Touching the cornerstone: An illustrative example of the effects of stigma and discrimination on vaccine-hesitant parents

Objectives

The concept of vaccine hesitancy encompasses multiple views on the subject. However, there has been an increasing polarization of the discourse on vaccine hesitancy leading to the stigmatization of those parents who expressed doubts or concerns regarding vaccination practices. The present study aimed to explore the drivers and consequences of polarized discourses on vaccination in the Portuguese context. This paper is part of a broader study which aims to gain a deeper understanding about the phenomenon of vaccine hesitancy at the European level.

Study design

A qualitative research design was used.

Methods

The sample was comprised of thirty-one Portuguese vaccine hesitant parents who were interviewed. A thematic analysis of the transcribed interviews was performed which allowed us to identify key themes.

Results

The results showed that the labelling of vaccine-hesitant parents as 'anti-vaxxers' along with social media play a crucial role in promoting the polarization of vaccine-related attitudes. The stigmatization of vaccine hesitant parents has a disruptive impact on their social network leading them to search for online platforms where they can exchange vaccines-related information without being discriminated.

Conclusions

The stigma and discrimination experienced by vaccine-hesitant parents stimulated that hesitancy becomes more entrenched. Therefore, pluralism should be used to tailor vaccination promotion campaigns to different targets, promoting its reach and efficacy.

Recruiting a Hard-to-Reach, Hidden and Vulnerable Population: The Methodological and Practical Pitfalls of Researching Vaccine-Hesitant Parents

While recruitment is an essential aspect of any research project, its challenges are rarely acknowledged. We intend to address this gap by discussing the challenges to the participation of vaccine-hesitant parents defined here as a hard-to-reach, hidden and vulnerable population drawing on extensive empirical qualitative evidence from seven European countries. The difficulties in reaching vaccine-hesitant parents were very much related to issues concerning trust, as there appears to be a growing distrust in experts, which is extended to the work developed by researchers and their funding bodies. These difficulties have been accentuated by the public debate around COVID-19 vaccination, as it seems to have increased parents' hesitancy to participate. Findings from recruiting 167 vaccine-hesitant parents in seven European countries suggest that reflexive and sensible recruitment approaches should be developed.

Prevalence Rate of Thalassemia Carriers among Individuals with Microcytosis or Hypochromia in Portugal

INTRODUCTION

Microcytosis and hypochromia result from deficient hemoglobin synthesis in red blood cells and are easily detected in a complete blood count test. These conditions are mainly due to iron nutritional deficiency, but may also result from some genetic diseases, such as thalassemia. The aim of this study was to determine the contribution of β- and α-thalassemia to these abnormal hematological phenotypes in a representative sample of adult individuals living in Portugal who participated in the first Portuguese National Health Examination Survey (INSEF).

MATERIAL AND METHODS

Among the 4808 INSEF participants, 204 had microcytosis, hypochromia or both. The corresponding 204 DNAs were screened for changes in the β-globin gene by next-generation sequencing and Sanger sequencing. In addition, α-thalassemia deletions within the α-globin cluster were investigated by Gap-PCR and multiplex ligation-dependent probe amplification.

RESULTS

In this selected subgroup of INSEF participants, 54 had α-thalassemia (26%), predominantly caused by the -α3.7kb deletion, and 22 were β-thalassemia carriers (11%) mainly due to point mutations in the β-globin gene previously known in Portugal.

CONCLUSION

Thalassemia trait is a frequent cause of microcytosis or hypochromia in Portugal since this genetic condition was found in 37% of the investigated cases.

Distribution and Clinical Significance of HPV16 Variants in Head and Neck Squamous Cell Carcinomas: Data from a Portuguese Cohort and Systematic Review

INTRODUCTION

Genomic variants of the human papillomavirus type 16 (HPV16) are thought to play differential roles in the susceptibility to head and neck squamous cell carcinomas (HNSCC) and its biological behaviour. This study aimed to establish the prevalence of HPV16 variants in an HNSCC cohort and associate them with clinical pathological characteristics and patient survival.

