Fast Healthcare Interoperability Resources-Based Support System for Predicting Delivery Type: Model Development and Evaluation Study.

BACKGROUND: The escalating prevalence of cesarean delivery globally poses significant health impacts on mothers and newborns. Despite this trend, the underlying reasons for increased cesarean delivery rates, which have risen to 36.3% in Portugal as of 2020, remain unclear. This study delves into these issues within the Portuguese health care context, where national efforts are underway to reduce cesarean delivery occurrences. OBJECTIVE: This paper aims to introduce a machine learning, algorithm-based support system designed to assist clinical teams in identifying potentially unnecessary cesarean deliveries. Key objectives include developing clinical decision support systems for cesarean deliveries using interoperability standards, identifying predictive factors influencing delivery type, assessing the economic impact of implementing this tool, and comparing system outputs with clinicians' decisions. METHODS: This study used retrospective data collected from 9 public Portuguese hospitals, encompassing maternal and fetal data and delivery methods from 2019 to 2020. We used various machine learning algorithms for model development, with light gradient-boosting machine (LightGBM) selected for deployment due to its efficiency. The model's performance was compared with clinician assessments through questionnaires. Additionally, an economic simulation was conducted to evaluate the financial impact on Portuguese public hospitals. RESULTS: The deployed model, based on LightGBM, achieved an area under the receiver operating characteristic curve of 88%. In the trial deployment phase at a single hospital, 3.8% (123/3231) of cases triggered alarms for potentially unnecessary cesarean deliveries. Financial simulation results indicated potential benefits for 30% (15/48) of Portuguese public hospitals with the implementation of our tool. However, this study acknowledges biases in the model, such as combining different vaginal delivery types and focusing on potentially unwarranted cesarean deliveries. CONCLUSIONS: This study presents a promising system capable of identifying potentially incorrect cesarean delivery decisions, with potentially positive implications for medical practice and health care economics. However, it also highlights the challenges and considerations necessary for real-world application, including further evaluation of clinical decision-making impacts and understanding the diverse reasons behind delivery type choices. This study underscores the need for careful implementation and further robust analysis to realize the full potential and real-world applicability of such clinical support systems.

Temporal dynamics and stoichiometry in human Notch signaling from Notch synaptic complex formation to nuclear entry of the Notch intracellular domain.

Mammalian Notch signaling occurs when the binding of Delta or Jagged to Notch stimulates the proteolytic release of the Notch intracellular domain (NICD), which enters the nucleus to control target gene expression. To determine the temporal dynamics of events associated with Notch signaling under native conditions, we fluorescently tagged Notch and Delta at their endogenous genomic loci and visualized them upon pairing of receiver (Notch) and sender (Delta) cells as a function of time after cell contact. At contact sites, Notch and Delta immediately accumulated at 1:1 stoichiometry in synapses, which resolved by 15-20 min after contact. Synapse formation preceded the entrance of the Notch extracellular domain into the sender cell and accumulation of NICD in the nucleus of the receiver cell, which approached a maximum after ∼45 min and was prevented by chemical and genetic inhibitors of signaling. These findings directly link Notch-Delta synapse dynamics to NICD production with spatiotemporal precision.

Individuals' attitudes toward digital mental health apps and implications for adoption in Portugal: web-based survey.

