Improving quality and patient safety in surgical care through standardisation and harmonisation of perioperative care (SAFEST project): A research protocol for a mixed methods study.

INTRODUCTION: Adverse events in health care affect 8% to 12% of patients admitted to hospitals in the European Union (EU), with surgical adverse events being the most common types reported. AIM: SAFEST project aims to enhance perioperative care quality and patient safety by establishing and implementing widely supported evidence-based perioperative patient safety practices to reduce surgical adverse events. METHODS: We will conduct a mixed-methods hybrid type III implementation study supporting the development and adoption of evidence-based practices through a Quality Improvement Learning Collaborative (QILC) in co-creation with stakeholders. The project will be conducted in 10 hospitals and related healthcare facilities of 5 European countries. We will assess the level of adherence to the standardised practices, as well as surgical complications incidence, patient-reported outcomes, contextual factors influencing the implementation of the patient safety practices, and sustainability. The project will consist of six components: 1) Development of patient safety standardised practices in perioperative care; 2) Guided self-evaluation of the standardised practices; 3) Identification of priorities and actions plans; 4) Implementation of a QILC strategy; 5) Evaluation of the strategy effectiveness; 6) Patient empowerment for patient safety. Sustainability of the project will be ensured by systematic assessment of sustainability factors and business plans. Towards the end of the project, a call for participation will be launched to allow other hospitals to conduct the self-evaluation of the standardized practices. DISCUSSION: The SAFEST project will promote patient safety standardized practices in the continuum of care for adult patients undergoing surgery. This project will result in a broad implementation of evidence-based practices for perioperative care, spanning from the care provided before hospital admission to post-operative recovery at home or outpatient facilities. Different implementation challenges will be faced in the application of the evidence-based practices, which will be mitigated by developing context-specific implementation strategies. Results will be disseminated in peer-reviewed publications and will be available in an online platform.

Investigating the role of symptom valorisation in tuberculosis patient delay in urban areas in Portugal.

BACKGROUND: Diagnosis delay contributes to increased tuberculosis (TB) transmission and morbimortality. TB incidence has been decreasing in Portugal, but median patient delay (PD) has risen. Symptom valorisation may determine PD by influencing help-seeking behaviour. We aimed to analyse the association between symptom valorisation and PD, while characterising individuals who disregarded their symptoms. METHODS: A cross-sectional study was conducted among TB patients in Lisbon and Oporto in 2019 - 2021. Subjects who delayed seeking care because they did not value their symptoms or thought these would go away on their own were considered to have disregarded their symptoms. PD was categorised using a 21-day cut-off, and a 30-day cut-off for sensitivity analysis. We estimated the effect of symptom valorisation on PD through a directed acyclic graph. Then, a multivariable regression analysis characterised patients that disregarded their symptoms, adjusting for relevant variables. We fitted Poisson regression models to estimate crude and adjusted prevalence ratios (PR). RESULTS: The study included 75 patients. Median PD was 25 days (IQR 11.5-63.5), and 56.0% of participants had PD exceeding 21 days. Symptom disregard was reported by 38.7% of patients. Patients who did not value their symptoms had higher prevalence of PD exceeding 21 days compared to those who valued their symptoms [PR 1.59 (95% CI 1.05-2.42)]. The sensitivity analysis showed consistent point estimates but wider confidence intervals [PR 1.39 (95% CI 0.77-2.55)]. Being a smoker was a risk factor for symptom disregard [PR 2.35 (95% CI 1.14-4.82)], while living in Oporto [PR 0.35 (95% CI 0.16-0.75)] and having higher household incomes [PR 0.39 (95% CI 0.17-0.94)] were protective factors. CONCLUSIONS: These findings emphasise the importance of symptom valorisation in timely TB diagnosis. Patients who did not value their symptoms had longer PD, indicating a need for interventions to improve symptom recognition. Our findings also corroborate the importance of the socioeconomic determinants of health, highlighting tobacco as a risk factor both for TB and for PD.

Non-transferrin-bound iron determination in blood serum using microsequential injection solid phase spectrometry- proof of concept.