METHODS

We retrieved samples and clinical data from 68 HNSCC patients. DNA samples were available from tumour biopsy at the time of the primary diagnosis. Targeted next-generation sequencing was used to obtain whole-genome sequences, and variants were established based on phylogenetic classification.

RESULTS

74% of samples clustered in lineage A, 5.7% in lineage B, 2.9% in lineage C, and 17.1% in lineage D. Comparative genome analysis revealed 243 single nucleotide variations. Of these, one hundred were previously reported, according to our systematic review. No significant associations with clinical pathological variables or patient survival were observed. The E6 amino acid variations E31G, L83V, and D25E and E7 N29S, associated with cervical cancer, were not observed, except for N29S in a single patient.

CONCLUSION

These results provide a comprehensive genomic map of HPV16 in HSNCC, highlighting tissue-specific characteristics which will help design tailored therapies for cancer patients.

Neutrophile-to-lymphocyte, lymphocyte-to-monocyte, and platelet-to-lymphocyte ratios as prognostic and response biomarkers for resectable locally advanced gastric cancer

BACKGROUND

Perioperative fluorouracil plus leucovorin, oxaliplatin, and docetaxel (FLOT) improves prognosis in locally advanced gastric cancer (LAGC). Neutrophil-to-lymphocyte (NLR), lymphocyte-to-monocyte (LMR), and platelet-to-lymphocyte (PLR) ratios are prognostic biomarkers but not predictive factors.

AIM

To assess blood ratios’ (NLR, LMR and PLR) potential predictive response to FLOT and survival outcomes in resectable LAGC patients.

METHODS

This was a multicentric retrospective study investigating the clinical potential of NLR, LMR, and PLR in resectable LAGC patients, treated with at least one preoperative FLOT cycle, from 12 Portuguese hospitals. Means were compared through non-parametric Mann-Whitney tests. Receiver operating characteristic curve analysis defined the cut-off values as: High PLR > 141 for progression and > 144 for mortality; high LMR > 3.56 for T stage regression (TSR). Poisson and Cox regression models the calculated relative risks/hazard ratios, using NLR, pathologic complete response, TSR, and tumor regression grade (TRG) as independent variables, and overall survival (OS) as the dependent variable.

RESULTS

This study included 295 patients (mean age, 63.7 years; 59.7% males). NLR was correlated with survival time (r = 0.143, P = 0.014). PLR was associated with systemic progression during FLOT (P = 0.022) and mortality (P = 0.013), with high PLR patients having a 2.2-times higher risk of progression [95% confidence interval (CI): 0.89-5.26] and 1.5-times higher risk of mortality (95%CI: 0.92-2.55). LMR was associated with TSR, and high LMR patients had a 1.4-times higher risk of achieving TSR (95%CI: 1.01-1.99). OS benefit was found with TSR (P = 0.015) and partial/complete TRG (P < 0.001). Patients without TSR and with no evidence of pathological response had 2.1-times (95%CI: 1.14-3.96) and 2.8-times (95%CI: 1.6-5) higher risk of death.

CONCLUSION

Higher NLR is correlated with longer survival time. High LMR patients have a higher risk of decreasing T stage, whereas high PLR patients have higher odds of progressing under FLOT and dying. Patients with TSR and a pathological response have better OS and lower risk of dying.

Clostridium difficile Severity and Outcome at a North of Portugal Healthcare Facility

INTRODUCTION

Clostridium difficile infection has been increasingly reported, with a significant healthcare burden and important morbimortality. This study aimed to characterize and describe the severity and outcomes of this event at a Portuguese hospital.

MATERIAL AND METHODS

We conducted a retrospective analysis, by clinical record review, of all confirmed cases diagnosed in a hospital in the North of Portugal, between January 2013 and December 2018. We included those who were non-pregnant and at least 18 years old.