BACKGROUND: The literature is consensual regarding the academic community exhibiting higher levels of mental disorder prevalence than the general population. The potential of digital mental health apps for improving access to resources to cope with these issues is ample. However, studies have yet to be performed in Portugal on individuals' attitudes and perceptions toward digital mental health applications or their preferences and decision drivers on obtaining mental health care, self-assessment, or treatment. OBJECTIVE: This study aims to understand the determinants of digital mental health applications use in the Portuguese academic community of Porto, along with potential adoption barriers and enablers. METHODS: A cross-sectional, web-based survey was delivered via dynamic email to the University of Porto's academic community. Data collection occurred between September 20 and October 20, 2022. We used structural equation modeling to build three models, replicating a peer-reviewed and published study and producing a newly full mediation model shaped by the collected data. We tested the relationships between use of digital mental health apps and perceived stress, perceived need to seek help for mental health, perceived stigma, past use of mental health services, privacy concerns, and social influence. RESULTS: Of the 539 participants, 169 (31.4%) reported having used digital mental health apps. Perceived stress and a latent variable, comprising perceptions of mental health problems and coping strategies, were positively associated with mental health app use, while privacy concerns regarding one's information being accessible to others were negatively associated. Perceived stigma, need to seek help, and close relationships did not have a statistically significant direct effect. CONCLUSIONS: These findings can inform product and policy development of new, better-targeted digital mental health app interventions, with implications for researchers and academia, industry, and policymakers. Our study concludes that, to maximize adherence to these apps, they should have low to no financial charges, demonstrate evidence of their helpfulness and focus on the timely delivery of care. We also conclude that to foster digital mental health app use, there is a need to improve mental health literacy, namely regarding self-awareness of one's conditions, acceptable stress levels, and overall behavior towards mental health. TRIAL REGISTRATION: RR2-10.2196/41040.

Cross-cultural validation of the Portuguese version of the Dialysis Symptom Index for haemodialysis patients.

Background: Patients with end-stage renal disease (ESRD) undergoing haemodialysis (HD) are associated with low quality of life (QoL) and high disease-related symptoms. The patient self-report instruments can assess the burden of physical and psychological symptoms. The Dialysis Symptom Index (DSI) is a specific instrument to evaluate the multidimensional reported symptoms by patients undergoing HD. Aims: To translate, validate and assess the psychometric properties of the Portuguese version of the DSI. Methods: A cross-cultural adaptation process from English to Portuguese and a validation study (n = 156) were conducted. Reliability, validity and responsiveness were assessed. Results: The patients' most reported symptoms were, nausea (n = 86, 55%), muscle cramps (n = 92, 59%), feeling tired or lack of energy (n = 92, 59%), bone or joint pain (n = 88, 56%) and trouble staying asleep (n = 95, 60%). Cronbach's alpha of the DSI was 0.87, and intraclass correlation coefficient was 0.868 (95%CI 0.836-0.896). The smallest detectable change was 28.32. Conclusion: The Portuguese DSI demonstrates excellent psychometric properties for assessing HD patients' reported symptoms. It highlights symptom severity and impact, providing valuable insights for healthcare practitioners. Nurses can use the DSI to tailor interventions and enhance patient-centred care.

Incorporating ChatGPT in Medical Informatics Education: Mixed Methods Study on Student Perceptions and Experiential Integration Proposals.

BACKGROUND: The integration of artificial intelligence (AI) technologies, such as ChatGPT, in the educational landscape has the potential to enhance the learning experience of medical informatics students and prepare them for using AI in professional settings. The incorporation of AI in classes aims to develop critical thinking by encouraging students to interact with ChatGPT and critically analyze the responses generated by the chatbot. This approach also helps students develop important skills in the field of biomedical and health informatics to enhance their interaction with AI tools. OBJECTIVE: The aim of the study is to explore the perceptions of students regarding the use of ChatGPT as a learning tool in their educational context and provide professors with examples of prompts for incorporating ChatGPT into their teaching and learning activities, thereby enhancing the educational experience for students in medical informatics courses. METHODS: This study used a mixed methods approach to gain insights from students regarding the use of ChatGPT in education. To accomplish this, a structured questionnaire was applied to evaluate students' familiarity with ChatGPT, gauge their perceptions of its use, and understand their attitudes toward its use in academic and learning tasks. Learning outcomes of 2 courses were analyzed to propose ChatGPT's incorporation in master's programs in medicine and medical informatics. RESULTS: The majority of students expressed satisfaction with the use of ChatGPT in education, finding it beneficial for various purposes, including generating academic content, brainstorming ideas, and rewriting text. While some participants raised concerns about potential biases and the need for informed use, the overall perception was positive. Additionally, the study proposed integrating ChatGPT into 2 specific courses in the master's programs in medicine and medical informatics. The incorporation of ChatGPT was envisioned to enhance student learning experiences and assist in project planning, programming code generation, examination preparation, workflow exploration, and technical interview preparation, thus advancing medical informatics education. In medical teaching, it will be used as an assistant for simplifying the explanation of concepts and solving complex problems, as well as for generating clinical narratives and patient simulators. CONCLUSIONS: The study's valuable insights into medical faculty students' perspectives and integration proposals for ChatGPT serve as an informative guide for professors aiming to enhance medical informatics education. The research delves into the potential of ChatGPT, emphasizes the necessity of collaboration in academic environments, identifies subject areas with discernible benefits, and underscores its transformative role in fostering innovative and engaging learning experiences. The envisaged proposals hold promise in empowering future health care professionals to work in the rapidly evolving era of digital health care.

