life for many children around the globe. However, data on the child-reported prevalence of experienced family violence are scarce and primarily based on parental reports. This study aimed to broaden the body of evidence and measure the lifetime prevalence of child-reported experience of violent disciplinary practices perpetrated by parents and to identify its associated sociodemographic and economic factors. We conducted a cross-sectional study using data from 5,281 Generation XXI participants recruited from 2005 to 2006 in Porto, Portugal. Parental disciplinary practices were reported by 7-year-old children using the Parent-Child Conflict Tactics Scale. Pearson's Chi-squared test was used to compare differences in child-reported frequencies of violent disciplinary practices by sociodemographic variables. We observed statistically significant differences in rates of violent disciplinary practices according to the child's and parent's gender. Specifically, fathers exhibited a higher likelihood than mothers to engage in psychological aggression and corporal punishment, while mothers were more prone to engage in severe and very severe physical assault. When fathers were the perpetrators, boys were more inclined than girls to report all forms of violent disciplinary measures, and when mothers were the perpetrators, boys were particularly susceptible to severe and very severe physical assault compared to girls. In our study, children reported being frequently subjected to violent parental disciplinary practices, independently of family socioeconomic background. Children were more likely to experience psychological aggression and corporal punishment if they were born into high-income families, while severe and very severe physical assaults were more common among children whose parents had lower educational levels. National public awareness of the negative effects of violent disciplinary practices is urgently needed, promoting child-friendly and nonviolent approaches to discipline.

Molecular characterization of cetacean poxviruses along the coast of mainland Portugal

Cetacean poxvirus (CePV) is the causative agent of tattoo skin disease (TSD) in dolphins, porpoises and whales, a condition characterized by pinhole, ring-like lesions or generalized tattoo-like skin lesions. This study genetically characterized cetacean poxviruses from stranded animals along mainland Portugal. Samples from skin lesions compatible with TSD were obtained from 4 odontocete species (Delphinus delphis, Stenella coeruleoalba, Phocoena phocoena, and Tursiops truncatus) and analyzed using a conventional PCR assay targeting the DNA polymerase gene partially. Among the positive samples (n = 29, 65.9%), a larger DNA polymerase gene fragment was obtained, allowing a robust phylogenetic analysis. Nineteen samples (43.2%) were successfully amplified and sequenced using Sanger sequencing. By combining 11 of these sequences with those from public databases, a maximum likelihood phylogenetic tree was constructed, revealing high heterogeneity within the group. These findings contribute to a better understanding of the genetic diversity, epidemiology, phylogenetics, and evolution of CePV.

Association between area-level walkability and glycated haemoglobin: a Portuguese population-based study

Diabetes poses a substantial disease burden, prompting preventive interventions. Physical inactivity, a major risk factor for type 2 diabetes, can potentially be mitigated by enhancing area-level walkability. Despite this, limited population-based studies have investigated the link between walkability and objective diabetes measures. Our study aims to estimate the association between area-level walkability and individual glycated haemoglobin levels in the Portuguese adult population without the diagnosis of diabetes. Data from the 2011 census and an updated street map were obtained to construct a walkability index based on residential density, land-use mix, and street connectivity. Individual health data were sourced from The National Health Examination Survey (INSEF) 2015, a representative survey of the Portuguese adult population. Gamma regression was employed for estimation of the main associations, revealing that residing in moderately walkable areas significantly reduced average glycated haemoglobin levels (Exp(β) = 0.906; 95% CI: 0.821, 0.999) compared to the least walkable areas. The association was less pronounced and not statistically significant for the third tertile of walkability (Exp(β) = 0.919; 95% CI: 0.822, 1.028). Our findings highlight a nonlinear protective association between walkability and glycated haemoglobin, emphasizing the potential policy implications for urban planning, diabetes prevention, and health promotion.

Systematic SARS-CoV-2 S-gene sequencing in wastewater samples enables early lineage detection and uncovers rare mutations in Portugal

As the COVID-19 pandemic reached its peak, many countries implemented genomic surveillance systems to track the evolution and transmission of SARS-CoV-2. Transition from the pandemic to the endemic phase prioritized alternative testing strategies to maintain effective epidemic surveillance at the population level, with less intensive sequencing efforts. One such promising approach was Wastewater-Based Surveillance (WBS), which offers non-invasive, cost-effective means for analysing virus trends at the sewershed level. From 2020 onwards, wastewater has been recognized as an instrumental source of information for public health, with national and international authorities exploring options to implement national wastewater surveillance systems and increasingly relying on WBS as early warning of potential pathogen outbreaks. In Portugal, several pioneer projects joined the academia, water utilities and Public Administration around WBS. To validate WBS as an effective genomic surveillance strategy, it is crucial to collect long term performance data. In this work, we present one year of systematic SARS-CoV-2 wastewater surveillance in Portugal, representing 35 % of the mainland population. We employed two complementary methods for lineage determination - allelic discrimination by RT-PCR and S-gene sequencing. This combination allowed us to monitor variant evolution in near-real-time and identify low-frequency mutations. Over the course of this year-long study, spanning from May 2022 to April 2023, we successfully tracked the dominant Omicron sub-lineages, their progression and evolution, which aligned with concurrent clinical surveillance data. Our results underscore the effectiveness of WBS as a tracking system for virus variants, with the ability to unveil mutations undetected via massive sequencing of clinical samples from Portugal, demonstrating the ability of WBS to uncover new mutations and detect rare genetic variants. Our findings emphasize that knowledge of the genetic diversity of SARS-CoV-2 at the population level can be extended far beyond via the combination of routine clinical genomic surveillance with wastewater sequencing and genotyping.

The socioeconomic epidemiology of inherited retinal diseases in Portugal

BACKGROUND

Inherited retinal diseases (IRDs) are a group of rare degenerative disorders of the retina that can lead to blindness from birth to late middle age. Knowing the target population and its resources is essential to better plan support measures. The aim of this study was to evaluate the socioeconomic characteristics of regions in Portugal where IRD patients reside to inform the planning of vision aid and rehabilitation intervention measures.

RESULTS

This study included 1082 patients from 973 families, aged 3 to 92 years, with a mean age of 44.8 ± 18.1 years. Patients living with an IRD were identified in 190 of the 308 municipalities. According to this study, the estimated IRD prevalence in Portugal was 10.4 per 100,000 inhabitants, and by municipalities, it ranged from 0 to 131.2 per 100,000 inhabitants. Overall, regions with a higher prevalence of IRD have a lower population density (r=-0.371, p < 0.001), a higher illiteracy rate (r = 0.404, p < 0.001) and an overall older population (r = 0.475, p < 0.001). Additionally, there is a lower proportion of doctor per capita (r = 0.350, p < 0.001), higher social security pensions beneficiaries (r = 0.439, p < 0.001), worse water quality for human consumption (r=-0.194, p = 0.008), fewer audiences at the cinema (r=-0.315, p < 0.001) and lower proportion of foreign guests in tourist accommodations (r=-0.287, p < 0.001).

CONCLUSION

The number of identified patients with IRD varied between regions. Using data from national statistics (PORDATA), we observed differences in socioeconomic characteristics between regions. Multiple targeted aid strategies can be developed to ensure that all IRD patients are granted full clinical and socioeconomic support.

Percutaneous kidney biopsies in children: a 24-year review in a tertiary center in northern Portugal

INTRODUCTION

Percutaneous kidney biopsy (KB) is crucial to the diagnosis and management of several renal pathologies. National data on native KB in pediatric patients are scarce. We aimed to review the demographic and clinical characteristics and histopathological patterns in children who underwent native percutaneous KB over 24 years.

METHODS

Retrospective observational study of patients undergoing native percutaneous KB in a pediatric nephrology unit between 1998 and 2021, comparing 3 periods: period 1 (1998-2005), period 2 (2006-2013), and period 3 (2014-2021).

RESULTS

We found that 228 KB were performed, 78 (34.2%) in period 1, 91 (39.9%) in period 2, and 59 (25.9%) in period 3. The median age at KB was 11 (7-14) years. The main indications for KB were nephrotic syndrome (NS) (42.9%), hematuria and/or non-nephrotic proteinuria (35.5%), and acute kidney injury (13.2%). Primary glomerulopathies were more frequent (67.1%), particularly minimal change disease (MCD) (25.4%), IgA nephropathy (12.7%), and mesangioproliferative glomerulonephritis (GN) (8.8%). Of the secondary glomerulopathies, lupus nephritis (LN) was the most prevalent (11.8%). In group 1, hematuria and/or non-nephrotic proteinuria were the main reasons for KB, as opposed to NS in groups 2 and 3 (p < 0.01). LN showed an increasing trend (period 1-3: 2.6%-5.3%) and focal segmental glomerular sclerosis (FSGS) showed a slight decreasing trend (period 1-3: 3.1%-1.8%), without statistical significance.

