Role of MTHFR, IRF6, PAX7 and TP63 SNPs in susceptibility to non-syndromic orofacial cleft, a candidate gene study in a Portuguese population.

BACKGROUND: Non-syndromic orofacial cleft (NSOC) is a complex phenotype, involving multiple genetic and environmental factors. Association studies exploring the genetic susceptibility to this prevalent oral malformation show variability of results in different populations. Using a candidate gene approach, we aimed to verify the role of four single-nucleotide polymorphisms (SNPs) in the susceptibility to NSOC in Portuguese patients. METHODS: A total of 254 non-consanguineous individuals of Portuguese were recruited, including 120 patients with NSOC and 134 controls. About 92% of these patients had non-syndromic cleft lip with or without cleft palate (NSCL/P) and 8% had only non-syndromic cleft palate (NSCP). SNPs in the MTHFR (rs1801133), IRF6 (rs642961), PAX7 (rs742071) and TP63 (rs9332461) genes were studied, using a real-time approach with TaqMan probes. Allelic, genotypic, dominant, recessive and over-dominant models were explored using a chi-squared test. Adjusted p-value was calculated for multiple comparisons using the Benjamini-Hochberg false discovery rate (FDR). RESULTS: All SNPs were in Hardy-Weinberg equilibrium. For MTHFR, IRF6, and PAX7 SNPs, no statistically significant difference was highlighted for any of the evaluated models. For TP63 SNP, data fitted an over-dominant model, with a protective effect for heterozygotes (OR 1.897; CI 95% [1.144-3.147]; p < .016, when comparing controls vs. cases), but significance was lost when applying adjusted p-value for multiple comparisons (4 × 5 tests). CONCLUSION: In this Portuguese population, there was no evidence of an association between the evaluated SNPs and NSOC. For TP63 SNP, the possibility of a protective effect of heterozygotes should be further investigated.

Salivary counts of Streptococcus mutans and Lactobacillus in patients with and without cleft lip and/or palate undergoing orthodontic treatment: A meta-analysis.

OBJECTIVE: To conduct a systematic review with meta-analysis to assess if cleft lip and palate (CLP) patients undergoing orthodontic treatment have a higher colonization of Streptococcus mutans and Lactobacillus than patients without this condition. METHODS: Five electronic databases were searched systematically. The inclusion criteria were as follows: randomized clinical trials, non-randomized, or quasi-randomized controlled trials, prospective and retrospective studies published until March, 2021; articles that evaluated S. mutans and Lactobacillus profile in patients with and without cleft lip and palate undergoing orthodontic treatment. The random-effect model was used to perform the analysis of all the data collected. Statistic heterogeneity was evaluated with I2 test. RESULTS: In this systematic review, 2 cohort studies were included. The data analysis from 160 patients revealed that patients without cleft lip and palate had 4.5 times more predisposition to oral colonization with S. mutans than CLP patients. No statistical significant difference was found between these patients for colonization with Lactobacillus. CONCLUSIONS: Despite the limitations in the included studies, this systematic review suggested that CLP patients have a lower predisposition to oral colonization with S. mutans when compared to healthy patients.

A retrospective and tridimensional study of the maxillary sinus in patients with cleft lip and palate.

INTRODUCTION: Structural or anatomic differences may arise during the development of the maxillary sinus and the process of fusion of the palate in the presence of cleft lip and palate. The present study aimed to compare the maxillary sinus volume of patients with unilateral cleft lip and palate and a control group (noncleft patients). METHODS: In this retrospective case-control study, 160 cone-beam computed tomography images of 80 unilateral cleft lip and palate patients (41 males and 39 females; mean age, 12.7 ± 6.03 years) and 80 control patients (43 males and 37 females; mean age, 13.1 ± 6.27 years) were evaluated through the ITK-SNAP software (Cognitica, Philadelphia, Pa) to access the maxillary sinus volume. Analysis of covariance and regression analysis were used to assess the differences between the groups while considering the relationship between maxillary sinus volume, age, and sex. RESULTS: No statistically significant differences were found in the maxillary sinus volume analyzing a unilateral cleft lip and palate and a control group (P = 0.677). Considering the cleft group, there is a tendency for the maxillary sinus volume of the cleft side to be smaller than its contralateral (P < 0.001). Statistically significant differences were found in the maxillary sinus volume, regarding the age and sex of cleft and noncleft patients (P < 0.001 for age; P = 0.001 for sex). CONCLUSIONS: According to these results, the presence of unilateral cleft lip and palate did not affect the maxillary sinus volume, comparing cleft and noncleft patients. A biphasic growth pattern of the maxillary sinus and a presence of sexual dimorphism were found.