Harnessing online digital data in biodiversity monitoring.

Online digital data from media platforms have the potential to complement biodiversity monitoring efforts. We propose a strategy for integrating these data into current biodiversity datasets in light of the Kunming-Montreal Global Biodiversity Framework.

Deep learning assisted single particle tracking for automated correlation between diffusion and function.

Sub-cellular diffusion in living systems reflects cellular processes and interactions. Recent advances in optical microscopy allow the tracking of this nanoscale diffusion of individual objects with an unprecedented level of precision. However, the agnostic and automated extraction of functional information from the diffusion of molecules and organelles within the sub-cellular environment, is labor-intensive and poses a significant challenge. Here we introduce DeepSPT, a deep learning framework to interpret the diffusional 2D or 3D temporal behavior of objects in a rapid and efficient manner, agnostically. Demonstrating its versatility, we have applied DeepSPT to automated mapping of the early events of viral infections, identifying distinct types of endosomal organelles, and clathrin-coated pits and vesicles with up to 95% accuracy and within seconds instead of weeks. The fact that DeepSPT effectively extracts biological information from diffusion alone illustrates that besides structure, motion encodes function at the molecular and subcellular level.

The Impact of Intra-Operative Heparin on Thromboembolism and Death in a Matched Cohort of Patients with a Ruptured Abdominal Aortic Aneurysm.

Objective: Portuguese nationwide estimates indicate that 20% of abdominal aortic aneurysms (AAAs) are treated when ruptured. In these cases, intra-operative unfractionated heparin (UFH) usage rates vary widely. Evidence on this topic is scarce and focused on patients treated by open repair (OSR). The aim was to determine the influence of UFH on peri-operative thromboembolic events (TEs) and death in a cohort of ruptured AAA (rAAA). Methods: Retrospective, single-centre, comparative study. From 2011 to April 2023, all consecutive rAAAs (endovascular repair [EVAR] and OSR) were considered. Primary outcomes were 30-day TE free survival and TE rates. The secondary outcome was 30-day death. Safety endpoints were procedural blood loss, blood product requirements, and secondary interventions due to haemorrhage. Using propensity score matching (PSM) each UFH patient was matched with one no UFH patient in a 1:1 ratio. Results: The study included 250 patients. After PSM, 190 patients were analysed (EVAR: 60.0% no-UFH vs. 64.4% UFH). TE free survival estimates favoured the UFH group (67.3% vs. 47.2%, p = .009; UFH adjusted odds ratio [aOR] 2.01, 95% confidence interval [CI] 1.04-4.17). TEs were more frequent in the no UFH group (20.0% vs. 44.2% patients, p < .001; UFH aOR 0.31, 95% CI 0.15-0.65 for any TE), driven by an increase in bowel ischaemia (17.9% no UFH vs. 3.2% UFH, p = .001). Most events occurred in the first 72 hours. EVAR was associated with reduced TE and improved TE free survival (aOR 0.20, 95% CI 0.09-0.45 and aOR 5.54, 95% CI 2.34-13.08, respectively). No significant differences in 30-day survival were noted (75% no-UFH vs. 83% UFH, p = .26; aOR 1.08, 95% CI 0.48-2.43) nor in blood loss, peri-operative red blood cell and fresh frozen plasma requirements, or secondary interventions due to haemorrhage (p = .10; p = .11; p = .13 and p = .18 respectively). Conclusion: In this cohort, intra-operative UFH was safe and associated with improved TE free survival, driven by a reduction in bowel ischaemia. Conversely, mortality remained unaffected. Randomised controlled trials are required to confirm these findings.

