Patient and Family Preferences About Place of End-of-Life Care and Death: An Umbrella Review

CONTEXT

The place where people are cared towards the end of their life and die is a complex phenomenon, requiring a deeper understanding. Honoring preferences is critical for the delivery of high-quality care.

OBJECTIVES

In this umbrella review we examine and synthesize the evidence regarding preferences about place of end-of-life care and death of patients with life-threatening illnesses and their families.

METHODS

Following the Joanna Briggs Institute methodology, we conducted a comprehensive search for systematic reviews in PsycINFO, MEDLINE, EMBASE, CINAHL, Epistemonikos, and PROSPERO without language restrictions.

RESULTS

The search identified 15 reviews (10 high-quality, three with meta-analysis), covering 229 nonoverlapping primary studies. Home is the most preferred place of end-of-life care for both patients (11%-89%) and family members (23%-84%). It is also the most preferred place of death (patient estimates from two meta-analyses: 51%-55%). Hospitals and hospice/palliative care facilities are preferred by substantial minorities. Reasons and factors affecting preferences include illness-related, individual, and environmental. Differences between preferred places of care and death are underexplored and the evidence remains inconclusive about changes over time. Congruence between preferred and actual place of death ranges 21%-100%, is higher in studies since 2004 and a meta-analysis shows noncancer patients are at higher risk of incongruence than cancer patients (OR 1.23, 95% CI: 1.01-1.49, I2 = 62%).

CONCLUSION

These findings are a crucial starting point to address gaps and enhance strategies to align care with patient and family preferences. To accurately identify patient and family preferences is an important opportunity to change their lives positively.

Beyond Work: The Role of "Family-Friendly" Practices in the Subjective Well-Being of Teleworkers and On-Site Workers in the COVID-19 Pandemic

During the COVID-19 pandemic, telework emerged as a pivotal strategy to mitigate the spread of the virus. However, telework's feasibility was contingent on job roles. This gave rise to two distinct groups: teleworkers and on-site workers. However, the impacts of social support and well-being extended to both groups. This study investigated the link between organisational and supervisory family support and subjective well-being, examining work engagement as a mediator. Conducted in Portugal, this cross-sectional study surveyed 515 individuals via web-based questionnaires. Data were analysed using descriptive statistics, correlation analysis, confirmatory factor analysis, and multiple-group analysis. The findings revealed a positive correlation between perceived organisational family support (POFS) and work engagement for both groups. Additionally, perceived supervisory family support (PSFS) positively correlated with work engagement for telecommuters but not on-site workers. Furthermore, work engagement was positively associated with subjective well-being for both groups. Moreover, work engagement mediated the relationship between POFS and subjective well-being. This study enriches the literature by analysing POFS, PSFS, work engagement, and subjective well-being dynamics among teleworkers and on-site employees.

EOLinPLACE: an international research project to reform the way dying places are classified and understood

Background

Whenever possible, a person should die where they feel it is the right place to be. There is substantial global variation in home death percentages but it is unclear whether these differences reflect preferences, and there are major limitations in how the place of death is classified and compared across countries.

Objectives

EOLinPLACE is an international interdisciplinary research project funded by the European Research Council aiming to create a solid base for a ground-breaking international classification tool that will enable the mapping of preferred and actual places towards death.

Design

Mixed-methods observational research.

Methods and analysis

We combine classic methods of developing health classifications with a bottom-up participatory research approach, working with international organizations representing patients and informal carers [International Alliance of Patients' Organizations (IAPO) and Eurocarers]. First, we will conduct an international comparative analysis of existing classification systems and routinely collected death certificate data on place of death. Secondly, we will conduct a mixed-methods study (ethnography followed by longitudinal quantitative study) in four countries (the Netherlands, Portugal, Uganda and the United States), to compare the preferences and experiences of patients with life-threatening conditions and their families. Thirdly, based on the generated evidence, we will build a contemporary classification of dying places; assess its content validity through focus groups with patients, carers and other stakeholders; and evaluate it in a psychometric study to examine construct validity, reliability, responsiveness, data quality and interpretability.

Ethics

Approved by the ethics committee of the University of Coimbra, Faculty of Medicine (CE-068-2022) and committees in each of the participating countries.