Chronic hepatitis C treatment in HIV co-infection in Portugal: Results from a cohort OF 2133 patients presented by GEPCOI (Portuguese Coinfection Study Group).

Direct-acting antiviral drugs (DAAs) have recently changed the paradigm of hepatitis C therapy, significantly improving treatment response rates, patient life expectancy and quality of life. In Portugal, sofosbuvir (SOF) and SOF/ledipasvir (SOF/LDV) were fully reimbursed by the National Health System since early 2015 and generalized use of interferon-free DAA based regimens became current practice. During 2016, the remaining DAAs were sequentially added and covered by the same health access policy. The Portuguese Study Group of Hepatitis and HIV Co-infection (GEPCOI) collected data from 15 clinical centres in Portugal, pertaining to the HCV treatment experience with DAA regimens. A cohort of 2133 patients was analysed, representing one of the largest DAA treated HCV/HIV co-infected individuals. The global sustained virologic response (SVR) achieved was 95% in this real-life cohort setting. Linear regression analysis showed significant differences in treatment response rates when using SOF plus ribavirin (RBV) combination in genotype 2 or 3 infected individuals (P < .002) and in those with liver cirrhosis (P < .002). These findings corroborate that early treatment is mandatory in HIV/HCV co-infected patients, as response rates may be negatively influenced by higher fibrosis stages and suboptimal DAA regimens. The current national Portuguese health policy should continue to promote wider treatment access and individualized therapy strategies, aiming at the elimination of HCV infection in this high-risk co-infected population.

Short-term pharyngeal airway space changes after mandibular advancement surgery in Class II patients-a two-dimensional retrospective study.

INTRODUCTION: Planning successful treatment for the correction of anatomic abnormalities of the upper airways, by surgical advancement of the mandible, depends on extensive knowledge of the pharyngeal airway space (PAS). However, there is limited scientific evidence about changes in PAS after mandibular advancement surgery. AIM: To evaluate the immediate changes in superior posterior airway space (SPAS) in Class II patients, after mandibular advancement surgery. MATERIALS AND METHODS: A cephalometric evaluation of 37 patients with skeletal Class II deformity was performed at 2 distinct time intervals: Pre-operative (T0) and immediate post-operative (T1), using Dolphin Image & Management Solutions, version 11.9, according to the method of Arnett/Gunson FAB Surgery. The differences due to the surgical intervention were assessed with Student's t test, and a Principal Component Analysis was used to evaluate the relationship between mandibular advancement and SPAS variables. Anticlockwise and clockwise rotation groups were also evaluated with Mann-Whitney tests. The statistical analysis was conducted in SPSS and R assuming a 0.05 level of significance. RESULTS: As an effect of mandibular advancement, an anteroposterior statistically significant increase in SPAS (P < 0.001) was perceived at all points measured. CONCLUSION: Our findings indicate that mandibular advancement surgery is a viable option to achieve widening of the SPAS in patients with Class II skeletal morphology.

Efficacy of Rapid Maxillary Expansion in the Treatment of Obstructive Sleep Apnea Syndrome: A Systematic Review With Meta-analysis.

OBJECTIVE: The objective of this study was to assess the efficacy of rapid maxillary expansion (RME) in the treatment of OSAS in children and adolescents. METHODS: Five electronic databases were searched systematically: PubMed, Web of Science, LILACS, Embase and Cochrane Library. SELECTION CRITERIA: Randomized controlled trials, nonrandomized controlled trials, cohort studies, and systematic reviews published in English, Spanish, or Portuguese between January 2000 and December 2016, performed on children and adolescents younger than 18 years with OSAS who underwent RME, and assessing RME efficacy as measured by the Apnea-Hypopnea Index (AHI) normalization were included. Qualitative assessment of the selected studies was performed using Critical Appraisal Skills Programme checklists. Statistical evaluation included 2 meta-analyses and was based on a random-effects model and Cochran's Q test and I2 statistics to assess heterogeneity across the publications. Electronic searches identified 84 publications. Five publications were considered valid and included in this systematic review. RESULTS: Results from the meta-analysis show an overall reduction in AHI after RME therapy. CONCLUSIONS: Increasingly the evidence indicates that RME devices reduce AHI in children with OSAS, making RME therapy an appropriate alternative treatment option for these patients.

