Attitudes of the Portuguese population towards advance directives: an online survey.

BACKGROUND: Advance directives (ADs) were implemented in Portugal in 2012. Although more than a decade has passed since Law 25/2012 came into force, Portuguese people have very low levels of adherence. In this context, this study aimed to identify and analyse the attitudes of people aged 18 or older living in Portugal towards ADs and to determine the relationships between sociodemographic variables (gender/marital status/religion/level of education/residence/whether they were a health professional/whether they had already drawn up a living will) and people's attitudes towards ADs. METHODS: An online cross-sectional analytical study was conducted using a convenience sample. For this purpose, a request (email) that publicized the link to a -form-which included sociodemographic data and the General Public Attitudes Toward Advance Care Directives (GPATACD) scale-was sent to 28 higher education institutions and 30 senior universities, covering all of mainland Portugal and the islands (Azores and Madeira). The data were collected between January and February 2023. RESULTS: A total of 950 adults from completed the online form. The lower scores (mean 1 and 2) obtained in most responses by applying the GPATACD scale show that the sample of the Portuguese population has a very positive attitude towards ADs. The data showed that women, agnostics/atheists, health professionals and those who had already made a living will had more positive attitudes (p < 0.001) towards ADs. There were no statistically significant differences in the attitudes of the Portuguese population sample towards ADs in relation to marital status, education level, and residence. CONCLUSION: The results obtained enable us to confirm that this sample of the Portuguese population has a positive attitude towards ADs. We verify that there are certain fringes of this sample with certain sociodemographic characteristics (women, agnostics/atheists, health professionals and those who had already made a living will) that have a more positive attitude towards ADs. This data could facilitate the implementation and adjustment of relevant measures, particularly in the field of health education and aimed at groups with less favourable attitudes, to increase the effectiveness of voluntary exercise of citizens' autonomy in end-of-life care planning.

Evaluation of genetic variants associated with the risk of thiopurine-related pancreatitis: a case control study from ENEIDA registry.

BACKGROUND: Risk factors for developing pancreatitis due to thiopurines in patients with inflammatory bowel disease (IBD) are not clearly identified. AIM: Our aim was to evaluate the predictive pharmacogenetic risk of pancreatitis in IBD patients treated with thiopurines. METHODS: We conducted an observational pharmacogenetic study of acute pancreatitis events in a cohort study of IBD patients treated with thiopurines from the prospectively maintained ENEIDA registry biobank of GETECCU. Samples were obtained and the CASR, CEL, CFTR, CDLN2, CTRC, SPINK1, CPA1, and PRSS1 genes, selected based on their known association with pancreatitis, were fully sequenced. RESULTS: Ninety-five cases and 105 controls were enrolled, 57% were women. Median age at pancreatitis diagnosis was 39 years. We identified 81 benign variants (50 in cases and 67 in controls) and a total of 35 distinct rare pathogenic and unknown significance variants (10 in CEL, 21 in CFTR, 1 in CDLN2, and 3 in CPA1). None of the cases or controls carried pancreatitis-predisposing variants within the CASR, CPA1, PRSS1, and SPINK1 genes, nor a pathogenic CFTR mutation. Four different variants of unknown significance were detected in the CDLN and CPA1 genes; one of them was in the CDLN gene in a single patient with pancreatitis, and 3 in the CPA1 gene in 5 controls. After the analysis of the variants detected, no significant differences were observed between cases and controls. CONCLUSION: In patients with IBD, genes known to cause pancreatitis seem not to be involved in thiopurine-related pancreatitis onset.

Impact of palliative care at end-of-life Covid-19 patients - a small-scale pioneering experience.

BACKGROUND: In March 2020, the outbreak caused by the SARS-CoV-2 virus was declared a pandemic, resulting in numerous fatalities worldwide. To effectively combat the virus, it would be beneficial to involve professionals who specialize in symptom control for advanced illnesses, working closely with other specialties throughout the illness process. This approach can help manage a range of symptoms, from mild to severe and potentially life-threatening. No studies have been conducted in Portugal to analyse the intervention of Palliative Medicine at the end of life of Covid-19 patients and how it differs from other specialties. This knowledge could help determine the importance of including it in the care of people with advanced Covid-19. OBJECTIVES: The objective of this study is to examine potential differences in the care provided to patients with Covid-19 during their Last Hours and Days of Life (LHDOL) between those who received care from Palliative Medicine doctors and those who did not. METHODS: This is a retrospective cohort study spanning three months (Dec 2020 to Feb 2021), the duration of the Support Unit especially created to deal with Covid-19 patients. The database included clinical files from 181 patients admitted to the Support Unit, 27 of which died from Covid-19. RESULTS: Statistically significant differences were identified in the care provided. Specifically, fewer drugs were administered at the time of death, including drugs for dyspnoea, pain and agitation, suspension of futile devices and use of palliative sedation to control refractory symptoms. CONCLUSIONS: End-of-life care and symptomatic control differ when there's regular follow-up by Palliative Medicine, which may translate less symptomatic suffering and promote a dignified and humane end of life.