Non-transferrin-bound iron (NTBI) is a group of circulating toxic iron forms, which occur in iron overload or health conditions with dysregulation of iron metabolism. NTBI is responsible for increased oxidative stress and tissue iron loading. Despite its relevance as a biochemical marker in several diseases, a standardized assay is still lacking. Several methods were developed to quantify NTBI, but results show high inter-method and even inter-laboratory variability. Thus, the development of a consistent NTBI assay is a major goal in the management of iron overload and related clinical conditions. In this work, a micro sequential injection lab-on-valve (µSI-LOV) method in a solid phase spectrophotometry (SPS) mode was developed for the quantification of NTBI, using a bidentate 3,4-hydroxypyridinone (3,4-HPO) ligand anchored to sepharose beads as a chromogenic reagent. To attain SPS, the functionalized beads were packed into a column in the flow cell, and the analyte, NTBI retained as iron (III), formed a colored complex at the beads while eliminating the sample matrix. The dynamic concentration range was 1.62-7.16 µmol L-1 of iron (III), with a limit of detection of 0.49 µmol L-1 and a limit of quantification of 1.62 µmol L-1. The proposed µSI-LOV-SPS method is a contribution to the development of an automatic method for the quantification of the NTBI in serum samples.

Delayed diagnosis of active pulmonary tuberculosis - potential risk factors for patient and healthcare delays in Portugal.

BACKGROUND: Early diagnosis and treatment of pulmonary tuberculosis (PTB) is essential for an effective control of the tuberculosis (TB) epidemic. Delayed diagnosis and treatment of TB increases the chance of complications and mortality for the patients, and enhances TB transmission in the population. Therefore, the aim of this study was to characterize patient, healthcare and total delay in diagnosing PTB and assess the effect of clinical and sociodemographic factors on the time until first contact with healthcare or reaching a PTB diagnosis. METHODS: Retrospective cohort study that included active PTB patients notified in the National Tuberculosis Surveillance System (SVIG-TB), between 2008 and 2017. Descriptive statistics, Kaplan-Meier estimates, logrank test and Cox proportional hazards model were used to characterize patient, healthcare and total delay and estimate the effect of clinical and sociodemographic variables on these delays. Significance level was set at 0.05. RESULTS: Median patient, healthcare and total delays was 37 days (Interquartile range (IQR): 19-71), 8 days (IQR: 1-32) and 62 days (IQR: 38-102), respectively. The median patient delay showed a constant increase, from 33 days in 2008 to 44 days in 2017. The median total delay presented a similar trend, increasing from 59 days in 2008 to 70 days in 2017. Healthcare delay remained constant during the study period. More than half of the PTB cases (82.9%) had a delay > 1 month between symptom onset and diagnosis. In the final Cox model, alcohol abuse, unemployment and being from a high TB incidence country were factors significantly associated with longer patient delay, while being female, having more than 45 years, oncologic and respiratory diseases were associated with longer healthcare delay. Being female, having more than 45 years and being from a high TB incidence country were associated with longer total delay. CONCLUSIONS: Patient delay and total delay have increased in recent years. Older patients, patients with alcohol problems, other comorbidities, unemployed or from countries with high TB incidence would benefit from the development of specific public health strategies that could help reduce the delay in TB diagnosis observed in our study. This study emphasizes the need to promote awareness of TB in the general population and among the healthcare community, especially at ambulatory care level, in order to reduce the gap between beginning of symptoms and TB diagnosis.

Foliar application of 3-hydroxy-4-pyridinone Fe-chelate [Fe(mpp)3 ] induces responses at the root level amending iron deficiency chlorosis in soybean.

Iron (Fe) deficiency chlorosis (IDC) affects the growth of several crops, especially when growing in alkaline soils. The application of synthetic Fe-chelates is one of the most commonly used strategies in IDC amendment, despite their associated negative environmental impacts. In a previous work, the Fe-chelate tris(3-hydroxy-1-(H)-2-methyl-4-pyridinonate) iron(III) [Fe(mpp)3 ] has shown great potential for alleviating IDC in soybean (Glycine max) in the early stages of plant development under hydroponic conditions. Herein, its efficacy was verified under soil conditions in soybean grown from seed to full maturity. Chlorophyll levels, plant growth, root and shoot mineral accumulation (K, Mg, Ca, Na, P, Mn, Zn, Ni, and Co) and FERRITIN expression were accessed at V5 phenological stage. Compared to a commonly used Fe chelate, FeEDDHA, supplementation with [Fe(mpp)3 ] led to a 29% higher relative chlorophyll content, 32% higher root biomass, 36% higher trifoliate Fe concentration, and a twofold increase in leaf FERRITIN gene expression. [Fe(mpp)3 ] supplementation also resulted in increased accumulation of P, K, Zn, and Co. At full maturity, the remaining plants were harvested and [Fe(mpp)3 ] application led to a 32% seed yield increase when compared to FeEDDHA. This is the first report on the use of [Fe(mpp)3 ] under alkaline soil conditions for IDC correction, and we show that its foliar application has a longer-lasting effect than FeEDDHA, induces efficient root responses, and promotes the uptake of other nutrients.