Therapies for White Spot Lesions-A Systematic Review.

INTRODUCTION: The first sign of dental caries is denoted by white spot lesions (WSLs) which can be defined as a demineralization of the enamel surface and subsurface, although these lesions can be reversed and do not form cavities. The aim of this systematic review was investigate which remineralization agents are effective for the treatment of WSLs. MATERIALS AND METHODS: For this systematic review a literature search was conducted on Pubmed, Cochrane Library and ScienceDirect. RESULTS: The initial search resulted in 273 references. After elimination of duplicate articles, 236 references remained. After reading titles and abstracts, all non-relevant results were excluded, resulting in 45 potentially relevant studies. After reading the full text, 13 references were included. CONCLUSION: More studies are required for scientific evidence in order to reach a conclusion of the most suitable therapeutic method for the treatment of surface and subsurface demineralization of the enamel.

Serotoninergic antidepressants positively affect platelet ADAM10 expression in patients with Alzheimer's disease.

BACKGROUND: Studies have demonstrated a decreased platelet ADAM10 expression in patients with Alzheimer's Disease (AD), classifying this protein as a blood-based AD biomarker. About 50% of the patients with AD are diagnosed with depression, which is commonly treated with tricyclic and tetracyclic antidepressants, monoaminoxidade (MAO) inhibitors and, more preferably, with selective serotonin reuptake inhibitors (SSRIs). Considering that a large proportion of patients with AD takes antidepressant medications during the course of the disease we investigated the influence of this medication on the expression of platelet ADAM10, which is considered the main α-secretase preventing beta-amyloid (ßA) formation. METHODS: Blood was collected for protein extraction from platelets. ADAM10 was analyzed by using western blotting and reactive bands were measured using ß-actin as endogenous control. RESULTS: Platelet ADAM10 protein expression in patients with AD was positively influenced by serotoninergic medication. CONCLUSION: More studies on the positive effects of serotonergic antidepressants on ADAM10 platelet expression should be performed in order to understand its biological mechanisms and to verify whether these effects are reflected in the central nervous system. This work represents an important advance for the study of AD biomarkers, as well as for more effective pharmacological treatment of patients with AD and associated depression.

A computed tomographic, mixed dentition, space analysis comparison.

INTRODUCTION: A considered space analysis aims to predict the combined mesiodistal widths of unerupted permanent canine and premolars. A miscalculation can lead to the application of inadequate and irreversible treatments. OBJECTIVE: To assess the level of agreement between predictions generated by three methods (Moyers' predictive tables at the 50th and 75th percentiles and Tanaka-Johnston's equations) on the sum of unerupted teeth compared with measurements derived from cone beam computed tomography, considered in the present study as a 'gold standard'. MATERIALS AND METHODS: The study sample was comprised of children (N = 26) aged 8-13 who visited the Department of Dentistry. Moyers' predictive tables and the Tanaka-Johnston equation were applied to ascertain the space requirements. Cone beam computed tomography was performed on each patient and the volumetric data analysed. A concordance correlation coefficient between each method's predictions was applied. RESULTS: The three methods tended to overestimate the cone beam computed tomography readings and were not able to entirely capture the variability of the sum of the unerupted teeth. Moyers' 50th percentile estimate revealed a more balanced distribution between over- and underestimation. CONCLUSION: The present study suggested that Moyers' 50th percentile is the predictive method with the lowest absolute error and is preferred for clinical use.

ADAM10 gene expression in the blood cells of Alzheimer's disease patients and mild cognitive impairment subjects.

ADAM10 is a potential biomarker for Alzheimer's disease (AD). ADAM10 protein levels are reduced in platelets of AD patients. The aim was to verify the total blood and platelet ADAM10 gene expression in AD patients and to compare with mild cognitive impairment (MCI) and healthy subjects. No significant differences in ADAM10 gene expression were observed. Therefore, the decrease of ADAM10 protein in platelets of AD patients is not caused by a reduction in ADAM10 mRNA. Further studies must be performed to investigate other pathways in the down regulation of ADAM10 protein.