Clinical and treatment outcomes of a second subcutaneous or intravenous anti-TNF in patients with ulcerative colitis treated with two consecutive anti-TNF agents: data from the ENEIDA registry.

Background: Infliximab seems to be the most efficacious of the three available anti-TNF agents for ulcerative colitis (UC) but little is known when it is used as the second anti-TNF. Objectives: To compare the clinical and treatment outcomes of a second subcutaneous or intravenous anti-TNF in UC patients. Design: Retrospective observational study. Methods: Patients from the ENEIDA registry treated consecutively with infliximab and a subcutaneous anti-TNF (or vice versa), naïve to other biological agents, were identified and grouped according to the administration route of the first anti-TNF into IVi (intravenous initially) or SCi (subcutaneous initially). Results: Overall, 473 UC patients were included (330 IVi and 143 SCi). Clinical response at week 14 was 42.7% and 48.3% in the IVi and SCi groups (non-statistically significant), respectively. Clinical remission rates at week 52 were 32.8% and 31.4% in the IVi and SCi groups (nonsignificant differences), respectively. A propensity-matched score analysis showed a higher clinical response rate at week 14 in the SCi group and higher treatment persistence in the IVi group. Regarding long-term outcomes, dose escalation and discontinuation due to the primary failure of the first anti-TNF and more severe disease activity at the beginning of the second anti-TNF were inversely associated with clinical remission. Conclusion: The use of a second anti-TNF for UC seems to be reasonable in terms of efficacy, although it is particularly reduced in the case of the primary failure of the first anti-TNF. Whether the second anti-TNF is infliximab or subcutaneous does not seem to affect efficacy.

OBJECTIVES: To compare the clinical and treatment outcomes of a second subcutaneous or intravenous anti-TNF in UC patients. DESIGN: Retrospective observational study. METHODS: Patients from the ENEIDA registry treated consecutively with infliximab and a subcutaneous anti-TNF (or vice versa), naïve to other biological agents, were identified and grouped according to the administration route of the first anti-TNF into IVi (intravenous initially) or SCi (subcutaneous initially). RESULTS: Overall, 473 UC patients were included (330 IVi, 143 SCi). Clinical response at week 14 was 42.7% and 48.3% in the IVi and SCi groups (non-statistically significant), respectively. Clinical remission rates at week 52 were 32.8% and 31.4%, in the IVi and SCi groups (nonsignificant differences), respectively. A propensity-matched score analysis showed a higher clinical response rate at week 14 in the SCi group and higher treatment persistence in the IVi group. Regarding long-term outcomes, dose escalation and discontinuation due to the primary failure of the first anti-TNF and more severe disease activity at the beginning of the second anti-TNF were inversely associated with clinical remission. CONCLUSION: The use of a second anti-TNF for UC seems to be reasonable in terms of efficacy, although it is particularly reduced in the case of the primary failure of the first anti-TNF. Whether the second anti-TNF is infliximab or subcutaneous does not seem to affect efficacy.

Clinical and treatment outcomes of a second subcutaneous or intravenous anti-TNF in patients with ulcerative colitis treated with two consecutive anti-TNF agents. Data from the ENEIDA registry Background: Infliximab seems to be the most efficacious of the three available anti-TNF agents for ulcerative colitis (UC), but little is known when it is used as the second anti-TNF.

Performance of a New Rapid Point-of-Care Test for Infliximab Levels in Patients with Inflammatory Bowel Disease: A Comparison to ELISA.