Inequalities in adherence to cervical cancer screening in Portugal.

Cervical cancer is the second cancer with the highest incidence and mortality in women aged 15-44 living in Europe. Screening is an effective strategy to reduce these rates, although in Portugal, as in other European countries, adherence to screening still presents significant disparities. Thus, this study aimed to assess the prevalence and factors associated with cervical cancer screening (CCS) nonadherence in Portugal. Cross-sectional data from 5929 women aged 25-64 included in the 2014 Portuguese National Health Survey (2014 NHS) were analyzed. The prevalence of CCS nonadherence was estimated. The association between multiple factors and CCS nonadherence was analyzed, using logistic regression, adjusting for age and educational level. The weighted prevalence of nonadherence was 13.2% [95% confidence interval (CI): 12.0-14.0]. Additionally, 10.5% of women had performed the last cervical cytology 3 years ago or more. Higher odds of nonadherence to screening were found for younger women, with low levels of education and income, unemployed, single, born outside Portugal, who never had a medical appointment or had over 12 months ago, who were never pregnant and who had never had a mammography. No association was found with other variables studied, including having public/private health insurance, BMI or smoking status. This study showed that inequalities in CCS adherence in Portugal persist. These findings reinforce the need for developing strategies to reduce inequalities in CCS adherence.

Daily tobacco consumption and associated socioeconomic factors in the Portuguese population: National Health Interview Survey data 1987-2014.

INTRODUCTION AND OBJECTIVES: Smoking patterns inform tobacco control policies. This study aimed to assess trends in smoking prevalence and associated socioeconomic factors in Portugal between 1987 and 2014. METHODS: We used data from National Health Interview Surveys (NHIS) conducted in 1987, 1995/96, 1998/99, 2005/06 and 2014/15. For each NHIS, we estimated gender-specific and age-standardized smoking prevalences, stratified by education, occupation, marital status and region. We constructed NHIS- and gender-specific logistic regression models, adjusting for the above-mentioned variables. We describe changes in smoking prevalence and inequalities in associated socioeconomic factors between 1987 and 2014. RESULTS: In men, smoking prevalence (32.2% and 26.7%, respectively) and inequalities for all factors except for education decreased between 1987 and 2014. For women, inequalities decreased for region, age and occupation, and these changes occurred through increasing smoking prevalence in all groups. For marital status and education, inequalities were stable but smoking prevalence increased for all groups within these variables. In both sexes, the unemployed (adjusted odds ratio [aOR] 2014: men 2.33, women 2.76) and divorced (aOR 2014: men 2.12, women 3.18) consistently had the highest prevalences and aORs of smoking. For the first three NHIS higher aORs of smoking were observed among less-educated men and highly-educated women, while for the last two the higher odds were for the less-educated in both sexes. CONCLUSIONS: Smoking trends among men showed decreasing prevalences and diminishing inequalities. For women, inequalities were stable but there was an overall increase in prevalence. The unemployed and divorced had the highest smoking prevalences in both sexes. Smoking prevention and cessation policies in Portugal should take into consideration inequalities, particularly among men, and increasing consumption among women.

Effect of tris(3-hydroxy-4-pyridinonate) iron(III) complexes on iron uptake and storage in soybean (Glycine max L.).

Iron deficiency chlorosis (IDC) is a serious environmental problem affecting the growth of several crops in the world. The application of synthetic Fe(III) chelates is still one of the most common measures to correct IDC and the search for more effective Fe chelates remains an important issue. Herein, we propose a tris(3-hydroxy-4-pyridinonate) iron(III) complex, Fe(mpp)3, as an IDC corrector. Different morphological, biochemical and molecular parameters were assessed as a first step towards understanding its mode of action, compared with that of the commercial fertilizer FeEDDHA. Plants treated with the pyridinone iron(III) complexes were significantly greener and had increased biomass. The total Fe content was measured using ICP-OES and plants treated with pyridinone complexes accumulated about 50% more Fe than those treated with the commercial chelate. In particular, plants supplied with compound Fe(mpp)3 were able to translocate iron from the roots to the shoots and did not elicit the expression of the Fe-stress related genes FRO2 and IRT1. These results suggest that 3,4-HPO iron(III) chelates could be a potential new class of plant fertilizing agents.