RESULTS

Fifty-seven cases occurred, mostly in females and aged patients; 33.3% were healthcare facility-outset, while 31.6% were community-associated. Regarding severity, 43.9% had non-severe, while 29.8% severe and 21.0% fulminant presentations, the latter with the need of admission. Exposure to antibiotics occurred in 68.4%, while to proton-pump inhibitors in 57.9%. Risk factors for severe disease were female gender, chronic renal disease, and high neutrophil-lymphocyte ratio. Moreover, renal disease and a higher ratio were associated with fulminant disease. Thirty-day all-cause mortality was found in 15.8% while 90-day in 28.1%. Risk factors for 30-day mortality were renal disease, higher Charlson score, and higher neutrophil-lymphocyte ratio. Risk factors for 90-day mortality were advanced age, previous antibiotic exposure, higher Charlson score, and higher neutrophil-lymphocyte ratio.

CONCLUSION

Data concerning Clostridium difficile infection severity and prognosis in Portugal is scarce, and future studies should focus on this important topic.

Perceived need of health care and barriers in access to health services among migrants in Portugal

 

Health care has been pointed out as a key determinant of migrants' health and social integration, but there is evidence of disparities in its access across subgroups. A deeper understanding of the barriers in access to health care, particularly among vulnerable groups, is needed. Our study aims to examine perceived need of health care, access to health services and barriers among migrants in Portugal. A cross-sectional survey was conducted with 1126 adult migrants (53.4% females), originated from African, Middle East, Asian countries and Brazil, living in Portugal for no longer than 10 years. The collected data included sociodemographic characteristics, perceived need of health care, access to health services and difficulties experienced. Differences between groups were analysed through chi-square tests. Results showed that most of the participants (64.7%) have needed health care in the previous 12 months in Portugal. Of these, 87.8% accessed a health care service. However, even needing health care, 3.3% decided not to seek care and 8.8% were not able to access a health care service. Reporting no access to health care was more frequent among migrants with shorter length of stay in the country (&lt;1 year: 19.4% vs. 1 to 5 years: 7.3% and 6 to 10 years: 4.6%; p = 0.001) and those with non-regular migration status (in regularisation process: 11.5% and undocumented: 9.5% vs. documented: 7.2%; p = 0.040). Most common barriers were lack of the National Health Service user card (38%), financial constraints (15%), undocumented status (11%) and language difficulties (7%). Although efforts have been made over the past decades in Portugal to adopt inclusive policies and promote migrants' access to health care, strategies are needed to improve information on migrants' health rights, especially of those undocumented and recently arrived. Economic and language difficulties should be further addressed in comprehensive interventions to promote equal access to health care.

Key messages

Migrants residing in the country for less than a year and those with non-regular migration status reported more frequently not being able to access health care. Despite the efforts to adopt inclusive policies and promote migrants’ access to health care, strategies are needed to improve information on migrants’ health rights and promote equal access to care.

Assessing health literacy among migrants and associated socioeconomic factors

 

Health literacy, the ability to understand, access, appraise, remember and use health information and health services, has great potential to reduce health inequalities and improve access to and quality of health care, particularly among groups that experience vulnerability, including migrant groups. Across Europe, including in Portugal, little is known about the health literacy strengths, needs and preferences among migrants. We aimed to assess the health literacy of diverse migrants living in Portugal and identify if health literacy needs differ across sociodemographic subgroups. A cross-sectional survey was administered to migrants living in Portugal. Data were collected using the Health Literacy Questionnaire (HLQ), an internationally tested and robust multi-dimensional measurement tool with nine scales, and a demographic and socioeconomic questionnaire. Associations were tested using Welch's ANOVA. In total, 1126 adult migrants were surveyed: 53.4% female, mean age of 35.8 years (range 18-77), 48.9% from African countries, 29.5% from Middle East/Asian countries, 21.6% from Brazil. Low scores on most HLQ scales were clearly associated with sociodemographic characteristics such as lower levels of education: 1. Feeling understood and supported by healthcare providers (p = 0.045); 2. Having sufficient information to manage health (p &lt; 0.001); 3. Actively managing health (p = 0.036); 4. Social support for health (p = 0.001); 5. Appraisal of health information (p &lt; 0.001); 7. Navigating the health system (p = 0.031); 8. Finding health information (p = 0.007). Similar patterns were found for participants who were unemployed and with lower income (&lt;650€). Health literacy needs of migrant communities should be taken into account when designing interventions aiming to mitigate health inequalities and to promote health literacy. This is even more pertinent in the current context of the COVID-19, where its adverse social and economic impacts are likely to aggravate health inequalities.