BACKGROUND: Therapeutic drug monitoring of infliximab levels in patients with inflammatory bowel disease (IBD) optimizes patients' treatment. The reference technique is based on enzyme-linked immunosorbent assay (ELISA) although point of care (POC) assays are being developed. AIMS: To assess the performance of a new rapid immunochromatographic POC assay (Promonitor Quick IFX) compared with ELISA technique to measure infliximab levels in patients with IBD. METHODS: A prospective, observational, unicentric study was performed on capillary blood samples from patients with IBD before infliximab infusion (trough levels). Infliximab levels and anti-infliximab antibodies were measured using the ELISA technique (Promonitor IFX) and the POC assay. Correlation between both techniques was assessed by Pearson's coefficient. Quantitative differences were evaluated by Bland-Altman analysis. Samples were stratified according to infliximab therapeutic ranges (< 3 µg/mL, 3-8 µg/mL, and > 8 µg/mL). RESULTS: A total of 135 experimental samples were assessed. Infliximab levels showed a high correlation between POC and ELISA tests (r = 0.84, P < 0.001). The mean difference between tests was 1.46 µg/mL (P < 0.001), being minimal for concentrations < 8 µg/mL. POC and ELISA assays showed an overall concordance of 87.4%. Most samples were in the same therapeutic range, which lead to equivalent therapeutic decisions. POC and ELISA assays detected the presence of anti-infliximab antibodies in 2.2% and 3.7% of the samples, respectively. CONCLUSIONS: POC assay results in blood samples from patients with IBD were comparable to those obtained with the reference ELISA technique. The POC assay could be considered for routine testing based on its ease of use and rapidity.

Burnout, resilience, and subjective well-being among Portuguese lecturers' during the COVID-19 pandemic.

Background: Lecturers face a large wide of occupational stressors. If the prolonged stress and the symptomatology associated with the working conditions to which lecturers were exposed were already a concern before the pandemic, the pandemic may have exacerbated this psychosocial vulnerability. Burnout is a psychological syndrome that develops in response to chronic work stress. This study aims to describe burnout amongst lecturers working in Portugal and to analyse potential determinants of burnout during the COVID-19 pandemic. Methods: A cross-sectional study was performed using an online questionnaire distributed via social networks. The survey collected sociodemographic and sleep patterns data in addition to applying the Copenhagen Burnout Inventory (personal, work- and student-related burnout), the Resilience Scale, the Depression Anxiety and Stress Scales, and the Satisfaction with Life Scale. Results: The sample included 331 lecturers from 35 different colleges and faculties. Three significant models explained personal (R2 = 54%), work- (R2 = 47%) and student- (R2 = 19%) related burnout. Lower levels of resilience and higher levels of depression and stress were significantly associated with personal and work-related burnout. Changes in sleep patterns were additionally associated with both personal and work-related burnout. Conclusion: Higher education institutions must recognize the impact of the work environment and organizational culture on faculty mental health and take proactive measures to improve this environment. These institutions can implement support strategies such as educational technology training, professional development programmes, emotional support resources, and workload flexibility. Implementing measures to enhance lecturers' resilience and overall life satisfaction could potentially help mitigate burnout and improve the well-being of educators, ultimately contributing to the overall quality of education.

The role of social support as a moderator between resilience and levels of burden of multimorbidity management among general practitioners: a cross-sectional study in Portugal.

BACKGROUND: Multimorbidity management poses significant challenges for general practitioners (GPs). The aim of this study is to analyse the role of resilience and social support on the burden experienced by GPs in managing patients with multiple health conditions in Portugal. METHODS: Cross-sectional quantitative study conducted among GPs in Portugal using an online questionnaire that included validated measurement tools: Questionnaire of Evaluation of Burden of Management of Multimorbidity in General and Family Medicine (SoGeMM-MGF), European Portuguese Version of the Resilience Scale (ER14), and the Oslo Social Support Scale-3 (OSSS-3) in Portuguese. A multiple linear regression analysis was conducted to examine the factors influencing the burden of managing multimorbidity. RESULTS: Two hundred and thirty-nine GPs were included, with 76.6% being female and a median age of 35 years. Most participants were specialists (66.9%) and had less than a decade of experience managing multimorbidity. Over 70% had not received specific training in multimorbidity. Female GPs and those with a higher proportion of multimorbid patients in the registries experienced higher burden levels. A multivariate regression model with moderation revealed that the effect of resilience on burden varied depending on the level of social support. Higher resilience was associated with higher burden in the "Poor Social Support" category, while it was associated with lower burden in the "Moderate Social Support" and "Strong Social Support" categories, although not statistically significant. CONCLUSIONS: The study highlights the importance of GPs' social support and resilience in managing the burden of multimorbidity, with poor social support potentially worsening the effects of high resilience.

Communication strategies used by medical physicians when delivering bad news at the Maputo Central Hospital, Mozambique: a cross-sectional study.

