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.

Effectiveness of Neuropsychological Rehabilitation in the Recovery of Executive Deficits in Patients with Alcohol Use Disorder: A Systematic Review Protocol.

INTRODUCTION: Changes in executive functions associated with alcohol consumption are frequently found in alcohol use disorder. Neuropsychological rehabilitation can play an essential role as an effective treatment in the recovery from these deficits, leading to the maintenance of abstinence. However, there are still some uncertainties regarding its impact on the recovery of deficits in executive functions. Our purpose is to present a protocol for a systematic review aiming to assess which neuropsychological rehabilitation programs are effective in the recovery of executive deficits in patients with alcohol use disorder. METHODS: We will search the following databases: PubMed, Cochrane Library (CENTRAL), Web of Science, and Scopus, as well as the list of references of the identified studies. Screening, data extraction, and synthesis, as well as evaluation of the risk of bias, will be carried out by two reviewers independently, using ROBINS-I and RoB 2. Disagreements will be resolved using a third additional reviewer. Primary outcomes will correspond to changes in executive functions, following a neuropsychological rehabilitation program in patients with alcohol use disorder. The evidence will be synthesized using a narrative description of neuropsychological rehabilitation programs and the indicators of their effectiveness will be identified. The neuropsychological rehabilitation programs for executive functions will be assessed considering their different components and their impact on the recovery of these functions. The review described in this protocol will allow the development of guidelines for the design of more effective rehabilitation programs for clinical populations with alcohol use disorder.

COVID-19 in Portugal: a retrospective review of paediatric cases, hospital and PICU admissions in the first pandemic year.

BACKGROUND: COVID-19 is considered by WHO a pandemic with public health emergency repercussions. Children often develop a mild disease with good prognosis and the recognition of children at risk is essential to successfully manage paediatric COVID-19. Quality epidemiological surveillance data are required to characterise and assess the pandemic. METHODS: Data on all reported paediatric COVID-19 cases, in Portugal, were retrospectively assessed from a fully anonymised dataset provided by the Directorate General for Health (DGS). Paediatric hospital admission results were obtained from the DGS vaccine recommendations and paediatric intensive care unit (PICU) admission results from the EPICENTRE.PT group. Reported cases and PICU admissions from March 2020 to February 2021 and hospital admissions between March and December 2020 were analysed. RESULTS: 92 051 COVID-19 cases were studied, 50.5% males, average age of 10.1 years, corresponding to 5.4% of children in Portugal. The most common symptoms were cough and fever, whereas gastrointestinal symptoms were infrequent. The most common comorbidity was asthma. A high rate of missing surveillance data was noticed, on presentation of disease and comorbidity variables, which warrants a cautious interpretation of results. Hospital admission was required in 0.93% of cases and PICU on 3.48 per 10 000 cases. PICU admission for Multisystem Inflammatory Syndrome in Children (MIS-C) was more frequent in children with no comorbidities and males, severe COVID-19 was rarer and occurred mainly in females and infants. Case fatality rate and mortality rates were low, 1.8 per 100 000 cases and 1.2 per 1 000 000 cases, respectively. CONCLUSIONS: The overall reported case incidence was 5.4 per 100 children and adolescents and <1% of cases required hospital admission. MIS-C was more frequent in patients with no comorbidities and males. Mortality and case fatality rates were low. Geographic adapted strategies, and information systems to facilitate surveillance are required to improve surveillance data quality.

Improving morbidity information in Portugal: Evidence from data linkage of COVID-19 cases surveillance and mortality systems.

BACKGROUND: COVID-19 rapidly spread around the world, putting health systems under unprecedented pressure and continuous adaptations. Well-established health information systems (HIS) are crucial in providing data to allow evidence-based policymaking and public health interventions in the pandemic response. This study aimed to compare morbidity information between two databases for COVID-19 management in Portugal and identify potential complementarities. METHODS: This is an observational study using records from both COVID-19 cases surveillance (National Epidemiological Surveillance System; SINAVE) and related deaths (National e-Death Certificates Information System; SICO) systems, which were matched on sex, age, municipality of residence and date of death. After the linkage, morbidity reported in SINAVE and identified in SICO, through the application of Charlson and Elixhauser comorbidity indexes algorithms, were compared to evaluate agreement level. RESULTS: Overall, 2285 matched cases were analyzed, including 53.9% males with a median age of 84 years. According to the method of data reporting assessment, the presence of any morbidity ranged between 26.3% and 62.5%. The reporting of ten morbidities could be compared between the information reported in SINAVE and SICO databases. The proportion of simultaneous reporting in both databases ranged between 5.7% for diabetes and 0.0% for human immunodeficiency virus infection or coagulopathy. Minimal or no agreement was found when assessing the similarity of the morbidity reporting in both databases, with neoplasms showing the highest level of agreement (0.352, 95% IC: 0.277-0.428; p < 0.001). CONCLUSION: Different information about reported morbidity could be found in two HIS used to monitor COVID-19 cases and related deaths, as data are independently collected. These results show that the interoperability of SICO and SINAVE databases would potentially improve available HIS and improve available information to decision-making and address COVID-19 pandemic management.