Alterations in Gas Exchange and Oxidative Metabolism in Rice Leaves Infected by Pyricularia oryzae are Attenuated by Silicon.

Rice blast, caused by Pyricularia oryzae, is the most important disease in rice worldwide. This study investigated the effects of silicon (Si) on the photosynthetic gas exchange parameters (net CO2 assimilation rate [A], stomatal conductance to water vapor [gs], internal-to-ambient CO2 concentration ratio [Ci/Ca], and transpiration rate [E]); chlorophyll fluorescence a (Chla) parameters (maximum photochemical efficiency of photosystem II [Fv/Fm], photochemical [qP] and nonphotochemical [NPQ] quenching coefficients, and electron transport rate [ETR]); concentrations of pigments, malondialdehyde (MDA), and hydrogen peroxide (H2O2); and activities of superoxide dismutase (SOD), catalase (CAT), ascorbate peroxidase (APX), glutathione reductase (GR), and lypoxigenase (LOX) in rice leaves. Rice plants were grown in a nutrient solution containing 0 or 2 mM Si (-Si or +Si, respectively) with and without P. oryzae inoculation. Blast severity decreased with higher foliar Si concentration. The values of A, gs and E were generally higher for the +Si plants in comparison with the -Si plants upon P. oryzae infection. The Fv/Fm, qp, NPQ, and ETR were greater for the +Si plants relative to the -Si plants at 108 and 132 h after inoculation (hai). The values for qp and ETR were significantly higher for the -Si plants in comparison with the +Si plants at 36 hai, and the NPQ was significantly higher for the -Si plants in comparison with the +Si plants at 0 and 36 hai. The concentrations of Chla, Chlb, Chla+b, and carotenoids were significantly greater in the +Si plants relative to the -Si plants. For the -Si plants, the MDA and H2O2 concentrations were significantly higher than those in the +Si plants. The LOX activity was significantly higher in the +Si plants than in the -Si plants. The SOD and GR activities were significantly higher for the -Si plants than in the +Si plants. The CAT and APX activities were significantly higher in the +Si plants than in the -Si plants. The supply of Si contributed to a decrease in blast severity, improved the gas exchange performance, and caused less dysfunction at the photochemical level.

Platelet a disintegrin and metallopeptidase 10 expression correlates with clock drawing test scores in Alzheimer's disease.

OBJECTIVE: Earlier studies have demonstrated that a disintegrin and metallopeptidase 10 (ADAM10) levels are reduced in Alzheimer's disease (AD) patients compared with healthy subjects. The objective of this study was to evaluate whether platelet ADAM10 levels correlates with the clock drawing test (CDT) scores, which is a simple and a reliable measure of visuospatial ability and executive function in AD patients. METHODS: Thirty elderly patients with probable AD and 25 healthy patients forming the control group, matched by age, gender, and educational level, were evaluated. Platelet proteins were analyzed by sodium dodecyl sulfate polyacrylamide gel electrophoresis, and ADAM10 was identified by western blotting. The Spearman's correlation coefficient between ADAM10 and CDT was obtained for each group. The areas under the curves were used to compare the receiver operating characteristic curves. RESULTS: The CDT scores and platelet ADAM10 expression were significantly different between patients with AD and controls and also along the disease's progression. In AD patients, there was a positive correlation between ADAM10 expression and CDT scores. Among non-AD subjects, no correlation was found. The combination of ADAM10 and CDT was significantly better to confirm the AD diagnosis than the AUCs of ADAM10 and CDT separately. CONCLUSIONS: The association of blood-based biomarkers, such as ADAM10, and cognitive tests may be helpful for a more reliable AD diagnosis.

[Cultural adaptation of the scale Pain Assessment in Advanced Dementia - PAINAD to Brazil]. / Adaptação cultural para o Brasil da escala Pain Assessment in Advanced Dementia - PAINAD*

OBJECTIVE: To translate and culturally adapt to Brazil the scale Pain Assessment in Advanced Dementia(PAINAD). METHOD: The cultural adaptation process followed the methodology of a theorical reference, in five steps: translation to Brazilian Portuguese, consensual version of translations, back-translation to the original language, revision by a committee of specialists in the field and a equivalency pre-test. The instrument was assessed and applied by 27 health professionals in the last step. RESULTS: The Escala de Avaliação de Dor em Demência Avançada was culturally adapted to Brazil and presented semantic equivalency to the original, besides clarity, applicability and easy comprehension of the instrument items. CONCLUSION: This process secured the psychometric properties as the reliability and content validity of the referred scale.