BACKGROUND: Physicians' communication with patients and their families is important during both the disease diagnosis and prognosis stages and through the follow-up process. Effective physician communication improves patients' quality of life and satisfaction with care and helps reduce suffering for those newly diagnosed with advanced progressive illnesses. This study aims to identify the communication strategies physicians use in the transition to palliative care and how these professionals perceive their academic and clinical preparation concerning this task. METHODS: A cross-sectional and quantitative study. Physicians providing palliative care at the Maputo Central Hospital, Mozambique, were invited to complete a 17-question questionnaire. This questionnaire was based on a Brazilian adaptation of the Setting-Perception-Invitation-Knowledge-Emotions-Strategy (SPIKES) tool, the P-A-C-I-E-N-T-E protocol, with additional questions regarding socio-demographic details and the integration of "communication of bad news" into hospital training. RESULTS: Of the 121 participants, 62 (51.2%) were male, and 110 (90.9%) were general practitioners, with a median age of 36 years old. They had worked in clinical practice for a median of 8 years and in their current department for three years. The majority of the participants considered that they have an acceptable or good level of bad news communication skills and believed that they do it in a clear and empathic way, paying attention to the patient's requests and doubts; however, most were not aware of the existing tools to assist them in this task and suggested that delivering bad news ought to be integrated into the undergraduate medical course and included in hospital training. CONCLUSIONS: This study adds to our understanding of physicians' strategies when communicating bad news in the context of palliative care at one Mozambique hospital. As palliative care is not fully implemented in Mozambique, it is important to use protocols suitable to the country's healthcare level to improve how doctors deal with patients and their family members.

Role of Artificial Intelligence in Colonoscopy Detection of Advanced Neoplasias : A Randomized Trial.

BACKGROUND: The role of computer-aided detection in identifying advanced colorectal neoplasia is unknown. OBJECTIVE: To evaluate the contribution of computer-aided detection to colonoscopic detection of advanced colorectal neoplasias as well as adenomas, serrated polyps, and nonpolypoid and right-sided lesions. DESIGN: Multicenter, parallel, randomized controlled trial. (ClinicalTrials.gov: NCT04673136). SETTING: Spanish colorectal cancer screening program. PARTICIPANTS: 3213 persons with a positive fecal immunochemical test. INTERVENTION: Enrollees were randomly assigned to colonoscopy with or without computer-aided detection. MEASUREMENTS: Advanced colorectal neoplasia was defined as advanced adenoma and/or advanced serrated polyp. RESULTS: The 2 comparison groups showed no significant difference in advanced colorectal neoplasia detection rate (34.8% with intervention vs. 34.6% for controls; adjusted risk ratio [aRR], 1.01 [95% CI, 0.92 to 1.10]) or the mean number of advanced colorectal neoplasias detected per colonoscopy (0.54 [SD, 0.95] with intervention vs. 0.52 [SD, 0.95] for controls; adjusted rate ratio, 1.04 [99.9% CI, 0.88 to 1.22]). Adenoma detection rate also did not differ (64.2% with intervention vs. 62.0% for controls; aRR, 1.06 [99.9% CI, 0.91 to 1.23]). Computer-aided detection increased the mean number of nonpolypoid lesions (0.56 [SD, 1.25] vs. 0.47 [SD, 1.18] for controls; adjusted rate ratio, 1.19 [99.9% CI, 1.01 to 1.41]), proximal adenomas (0.94 [SD, 1.62] vs. 0.81 [SD, 1.52] for controls; adjusted rate ratio, 1.17 [99.9% CI, 1.03 to 1.33]), and lesions of 5 mm or smaller (polyps in general and adenomas and serrated lesions in particular) detected per colonoscopy. LIMITATIONS: The high adenoma detection rate in the control group may limit the generalizability of the findings to endoscopists with low detection rates. CONCLUSION: Computer-aided detection did not improve colonoscopic identification of advanced colorectal neoplasias. PRIMARY FUNDING SOURCE: Medtronic.

Association of hypertension and insulin resistance in individuals free of diabetes in the ELSA-Brasil cohort.

Insulin resistance (IR) is defined as the subnormal response to insulin action on its target tissues. Studies suggest that IR may increase the risk of hypertension, but the results are inconsistent and it is not known whether such an effect is independent of overweight/obesity. We aimed to evaluate the association between IR and the incidence of prehypertension and hypertension in the Brazilian population and whether this association is independent of overweight/obesity. In 4717 participants of the Brazilian Longitudinal Study of Adult's Health (ELSA-Brasil), free of diabetes and cardiovascular disease at baseline (2008-2010), we investigated the incidence of prehypertension and hypertension after a mean follow-up of 3.8 ± 0.5 years. Insulin resistance at baseline was assessed by the Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) index, defined if above the 75th percentile. The risk of IR-associated prehypertension/hypertension was estimated by multinomial logistic regression after adjustment for confounding factors. Secondary analysis were stratified by body mass index. The mean (SD) age of participants was 48 (8) years, 67% were women. The 75th percentile of HOMA-IR at baseline was 2.85. The presence of IR increased the chance of developing prehypertension by 51% (95% CI 1.28-1.79) and hypertension by 150% (95% CI 1.48-4.23). In individuals with BMI < 25 kg/m2, the presence of IR remained associated with the incidence of prehypertension (OR 1.41; 95% CI 1.01-1.98) and hypertension (OR 3.15; 95% CI 1.27-7.81). In conclusion, our results suggest that IR is a risk factor for hypertension, regardless of the presence of overweight or obesity.