Key messages

Lower health literacy is related to lower socioeconomic status. Mapping health literacy needs can inform interventions to mitigate health inequalities among vulnerable migrant groups.

ATENA-A Novel Rapidly Manufactured Medical Invasive Ventilator Designed as a Response to the COVID-19 Pandemic: Testing Protocol, Safety, and Performance Validation

Background: The urgent need for mechanical ventilators to support respiratory insufficiency due to SARS-CoV-2 led to a worldwide effort to develop low-cost, easily assembled, and locally manufactured ventilators. The ATENA ventilator project was developed in a community-based approach targeting the development, prototyping, testing, and decentralized manufacturing of a new mechanical ventilator. Objective: This article aims to demonstrate ATENA's adequate performance and safety for clinical use. Material: ATENA is a low-cost ventilator that can be rapidly manufactured, easily assembled, and locally produced anywhere in the world. It was developed following the guidelines and requirements provided by European and International Regulatory Authorities (MHRA, ISO 86201) and National Authorities (INFARMED). The device was thoroughly tested using laboratory lung simulators and animal models. Results: The device meets all the regulatory requirements for pandemic ventilators. Additionally, the pre-clinical experiences demonstrated security and adequate ventilation and oxygenation, in vivo. Conclusion: The ATENA ventilator had a good performance in required tests in laboratory scenarios and pre-clinical studies. In a pandemic context, ATENA is perfectly suited for safely treating patients in need of mechanical ventilation.

Evaluation and application of a new scintillator-based heat-resistant back-scattered electron detector during heat treatment in the scanning electron microscope

A new high-temperature detector dedicated to the collection of backscattered electrons is used in combination with heating stages up to 1050°C, in high-vacuum and low-vacuum modes in order to evaluate its possibilities through signal-to-noise ration measurements and different applications. Four examples of material transformations occurring at high temperature are herein reported: grain growth during annealing of a rolled platinum foil, recrystallisation of a multiphased alloy, oxidation of a Ni-based alloy and complex phase transformations occurring during the annealing of an Al-Si coated boron steel. The detector could be potentially adapted to any type of SEM and it offers good opportunities to perform high-temperature experiments in various atmospheres.

Biomarkers and genetic modulators of cerebral vasculopathy in sub-Saharan ancestry children with sickle cell anemia

We investigated biomarkers and genetic modulators of the cerebral vasculopathy (CV) subphenotype in pediatric sickle cell anemia (SCA) patients of sub-Saharan African ancestry. We found that one VCAM1 promoter haplotype (haplotype 7) and VCAM1 single nucleotide variant rs1409419_T were associated with stroke events, stroke risk, as measured by time-averaged mean of maximum velocity in the middle cerebral artery, and with high serum levels of the hemolysis biomarker lactate dehydrogenase. Furthermore, VCAM-1 ligand coding gene ITGA4 variants rs113276800_A and rs3770138_T showed a positive association with stroke events. An additional positive relationship between a genetic variant and stroke risk was observed for ENPP1 rs1044498_A. Conversely, NOS3 variants were negatively associated with silent cerebral infarct events (VNTR 4b_allele and haplotype V) and CV globally (haplotype VII). The -alpha^3.7kb-thal deletion did not show association with CV. However, it was associated with higher red blood cell and neutrophil counts, and lower mean corpuscular volume, mean corpuscular hemoglobin and red cell distribution width. Our results underline the importance of genetic modulators of the CV sub-phenotype and their potential as SCA therapeutic targets. We also propose that a biomarker panel comprising biochemical, hematological, imaging and genetic data would be instrumental for CV prediction, and prevention.