Lessons Learned from an Interprofessional European Summer School in Health Informatics.

The aim of this European interprofessional Health Informatics (HI) Summer School was (i) to make advanced healthcare students familiar with what HI can offer in terms of knowledge development for patient care and (ii) to give them an idea about the underlying technical and legal mechanisms. According to the students' evaluation, interprofessional education was very well received, problem-based learning focussing on cases was rated positively and the learning goals were met. However, it was criticised that the online material provided was rather detailed and comprehensive and could have been a bit overcharging for beginners. These drawbacks were obviously compensated by the positive experience of working in international and interprofessional groups and a generally welcoming environment.

Using social media records to inform conservation planning.

Citizen science plays a crucial role in helping monitor biodiversity and inform conservation. With the widespread use of smartphones, many people share biodiversity information on social media, but this information is still not widely used in conservation. Focusing on Bangladesh, a tropical megadiverse and mega-populated country, we examined the importance of social media records in conservation decision-making. We collated species distribution records for birds and butterflies from Facebook and Global Biodiversity Information Facility (GBIF), grouped them into GBIF-only and combined GBIF and Facebook data, and investigated the differences in identifying critical conservation areas. Adding Facebook data to GBIF data improved the accuracy of systematic conservation planning assessments by identifying additional important conservation areas in the northwest, southeast, and central parts of Bangladesh, extending priority conservation areas by 4,000-10,000 km2 . Community efforts are needed to drive the implementation of the ambitious Kunming-Montreal Global Biodiversity Framework targets, especially in megadiverse tropical countries with a lack of reliable and up-to-date species distribution data. We highlight that conservation planning can be enhanced by including available data gathered from social media platforms.

Registros de las redes sociales para guiar la planeación de la conservación Resumen La ciencia ciudadana es importante para monitorear la biodiversidad e informar la conservación. Con el creciente uso de los teléfonos inteligentes, muchas personas comparten información de la biodiversidad en redes sociales, pero todavía no se usa ampliamente en la conservación. Analizamos la importancia de los registros de las redes sociales para las decisiones de conservación enfocados en Bangladesh, un país tropical megadiverso y mega poblado. Cotejamos los registros de distribución de especies de aves y mariposas en Facebook y Global Biodiversity Information Facility (GBIF), las agrupamos en datos sólo de GBIF o datos combinados de Facebook y GBIF e investigamos las diferencias en la identificación de las áreas de conservación críticas. La combinación de los datos de Facebook con los de GBIF mejoró la precisión de las evaluaciones de la planeación de la conservación sistemática al identificar otras áreas importantes de conservación en el noroeste, sureste y centro de Bangladesh, extendiendo así las áreas prioritarias de conservación en unos 4,000-10,000 km2 . Se requieren esfuerzos comunitarios para impulsar la implementación de los objetivos ambiciosos del Marco Global de Biodiversidad Kunming-Montreal, especialmente en países tropicales que carecen de datos confiables y actuales sobre la distribución de las especies. Destacamos que la planeación de la conservación puede mejorarse si se incluye información tomada de las redes sociales.

Deep learning assisted single particle tracking for automated correlation between diffusion and function.

Sub-cellular diffusion in living systems reflects cellular processes and interactions. Recent advances in optical microscopy allow the tracking of this nanoscale diffusion of individual objects with an unprecedented level of precision. However, the agnostic and automated extraction of functional information from the diffusion of molecules and organelles within the sub-cellular environment, is labor-intensive and poses a significant challenge. Here we introduce DeepSPT, a deep learning framework to interpret the diffusional 2D or 3D temporal behavior of objects in a rapid and efficient manner, agnostically. Demonstrating its versatility, we have applied DeepSPT to automated mapping of the early events of viral infections, identifying distinct types of endosomal organelles, and clathrin-coated pits and vesicles with up to 95% accuracy and within seconds instead of weeks. The fact that DeepSPT effectively extracts biological information from diffusion alone indicates that besides structure, motion encodes function at the molecular and subcellular level.