Machine learning models based on clinical indices and cardiotocographic features for discriminating asphyxia fetuses-Porto retrospective intrapartum study.

Introduction: Perinatal asphyxia is one of the most frequent causes of neonatal mortality, affecting approximately four million newborns worldwide each year and causing the death of one million individuals. One of the main reasons for these high incidences is the lack of consensual methods of early diagnosis for this pathology. Estimating risk-appropriate health care for mother and baby is essential for increasing the quality of the health care system. Thus, it is necessary to investigate models that improve the prediction of perinatal asphyxia. Access to the cardiotocographic signals (CTGs) in conjunction with various clinical parameters can be crucial for the development of a successful model. Objectives: This exploratory work aims to develop predictive models of perinatal asphyxia based on clinical parameters and fetal heart rate (fHR) indices. Methods: Single gestations data from a retrospective unicentric study from Centro Hospitalar e Universitário do Porto de São João (CHUSJ) between 2010 and 2018 was probed. The CTGs were acquired and analyzed by Omniview-SisPorto, estimating several fHR features. The clinical variables were obtained from the electronic clinical records stored by ObsCare. Entropy and compression characterized the complexity of the fHR time series. These variables' contribution to the prediction of asphyxia perinatal was probed by binary logistic regression (BLR) and Naive-Bayes (NB) models. Results: The data consisted of 517 cases, with 15 pathological cases. The asphyxia prediction models showed promising results, with an area under the receiver operator characteristic curve (AUC) >70%. In NB approaches, the best models combined clinical and SisPorto features. The best model was the univariate BLR with the variable compression ratio scale 2 (CR2) and an AUC of 94.93% [94.55; 95.31%]. Conclusion: Both BLR and Bayesian models have advantages and disadvantages. The model with the best performance predicting perinatal asphyxia was the univariate BLR with the CR2 variable, demonstrating the importance of non-linear indices in perinatal asphyxia detection. Future studies should explore decision support systems to detect sepsis, including clinical and CTGs features (linear and non-linear).

Burnout among Physicians Working in Palliative Care During the COVID-19 Pandemic in Portugal: A Cross-Sectional Study.

INTRODUCTION: Physicians working in palliative care have a greater risk of burnout. Burnout has three dimensions: emotional exhaustion, depersonalization and reduction of personal accomplishments. Burnout is associated with different consequences for the professionals like less professional satisfaction and increase of overall levels of exhaustion. Burnout in healthcare professionals has an impact in the patients with increased probability of clinical erros. In order to monitor the quality of the care it is mandatory to assess overall levels of burnout. This study aimed to determine burnout levels and associated variables of physicians working in the Portuguese national network of palliative care. MATERIAL AND METHODS: A cross-sectional, exploratory and quantitative design was employed and participants were sampled using convenience and snowball technique. The Copenhagen Burnout Inventory was used to determine burnout levels of physicians working in the Portuguese National Network of Palliative Care. The contributions of personal, work and COVID-19 variables were evaluated in three subclasses: work, personal and patient-related burnout. The results obtained enabled the identification of healthcare professionals at risk, comparison with previous results published and to assess the impact of COVID-19 in their non COVID-19 activity. RESULTS: Seventy-five physicians participated. Socio-demographic characterization was conducted and the levels of burnout and determinants were explored. High levels of personal, work and patient-related burnout were present in 32 (43%), 39 (52%) and 16 (21%) physicians, respectively. The majority agreed that COVID-19 had an impact on their activities. Exclusive dedication to palliative care and type of palliative care unit were associated with lower levels of patient and work-related burnout. Weekly physical activity was associated with lower levels of work and personal burnout. Self-perceived health status was associated with lower levels of burnout for all subclasses. CONCLUSION: There was a high level of burnout among physicians working in the Portuguese National Network of Palliative Care. Measures to identify and prevent burnout are necessary in order to protect these professionals.