Missed Opportunities for HIV Diagnosis and Their Clinical Repercussions in the Portuguese Population-A Cohort Study.

Late human immunodeficiency virus (HIV) diagnosis has been associated with missed opportunities for earlier diagnosis. We conducted a retrospective, longitudinal, single-centre cohort study evaluating these missed opportunities and their clinical repercussions in adults with a new HIV diagnosis or who were drug-naïve, who attended our Infectious Diseases Department between 2018 and 2023. We assessed missed opportunities in the two years prior to diagnosis or after the last negative HIV test. We compared clinical and laboratorial data from individuals with and without missed opportunities. The primary outcome considered was AIDS-defining conditions at diagnosis. Among the 436 included individuals, 27.1% experienced at least one missed opportunity. Those with missed opportunities were more likely to be female (p = 0.007), older at their first consultation (p < 0.001), born in Africa (p < 0.001) and in countries with a high HIV prevalence (p < 0.001), and have heterosexual transmission (p < 0.001). The adjusted analysis showed that missed opportunities were significantly associated with AIDS-defining conditions at diagnosis (OR 3.23, CI 95% [1.62-6.46], p < 0.001). These findings highlight the impact of missed opportunities on HIV severity, underscoring the need for more targeted interventions to reduce them.

Comparison of in-office and at-home bleaching techniques: An umbrella review of efficacy and post-operative sensitivity.

Objectives: The objective of this umbrella review is to evaluate the efficacy and adverse effects of different teeth whitening techniques in-office (IO) and at-home (AH), regarding chromatic changes and teeth sensitivity. Materials and methods: The search was carried out from several databases. The included studies were all systematic reviews with or without meta-analysis of RCT or quasi-RCT. The participants were patients that underwent external dental bleaching in permanent vital teeth. The interventions were in-office (IO) bleaching techniques and at-home (AT) bleaching techniques with different bleaching agents and concentrations. Results: The search resulted in a total of 257 articles, and 28 SR were included in the qualitative analysis and nine in the quantitative analysis. There is no difference between in-office and at-home techniques in terms of color change (p = 0.95) and post-treatment sensitivity (p = 0.85). There is similarity risk and intensity of teeth sensitivity between AH and IO bleaching. IO bleaching with light-activated systems with low concentrations of bleaching agent showed similar results to IO bleaching techniques with high concentrated bleaching gels. With the application of the criteria of the AMSTAR 2 tool, the reviews were considered critically low to high. Conclusions: There are no significant differences in terms of color change between the different bleaching techniques compared. Teeth sensitivity is always present regardless of the technique used. The use of light activation systems did not increase the intensity and risk of post-operative sensitivity.

Patient-Reported Outcomes of Maxillomandibular Surgery for Obstructive Sleep Apnea Treatment: A Scoping Review.

(1) Background: The present scoping review aims to scrutinize all existing patient-reported outcomes and assess the perspectives of obstructive sleep apnea patients after maxillomandibular surgery. (2) Methods: The review was carried out according to the extensions for scoping reviews using the PRISMA-ScR guidelines. Several databases were used to carry out the initial search. This study included randomized controlled trials, cohort studies, cross-sectional and case-control studies. The included studies considered patients with obstructive sleep apnea who were submitted to orthognathic surgery as the main subjects, and the patient's perception of quality of life, satisfaction, treatment experience and side effects were assessed. (3) Results: From 1407 examined articles, a total of 16 were included. Most of the included studies used more than one questionnaire to assess quality of life, except for five articles. The most commonly referred instruments were the Epworth Sleepiness Scale, SF-36, the Functional Outcomes of Sleep and Ottawa Sleep Apnea. The most commonly assessed outcomes were sleep quality, daytime function, facial aesthetics, dental function and emotional health. (4) Conclusions: The number of variables that can be evaluated from a patient's perspective are endless, as are the tools available to assess them. Not all of these tools, which are generally questionnaires, assess all the various outcomes, and some do not compare the pre- and post-surgical situations. Most of them are generic and lack specificity for obstructive sleep apnea.