Multimorbidity Profile of COVID-19 Deaths in Portugal during 2020.

BACKGROUND: COVID-19 is caused by SARS-CoV-2 infection and has reached pandemic proportions. Since then, several clinical characteristics have been associated with poor outcomes. This study aimed to describe the morbidity profile of COVID-19 deaths in Portugal. METHODS: A study was performed including deaths certificated in Portugal with "COVID-19" (ICD-10: U07.1 or U07.2) coded as the underlying cause of death from the National e-Death Certificates Information System between 16 March and 31 December 2020. Comorbidities were derived from ICD-10 codes using the Charlson and Elixhauser indexes. The resident Portuguese population estimates for 2020 were used. RESULTS: The study included 6701 deaths (death rate: 65.1 deaths/100,000 inhabitants), predominantly males (72.1). The male-to-female mortality ratio was 1.1. The male-to-female mortality rate ratio was 1.2; however, within age groups, it varied 5.0-11.4-fold. COVID-19 deaths in Portugal during 2020 occurred mainly in individuals aged 80 years or older, predominantly in public healthcare institutions. Uncomplicated hypertension, uncomplicated diabetes mellitus, congestive heart failure, renal failure, cardiac arrhythmias, dementia, and cerebrovascular disease were observed among COVID-19 deceased patients, with prevalences higher than 10%. A high prevalence of zero morbidities was registered using both the Elixhauser and Charlson comorbidities lists (above 40.2%). Nevertheless, high multimorbidity was also identified at the time of COVID-19 death (about 36.5%). Higher multimorbidity levels were observed in men, increasing with age up to 80 years old. Zero-morbidity prevalence and high multimorbidity prevalences varied throughout the year 2020, seemingly more elevated in the mortality waves' peaks, suggesting variation according to the degree of disease incidence at a given period. CONCLUSIONS: This study provides detailed sociodemographic and clinical information on all certificated deaths from COVID-19 in Portugal during 2020, showing complex and extreme levels of morbidity (zero-morbidity vs. high multimorbidity) dynamics during the first year of the pandemic in Portugal.

Reply to Comment on Nogueira, P.J., et al. "The Role of Health Preconditions on COVID-19 Deaths in Portugal: Evidence from Surveillance Data of the First 20293 Infection Cases". J. Clin. Med. 2020, 9, 2368.

We thank Costa-Santos C [...].

Emotional dysregulation features and problem gambling in university students: a pilot study.

Undergraduate students typically cope with various changes in their lives and experience many stressors associated with academic issues. Distress can make them more vulnerable to particular behavioral patterns in order to cope with negative affect. The association of problematic gambling with particular emotion regulation characteristics-some of which are developmentally dependent-becomes a recent focus of research with clinical and preventive implications. We carried out a pilot study enrolling voluntarily young adults of a public university in the Lisbon area, and 117 Portuguese-speaking individuals were interviewed. Participants, mainly female (M = 20.6; SD = 3.9), were investigated taking into consideration their gambling practices, characteristics of impulsivity and alexithymia, along with the symptoms of depression and anxiety. Portuguese versions of the South Oaks Gambling Scale (SOGS) and Short-Version of Impulsive Behavior Scale (S-UPPSP) were prepared (i.e., translation and back-translation of the original versions were performed). The prevalence of gambling problems in this sample is modest, although they were associated with negative urgency and sensation-seeking, as well as with depression symptoms. Multiple correspondence analysis, a particular multivariate model associating gambling problems with socio-demographic and psychological variables, allowed identifying different profiles of individuals. Trace and state emotional dysregulation features are selectively associated with distinctive gambling patterns, according to some previous findings in studies with other groups. Results may address new findings in terms of morbidity, risk factors and the design of future preventive strategies among such individuals.

The Role of Health Preconditions on COVID-19 Deaths in Portugal: Evidence from Surveillance Data of the First 20293 Infection Cases.