Introdução: Os médicos que trabalham em cuidados paliativos apresentam um risco mais elevado de burnout. Esta perturbação psicológica carateriza-se por três dimensões ­ exaustão emocional, despersonalização e redução da realização pessoal ­ e está associada a diversas consequências para os profissionais como a diminuição da satisfação profissional ou o aumento dos níveis de exaustão. Ao afetar os profissionais de saúde, o burnout tem também impacto nos utentes, visto causar um aumento da probabilidade de erros clínicos. Com vista a monitorizar a qualidade dos cuidados prestados é fundamental monitorizar os níveis de burnout. O objetivo deste estudo foi o de determinar os níveis de burnout e varíaveis associadas dos médicos que trabalham na Rede Nacional de Cuidados Paliativos em Portugal. Material e Métodos: Estudo transversal, exploratório e quantitativo com amostragem por conveniência e bola de neve. Foi utilizado o questionário Copenhagen Burnout Inventory para determinar os níveis de burnout de médicos que exercem funções na Rede Nacional de Cuidados Paliativos. As contribuições das varíaveis pessoais, laborais e decorrentes da pandemia de COVID-19 foram analisadas segundo três subclasses: burnout pessoal, burnout relacionado com a atividade profissional e burnout relacionado com o utente. Os resultados obtidos permitiram identificar profissionais em risco, fazer uma comparação com resultados prévios na literatura e determinar o impacto da COVID-19 na atividade assistencial não relacionada com COVID-19. Resultados: Setenta e cinco médicos participaram neste estudo. Foi realizada a caraterização socio-demográfica e determinados os níveis de burnout e variáveis associadas. Níveis elevados de burnout pessoal, relacionados com a atividade profissional e para com o utente estavam presentes, respetivamente, em 32 (43%), 39 (52%) e 16 (21%) dos participantes. A maioria considerou que a COVID-19 teve um impacto na sua atividade clínica. A dedicação exclusiva em cuidados paliativos e o tipo de unidade de cuidados paliativos estavam associados a menor nível de burnout relacionado com atividade profissional e para com o utente. A autopercepção de saúde estava associada a menores níveis de burnout em todas as subclasses. Conclusão: Foi observado um elevado nível de burnout nos médicos que trabalham na Rede Nacional de Cuidados Paliativos. São necessárias medidas para identificar e prevenir o burnout nestes profissionais,com vista à sua proteção.

Advance Care Planning and Goals of Care Discussion: Barriers from the Perspective of Medical Residents.

BACKGROUND: Advance care planning (ACP) and goals of care discussion involve the exploration of what is most important to a person to prepare for health-care decision making. Despite their well-established benefits, they are still not frequently performed in clinical oncology practice. This study aims to describe the barriers to discussion goals of care with oncology patients from the perspective of medical residents. METHODS: This cross-sectional and qualitative study applied the "Decide-Oncology" questionnaire, adapted to Portuguese language, to assess barriers to goals of care discussion among medical residents from three university hospitals in Brazil. Residents were asked to rank the importance of various barriers to discuss goals of care (ranging from 1-extremely unimportant to 7-extremely important). RESULTS: Twenty-nine residents answered the questionnaire (30.9%). The most reported barriers were related to patients and their families' difficulty in understanding and accepting the diagnosis and the prognosis as well as patients' desire to receive full active treatment. Furthermore, the physician and external factors such as lack of training and lack of time to have these conversations were also very important barriers. The identification of the key barriers that limit the discussion of ACP and early palliative care referrals can certainly help to prioritize the next steps for future studies aimed at improving ACP and goals of care discussions.

Equity in the Access of Chinese Immigrants to Healthcare Services in Portugal.

International studies indicate that Chinese immigrants face barriers when trying to access healthcare in the host country. The aim of this study was to identify the barriers that Chinese immigrants face when accessing the Portuguese National Health Service. An observational, cross-sectional and quantitative study was carried out via a bilingual Portuguese/Mandarin self-completed paper questionnaire was applied. The study population consisted of individuals with Chinese nationality who were residing in mainland Portugal for at least one year and aged 18 years or over. A total of 304 individuals answered the questionnaire. The results show that 284 (93.4%) of the participants had already sought healthcare in Portugal. The participants identified language difficulties and health professionals' lack of knowledge of Chinese cultural habits as the most significant barriers to accessing healthcare in Portugal. Of a total of 165 participants who sought healthcare in China, confidence in treatment outcomes and health professionals' knowledge of Chinese cultural habits were the reasons given by 151 (91.5%) individuals. This study reveals the existence of linguistic and cultural barriers that can condition the access of the Chinese immigrant population to healthcare systems. Immigrants' access to healthcare can be promoted via policies that contribute to proficiency in the Portuguese language and medical literacy among the Chinese immigrant population. It can also be promoted by raising the awareness of health professionals to Chinese cultural habits.

Ability of Swept-source OCT and OCT-angiography to detect neuroretinal and vasculature changes in patients with Parkinson disease and essential tremor.