Drivers of species knowledge across the tree of life.

Knowledge of biodiversity is unevenly distributed across the Tree of Life. In the long run, such disparity in awareness unbalances our understanding of life on Earth, influencing policy decisions and the allocation of research and conservation funding. We investigated how humans accumulate knowledge of biodiversity by searching for consistent relationships between scientific (number of publications) and societal (number of views in Wikipedia) interest, and species-level morphological, ecological, and sociocultural factors. Across a random selection of 3019 species spanning 29 Phyla/Divisions, we show that sociocultural factors are the most important correlates of scientific and societal interest in biodiversity, including the fact that a species is useful or harmful to humans, has a common name, and is listed in the International Union for Conservation of Nature Red List. Furthermore, large-bodied, broadly distributed, and taxonomically unique species receive more scientific and societal attention, whereas colorfulness and phylogenetic proximity to humans correlate exclusively with societal attention. These results highlight a favoritism toward limited branches of the Tree of Life, and that scientific and societal priorities in biodiversity research broadly align. This suggests that we may be missing out on key species in our research and conservation agenda simply because they are not on our cultural radar.

Assessing Brazilian protected areas through social media: Insights from 10 years of public interest and engagement.

Social media platforms are a valuable source of data for investigating cultural and political trends related to public interest in nature and conservation. Here, we use the micro-blogging social network Twitter to explore trends in public interest in Brazilian protected areas (PAs). We identified ~400,000 Portuguese language tweets pertaining to all categories of Brazilian PAs over a ten-year period (1 January 2011-31 December 2020). We analysed the content of these tweets and calculated metrics of user engagement (likes and retweets) to uncover patterns and drivers of public interest in Brazilian PAs. Our results indicate that users / tweets mentioning PAs remained stable throughout the sample period. However, engagement with tweets grew steeply, particularly from 2018 onward and coinciding with a change in the Brazilian federal government. Furthermore, public interest was not evenly distributed across PAs; while national parks were the subject of the most tweets, mainly related to tourism activities, tweets related to conflicts among park users and managers were more likely to engage Twitter users. Our study highlights that automatic or semi-automatic monitoring of social media content and engagement has great potential as an early warning system to identify emerging conflicts and to generate data and metrics to support PA policy, governance and management.

Temporal Dynamics and Stoichiometry in Notch Signaling - from Notch Synaptic Complex Formation to NICD Nuclear Entry.

Mammalian Notch signaling occurs when binding of Delta or Jagged to Notch stimulates proteolytic release of the Notch intracellular domain (NICD), which enters the nucleus to regulate target gene expression. To determine the temporal dynamics of events associated with Notch signaling under native conditions, we fluorescently tagged Notch and Delta at their endogenous genomic loci and visualized them upon pairing of receiver (Notch) and sender (Delta) cells as a function of time after cell contact. At contact sites, Notch and Delta immediately accumulated at 1:1 stoichiometry in synapses, which resolved by 15-20 min after contact. Synapse formation preceded entrance of the Notch extracellular domain into the sender cell and accumulation of NICD in the nucleus of the receiver cell, which approached a maximum after ∼45 min and was prevented by chemical and genetic inhibitors of signaling. These findings directly link Notch-Delta synapse dynamics to NICD production with unprecedented spatiotemporal precision.

Vaccine-induced neutralizing antibody responses to seasonal influenza virus H1N1 strains are not enhanced during subsequent pandemic H1N1 infection.