CONCLUSIONS

The main indication for KB was NS, which increased over time, justifying the finding of MCD as main histological diagnosis. LN showed an increase in incidence over time, while FSGS cases did not increase.

Barriers and facilitators of the reporting by family doctors of cases of domestic violence - a qualitative study across Portugal

BACKGROUND

Domestic violence (DV) is a serious and prevalent public health problem with devastating consequences for the victims and their families. Whilst the number of cases reported to the authorities has risen in recent years, many victims still chose not to present a complaint. In Portugal, to address this, DV became a public crime. As victims of DV present multiple health problems and frequently seek professional help, family doctors are in a privileged position to detect and report cases of DV to the authorities. However, little is known about what motivates these professionals to report or not the DV cases they encounter in their practice to the authorities.

METHODS

We conducted semi-structured interviews with family doctors from all regional health administrations of continental Portugal. Interviews occurred between July 2020 and September 2022, were conducted in person or remotely, audio recorded, transcribed, and analysed using thematic analysis. Content analysis was conducted to assess the agreement or disagreement regarding mandatory reporting in each of the themes and subthemes.

RESULTS

Fifty-four family doctors took part in this study (n = 39 women, n = 15 men). The main themes that arose from the analysis were: "Barriers related to the physician's activity," "Barriers related to the victim or aggressor," "Facilitators related to the physician's activity," "Facilitators related to the victim or aggressor." Although different barriers were described, most doctors agreed with the mandatory reporting of DV cases.

CONCLUSIONS

Family doctors encounter multiple barriers and facilitators when considering reporting a DV case to the authorities. The results of this study can help develop new interventions to address the barriers described by the doctors, increasing their compliance with mandatory reporting, the protection of victims and the just persecution of the aggressor.

Is a tiered restrictions system an effective intervention for COVID-19 control? Results from Portugal, November-December 2020

BACKGROUND

In November 2020, similar to other European countries, Portugal implemented a tiered restrictions system to control the COVID-19 pandemic. We aimed to compare the COVID-19 growth rate across tiers to assess the effect of a tiered restrictions system in Portugal, using models with different times between tiers assessment. Our hypothesis was that being in a higher tier brings a faster deceleration in the growth rate than being in a lower tier.

METHODS

The national database of notified COVID-19 cases and publicly available data were used to analyse the effect of the tiered restrictions system on the COVID-19 incidence growth rate. The tiers were based on the European Centre for Disease Control risk classification: moderate, high, very and extremely high. We used a generalised mixed-effects regression model to estimate the growth rate ratio (GRR) for each tier, comparing the growth rates of higher tiers using moderate tier as reference. Three models were fitted using different times between tiers assessment, separated by 14 days.

RESULTS

We included 156 034 cases. Very high tier was the most frequent combination in all the three moments assessed (21.2%), and almost 50% of the municipalities never changed tier during the study period. Immediately after the tiers implementation, a reduction was identified in the municipalities in high tier (GRR high tier: 0.90 [95%CI: 0.79; 1.02]) and very high tier (GRR very high tier: 0.68 [95%CI: 0.61; 0.77]), however with some imprecision in the 95% confidence interval for the high tier. A reduction in very high tier growth rate was identified two weeks (GRR: 0.79 [95%CI: 0.71; 0.88]) and four weeks (GRR: 0.77 [95%CI: 0.74; 0.82]) after the implementation, compared to moderate tier. In high tier, a reduction was also identified in both times, although smaller.

CONCLUSIONS

We observed a reduction in the growth rate in very high tier after the tiered restriction system was implemented, but we also observed a lag between tiered restriction system implementation and the onset of consequent effects. This could suggest the importance of early implementation of stricter measures for pandemic control. Thus, studies analysing a broader period of time are needed.

Carbapenemase-producing Enterobacterales strains causing infections in companion animals-Portugal

An increase in Klebsiella pneumoniae carbapenem-resistant human nosocomial strains is occurring in Europe, namely with the blaOXA-48-like and blaKPC-like genes. We determined the prevalence of carbapenemase-producing Enterobacterales clinical strains in companion animals in Portugal and characterized their mobile genetic elements. Susceptibility data of a consecutive collection of 977 Enterobacterales clinical strains from a Portuguese private veterinary diagnostic laboratory were evaluated (January-December 2020). Additional phenotypical and genotypical assays were performed in a subset of 261 strains with a resistant phenotype. Whole-genome sequencing was performed for carbapenemase-producing strains. The frequency of carbapenemase-producing Enterobacterales clinical strains in companion animals in Portugal was 0.51% (n = 5/977). Thus, five strains were characterized: (i) one OXA-181-producing K. pneumoniae ST273, (ii) two KPC-3-producing K. pneumoniae ST147; (iii) one KPC-3-producing K. pneumoniae ST392; and (iv) one OXA-48-producing E. coli ST127. The blaKPC-3 gene was located on transposon Tn4401d on IncFIA type plasmid for the K. pneumoniae ST147 strains and on a IncN-type plasmid for the K. pneumoniae ST392 strain, while blaOXA-181 gene was located on an IncX3 plasmid. All de novo assembled plasmids and plasmid-encoded transposons harboring carbapenemase genes were homologous to those previously described in the human healthcare. No plasmid replicons were detected on the OXA-48-producing E. coli ST127. The dissemination of carbapenem resistance is occurring horizontally via plasmid spreading from the human high burden carbapenem resistance setting to the companion animal sector. Furthermore, companion animals may act as reservoirs of carbapenem resistance. Implementation of carbapenemase detection methods in routine clinical veterinary microbiology is urgently needed.

IMPORTANCE

This is the first study on the prevalence of carbapenemase-producing Enterobacterales (CPE) clinical strains from companion animals in Portugal. Despite the generally low prevalence of CPE in companion animals, it is imperative for veterinary diagnostic laboratories to employ diagnostic methods for carbapenemase detection. The resemblance found in the mobile genetic elements transporting carbapenemase genes between veterinary medicine and human medicine implies a potential circulation within a One Health framework.

Establishment of Diagnostic Reference Levels in Portuguese Interventional Radiology departments

PURPOSE

To establish Portuguese Diagnostic Reference Levels (DRLs), for six body fluoroscopy guided interventional procedures (FGIP).

METHOD

A retrospective study was conducted in five interventional departments most representative of Interventional Radiology (IR) practice. Dose values, in terms of air kerma area product (PKA in Gy.cm2), air kerma at the patient entrance reference point (Ka,r in mGy), and exposure parameters (fluoroscopy time (FT) and number of cine runs) were collected. Examinations were selected per procedure (at least 20), according to the antero-posterior and lateral diameter mean value (±5 cm), measured on previous Computed Tomography (CT) examinations.

RESULTS

Data of 489 body FGIP show a large variation on dose values per procedure and per department. National DRLs in terms of PKA were 20.2 Gy.cm2 for Percutaneous transhepatic biliary drainage (PTBD), 98.2 Gy.cm2 for Bronchial artery embolisation (BAE), 247.7 Gy.cm2 for Transarterial chemoembolisation (TACE), 331.6 Gy.cm2 for Inferior epigastric arteries embolisation (IEAE), 312.0 Gy.cm2 for Transjugular intrahepatic portosystemic shunt (TIPS) and 19.3 Gy.cm2 for Endovascular treatment of femoral popliteal arteries (ETFPA).

CONCLUSIONS

This is the first study reporting Interventional Radiology DRLs in Portugal and we propose preliminary national estimates for the six more common body FGIP. The results of this study will be presented and discussed with all Portuguese IR departments, to promote procedures optimisation.

Associations between the severity of menopausal symptoms and musculoskeletal pain in postmenopausal Portuguese women

OBJECTIVE

To analyze the association of the severity of the menopausal symptoms with musculoskeletal pain in Portuguese postmenopausal women.

METHODS

A cross-sectional, observational study was conducted on 167 women (63.85 ± 9.36 years). The Menopause Rating Scale was used to evaluate the menopausal symptoms severity, while the Nordic Musculoskeletal Questionnaire was employed to assess the localization of the musculoskeletal pain, and multi-located pain was determined if two or more body regions were affected. Depression (Hospital Anxiety and Depression Scale), age, body mass index (BMI) and physical activity level were considered as potential confounders.

RESULTS

A greater severity of the somato-vegetative menopausal symptoms was related to the prevention from usual activities because of pain in the neck, shoulders, elbows, wrists/hands and knees (R2 of Nagelkerke = 0.064, 0.043, 0.074, 0.045 and 0.045, respectively). Associations were also observed between greater age and pain in the knees, ankles and feet (R2 of Nagelkerke = 0.036 and 0.034, respectively), and being physically inactive with upper back pain (R2 of Nagelkerke = 0.060). Higher depressive symptoms were linked to pain in the hip/thighs and knees (R2 of Nagelkerke = 0.067 and 0.085, respectively), as well as being physically inactive was related ton in the neck (R2 of Nagelkerke = 0.053). Only a greater BMI was related to multi-located pain in the last 7 days (R2 of Nagelkerke = 0.041).