An Overlapping Case of Miller Fisher Syndrome and the Pharyngeal-Cervical-Brachial Variant of Guillain-Barré Syndrome

A 55-year-old Caucasian male presented initially to the emergency room (ER) reporting myalgia, chills and fever. Physical examination and laboratory tests were unremarkable and he was discharged with symptomatic care. He returned to our ER 2 weeks later reporting dizziness, loss of balance, blurred vision, mild dysarthria and bilateral hand paraesthesia. On examination, he presented complete bilateral ophthalmoplegia, mild dysarthria, left finger-to-nose dysmetria, ataxia, areflexia and bilateral hand hypoaesthesia without fever. Blood tests and head computed tomography were normal. The patient was admitted to the Internal Medicine department. On the second day on the ward, the patient presented dysphagia. A head magnetic resonance angiogram showed no signs of ischaemia or vascular disease and a lumbar puncture was performed but no pleocytosis, albumin-cytological dissociation or hypoglycorrhachia was present. Despite the normal results we suspected a Guillain-Barré syndrome variant, and started treatment with intravenous immunoglobulin (IVIG) at a dose of 400 mg per kilogram which continued for 5 days with immediate neurological improvement. We present a rare overlapping case of Miller Fisher syndrome and the pharyngeal-cervical-brachial variant of Guillain-Barré syndrome.

Genetic modulators of fetal hemoglobin expression and ischemic stroke occurrence in African descendant children with sickle cell anemia

Sickle cell anemia (SCA) is an autosomal recessive monogenic disease with significant clinical variability. Cerebrovascular disease, particularly ischemic stroke, is one of the most severe complications of SCA in children. This study aimed to investigate the influence of genetic variants on the levels of fetal hemoglobin (Hb F) and biochemical parameters related with chronic hemolysis, as well as on ischemic stroke risk, in ninety-one unrelated SCA patients, children of sub-Saharan progenitors. Our results show that a higher Hb F level has an inverse relationship with the occurrence of stroke, since the group of patients who suffered stroke presents a significantly lower mean Hb F level (5.34 ± 4.57% versus 9.36 ± 6.48%; p = 0.024). Furthermore, the co-inheritance of alpha-thalassemia improves the chronic hemolytic pattern, evidenced by a decreased reticulocyte count (8.61 ± 3.58% versus 12.85 ± 4.71%; p < 0.001). In addition, our findings have confirmed the importance of HBG2 and BCL11A loci in the regulation of Hb F expression in sub-Saharan African SCA patients, as rs7482144_A, rs11886868_C, and rs4671393_A alleles are significantly associated with a considerable increase in Hb F levels (p = 0.019, p = 0.026, and p = 0.028, respectively). Concerning KLF1, twelve different variants were identified, two of them novel. Seventy-three patients (80.2%) presented at least one variant in this gene. However, no correlation was observed between the presence of these variants and Hb F level, severity of hemolysis, or stroke occurrence, which is consistent with their in silico-predicted minor functional consequences. Thus, we conclude that the prevalence of functional KLF1 variants in a sub-Saharan African background does not seem to be relevant to SCA clinical modulation.

Dual Diagnosis and Treatment: The Experience of a Multiprofessional Team in Mental Health

Introduction

The work was developed with the people hospitalized in the period of 1 year in a psychiatric clinic in Rio de Janeiro city, Brazil. 175 patients who presented dual diagnosis were evaluated.

Objectives

The research aims to know the distribution of the most frequent psychiatric diagnosis associated with the disorders for the use of psychoactive substances. The work also has as objective to assess the treatment of patients carrying these disorders so that there is a better efficiency of the individual treatment plan.

Methods

The work consisted of the evaluation of all patients who were admitted to the clinic in the period of 1 year, using the ICD-10 for the diagnosis of dual pathologies. All the patients were assessed by the multiprofessional team, composed by general practicioner, psychiatrist, psychologist, pharmaceutic, therapist in chemical dependence, family therapist and physiotherapist. The patients were treated with the use of psychopharms, cognitive behavioral psychotherapy, 12-step program, art therapy and moderate physical activity. Family members of all patients were also interviewed.