The first exposure to influenza is presumed to shape the B-cell antibody repertoire, leading to preferential enhancement of the initially formed responses during subsequent exposure to viral variants. Here, we investigated whether this principle remains applicable when there are large genetic and antigenic differences between primary and secondary influenza virus antigens. Because humans usually have a complex history of influenza virus exposure, we conducted this investigation in influenza-naive cynomolgus macaques. Two groups of six macaques were immunized four times with influenza virus-like particles (VLPs) displaying either one (monovalent) or five (pentavalent) different hemagglutinin (HA) antigens derived from seasonal H1N1 (H1N1) strains. Four weeks after the final immunization, animals were challenged with pandemic H1N1 (H1N1pdm09). Although immunization resulted in robust virus-neutralizing responses to all VLP-based vaccine strains, there were no cross-neutralization responses to H1N1pdm09, and all animals became infected. No reductions in viral load in the nose or throat were detected in either vaccine group. After infection, strong virus-neutralizing responses to H1N1pdm09 were induced. However, there were no increases in virus-neutralizing titers against four of the five H1N1 vaccine strains; and only a mild increase was observed in virus-neutralizing titer against the influenza A/Texas/36/91 vaccine strain. After H1N1pdm09 infection, both vaccine groups showed higher virus-neutralizing titers against two H1N1 strains of intermediate antigenic distance between the H1N1 vaccine strains and H1N1pdm09, compared with the naive control group. Furthermore, both vaccine groups had higher HA-stem antibodies early after infection than the control group. In conclusion, immunization with VLPs displaying HA from antigenically distinct H1N1 variants increased the breadth of the immune response during subsequent H1N1pdm09 challenge, although this phenomenon was limited to intermediate antigenic variants.

Ascending aortobifemoral and adjunct carotid bypass grafts.

We describe a case of simultaneous ascending aortobifemoral and right common carotid artery bypass to treat a symptomatic brachiocephalic artery and juxtarenal chronic total occlusion in a 68-year-old female patient with unfavorable characteristics for endovascular and standard aortofemoral procedures. Mid-term follow-up revealed sustained remission of symptoms, quality of life quality of life improvement, and patent bypass grafts. In highly selected patients, this solution can be useful when treating other intrathoracic diseases, as well as allowing the simultaneous revascularization of two remote arterial beds.

Cross-cultural validation of the Short-Form Vascular Access Questionnaire.

BACKGROUND: Vascular access (VA) is a central condition for hemodialysis (HD). Screening patients' views regarding their VA is a significant end point for improving the quality of care. The Short-form Vascular Access Questionnaire (SF-VAQ) is a specific questionnaire to assess patients' satisfaction levels regarding their VA. PURPOSE: This study aims to develop the Portuguese version of the SF-VAQ and assess its psychometric properties. METHODS: A forward and back translation was used. A multicentric study was conducted with 156 patients undergoing hemodialysis to psychometric testing. Reliability (internal consistency and test-retest) was assessed using Cronbach's alpha and Intraclass Correlation Coefficient. A construct validity test was conducted using factor analysis. The convergent validity was calculated using the correlation coefficient. RESULTS: An obtained Cronbach's alpha of 0.77 indicates good internal consistency. The test-retest reliability was established using the Intraclass Correlation Coefficient (ICC) of 0.771. The four sub-scales proposed by the instrument's designer were confirmed, which together accounted for 53% of the variance. The correlation with the Visual Analogue Scale was r = 0.895 (p < 0.001), confirming the convergent validity. CONCLUSION: The Portuguese version of the SF-VAQ is a valid and reliable instrument with good psychometric properties to be implemented to promote an evaluation of VA satisfaction in HD patients and improve patient care.

Mental Health Professionals' Attitudes Toward Digital Mental Health Apps and Implications for Adoption in Portugal: Mixed Methods Study.