CONCLUSIONS

The findings of our study showed that, taking into account possible confounders, greater severity of the menopausal symptoms at a somatic-vegetative level was associated with more anatomical regions with musculoskeletal pain.

Mental health conditions and utilisation of mental health services by survivors of physical intimate partner violence in Portugal: Results from the WHO world mental health survey

The aim of this article is to study mental health conditions among survivors of severe physical intimate partner violence (IPV) and their utilisation of mental health services. This study is an integrated part of the World Mental Health Survey Initiative-Portugal, for which data was collected from a nationally representative adult sample using well-validated scales. Logistic regression models were used in the analysis. The most common statistically significant mental health conditions among IPV survivors were suicide ideation, PTSD, major depressive episode, and generalised anxiety disorder. More than one in three survivors developed PTSD. Suicide ideation was likely to occur after first experiencing IPV. Almost a half of survivors received specialised mental health treatment; in most cases, delivered by a psychiatrist. Over 60 % addressed their mental health issues consulting general physicians or other healthcare professionals. Those who experienced family violence in childhood had greater odds of also experiencing IPV; survivors of IPV with this experience were more likely to receive mental health treatment. The need to promote greater awareness and competencies of not only mental health professionals but also of general physicians and other healthcare professionals to provide support more effectively to survivors of any type of IPV deserves to be emphasised.

Rare serotype c Haemophilus influenzae invasive isolate: characterization of the first case in Portugal

We report for the first time in Portugal a serotype c Haemophilus influenzae isolated from an adult, with HIV-1 infection. Whole-genome sequencing characterized the isolate as clonal complex ST-7, albeit with a novel MLST (ST2754) due to a unique atpG profile. Integration of this genome with other available H. influenzae serotype c genomes from PubMLST revealed its overall genetic distinctiveness, with the closest related isolate being identified in France in 2020. This surveillance study, involving collaboration among hospitals and reference laboratory, successfully contributed to the identification and characterization of this rare serotype.

AdultCarbQuiz for the Portuguese population with type 1 diabetes mellitus: translation, cultural adaptation and validation of its metabolic impact

AIMS

In type 1 diabetes mellitus (T1DM), functional insulin therapy, based on carbohydrate (CH) counting and individualized insulin-to-carbohydrate ratio, is essential to achieve an adequate metabolic control. However, to date, few tools have been validated to assess patients' knowledge about CH counting, with the AdultCarbQuiz questionnaire having proved to be a reliable method in an American cohort. The aim of this study was to translate, culturally adapt and validate the AdultCarbQuiz questionnaire for the Portuguese population.  METHODS: This was a cross-sectional study of patients with T1DM on functional insulin therapy through continuous subcutaneous insulin infusion (CSII). Prior to its application, the AdultCarbQuiz questionnaire was translated and culturally adapted to the Portuguese context. Statistical analyses include descriptive, correlation and intern consistency analysis using IBM® SPSS® Statistics, version 27.

RESULT

One hundred patients were included, 58% of female sex, with a mean age of 31.09 ± 10.77 years. Mean disease duration was 15.04 ± 9.23 years, and mean CSII usage time was 4.02 ± 3.90 years. The average value of glycated haemoglobin (HbA1c), time in range (TIR), time above range (TAR) and time below range was, respectively, 7.32 ± 0.87, 59.75 ± 14.13, 34.38 ± 15.40 and 5.75 ± 6.58%. The average score of the questionnaire was 30.86 points ± 3.58 points, considered high. The Kuder-Richardson 20 coefficient value was 0.63 for the total score, with a Spearman-Brown value for the half-split of 0.63. Individuals with lower HbA1c values scored significantly higher on knowledge about hypoglycaemia prevention and correction (r = - 0.269, p = 0.007) and on the total questionnaire score (r = - 0.205, p = 0.041). A higher TIR and a lower TAR were also associated with a higher total score (r = 0.274, p = 0.007 and r = - 0.274, p = 0.007, respectively).

CONCLUSIONS

In this study, the AdultCarbQuiz questionnaire, translated and culturally adapted to the Portuguese context, proved to be a useful tool in assessing knowledge about CH counting in patients with T1DM, allowing to optimize, individually, the therapeutic strategy in consultation.

Clinical and ultrasound findings of 'swimmer's shoulder' and its association with training history in elite Portuguese swimmers: a cross-sectional study

OBJECTIVES

To assess the prevalence of shoulder injuries and ultrasound findings in elite Portuguese swimmers and their association with symptoms and personal or training-related factors.

METHODS

This cross-sectional study was conducted at the Portuguese Open and Youth Swimming National Championships between 27 and 30th July 2022. Each athlete entered details regarding personal and training history into a questionnaire and underwent a physical and ultrasound shoulder examination.

RESULTS

A total of 102 swimmers out of 662 Portuguese athletes were included in the study. Shoulder pain experienced during the previous season was reported by 42% of the athletes. A high prevalence of shoulder structural abnormalities was noted, specifically supraspinatus tendinosis (91%), tears (29%), and subacromial bursitis (29%). Specific training for injury prevention was associated with higher rates of infraspinatus tendinosis (p = 0.047), and supraspinatus tears were linked to greater swimming distances per week (p < 0.001) and practice (p < 0.001), more years of practice (p = 0.018), shoulder pain at the time of evaluation (p = 0.023), a higher number of missed competitions (p = 0.041), and shoulder injections (p = 0.009). Subacromial bursitis was associated with shoulder pain at the time of evaluation (p = 0.002) and during the previous season (p < 0.001), missed competitions (p < 0.001), and requirement for physical therapy (p = 0.006).

CONCLUSIONS

A high prevalence of shoulder morphological changes was found in surveyed swimmers and there were several associations with training load, regardless of individual characteristics of each athlete. It is essential to understand the true impact of current injury prevention programs and to develop effective measures to protect swimmers' health.

Molecular detection and characterization of Blastocystis in herbivore livestock species in Portugal

Blastocystis is a ubiquitous intestinal protist in humans and animals worldwide. The traditional livestock free-roaming raising system in rural communities increases the risk of infection with contact with a wider range of pathogens transmitted via the faecal-oral route associated with that wildlife-livestock-human interface. However, no studies have been conducted to determine the occurrence and subtype distribution of Blastocystis in livestock in Portugal. Here, we collected 180 faecal samples from herbivore livestock (cattle, goats, horses, and sheep) in different regions of the country to investigate Blastocystis prevalence and subtype diversity using PCR and next-generation amplicon sequencing. Blastocystis was present in 40.6% (73/180; 95% CI: 33.31-48.11) of the samples (goats, 81.0%; sheep, 60.9%; cattle, 32.2%). None of the horse samples were Blastocystis-positive. Eighteen subtypes were detected (ST1-ST3, ST5-ST7, ST10, ST13, ST14, ST21, ST23-ST26, ST30, ST42-ST44). Mixed infections were detected in 97.3% of the Blastocystis-positive samples. Potentially zoonotic subtypes were identified in 75.0%, 96.4%, and 100% of the Blastocystis-positive specimens collected from cattle, sheep, and goats, respectively. These results demonstrate that cattle, sheep, and goats harbour a high diversity of Blastocystis subtypes in the study regions. Importantly, our data provide novel molecular evidence strongly suggesting that some Blastocystis STs/ST subgroups may have differential host specificity.

Design and Development of a Web-Based Prospective Nationwide Registry for Ocular Inflammatory Diseases: UVEITE.PT - The Portuguese Ocular Inflammation Registry

Uveitis is a heterogeneous collection of infrequent diseases, which poses significant challenges to cost-effective research in the field. Medical registries are being increasingly recognized as crucial tools to provide high-quality data, thus enabling prospective clinical research. This paper describes the design and technical structure development of an innovative countrywide electronic medical record for uveitis, Uveite.pt, and gives an overview of the cohort registered since its foundation, March 2020.Uveite.pt is an electronic medical record platform developed by the Portuguese Ocular Inflammation Group (POIG), a scientific committee of the Portuguese Ophthalmology Society. This is a nationwide customized web-based platform for uveitis patients useful for both clinical practice and real-world-based research, working as a central repository and reporting tool for uveitis. This paper describes the technical principles, the design and the development of a web-based interoperable registry for uveitis in Portugal and provides an overview of more than 400 patients registered in the first 18 months since inception.In infrequent diseases, the existence of registries enables to gather evidence and increase research possibilities to clinicians. The adoption of this platform enables standardization and improvement of clinical practice in uveitis. It is useful to apprehend the repercussion of medical and surgical treatments in uveitis and scleritis, supporting clinicians in the strict monitoring of drug adverse reactions and surgical outcomes.