BACKGROUND/OBJECTIVES: To evaluate the ability of swept-source optical coherence tomography (SS-OCT) implemented with angiography analysis (SS-OCTA) to detect neuro-retinal and vasculature changes in patients with Parkinson's disease (PD) and essential tremor (ET), and to distinguish between both pathologies. SUBJECTS/METHODS: A total 42 PD and 26 ET patients and 146 controls underwent retinal evaluation using SS-OCT plus OCT-Angio™. The macular (m) and peripapillary (p) retinal nerve fiber layer (RNFL) and ganglion cell layer (GCL), and macular vasculature were assessed. A Linear discriminant function (LDF) was calculated to evaluate the diagnostic ability of SS-OCTA in both PD and ET. RESULTS: PD patients presented a reduction in mRNFL (p < 0.005), mGCL (all sectors, p < 0.05) and pRNFL (p < 0.005) vs healthy controls, and in mRNFL and pRNFL vs ET patients (p < 0.001). ET patients showed a significant reduction in mGCL vs controls (p < 0.001). No differences were observed in the macular vasculature between groups. Predictive diagnostic variables were significant only for PD and a LDF was obtained with an area under the ROC curve of 0.796. CONCLUSIONS: Neuro-retinal thinning is present in both diseases, being greater in PD. While SS-OCT could be useful in diagnosing ET and PD, the diagnostic potential for SS-OCTA based on an LDF applies only to PD, not ET.

Long-Term Outcomes of Biological Therapy in Crohn's Disease Complicated With Internal Fistulizing Disease: BIOSCOPE Study From GETECCU.

INTRODUCTION: The prevalence of penetrating complications in Crohn's disease (CD) increases progressively over time, but evidence on the medical treatment in this setting is limited. The aim of this study was to evaluate the effectiveness of biologic agents in CD complicated with internal fistulizing disease. METHODS: Adult patients with CD-related fistulae who received at least 1 biologic agent for this condition from the prospectively maintained ENEIDA registry were included. Exclusion criteria involved those receiving biologics for perianal disease, enterocutaneous, rectovaginal, anastomotic, or peristomal fistulae. The primary end point was fistula-related surgery. Predictive factors associated with surgery and fistula closure were evaluated by multivariate logistic regression and survival analyses. RESULTS: A total of 760 patients from 53 hospitals (673 receiving anti-tumor necrosis factors, 69 ustekinumab, and 18 vedolizumab) were included. After a median follow-up of 56 months (interquartile range, 26-102 months), 240 patients required surgery, with surgery rates of 32%, 41%, and 24% among those under anti-tumor necrosis factor, vedolizumab, or ustekinumab, respectively. Fistula closure was observed in 24% of patients. Older patients, ileocolonic disease, entero-urinary fistulae, or an intestinal stricture distal to the origin of the fistula were associated with a higher risk of surgery, whereas nonsmokers and combination therapy with an immunomodulator reduced this risk. DISCUSSION: Biologic therapy is beneficial in approximately three-quarters of patients with fistulizing CD, achieving fistula closure in 24%. However, around one-third still undergo surgery due to refractory disease. Some patient- and lesion-related factors can identify patients who will obtain more benefit from these drugs.

Impact of COVID-19 pandemic on the mental health of healthcare workers during the first wave in Portugal: a cross-sectional and correlational study.

OBJECTIVES: The COVID-19 pandemic has had a negative impact on the mental health of healthcare workers (HCWs) worldwide. This study aims to identify the degree to which sociodemographic variables and indicators of subjective well-being and psychological resilience are associated, positively and negatively, with the outcomes of burnout, stress, depression and anxiety among Portuguese HCWs observed during the first wave. It also aims to evaluate the strength of association of these variables and indicators with each outcome. DESIGN: Cross-sectional quantitative study. The statistical methods used are simple logistic model, multiple logistic regression model and -2*log-likelihood statistic. SETTING: Portuguese HCWs living in Portugal and working in the Portuguese healthcare system. PARTICIPANTS: The study included 1535 professionals, with a mean age of 38 years. PRIMARY AND SECONDARY OUTCOMES MEASURES: Psychological variables were measured by Copenhagen Burnout Inventory, the Resilience Scale, the Depression, Anxiety and Stress Scales and the Satisfaction with Life Scale. RESULTS: High levels of personal (55%; n=844), work-related (55.1%; n=846) and client-related burnout (35.4%; n=543) were found. Additionally, participants expressed substantial levels of depression (28.7%; n=441), stress (36.4%; n=558) and anxiety (33.1%; n=508). About 1202 participants (78.3%) demonstrated moderate-to-high levels of resilience. Profession, work regime during the pandemic, having a health problem, resilience and satisfaction with life are independent variables significantly associated with the outcomes of burnout, stress, depression and anxiety. Satisfaction with life was the independent variable that had a major association with all outcomes. CONCLUSIONS: Governments and hospital administrations should take action to promote resilience and satisfaction with life as these variables are protective relating to mental health problems. Interventions as educational sessions, psychological support at work, programmes promoting resilience and coping mechanisms and better work conditions may improve mental health. The implementation of measures to protect healthcare students from developing prejudicial outcomes seams very adequate and important.