BACKGROUND: Digital health apps are among the most visible facets of the ongoing digital transition in health care, with mental health-focused apps as one of the main therapeutic areas. However, concerns regarding their scientific robustness drove regulators to establish evaluation procedures, with Germany's Digitale Gesundheitsanwendungen program pioneering in app prescription with costs covered by statutory health insurance. Portugal gathers a set of conditions and requirements that position it as an excellent test bed for digital health apps. Its daunting mental health landscape reinforces the potential interest in new interventions. To understand if they would be acceptable, we need to understand the supply side's attitudes and perceptions toward them, that is, those of psychiatrists and psychologists. OBJECTIVE: This study aims to understand the attitudes and expectations of psychiatrists and psychologists toward digital mental health apps (DMHAs) in the Portuguese context, as well as perceived benefits, barriers, and actions to support their adoption. METHODS: We conducted a 2-stage sequential mixed methods study. Stage 1 consisted of a cross-sectional web survey adapted to the Portuguese context that was delivered to mental health professionals and psychologists. Stage 2 complemented the insights of the web survey results with a key opinion leader analysis. RESULTS: A total of 160 complete survey responses were recorded, most of which were from psychologists. This is the most extensive study on mental health professionals' attitudes and perceptions of DMHAs in Portugal. A total of 87.2% (136/156) of the respondents supported the opportunity to prescribe DMHAs. Increased health literacy (139/160, 86.9%), wider adherence to treatment (137/160, 85.6%), and proper disease management (127/160, 79.4%) were the most frequently agreed upon benefits of DMHAs. However, only less than half (68/156, 43.6%) of the respondents planned to prescribe or recommend DMHAs, with psychologists being more favorable than psychiatrists. Professionals faced substantial barriers, such as a lack of information on DMHAs (154/160, 96.3%), the level of initial training effort (115/160, 71.9%), and the need for adjustments of clinical processes and records (113/160, 70.6%). Professionals reported that having more information on the available apps and their suitability for health objectives (151/160, 94.4%), more scientific evidence of the validity of the apps as a health intervention (147/160, 91.9%), and established recommendations of apps by specific clinical guidelines or professional societies (145/160, 90.6%) would be essential to foster adoption. CONCLUSIONS: More information about DMHAs regarding their clinical validity and how they work is necessary so that such an intervention can be adopted in Portugal. Recommendations from professional and scientific societies, as well as from governmental bodies, are strongly encouraged. Although the benefits of and the barriers to using these apps are consensual, more evidence, along with further promotion of mental health professionals' digital literacy, is needed. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/41040.

Economic Impact of a Hospital Cyberattack in a National Health System: Descriptive Case Study.

BACKGROUND: Over the last decade, the frequency and size of cyberattacks in the health care industry have increased, ranging from breaches of processes or networks to encryption of files that restrict access to data. These attacks may have multiple consequences for patient safety, as they can, for example, target electronic health records, access to critical information, and support for critical systems, thereby causing delays in hospital activities. The effects of cybersecurity breaches are not only a threat to patients' lives but also have financial consequences due to causing inactivity in health care systems. However, publicly available information on these incidents quantifying their impact is scarce. OBJECTIVE: We aim, while using public domain data from Portugal, to (1) identify data breaches in the public national health system since 2017 and (2) measure the economic impact using a hypothesized scenario as a case study. METHODS: We retrieved data from multiple national and local media sources on cybersecurity from 2017 until 2022 and built a timeline of attacks. In the absence of public information on cyberattacks, reported drops in activity were estimated using a hypothesized scenario for affected resources and percentages and duration of inactivity. Only direct costs were considered for estimates. Data for estimates were produced based on planned activity through the hospital contract program. We use sensitivity analysis to illustrate how a midlevel ransomware attack might impact health institutions' daily costs (inferring a potential range of values based on assumptions). Given the heterogeneity of our included parameters, we also provide a tool for users to distinguish such impacts of different attacks on institutions according to different contract programs, served population size, and proportion of inactivity. RESULTS: From 2017 to 2022, we were able to identify 6 incidents in Portuguese public hospitals using public domain data (there was 1 incident each year and 2 in 2018). Financial impacts were obtained from a cost point of view, where estimated values have a minimum-to-maximum range of €115,882.96 to €2,317,659.11 (a currency exchange rate of €1=US $1.0233 is applicable). Costs of this range and magnitude were inferred assuming different percentages of affected resources and with different numbers of working days while considering the costs of external consultation, hospitalization, and use of in- and outpatient clinics and emergency rooms, for a maximum of 5 working days. CONCLUSIONS: To enhance cybersecurity capabilities at hospitals, it is important to provide robust information to support decision-making. Our study provides valuable information and preliminary insights that can help health care organizations better understand the costs and risks associated with cyber threats and improve their cybersecurity strategies. Additionally, it demonstrates the importance of adopting effective preventive and reactive strategies, such as contingency plans, as well as enhanced investment in improving cybersecurity capabilities in this critical area while aiming to achieve cyber-resilience.