Second primary cancers among females with a first primary breast cancer: a population-based study in Northern Portugal

PURPOSE

To estimate the incidence rate of second primary cancers (SPCs) and the cumulative incidence of metachronous [diagnosed > 2 months after a first primary cancer (FPC)] SPCs in patients with a breast FPC, and to compare the incidence of SPC [overall, synchronous (≤ 2 months of the FPC) and metachronous] with that expected in the general female population.

METHODS

A cohort of patients with a breast FPC from the North Region Cancer Registry of Portugal, diagnosed in 2000-2010 (n = 15,981), was followed to 31 December 2015 for synchronous and metachronous SPCs. Cumulative incidence of metachronous SPCs considering death as a competing event, and incidence rates and standardized incidence ratios of SPCs were estimated.

RESULTS

The diagnosis of an SPC occurred in 1229 (7.7%) of patients with a breast FPC. SPCs occurred mainly in the breast, followed by digestive organs, lung, thyroid, and female genital organs. Globally, patients with a breast FPC had a higher incidence for all types of cancer compared to the general female population, and in particular for cancers of the breast, stomach, colon, lung, lymphoma, uterus, and ovary. The 10-year cumulative incidence of metachronous SPCs following a breast FPC was 6.6% and the corresponding 10-year cumulative mortality was 26.2%.

CONCLUSION

In Portugal, patients with a breast FPC have a higher incidence of cancer compared to the general female population, highlighting important aspects of care, surveillance, and counselling among this growing number of patients.

Stressful life events and heart disease and stroke: A study among Portuguese older adults

The link between stressful life events (SLE) and cardiovascular diseases (CVD) remains underexplored. This study aimed to examine the association between SLE and the diagnosis of heart disease or stroke, among older adults. Data from 678 participants from the population-based cohort EPIPorto, with ≥60 years and complete information regarding SLE and heart disease or stroke, were analysed. Stressful life events were measured through the 'Stressful Life Events Screening Questionnaire'. A previous diagnosis of heart disease or stroke was self-reported. Adjusted odds ratios (OR) with the respective 95% confidence intervals were computed through logistic regression. Almost a fourth of the participants never experienced any SLE throughout life, 30.0% experienced at least one event, 17.5% experienced two and 27.7% had experienced three or more SLE. A dose-effect association between SLE and the diagnosis of heart disease or stroke was observed, statistically significant for those who had at least 3 types of SLE, independently of confounders (≥3SLE vs. 0SLE: OR = 2.00; 95% CI: 1.12-3.57). This cross-sectional study suggests that cumulative exposure to different types of SLE during the life course was associated with a higher likelihood of having a diagnosis of heart disease or a stroke at a later age. Future longitudinal studies should better deepen this association, particularly by evaluating which type of SLE is more related to a higher prevalence of heart disease and stroke, and how the timing of the SLE influence this relation.

Monthly Analysis of Infant Mortality Rate in Portugal during the COVID-19 Pandemic: Insights from Continuous Monitoring

INTRODUCTION

The COVID-19 pandemic significantly impacted global public health. Infant mortality rate (IMR), a vital statistic and key indicator of a population's overall health, is essential for developing effective health prevention programs. Existing evidence primarily indicates a decrease in IMR during the COVID-19 pandemic. We conducted a national-level analysis to calculate IMR and describe its course over the years (from 2016 until 2022), using a month-by-month analysis.

METHODS

Data on the number of deaths under one year of age was collected from the Portuguese E-Death Certification System (SICO), and data on the number of monthly live births was obtained from Statistics Portugal. The IMR was calculated per month, considering the previous 12 months' cumulative number of deaths under one year of age and the number of live births.

RESULTS

In Portugal, the IMR decreased before and during the COVID-19 pandemic. The lowest values were observed in September and October 2021 (2.15 and 2.14 per 1000 live births, respectively). The IMR remained below the threshold of three deaths per 1000 live births during the pandemic's critical period.

CONCLUSION

Portugal has achieved remarkable progress in reducing its IMR over the last 60 years. The country recorded its lowest-ever IMR values during the COVID-19 pandemic. Further studies are needed to fully understand the observed trends.

Molecular detection of Enterocytozoon bieneusi in bats from Portugal

Enterocytozoon bieneusi is a microsporidia commonly found in the gastrointestinal tract of humans and a wide range of other animals, constituting a major cause of microsporidiosis in humans. Although E. bieneusi has been detected in humans, domestic, and wild animals in Portugal, and its presence in bats has been linked to zoonotic characteristics, its occurrence in bats within the country has not been reported. In this study, we investigated the presence of E. bieneusi in 380 bat fecal samples collected in mainland Portugal through a nested PCR assay targeting the internal transcribed spacer region and the flanking small and large subunits of the ribosomal RNA. Enterocytozoon bieneusi was detected in one bat sample (i.e., 0.26%; Pipistrellus pipistrellus). Additionally, another sample tested positive for Enterocytozoon sp. Phylogenetic analysis of the obtained ITS sequence of E. bieneusi revealed clustering within the potentially zoonotic Group 1. This study represents the first report of E. bieneusi in a bat from Europe. Findings presented here contribute to an enhanced understanding of E. bieneusi epidemiology.

The burden of atopic dermatitis in Portuguese patients: an observational study

Atopic dermatitis (AD) is a common inflammatory skin condition that significantly affects patients' lives and imposes both economic and non-economic burdens. The precise societal and individual consequences of AD remain incompletely understood. This study aimed to characterize AD in Portuguese patients and assess its personal, familial, and societal implications, including health status and quality of life. The research, conducted from June 2019 to January 2020, involved 204 confirmed AD patients in Portugal, who completed a 70-question questionnaire. Results show that, on average, patients experienced a two-year delay in diagnosis, with two-thirds having allergic comorbidities. Late-onset AD (after age 20) was found to be correlated with worsening symptoms post-diagnosis. Globally, patients reported substantial effects on health, quality of life, and mental well-being. Effects include significant levels of anxiety, frustration and sleep disorders. Severe AD correlated with more suffering and reduced perceived health, indicating a link between disease severity and quality of life. Remarkably, despite questionable effectiveness, 92% of severe AD patients were prescribed antihistamines, while only 19% received biological treatments. In Portugal, delayed AD diagnosis hinders timely treatment, and despite its profound impact and high comorbidity rates, AD patients tend to remain undertreated. Recognizing the personal and societal repercussions is crucial for enhancing care, contributing to improving QoL, social functioning and global well-being.

Unresectable stage III non-small cell lung cancer: Insights from a Portuguese expert panel

INTRODUCTION

The management of unresectable stage III non-small cell lung cancer (NSCLC) is clinically challenging and there is no current consensus on optimal strategies. Herein, a panel of Portuguese experts aims to present practical recommendations for the global management of unresectable stage III NSCLC patients.

METHODS

A group of Portuguese lung cancer experts debated aspects related to the diagnosis, staging and treatment of unresectable stage III NSCLC in light of current evidence. Recent breakthroughs in immunotherapy as part of a standard therapeutic approach were also discussed. This review exposes the major conclusions obtained.

RESULTS

Practical recommendations for the management of unresectable stage III NSCLC were proposed, aiming to improve the pathways of diagnosis and treatment in the Portuguese healthcare system. Clinical heterogeneity of patients with stage III NSCLC hinders the development of single standardised algorithm where all fit.

CONCLUSIONS

A timely diagnosis and a proper staging contribute to the best management of each patient, optimizing treatment tolerance and effectiveness. The expert panel considered chemoradiotherapy as the preferable approach when surgery is not possible. Management of adverse events and immunotherapy as a consolidation therapy are also essential steps for a successful strategy.

Impact of annual TB screening on stone quarry workers in high-incidence Portuguese municipalities

SETTING

The Portuguese municipalities of Penafiel and Marco de Canaveses are high TB incidence areas, where stone quarry workers represent a vulnerable population.

OBJECTIVE

To assess the annual rate of TB infection (ARI) in stone quarry workers and to compare it with the TB notification rate in the general community.

DESIGN

An annual TB infection screening strategy using interferon-gamma release assay (IGRA) was implemented in 2018 for workers from high-risk stone quarries. A prospective cohort was enrolled and workers screened in periods of 2 years were included. IGRA-positive workers were referred for preventive treatment. ARI was calculated as the proportion of workers with IGRA conversion.

RESULTS

Of the 232 IGRA-negative workers in 2018, 20 tested positive in 2019 (8.6% ARI). Of 171 IGRA-negative workers in 2019, eight tested positive in 2021 (4.7% in 2 years). Two of the 150 IGRA-negative workers in 2021 tested positive in 2022 (1.3% ARI). ARI decreased by 84.9% between 2019 and 2022. In the two municipalities, the TB notification rate declined 23.9% between 2018 and 2021.