Long-term health-related quality of life in patients on home mechanical ventilation.

BACKGROUND: It is fundamental to optimize and retain health-related quality of life (HRQoL) in the long term in patients with home mechanical ventilation (HMV). Therefore, this study aimed to evaluate the evolution of the HRQoL in patients already established on HMV across a period of 5 years and whether the HRQoL is associated with mortality. METHODS: This was a 5-year longitudinal cohort study conducted in an Outpatient Ventilation Clinic. Consecutive patients on HMV for at least 30 days responded to the Severe Respiratory Insufficiency (SRI) questionnaire at inclusion and again at 5 years. RESULTS: A total of 104 patients were included (male 56.7%, median age 69 [P25;P75] [61;77] years). Almost half of the patients had COPD (49.0%). Patients were on HMV for a median of 43.5 [22;85.5] months, with overall good adherence (median 8 [6;9] daily hours). Fifty-seven (54.8%) patients were alive at 5 years. In surviving patients, the only difference with statistical significance was in the attendant symptoms and sleep subscale, with patients scoring 7.1 [-4.5;25] points higher in the final questionnaire (p = 0.002). Survivors had significantly better scores in the SRI at inclusion than deceased patients (median 59.6 [49.2;71.7] vs 48.7 [38.4;63.2]; p = 0.004). CONCLUSIONS: These results shows that HRQoL remains stable in surviving patients with HMV at five years. It also suggests that SRI can be of important prognostic value and help predict the terminal phase of the disease course in patients with long-term HMV.

The impact of teleworking in psychologists during COVID-19: Burnout, depression, anxiety, and stress.

Background: The COVID-19 pandemic has forced mental health professionals to adapt quickly. The pandemic has created multiple new tasks for the psychologist. In addition to the various stressors closely linked to the COVID-19 pandemic, psychologists were forced to make their services more flexible. Teleworking was a way of continuing to work. Objective: This study aimed to identify the impact of working pattern on the levels of burnout, depression, anxiety, and stress. Methods: This was a cross-sectional study based on an online questionnaire applied to eighty-three Portuguese psychologists. Data were collected from May 9 to June 8, 2020, a period comprising the declaration of a national calamity and then state of emergency, and the subsequent ease of lockdown measures. The Copenhagen Burnout Inventory Scale and Depression Anxiety and Stress Scale were used. Univariate multiple linear regression models were estimated for each mental health outcome. Results: Significant differences were found between psychologists working in the workplace and in teleworking at the personal burnout, work-related burnout, client-related burnout, depression, and stress. In multiple linear regression, teleworking, not working, and being unmarried was significantly associated with higher levels of depression. Teleworking was significantly associated with higher stress scores and client-related and work burnout. Conclusions: This exceptional time of sudden, mandatory, and high-intensity teleworking, required rapid adaptation, giving rise to new stressors that might have been responsible for burnout levels in psychologists.

Evolution of Heart Rate Complexity Indices in the Early Detection of Neonatal Sepsis.

Despite advances in prenatal health care, neonatal sepsis remains a major cause of neonatal mortality. Early diagnosis and adequate treatment are essential to reduce morbidity and mortality related to this disease. In this paper, we propose a new method to detect neonatal sepsis based on heart rate (HR) complexity measures (entropy and compression indices) that takes into consideration neonatal gestational age. First, the percentile curves were computed for all the complexity indices using data from 118 control neonates. Eight indices were computed: the sample entropy (SampEn) and three indices to quantify the multiscale entropy (MSE) curve - the sum, the slope, and the product of the previous two - and the compression ratio (CR), using the bzip2 compressor, as well as the same three indices but related to the multiscale compression (MSC) curve. Then, the corresponding percentile was estimated for 23 sepsis neonates. Results show a significant decrease in the entropy indices SampEn and MSEsum and in the MSCslope a day before the detection of sepsis by the clinicians. The indices CR and MSCsum increased before the antibiotic take. These results imply that sepsis causes a random, uncorrelated pattern on the HR signal. Future studies should include a bigger data set to calculate a compound index comprising information of other physiological signals. Clinical Relevance - Prompt and accurate diagnosis of neona-tal sepsis is essential for the successful clinical management of neonates and significantly reduce morbidity and mortality. Complexity measures applied to the HR time series appear to detect sepsis in neonates starting one day before the clinical detection.