Surface Treatment of Dental Mini-Sized Implants and Screws: A Systematic Review with Meta-Analysis.

Miniscrews are devices that allow for absolute skeletal anchorage. However, their use has a higher failure rate (10-30%) than dental implants (10%). To overcome these flaws, chemical and/or mechanical treatment of the surface of miniscrews has been suggested. There is no consensus in the current literature about which of these methods is the gold standard; thus, our objective was to carry out a systematic review and meta-analysis of the literature on surface treatments of miniscrews. The review protocol was registered (PROSPERO CRD42023408011) and is in accordance with the PRISMA guidelines. A bibliographic search was carried out on PubMed via MEDLINE, Cochrane Library, Embase and Web of Science. The initial search of the databases yielded 1684 results, with 98 studies included in the review, with one article originating from the search in the bibliographic references of the included studies. The results of this systematic review show that the protocols of miniscrew surface treatments, such as acid-etching; sandblasting, large-grit and acid-etching; photofunctionalization with ultraviolet light; and photobiomodulation, can increase stability and the success of orthodontic treatment. The meta-analysis revealed that the treatment with the highest removal torque is SLA, followed by acid-etching. On the other hand, techniques such as oxidative anodization, anodization with pre-calcification and heat treatment, as well as deposition of chemical compounds, require further investigation to confirm their effectiveness.

ADAM10 as a biomarker for Alzheimer's disease: a study with Brazilian elderly.

Alzheimer's disease (AD) is the most common cause of dementia in people above age 65. Platelet studies with ADAM10 have shown that its expression is reduced in AD patients. The aim of this research was to compare the platelet levels of ADAM10 protein in two Brazilian elderly groups, considering the stages of the disease. The SDS-PAGE technique followed by Western blotting was used. Data were analyzed using comparison, correlation and association statistical methods. The results showed reduced platelet ADAM10 levels in AD elderly compared to non-AD subjects. The disease progression intensified this reduction. ADAM10 was the only statistically significant variable (p = 0.01) to increase the AD occurrence probability. The cutoff value of 0.4212 in the receiver operating characteristic curve captured sensitivity and specificity of 70 and 80.77%, respectively. Together with other clinical criteria, ADAM10 seems to be a relevant biomarker tool for early and accurate AD diagnosis.

The COVID-19 Impact on Oral Healthcare Demand and Performance: The Experience of a Clinical and Academic Centre in Portugal (EU).

INTRODUCTION: The SARS-CoV-2 pandemic has reshaped the global landscape as we know it and had a tremendous effect on healthcare systems around the world. However, its impact on oral healthcare is still to be fully assessed. The aim of this study was to understand if and how COVID-19 affected the demand and performance of oral healthcare, taking the Clinical and Academic Centre of Coimbra as an example, more specifically, the Department of Stomatology of the Coimbra Hospital and University Centre and the Dentistry Department of the Faculty of Medicine of the University of Coimbra. MATERIAL AND METHODS: An observational study was designed for collecting the data of a series of key oral healthcare indicators: number of appointments; referrals from primary healthcare; missed appointments; number of surgeries performed in the operating room; number of biopsies; number of patients admitted through the emergency department and epidemiologic parameters over two 18-month periods between September 2018 and August 2021: pre-COVID-19 and during the COVID-19 pandemic, with the latter divided in four stages. A statistical analysis which included descriptive and inferential procedures was then performed, with an established significance level of 5% and the application of parametric tests, t-Student test for a sample and for independent samples and One-Way ANOVA for the variance analysis. RESULTS: There was a general decline in all indicators comparing the pre-COVID-19 with the COVID-19 period, with a reduction of 50.61% in the number of appointments, 44.06% in referrals, 24.41% in surgeries, 26.30% in biopsies and 32.33% in patients seen in the Emergency Room. The number of missed appointments also increased by 181.82%. All variations revealed statistically significant differences (p < 0.05). The individual COVID-19 stage analysis, when compared with the pre-COVID-19 reference, and variance analysis of these different stages also showed statistically significant differences (p < 0.05 and p < 0.001), except for the number of biopsies during the third and fourth stages. CONCLUSION: The results of this study suggest that the SARS-CoV-2 pandemic has had a considerable impact on oral healthcare demand and performance. However, results also show a remarkable adjustment and improvement in the provided care, with a positive evolution throughout the COVID-19 period.