CONCLUSION

A more pronounced reduction in ARI was observed among stone quarry workers regularly screened for TB infection compared to the notification rate among the general population in high-incidence municipalities. A screening strategy for high-risk populations, together with enforced community measures, could foster risk reduction in the community..

Diversity of Human T-Lymphotropic Virus Type 1 Cosmopolitan Subtype (HTLV-1a) Circulating in Infected Residents in Portugal

Human T-cell lymphotropic virus type 1 (HTLV-1) prevalence in Portugal is low and mainly affects immigrants from endemic areas where human immunodeficiency virus (HIV) infection represents a public health problem. Despite the majority of HTLV-1-infected individuals remains asymptomatic, severe pathologies may develop after prolonged viral persistence, namely an aggressive form of leukemia. An increased mortality rate and faster progression to death is often related to HTLV-1/HIV coinfection. Nevertheless, studies showed that some antiretrovirals used in HIV treatment lead to a positive immune response against HTLV-1. This study aimed to analyze epidemiological and clinical data, and to assess the diversity of HTLV-1 strains circulating in infected residents diagnosed in the Portuguese national reference laboratory between 2010 and 2021. Long terminal repeat and env proviral sequences derived from 20 individuals were used to generate phylogenetic trees along with multiples reference sequences from different geographic origins retrieved from the database. Three samples belong to Portuguese natives and 17 belong to immigrants: 15 from several countries of Africa, 1 from South America, and 1 from Europe; 6 patients (30%, mean age 40.3 years) showed HTLV-1-related diseases, and 6 (30%, mean age 45.2 years) were coinfected with HIV/AIDS. The results show that the Cosmopolitan subtype is circulating in Portugal, with 10 sequences being classified as subgroup A, that include Portuguese and natives from S. Tomé and Príncipe with a mean age of 39.4 years, and 10 sequences that segregated into the Senegal cluster derived from natives born in Guinea-Bissau with a mean age of 43.5 years. A high proportion of HTLV-1-related diseases and HIV/AIDS coinfection was observed. Risk behavior practices and the absence of specific control measures, including diagnostic and treatment, may contribute to a silent dissemination of a broad diversity of HTLV-1 strains and, therefore, the increased rate of progression to debilitating diseases. In this manner, an early diagnostic and a molecular surveillance of HTLV-1 transmission remains necessary in Portugal.

Sensitization to genuine markers of timothy grass pollen (Phleum pratense) in the North-Central region of Portugal

Summary

Background. Pollen is the main cause of respiratory allergy and its prevalence is increasing. Timothy grass (Phleum pratense) is one of the most common pollen sources, and one of the best characterized allergenic grasses. The major allergens Phl p1, Phl p2, Phl p5 and Phl p6 are considered markers of genuine grass pollen sensitization. Methods. Retrospective study. IgE levels of Phl p1 and Phl p5 in patients living in the North-Central region of Portugal were analyzed, considering age and area of residence (inland or costal). Results. Among the 188 patients with IgE results for Phl p1 and Phl p5, sensitization to Phl p1 and Phl p5b was observed in 97.87% and 63.83%, respectively. The majority demonstrated co-sensitization to both Phl p1 and Phl p5b, while 68 patients were monosensitized to Phl p1 and 4 patients were monosensitized to Phl p5b. Either patients living in costal or inland areas showed IgE levels of Phl p1 higher than Phl p5b. Conclusions. Regarding genuine grass pollen sensitization, Phl p1 sensitization is more prevalent than Phl p5b in the North-Central region of Portugal.

Genomic and epidemiological insight of an outbreak of carbapenemase-producing Enterobacterales in a Portuguese hospital with the emergence of the new KPC-124

BACKGROUND

Carbapenemase-producing Enterobacterales (CPE) is an increasing problem in healthcare settings. This study aimed to identify the source of a CPE outbreak that occurred in 2022, in a tertiary hospital in the North of Portugal, to identify exposed patients, and to assess the risk of becoming CPE-positive following hospital admission.

METHODS

A multi-disciplinary investigation was conducted including descriptive, analytical, and molecular epidemiology, environmental screening, and assessment of infection control measures. Clinical and environmental isolates were analyzed using whole-genome sequencing and phylogenetic analysis. Additionally, a prospective observational cohort study was conducted to further investigate the risk factors associated with the emergence of new cases in cohorts of CPE-negative admitted patients.

RESULTS

We observed the presence of multispecies KPC-, IMP-, and/or NDM-producing isolates. Genetically indistinguishable clinical and environmental isolates were found on the same room/ward. The ST45 KPC-3-producing Klebsiella pneumoniae clone was the responsible for the outbreak. During patients' treatment, we detected the emergence of resistance to ceftazidime-avibactam, associated with mutations in the blaKPC-3 gene (blaKPC-46, blaKPC-66 and blaKPC-124, the last variant never previously reported), suggesting a vertical evolutionary trajectory. Patients aged ≥ 75 years, hygiene/feeding-care dependent, and/or subjected to secretion aspiration were risk factors for CPE colonization after hospital admission. Additionally, cases with previous admission to the emergency department suggest that CPE dissemination may occur not only during hospitalization but also in the emergency department.

CONCLUSION

Overall, the study highlights that selection pressure with antibiotics, like ceftazidime-avibactam, is a contributing factor to the emergence of new β-lactamase variants and antibiotic resistance. It also shows that the hospital environment can be a significant source of CPE transmission, and that routine use of infection control measures and real-time molecular epidemiology investigations are essential to ensure the long-term termination of CPE outbreaks and prevent future resurgences.

Determinants of HIV late presentation among men who have sex with men in Portugal (2014-2019): who's being left behind?

Introduction

HIV late presentation (LP) remains excessive in Europe. We aimed to analyze the factors associated with late presentation in the MSM population newly diagnosed with HIV in Portugal between 2014 and 2019.

Methods

We included 391 newly HIV-1 diagnosed Men who have Sex with Men (MSM), from the BESTHOPE project, in 17 countrywide Portuguese hospitals. The data included clinical and socio-behavioral questionnaires and the viral genomic sequence obtained in the drug resistance test before starting antiretrovirals (ARVs). HIV-1 subtypes and epidemiological surveillance mutations were determined using different bioinformatics tools. Logistic regression was used to estimate the association between predictor variables and late presentation (LP).

Results

The median age was 31 years, 51% had a current income between 501-1,000 euros, 28% were migrants. 21% had never been tested for HIV before diagnosis, with 42.3% of MSM presenting LP. 60% were infected with subtype B strains. In the multivariate regression, increased age at diagnosis, higher income, lower frequency of screening, STI ever diagnosed and higher viral load were associated with LP.

Conclusion

Our study suggests that specific subgroups of the MSM population, such older MSM, with higher income and lower HIV testing frequency, are not being targeted by community and clinical screening services. Overall, targeted public health measures should be strengthened toward these subgroups, through strengthened primary care testing, expanded access to PrEP, information and promotion of HIV self-testing and more inclusive and accessible health services.

Assessment of physical activity levels and back pain among poles and Portuguese in the further year of the COVID-19 pandemic - a pilot study

BACKGROUND

The vast majority of people have experienced the problem of back pain at least once in their lives for a variety of reasons. It is well known that regular physical activity at a moderate level has a number of health benefits regardless of age or gender with positive effects on the musculoskeletal, cardiovascular, respiratory or nervous systems improving fitness levels. During the pandemic, Poland experienced one of the longest periods of school lockdown in Europe. In Portugal, this period was considerably shorter. The aim of this study was to determine the level of physical activity and back pain as well as relationship between physical activity and back pain in a group of Polish and Portuguese students in the following year the COVID-19 pandemic.

METHODS

The study was conducted via the Internet among students from Poland and Portugal (398 respondents - 229 from Poland and 169 from Portugal) in October 2022. In the pilot study, the International Physical Activity Questionnaire and The Oswestry Disability Index and Neck Disability Index questionnaires were used to assess the level of back pain.

RESULTS

There are no statistically significant differences in the level of physical activity and pain complaints of respondents from the two countries. At least half of the students do not report any pain complaints (median in some groups being 0). In the Portuguese men, there is a correlation between the level of physical activity and the Neck Disability Index score (p = 0.0304).

CONCLUSIONS

The following year, after the pandemic COVID-19 was declared, the prevalence of back pain among students in Poland and Portugal is still significant.

Stress, anxiety, and depression trajectories during the "first wave" of the COVID-19 pandemic: what drives resilient, adaptive and maladaptive responses in the Portuguese population?

Introduction

The COVID-19 outbreak and the community mitigation strategies implemented to reduce new SARS-CoV-2 infections can be regarded as powerful stressors with negative consequences on people's mental health. Although it has been shown that negative emotional symptoms subside during lockdown, it is likely the existence of inter-individual differences in stress, anxiety and depression trajectories throughout lockdown.