Effects of the topical application of an ethyl acetate fraction from Vernonia scorpioides on excisional wounds infected with Staphylococcus aureus in rats

We investigated the healing process on excisional wounds infected with Staphylococcus aureus in rats, treated with 50 µL of ethyl acetate III from Vernonia scorpioides (Lam.) Pers., Asteraceae, rifamycin diethylamide B 25 mg, or saline. The lesions were measured daily and after seven days were surgically removed and histologically processed. The results indicate a favorable action of the EAIII, demonstrated by the increased wound contraction, smaller area of necrotic tissue, good development of granulation tissue, extensive extracellular matrix deposition and epithelial regeneration. This sub-fraction was phytochemically investigated in parallel studies, revealing the presence of sesquiterpene lactones (glaucolides and hirsutinolides) such as diacethylpiptocarphol and related hirsutinolides, flavonoids and cinnamic acid derivatives and also a new polyacetylene, which have been previously published. Results support the effectiveness of V. scorpioides antimicrobial activity in infected wound healing in rats.

Fluorescent 3-hydroxy-4-pyridinone hexadentate iron chelators: intracellular distribution and the relevance to antimycobacterial properties.

We report the synthesis and characterization of a fluorescent iron chelator (4), shown to be effective in inhibiting the growth of Mycobacterium avium in macrophages, together with the synthesis and characterization of two unsuccessful analogues selected to facilitate identification of the molecular properties responsible for the antimicrobial activity. Partition of the chelators in liposomes was investigated and the compounds were assessed with respect to uptake by macrophages, responsiveness to iron overload/iron deprivation and intracellular distribution by flow cytometry and confocal microscopy. The synthesis of the hexadentate chelators is based on a tetrahedral structure to which three bidentate 3-hydroxy-4-pyridinone chelating units are linked via amide bonds. The structure is synthetically versatile, allowing further addition of functional groups such as fluorophores. Here, we analyse the non-functionalized hexadentate unit (3) and the corresponding rhodamine B (4) and fluorescein (5) labelled chelators. The iron(III) stability constant was determined for 3 and the values log beta = 34.4 and pFe(3+) = 29.8 indicate an affinity for iron of the same order of magnitude as that of mycobacteria siderophores. Fluorescence properties in the presence of liposomes show that 4 strongly interacts with the lipid phase, whereas 5 does not. Such different behaviour may explain their distinct intracellular localization as revealed by confocal microscopy. The flow cytometry and confocal microscopy studies indicate that 4 is readily engulfed by macrophages and targeted to cytosol and vesicles of the endolysosomal continuum, whereas 5 is differentially distributed and only partially colocalizes with 4 after prolonged incubation. Differential distribution of the compounds is likely to account for their different efficacy against mycobacteria.

New lipophilic 3-hydroxy-4-pyridinonate iron(III) complexes: synthesis and EXAFS structural characterisation.

New tris-iron(III) chelates of 3-hydroxy-4-pyridinone ligands derived from maltol (3-hydroxy-2-methyl-4-pyrone) or ethylmaltol (2-ethyl-3-hydroxy-4-pyrone), including a variety of N-aryl (phenyl, 4'-tolyl, 4'-(n-butyl)phenyl, 4'-(n-hexyl)phenyl) and N-benzyl (4'-methylbenzyl, 4'-fluorobenzyl and 4'-(trifluoromethyl)benzylamine) substituents on the nitrogen atom of the pyridinone ring, have been prepared. Characterization by C,H,N elemental analysis and thermogravimetric measurements indicates that most of the complexes are obtained as hydrates of general formula ML3.xH2O. Structural characterization of these difficult to crystallize lipophilic complexes has been achieved by EXAFS spectroscopy. Solutions of iron(III) complexes of maltol, ethylmaltol, 1,2-dimethyl-3-hydroxy-4-pyridinone and 1-phenyl-2-methyl-3-hydroxy-4-pyridinone in methanol-water mixtures were also examined by EXAFS. Distances from the central atom to ligand atoms, within 6 A of the metal, have been determined in the solid and solution samples and the results show that the structure observed in the powder is maintained in solution. The local structure around the metal centre, bond distances and bond angles, does not change significantly with variable lipophilicity, thus indicating that ligands may be tailored according to specific needs without altering their chelation properties. EXAFS data analysis for this set of tris-iron(III) compounds illustrates the important contribution of both intra-ligand and inter-ligand multiple scattering pathways through the metal centre to a peak observed in the FT spectrum at twice the metal ligand distance (approximately 4 A). The present results demonstrate that EXAFS features at twice the metal-ligand distance are valuable in the assignment of molecular geometry and that location of hydration water molecules, by EXAFS analysis, is limited by the geometry of the complexes, in particular for those in which ligands containing phenyl rings are present.