BACKGROUND: It is essential to study the effect of potential co-factors on the risk of death in patients infected by COVID-19. The identification of risk factors is important to allow more efficient public health and health services strategic interventions with a significant impact on deaths by COVID-19. This study aimed to identify factors associated with COVID-19 deaths in Portugal. METHODS: A national dataset with the first 20,293 patients infected with COVID-19 between 1 January and 21 April 2020 was analyzed. The primary outcome measure was mortality by COVID-19, measured (registered and confirmed) by Medical Doctors serving as health delegates on the daily death registry. A logistic regression model using a generalized linear model was used for estimating Odds Ratio (OR) with 95% confidence intervals (95% CI) for each potential risk indicator. RESULTS: A total of 502 infected patients died of COVID-19. The risk factors for increased odds of death by COVID-19 were: sex (male: OR = 1.47, ref = female), age ((56-60) years, OR = 6.01; (61-65) years, OR = 10.5; (66-70) years, OR = 20.4; (71-75) years, OR = 34; (76-80) years, OR = 50.9; (81-85) years, OR = 70.7; (86-90) years, OR = 83.2; (91-95) years, OR = 91.8; (96-104) years, OR = 140.2, ref = (0-55)), Cardiac disease (OR = 2.86), Kidney disorder (OR = 2.95), and Neuromuscular disorder (OR = 1.58), while condition (None (absence of precondition); OR = 0.49) was associated with a reduced chance of dying after adjusting for other variables of interest. CONCLUSIONS: Besides age and sex, preconditions justify the risk difference in mortality by COVID-19.

Decrease of perforin positive CD3+γδ-T cells in patients with obstructive sleep disordered breathing.

INTRODUCTION: Sleep related breathing disorders (SRBD) cause sleep fragmentation, intermittent hypoxia or a combination of both leading to homeostasis perturbations, including in the immune system. We investigated whether SRBD patients with or without intermittent hypoxia show substantial differences in perforin and granzyme-B positive peripheral blood lymphocytes. METHODS: A total of 87 subjects were included and distributed as follows: 24 controls (C), 19 patients with respiratory effort related arousals due to increased upper airway resistance (UAR) without hypoxic events, 24 obese patients with obstructive sleep apnea (OSA) (oOSA), and 20 without obesity (noOSA). After polysomnographic recording, we analyzed in fasting blood samples routine hematologic and biochemical parameters and the percentage of lymphocytes containing the proteins perforin and granzyme-B (GrB). Kruskal-Wallis tests and a posteriori multiple comparisons were applied for statistical analysis of results. RESULTS: Perforin-positive γδ-cells revealed significant differences between groups (p = 0.017), especially between the Control group and the oOSA (p-value = 0.04); the remaining SRBD groups also showed differences from the control (C vs UAR: p = 0.08; C vs noOSA = 0.09), but they did not raise to statistical significance. There were no differences among the SRBD groups. Granzyme-B cells were decreased in SRBD patients, but the differences were not statistically significant. No additional statistical significant result was found in the other investigated lymphocyte subsets. CONCLUSIONS: Obstructive sleep-disordered breathing is associated with a decrease in perforin-positive CD3+γδ-T cells. Although this finding was detected in lean patients without intermittent hypoxia, the reduction was only statistically significant in obese patients with severe OSA. Because CD3+γδ-T cells play an important role in the control of tumor cells, our findings are directly relevant for the study of the association of OSA and cancer.

A comparison of in-hospital acute myocardial infarction management between Portugal and the United States: 2000-2010.

OBJECTIVE: To compare healthcare in acute myocardial infarction (AMI) treatment between contrasting health systems using comparable representative data from Europe and USA. DESIGN: Repeated cross-sectional retrospective cohort study. SETTING: Acute care hospitals in Portugal and USA during 2000-2010. PARTICIPANTS: Adults discharged with AMI. INTERVENTIONS: Coronary revascularizations procedures (percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) surgery). MAIN OUTCOME MEASURES: In-hospital mortality and length of stay. RESULTS: We identified 1 566 601 AMI hospitalizations. Relative to the USA, more hospitalizations in Portugal presented with elevated ST-segment, and fewer had documented comorbidities. Age-sex-adjusted AMI hospitalization rates decreased in USA but increased in Portugal. Crude procedure rates were generally lower in Portugal (PCI: 44% vs. 47%; CABG: 2% vs. 9%, 2010) but only CABG rates differed significantly after standardization. PCI use increased annually in both countries but CABG decreased only in the USA (USA: 0.95 [0.94, 0.95], Portugal: 1.04 [1.02, 1.07], odds ratios). Both countries observed annual decreases in risk-adjusted mortality (USA: 0.97 [0.965, 0.969]; Portugal: 0.99 [0.979, 0.991], hazard ratios). While between-hospital variability in procedure use was larger in USA, the risk of dying in a high relative to a low mortality hospital (hospitals in percentiles 95 and 5) was 2.65 in Portugal when in USA was only 1.03. CONCLUSIONS: Although in-hospital mortality due to an AMI improved in both countries, patient management in USA seems more effective and alarming disparities in quality of care across hospitals are more likely to exist in Portugal.