Objectives

We aimed to cluster participants' according to their trajectories of stress, anxiety and depression scores throughout lockdown, and identify the sociodemographic, clinical, and lifestyle factors that may distinguish the subjects included in the different clusters.

Methods

From March 23, 2020, to May 31, 2020, participants completed weekly online questionnaires on sociodemographic information (age, sex, education level, and employment status), psychological functioning (DASS-21, NEO-FFI-20), and clinical data (psychiatric disorders, psychiatric medication, physical disorders). Data regarding smoking status, alcohol consumption, physical activity, and time spent daily looking for COVID-19-related information were also collected. Stress, anxiety and depression trajectories were determined using latent class mixed models.

Results

A total of 2040 participants answered the survey at baseline and 603 participants answered all surveys. Three groups ("Resilient," "Recovered," and "Maladaptive") with distinct mental health trajectories were identified. Younger participants, women, participants with lower education level, not working, studying, diagnosed with a mental disorder, taking psychiatric medication, smokers, those who spent more time consuming COVID-19-related information and those with higher neuroticism tended to cluster in the "Maladaptive" group, placing them at higher risk of persistent negative emotional symptoms during compulsory confinement.

Conclusion

Accordingly, a tailored approach to emotional suffering for vulnerable subjects during the COVID-19 and future pandemics must be devised.

Wound, Ischemia, Foot Infection (Wifi) Classification System And Its Predictive Ability Concerning Amputation-Free Survival, Mortality And Major Limb Amputation In A Portuguese Population: A Single Center Experience

INTRODUCTION

Commonly used chronic limb-threatening ischemia (CLTI) classifications lack granularity and detail to precisely stratify patients according to risk of limb loss, expected revascularization benefit and mortality. The aim of this study is to evaluate in a Portuguese population the prognostic value of an updated CLTI classification based on Wound, Ischemia, and foot Infection (WIfI) proposed by the Society for Vascular Surgery.

MATERIALS AND METHODS

Single-center retrospective evaluation of prospectively collected data of consecutive patients with CLTI submitted to lower limb revascularization from January to December of 2017. All consecutive patients with chronic peripheral artery disease with ischemic rest pain or tissue loss were included. The exclusion criteria were patients with intermittent claudication, vascular trauma, acute ischemia, non-atherosclerotic arterial disease and isolated iliac intervention. The primary end-point was major limb amputation, mortality and amputation-free survival (AFS) at 30 days, 1 year and 2 year follow-up. Secondary end-points were minor amputation, wound healing time (WHT) and rate (WHR).

RESULTS

A total of 111 patients with CLTI were submitted to infra-inguinal revascularization: 91 endovascular and 20 open surgery. After categorizing them according to the WIfI: 20 had stage 1 (18.52%), 29 stage 2 (26.85%), 38 stage 3 (35.19%) and 21 stage 4 (19.44%). Overall mortality rate was 1.8%, 17% and 22.3% at 30 days, 1 year and 2 years follow-up. Major amputation rate was 0.9%, 2.7% and 2.7% at 30 days, 1 year and 2 years follow-up. AFS rate was 97.3%, 82.1%, and 76.8% at 30 days, 1 year, 2 years follow-up. In multi-variable analysis, higher WIfI score was the only predictive factor for mortality and AFS. WIfI 3 and 4 were also associated with increased risk of non-healing ulcer.

CONCLUSION

This study proved the prognostic value of the WIfI classification in a Portuguese population by showing an association between higher scores and increased mortality, lower AFS and non-healing ulcer.

Fear of COVID-19 among professional caregivers of the elderly in Central Alentejo, Portugal

The coronavirus disease 2019 (COVID-19) has infected many institutionalised elderly people. In Portugal, the level of pandemic fear among professional caregivers of the elderly is unknown, as are its predictive factors. This study aimed to investigate predictors of fear of COVID-19 among workers caring for institutionalised elderly people in nursing homes. This is a cross-sectional study using multiple linear regression applied to a population of 652 caregivers located in 14 municipalities in Central Alentejo, Portugal, at March 2021. The criterion variable was the fear of COVID-19. Standardised regression coefficients showed that the higher the level of education, the lower the level of fear (β = - 0.158; t = - 4.134; p < .001). Other predictors of the level of fear were gender, with women having higher levels (β = 0.123; t = t = 3.203; p < 0.001), higher scores on COVID-19-like suspicious symptoms (β = 0.123; t = 3.219; p < 0.001) and having received a flu vaccine (β = 0.086; t = 2.252; p = 0.025). The model explains 6.7% of the variation in fear of COVID-19 (R2Adj = 0.067). Health literacy can minimise the impact on the physical and mental health of these workers. In Central Alentejo, caregivers of the elderly play a fundamental role in social balance. Further studies are needed to better understand the factors that can improve their personal and professional well-being.

Burnout syndrome in Spanish, Portuguese and Latin American ophthalmologists: a cross-sectional analysis

PURPOSE

Despite the well-known consequences of burnout syndrome, there has been little research into this syndrome in the field of ophthalmology. Our objective is to determine the frequency of burnout syndrome between Spanish, Portugal and Latin-American ophthalmologists, as well as to analyse its relationship with different sociodemographic variables.

METHODS

This is an observational cross-sectional descriptive study including ophthalmologists from Spain, Portugal and 15 Latin American countries. Burnout syndrome was evaluated by the Maslach Burnout Inventory-Human Services Survey. Burnout syndrome was defined as high emotional exhaustion, high depersonalization or low personal accomplishment. In addition, we recorded sociodemographic variables and aspects related to the type of work. A conditional backwards stepwise multivariate binomial logistic regression analysis was run to assess the variables associated with burnout syndrome, expressed as an odds ratio (OR).

RESULTS

A total of 527 surveys were analysed, the majority from Spain (401; 76.1%), followed by Argentina (45; 8.5%), and Mexico (31; 5.9%). The number of ophthalmologists with burnout syndrome was 351 (66.6%). The results show the profile of a young ophthalmologist (age OR 0.985), carrying out a public activity (OR 2.118) and dedicated to general ophthalmology (OR 1.860).

CONCLUSIONS

The frequency detected in this study confirms a steady increase in rates of burnout among ophthalmologists. As the consequences of this are well known, it is vital for health centre managers to develop a strategic plan to allow the causes to be understood better and to implement steps to improve the situation in each medical centre.

Serological screening in a large-scale municipal survey in Cascais, Portugal, during the first waves of the COVID-19 pandemic: lessons for future pandemic preparedness efforts

Background

Serological surveys for SARS-CoV-2 were used early in the COVID-19 pandemic to assess epidemiological scenarios. In the municipality of Cascais (Portugal), serological testing combined with a comprehensive socio-demographic, clinical and behavioral questionnaire was offered to residents between May 2020 and beginning of 2021. In this study, we analyze the factors associated with adherence to this municipal initiative, as well as the sociodemographic profile and chronic diseases clinical correlates associated to seropositivity. We aim to contribute with relevant information for future pandemic preparedness efforts.

Methods

This was a cross-sectional study with non-probabilistic sampling. Citizens residing in Cascais Municipality went voluntarily to blood collection centers to participate in the serological survey. The proportion of participants, stratified by socio-demographic variables, was compared to the census proportions to identify the groups with lower levels of adherence to the survey. Univariate and multivariate logistic regression were used to identify socio-demographic, clinical and behavioral factors associated with seropositivity.

Results

From May 2020 to February 2021, 19,608 participants (9.2% of the residents of Cascais) were included in the study. Based on the comparison to census data, groups with lower adherence to this survey were men, the youngest and the oldest age groups, individuals with lower levels of education and unemployed/inactive. Significant predictors of a reactive (positive) serological test were younger age, being employed or a student, and living in larger households. Individuals with chronic diseases generally showed lower seroprevalence.

Conclusion

The groups with low adherence to this voluntary study, as well as the socio-economic contexts identified as more at risk of viral transmission, may be targeted in future pandemic situations. We also found that the individuals with chronic diseases, perceiving higher risk of serious illness, adopted protective behaviors that limited infection rates, revealing that health education on preventive measures was effective for these patients.

Impact of the COVID-19 pandemic on cancer screenings in Portugal

OBJECTIVES

This study aimed to evaluate the impact of the COVID-19 pandemic on cancer screening in Portugal, and its consequences on cancer morbidity and mortality.

METHODS

The pre-pandemic and pandemic periods were compared using publicly available data on performance and health outcomes indicators of the Portuguese NHS, namely the numbers and proportions of eligible individuals who underwent cancer screening (breast, cervical or colorectal). Pre-pandemic data were modelled to project hypothetical scenarios without a pandemic using an exponential smoothing algorithm, and then compared with data collected during the COVID-19 pandemic. A Markov model was developed to estimate years of life lost (YLL) due the reduction in the number of cancer screenings during the pandemic. The MS Excel and the PRISM symbolic model checker software were used.