Results

In the evaluation conducted by the team, it was found the following distribution of the most frequent diagnosis associated to disorder for the use of psychoactive substances: depression (26.3%), personality disorder (22.9%), bipolar disorder (22.3%), non-schizophrenic psychosis (12.6%), schizophrenia (9.1%), and other diagnosis (6.8%).

Conclusions

The formulation of the dual diagnosis provided a better approach of the patients on the part of the team, promoting the strengthening of the therapeutic bond and causing positive impact on the evolution of these disorders.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Obese patients: respiratory complications in the post-anesthesia care unit

INTRODUCTION

Obesity has been associated with respiratory complications, and the majority of these complications occur in the Post-Anesthesia Care Unit (PACU). The aim of this study was to evaluate the outcome and incidence of adverse respiratory events (AREs) in obese patients during their stay in the PACU METHODS: We conducted a prospective control study that included 27 obese patients matched with an equal number of patients with body mass index (BMI)<30 (non-obese control group); the 2 groups of patients were similar in respect to gender distribution, age, and type of surgery and had been admitted into the PACU after elective surgery (May 2011). The AREs were identified during PACU stay. Descriptive analysis of variables was performed, and the Mann-Whitney U test, Chi-square test, or Fisher's exact test were used for comparisons. Associations with AREs were studied using univariate and multivariate logistic regression models.

RESULTS

There was a higher frequency of STOP-BANG ≥3 (89% vs. 11%, P<.001) among obese patients and they were less frequently scheduled to undergo high-risk surgery (7% vs. 41%, P=.005) and major surgery (4% vs. 15%, P=.008). Obese patients had more frequent AREs in the PACU (33% vs. 7%, P<.018). Multivariate analysis identified obesity and residual neuromuscular blockade as independent risk factors for the occurrence of AREs. Stay in the PACU was longer for obese patients (120min vs. 84min, P<.01).

CONCLUSIONS

Obesity was considered an independent risk factor for AREs in the PACU. Obese patients stayed longer in the PACU, but they did not stay longer in the hospital.

Patients with a high risk for obstructive sleep apnea syndrome: postoperative respiratory complications

BACKGROUND

STOP-BANG score (snore; tired; observed apnea; arterial pressure; body mass index; age; neck circumference and gender) can predict the risk of a patient having Obstructive Syndrome Apnea (OSA). The aim of this study was to evaluate the incidence STOP-BANG score≥3, in surgical patients admitted to the Post-Anesthesia Care Unit (PACU).

METHODS

Observational, prospective study conducted in a post-anesthesia care unit (PACU) during three weeks (2011). The study population consisted of adult patients after noncardiac and non-neurological surgery. Patients were classified as high risk of OSA (HR-OSA) if STOP-BANG score≥3 and Low-risk of OSA (LR-OSA) if STOP-BANG score<3 (LR-OSA). Patient demographics, intraoperative and postoperative data were collected. Patient characteristics were compared using Mann-Whitney U-test, t-test for independent groups, and chi-square or Fisher's exact test.

RESULTS

A total of 357 patients were admitted to PACU; 340 met the inclusion criteria. 179 (52%) were considered HR-OSA. These patients were older, more likely to be masculine, had higher BMI, higher ASA physical status, higher incidence of ischemic heart disease, heart failure, hypertension, dyslipidemia and underwent more frequently insulin treatment for diabetes. These patients had more frequently mild/moderated hypoxia in the PACU (9% vs. 3%, p=0.012) and had a higher incidence of residual neuromuscular blockade (NMB) (20% vs. 16%, p=0.035). Patients with HR-OSA had a longer hospital stay.

CONCLUSIONS

Patients with HR-OSA had an important incidence among patients scheduled for surgery in our hospital. These patients had more co-morbidities and were more prone to post-operative complications.

Alpha-1-antitrypsin and transferrin null alleles in the Portuguese population

In a Portuguese family, a null allele was found in the Pi system. An apparent 'exclusion' of the mother was found to be due to the presence of null alleles in mother and child. A transferrin (Tf) null allele was found in a case of disputed paternity. The mother and putative father were heterozygous for Tf null alleles and the child was homozygous (TfQ0) and presented hypotransferrinemia.