The Atlantic divide in coronary heart disease: Epidemiology and patient care in the US and Portugal.

INTRODUCTION AND OBJECTIVES: We aimed to compare access to new health technologies to treat coronary heart disease (CHD) in the health systems of Portugal and the US, characterizing the needs of the populations and the resources available. METHODS: We reviewed data for 2000 and 2010 on epidemiologic profiles of CHD and on health care available to patients. Thirty health technologies (16 medical devices and 14 drugs) introduced during the period 1980-2015 were identified by interventional cardiologists. Approval and marketing dates were compared between countries. RESULTS: Relative to the US, Portugal has lower risk profiles and less than half the hospitalizations per capita, but fewer centers per capita provide catheterization and cardiothoracic surgery services. More than 70% of drugs were available sooner in the US, whereas 12 out of 16 medical devices were approved earlier in Portugal. Nevertheless, at least five of these devices were adopted first or diffused faster in the US. Mortality due to CHD and myocardial infarction (MI) was lower in Portugal (CHD: 72.8 vs. 168 and MI: 48.7 vs. 54.1 in Portugal and the US, respectively; age- and gender-adjusted deaths per 100000 population, 2010); but only CHD deaths exhibited a statistically significant difference between the countries. CONCLUSIONS: Differences in regulatory mechanisms and price regulations have a significant impact on the types of health technologies available in the two countries. However, other factors may influence their adoption and diffusion, and this appears to have a greater impact on mortality, due to acute conditions.

Environment in pediatric wards: light, sound, and temperature.

UNLABELLED: The mutual relationship between sleep and disease is well known, becoming more relevant whenever the disease leads to hospitalization. We intend to describe patterns of environmental factors of some pediatric wards, and to verify if these are in line with those recommended. As a secondary aim, we characterize sleep quality during hospitalization. METHODS: Five pediatric wards of a tertiary-level hospital were included. Light, sound, and temperature were measured and assessed through descriptive statistics. The following recommended values were considered: maximum light 100 Lux, maximum sound 45 dB, and optimal temperature 20-24 °C. A questionnaire was prepared to assess children's sleep, and it was completed by a caregiver. RESULTS: Light values were within the desirable limits for 86% of evaluated time. In all wards, the intensity of sound was much higher than desirable, being above 45 dB during 85% of evaluated time. The temperature was above 24 °C during 78% of total time. Based on 34 answered questionnaires (out of 50 distributed), almost half of the respondents believe that sleep quality and restlessness are worse at the hospital. Most children slept for a longer time at home. Eighteen children awoke more times at the hospital, and those awakenings were mostly attributed to noise. CONCLUSIONS: The sound and temperature were higher than recommended. The different values between these wards may be due to different levels of care, but this shows that there are no standard rules on this matter. A worse quality and shorter duration of sleep at hospital were reported. Comprehensive studies are necessary to evaluate the impact of environmental factors on disease recovery.

Risk score to predict the outcome of patients with cerebral vein and dural sinus thrombosis.

BACKGROUND: Around 15% of patients die or become dependent after cerebral vein and dural sinus thrombosis (CVT). METHOD: We used the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT) sample (624 patients, with a median follow-up time of 478 days) to develop a Cox proportional hazards regression model to predict outcome, dichotomised by a modified Rankin Scale score >2. From the model hazard ratios, a risk score was derived and a cut-off point selected. The model and the score were tested in 2 validation samples: (1) the prospective Cerebral Venous Thrombosis Portuguese Collaborative Study Group (VENOPORT) sample with 91 patients; (2) a sample of 169 consecutive CVT patients admitted to 5 ISCVT centres after the end of the ISCVT recruitment period. Sensitivity, specificity, c statistics and overall efficiency to predict outcome at 6 months were calculated. RESULTS: The model (hazard ratios: malignancy 4.53; coma 4.19; thrombosis of the deep venous system 3.03; mental status disturbance 2.18; male gender 1.60; intracranial haemorrhage 1.42) had overall efficiencies of 85.1, 84.4 and 90.0%, in the derivation sample and validation samples 1 and 2, respectively. Using the risk score (range from 0 to 9) with a cut-off of >or=3 points, overall efficiency was 85.4, 84.4 and 90.1% in the derivation sample and validation samples 1 and 2, respectively. Sensitivity and specificity in the combined samples were 96.1 and 13.6%, respectively. CONCLUSIONS: The CVT risk score has a good estimated overall rate of correct classifications in both validation samples, but its specificity is low. It can be used to avoid unnecessary or dangerous interventions in low-risk patients, and may help to identify high-risk CVT patients.