RESULTS

There was a decrease in the number of breast (13 %), cervical (15 %) and colorectal (9-11 %) cancers screenings during the first two years of the pandemic. The model projections are 506, 41, and 148 additional deaths, losses of 11, 6, and 4 months of life per patient, and 12.8 thousand, 576, and 4 thousand YLL by the population due to breast, cervical, and colorectal cancer, respectively, over a 25-year time horizon in Portugal.

CONCLUSIONS

The disruption in cancer screening may contribute to increase cancer morbidity and mortality, with significant YLL. The long-term implications of the impaired cancer screening should be assessed, and proactive measures put in place to mitigate the increase in cancer morbidity, and mortality associated with the COVID-19 pandemic.

Obstructive sleep related breathing disorders and cardiometabolic risk factors - A Portuguese birth cohort

BACKGROUND

Pediatric obstructive sleep related breathing disorders (SRBD) are an important under-diagnosed health problem with associated cardiometabolic comorbidities, demonstrated with polysomnographic studies in selected samples. Our main goal was to assess the prevalence of SRBD in a population-based cohort and to analyze its association with cardiometabolic risk factors, in general and by sex.

METHODS

Pediatric Sleep Questionnaire (PSQ) was applied to parents of 7-years-old children evaluated in the birth cohort, Generation XXI. Sex, anthropometrics, blood pressure (BP), lipid profile, glucose, insulin, HOMA-IR, and high-sensitivity C-reactive protein were compared among children with/without SRBD, using Chi-square, Mann-Whitney tests and logistic regression models.

RESULTS

A total of 1931 children (51.2 % boys) were included; 17.5 % were overweight and 15.7 % obese. The prevalence of SRBD was 13.4 %, more frequent among boys (15.7 % vs.10.9 %, p = 0.002) and in overweight/obese children (22.0 % vs.13.6 % vs.11.3 % in obese, overweight and normal weight group, respectively, p < 0.001). Children with SRBD had higher systolic BP (107 ± 8 vs.105±9 mmHg; p = 0.001) and lower HDL-cholesterol levels (54 ± 11 vs.56 ± 11 mg/dL; p = 0.04) than children without SRBD. After adjustment for sex, age, birthweight-for-gestational age and maternal age, children with SRBD had higher BMI-z-score, systolic BP, insulin and HOMA-IR levels, and lower HDL-cholesterol, when compared to those without SRBD, but these associations were lost when adjusting to BMI z-score. Analyzing obese children with the same regression model, those with SRBD presented lower HDL-cholesterol than those without SRBD.

CONCLUSIONS

Our results identified a male predominance of SRBD in pre-pubertal children and highlighted the potential contribution of SRBD to cardiovascular risk in obese children.

Protective Association of APOC1/rs4420638 with Risk of Obesity: A case-control Study in Portuguese Children

The association of the rs4420638 polymorphism, near the APOC1 gene, was examined with the risk of obesity among Portuguese children. A sample of 446 Portuguese individuals (231 boys and 215 girls) of European descent, aged 3.2 to 13.7 years old (mean age: 7.98 years), were selected to conduct a case-control study. Body mass index (BMI), BMI Z-scores, and waist circumference were calculated. Genotyping was performed by real time PCR using a pre-designed TaqMan probe. Logistic regression and the nonparametric Mann-Whitney test were used to test the associations. The association results revealed a significant protective effect from the minor G-allele of SNP rs4420638 against obesity, with an odds ratio (OR) of 0.619 (95% CI 0.421-0.913; p = 0.0155) in the additive model, and OR of 0.587 (95% CI 0.383-0.9; p = 0.0145) in the dominant model. Moreover, comparing genotype groups (AA vs. AG + GG), significantly lower values (p < 0.05) for the anthropometric traits weight, height, BMI, BMI Z-score and waist circumference, were observed in the carriers of allele G. The present study provides further evidence for the APOE/APOC1 candidate-region association with the risk of obesity. This was the first study to describe the protective association of the rs4420638 minor G-allele against obesity in childhood exclusively.

In vitro activity of cefiderocol and other newly approved antimicrobials against multi-drug resistant Gram-negative pathogens recovered in intensive care units in Spain and Portugal

OBJECTIVE

The antimicrobial resistance is a significant public health threat, particularly for healthcare-associated infections caused by carbapenem-resistant Gram-negative pathogens which are increasingly reported worldwide. The aim of this study was to provide data on the in vitro antimicrobial activity of cefiderocol and that of commercially available comparator antibiotics against a defined collection of recent clinical multi-drug resistant (MDR) microorganisms, including carbapenem resistant Gram-negative bacteria collected from different regions in Spain and Portugal.

METHODS

A total of 477 clinical isolates of Enterobacterales, Pseudomonas aeruginosa, Acinetobacter baumannii and Stenotrophomonas maltophilia were prospectively (n=265) and retrospectively (n=212) included (2016-2019). Susceptibility testing was performed using standard broad microdilution and results were interpreted using CLSI-2021 and EUCAST-2021 criteria.

RESULTS

Overall, cefiderocol showed a good activity against Enterobacterales isolates, being 99.5% susceptible by CLSI and 94.5% by EUCAST criteria. It also demonstrated excellent activity against P. aeruginosa and S. maltophilia isolates, all being susceptible to this compound considering CLSI breakpoints. Regarding A. baumannii (n=64), only one isolate was resistant to cefiderocol.

CONCLUSIONS

Our results are in agreement with other studies performed outside Spain and Portugal highlighting its excellent activity against MDR gram-negative bacteria. Cefiderocol is a therapeutic alternative to those available for the treatment of infections caused by these MDR bacteria.

A study of knowledge, attitudes, and practices on ticks and tick-borne diseases of cattle among breeders of two bovine Portuguese autochthonous breeds

Beef cattle production in Portugal is an important sector of national agricultural production, with half of the herd being in the Alentejo region. Despite this, animal health is essential for its productivity, which may be compromised by ticks and tick-borne diseases. So far, no study has been conducted in Portugal to assess knowledge, attitudes, and practices (KAP) on ticks and tick-borne diseases in cattle, which the authors are aware of. This type of questionnaire is a very useful tool in the development and application of effective and sustainable prevention and control measures. Therefore, a KAP questionnaire was applied to 44 cattle breeders of autochthonous Portuguese breeds, namely 14 breeders of the Alentejana breed and 30 of the Mertolenga breed, between January 1 and May 9, 2023. Based on the analysis criteria of these surveys, 64% of the Alentejana breeders and 63% of the Mertolenga breeders have an average level of knowledge about ticks and tick-borne diseases, and 21% of the Alentejana breeders and 33% of the Mertolenga breeders have a high level of knowledge. Although only 21.4% of the Alentejana and 36.7% of the Mertolenga breeders consider tick infestation as a major animal health problem, 71.4% of the Alentejana and 63.3% of breeders of the Mertolenga state that one of the main reasons for veterinary consultations on their farm is deworming of animals, and 92.9% of breeders of the Alentejana and 96.7% of breeders of the Mertolenga refer the use of dewormers as a strategy to control tick infestation. The results of this study contribute to highlighting the importance of correcting some identified knowledge gaps and improving knowledge, especially on the life cycle of this parasite, its local distribution and seasonality, resistance to acaricides, and alternative control strategies.

Epidemiology, Management, and Survival Outcomes of Germ Cell Cancer in Southern Portugal: A Population-Based Study (2008-2012)

INTRODUCTION

Building on previous suboptimal survival results, we aimed to perform a study of the epidemiological status, management, and outcomes of germ cell tumors (GCT) in the Portuguese population.

MATERIALS AND METHODS

Retrospective populational study of GCT cases diagnosed between 2008 and 2012 in southern Portugal. Joinpoint regression was used to compute average annual percentage change (AAPC) in incidence rate. ESMO/EAU guidelines served as references to evaluate compliance. Association between compliance with guidelines and hospital GCT case load was performed by generalized estimating equation. Survival was calculated by Kaplan-Meier and prognostic factors by Cox models.

RESULTS

The study included 401 GCT male cases. The AAPC was 5.4% (IC 95% 3.3-7.4, P < .001) from 1999 (an earlier cohort published) to 2012. The median time to diagnosis was 63 days (Q25 = 33 days; Q75 = 114 days; IQR = 81 days). For stage II/III the median time to start chemotherapy was 34 days (Q25 = 22 days; Q75 = 56 days; IQR = 22 days). In 86% cases there was noncompliance with guidelines for the orchiectomy report, 6% for staging, 38% for tumor markers evaluation, 20% for treatment and 25% for chemotherapy dose intensity. The 5-year overall survival was 93.8% (95% CI, 91.3%-96.4%). Hospitals that managed ≤ 3 GCT cases/ year had higher odds for noncompliance with guidelines of blood markers, treatment and dose intensity. None of GCT healthcare access and management factors studied were associated with prognosis.

CONCLUSIONS

The burden of GCT is rising in Portugal. Although survival has improved, efforts must be made to nationally enhance training and expertise in GCT and support region adapted models of centralization of care.

Quality of death in patients in advanced chronic liver disease and cancer patients managed by gastroenterologists in Portugal: are we doing it right?

INTRODUCTION

The incidence of chronic progressive diseases is rising and investment on quality of death and dying is of utmost importance to minimize physical and emotional suffering. There is still a gap in palliative care (PC) between patients with cancer and those with advanced chronic liver disease (ACLD). Our objectives were to characterize clinical attitudes and therapeutic interventions and to evaluate the differences in end-of-life care between inpatients with cancer and ACLD under gastroenterology care.

METHODS

Retrospective cohort study, including patients with cancer or ACLD who died in a Gastroenterology department between 2012 and 2021. Demographic characteristics, clinical and endoscopic procedures and symptom control were compared between the groups.

RESULTS

From 150 patients, 118 (78.7%) died with cancer and 32 (21.3%) died from ACLD without concomitant hepatocellular carcinoma. ACLD patients were more frequently male ( P  = 0.001) and younger ( P  = 0.001) than patients with cancer. Median time of hospitalization in the last month of life was 16 days for both groups. Discussion of prognosis with the patient was more frequent for cancer patients (35.6% versus 3.2%, P  < 0.001). Referral to PC occurred in 18.8% and 61% of the patients with ACLD and cancer respectively ( P  < 0.001). Endoscopic procedures were performed in half of the patients and were more likely to be unsuccessful in those with cancer.

CONCLUSION

Clinical decisions were different between groups in terms of PC access and discussion of prognostic with the patient. It is urgent to define and implement metrics of quality of death and dying to prevent potentially inappropriate treatment.

Intimate Partner Homicide: Comparison Between Homicide and Homicide-Suicide in Portugal

Intimate partner homicide (IPH) is a tragic event. Studies involving the comparison between IPH and intimate partner homicide-suicide (IPH-S) are scarce, with few studies in Portugal about this issue. The current study aims to compare IPH and IPH-S perpetrators, the victim-perpetrator relationships dynamics, and homicide circumstances. The data was collected through the analysis of 78 judicial processes of IPH that occurred in Portugal, between 2010 and 2015. Of the cases, 51 were IPH, 20 were IPH-S cases, and seven were attempted suicide cases, being perpetrated in 84.6% (n = 66) for male perpetrators. Suicide after intimate homicide were all committed by men. All judicial processes analyzed refer to heterosexual relationships. Bivariate and multivariate analyses were performed to compare the groups concerning perpetrator and victim sociodemographic characteristics, victim-perpetrator dyadic dynamics, and crime circumstances. The results show mostly common trends between the two groups with some differentiating factors when compared individually (e.g., perpetrator professional status, criminal records). Regression logistic analysis showed no differences between IPH and IPH-S.

Understanding spatiotemporal patterns of COVID-19 incidence in Portugal: A functional data analysis from August 2020 to March 2022

During the SARS-CoV-2 pandemic, governments and public health authorities collected massive amounts of data on daily confirmed positive cases and incidence rates. These data sets provide relevant information to develop a scientific understanding of the pandemic's spatiotemporal dynamics. At the same time, there is a lack of comprehensive approaches to describe and classify patterns underlying the dynamics of COVID-19 incidence across regions over time. This seriously constrains the potential benefits for public health authorities to understand spatiotemporal patterns of disease incidence that would allow for better risk communication strategies and improved assessment of mitigation policies efficacy. Within this context, we propose an exploratory statistical tool that combines functional data analysis with unsupervised learning algorithms to extract meaningful information about the main spatiotemporal patterns underlying COVID-19 incidence on mainland Portugal. We focus on the timeframe spanning from August 2020 to March 2022, considering data at the municipality level. First, we describe the temporal evolution of confirmed daily COVID-19 cases by municipality as a function of time, and outline the main temporal patterns of variability using a functional principal component analysis. Then, municipalities are classified according to their spatiotemporal similarities through hierarchical clustering adapted to spatially correlated functional data. Our findings reveal disparities in disease dynamics between northern and coastal municipalities versus those in the southern and hinterland. We also distinguish effects occurring during the 2020-2021 period from those in the 2021-2022 autumn-winter seasons. The results provide proof-of-concept that the proposed approach can be used to detect the main spatiotemporal patterns of disease incidence. The novel approach expands and enhances existing exploratory tools for spatiotemporal analysis of public health data.

Exploring refugees' health care access in times of COVID-19: a quantitative study in the Lisbon region, Portugal

Background

To address the health needs of refugees, health services must be culturally competent and facilitate this population's access to health care, especially in a context prone to the amplification of social inequities, such as the COVID-19 pandemic. However, few quantitative studies exist in the European Union, and to the extent of our knowledge, there are no published quantitative studies exploring refugees' access to health care during the pandemic in Portugal. The objective of this study is to describe the demographic and socioeconomic characteristics of refugees living in Lisbon and to explore their healthcare access patterns during the COVID-19 pandemic.

Methods

We conducted a cross-sectional, descriptive, and quantitative study from May to November 2022. Using Levesque' s theory on health care access, we designed and applied a 38-item questionnaire through face-to-face interviews with refugees living in Lisbon for at least 12 months, and used descriptive statistics to characterize sociodemographic and healthcare access profiles during the pandemic.

Results

The mean age of the 36 recruited refugees was 35 years (SD = 10.24), the majority were male (56%), married (72%), had at least a secondary education (69%), were unemployed (77.8%), and had a median length of stay in Portugal of 17 months (IQR = 45). All were registered in a primary care center, and 94% used healthcare services during the pandemic. The majority never tested positive for the coronavirus (58%) and one out of the positive was admitted to hospital due to severe COVID-19. A total of 97% received COVID-19 vaccination, of which 69% had an incomplete schedule. A quarter of the participants did not have access to information about COVID-19 in a language they understood, and although 97% needed health care during the pandemic, more than half (63%) did not seek it because of structural and cultural barriers. Half of the respondents had difficulty getting medical advice by phone or email, and 39.4% could not afford a medical examination or treatment. Only 18.2% sought counseling services. A total of 58.8% of the participants felt like healthcare professionals did not always show respect towards their culture, and 64.7% reported that healthcare professionals did not always discuss treatment options with them.

Conclusion

This study's findings highlight the need to endow inclusive communication, cultural competency, and patient involvement in health care, alongside improving the socioeconomic condition of refugees. Identified population characteristics and barriers to health care access by refugees in this study may inform future research on the health care needs of refugees in Portugal and ultimately assist in the devising of strategies to reduce inequalities in health care access.

Increasing and sustaining blood-borne virus screening in Spain and Portugal throughout the COVID-19 pandemic: a multi-center quality improvement intervention

Background

Around 57,000 people in Spain and Portugal currently living with HIV or chronic hepatitis C are unaware of their infection. The COVID-19 pandemic severely disrupted screening efforts for these infections. We designed an intervention to increase and sustain opportunistic blood-borne virus (BBV) screening and linkage to care (SLTC) by implementing the TEST model.

Methods

The Plan Do Study Act (PDSA) method of quality improvement (QI) was implemented in 8 healthcare organizations (HCOs), including four hospitals, two clusters of community health centers, and two community-based organizations (CBOs). Baseline assessment included a review of BBV SLTC practices, testing volume, and results 12 months before the intervention. Changes in BBV testing rates over time were measured before, during, and after the COVID-19 lockdowns in 2020. A mixed ANOVA model was used to analyze the possible effect on testing volumes among HCOs over the three study periods.

Intervention

BBV testing was integrated into normal clinical flow in all HCOs using existing clinical infrastructure and staff. Electronic health record (EHR) systems were modified whenever possible to streamline screening processes, implement systemic institutional policy changes, and promote QI.

Results

Two years after the launch of the intervention in screening practices, testing volumes increased by 116%, with formal healthcare settings recording larger increases than CBOs. The start of the COVID-19 lockdowns was accompanied by a global 60% decrease in testing in all HCOs. Screening emergency department patients or using EHR systems to automate screening showed the highest resilience and lowest reduction in testing. HCOs recovered 77% of their testing volume once the lockdowns were lifted, with CBOs making the fullest recovery. Globally, enhanced screening techniques enabled HCOs to diagnose a total of 1,860 individuals over the research period.

Conclusions

Implementation of the TEST model enabled HCOs to increase and sustain BBV screening, even during COVID-19 lockdowns. Although improvement in screening was noted in all HCOs, additional work is needed to develop strong patient linkage to care models in challenging times, such as global pandemics.