Discussion

The findings will provide a deeper understanding of the diversity in individual end-of-life pathways. They will enable key developments such as measurement of progress towards achievement of preferences when care can be planned. The project will open new directions in how to care for the dying.

Trial registration

Research Registry UIN 9213.

Phenylpropiolic acid isolated in cryogenic nitrogen and xenon matrices: NIR and UV-induced study

Phenylpropiolic acid (C6H5C≡CCOOH, PPA) isolated in nitrogen and xenon cryogenic matrices was studied by infrared spectroscopy. The experimental studies were complemented by a series of quantum chemical calculations carried out at the density functional theory (B3LYP) and MP2 levels of theory (with different basis sets). The calculations predicted the existence of two planar PPA conformers, differing in the arrangement of the carboxylic group. The higher-energy trans-PPA conformer has a negligible population in the gas phase at room temperature and was prepared in situ in the N2 cryomatrix through vibrationally-induced rotamerization of the lower-energy cis-PPA conformer, achieved using selective narrowband infrared excitation of the OH stretching coordinate of the latter species. Broadband UV (λ > 235 nm) irradiation of matrix-isolated cis-PPA was also undertaken, leading to the observation of cis-PPA → trans-PPA isomerization. No other UV-induced photoreactions were observed. The in situ generated trans-PPA conformer was found to decay back to cis-PPA in the dark by tunneling, and its lifetimes under different experimental conditions were determined. The assignment of the infrared spectra of both conformers is presented, considerably extending the vibrational information available on this molecule.

Acute and chronic effects of the organophosphate malathion on the pancreatic α and β cell viability, cell structure, and voltage-gated K+ currents

Studies indicate that the pesticide malathion may have a role in diabetes. Herein, we determined the effects of different concentrations of malathion on survival, ultrastructure, and electrophysiologic islet cell parameters. Acutely, high concentrations of malathion (0.5 or 1 mM) increased cell death in rat islet cells, while low concentrations (0.1 mM) caused signs of cell damage in pancreatic α and β cells. Exposure of RINm5F cells to malathion for 24 or 48 h confirmed the reduction in β-cell viability at lower concentrations (0.001-100 µM). Chronic exposure of mouse pancreatic α and β cells to 3 nM of malathion led to increased voltage-gated K⁺ (K_v) currents in α-cells. Our findings show a time and concentration dependency for the malathion effect on the reduction of islet cell viability and indicate that pancreatic α cells are more sensitive to malathion effects on K_v currents and cell death.

Parenting in Cerebral Palsy: Understanding the Perceived Challenges and Needs Faced by Parents of Elementary School Children

Cerebral palsy (CP) can be considered the most frequent childhood physical disorder. The severity and type of dysfunction depend on the brain injury. Movement and posture are the most affected areas. CP is a lifelong condition, and parenting a child with this disorder brings additional challenges (e.g., dealing with grief) and needs (e.g., information). Identifying and characterizing their challenges and needs are pivotal to enrich the knowledge in this field and help draw more suitable support for parents. Interviews with 11 parents of children with CP attending elementary school were conducted. The discourse was transcribed, and a thematic analysis was performed. Three themes emerged from the data: (i) challenges of parenting a child with CP (e.g., internal challenges), (ii) crucial needs for parents to cope with a child with CP (e.g., information), and (iii) the intersection between challenges and needs of parents of children with CP (e.g., unawareness). Regarding the challenges and needs characterization, lifespan was the most frequent period of child development, and the microsystem was the context of life most reported. The findings may inform the design of educational and remediation interventions to support families of children with CP attending elementary school.

Effect of the COVID-19 pandemic on the frequency of emergency department visits in Portugal: An interrupted time series analysis until July 2021

Objectives

This study aims to evaluate the effect of the COVID-19 pandemic on the frequency of emergency department (ED) visits in Portugal between March 2020 and July 2021.

Methods

We used data on the monthly number of visits for all public hospitals' EDs from mainland Portugal between January 2017 and July 2021. We studied the impact of the pandemic overall, by type of ED (general, pediatric, and obstetric) and by Manchester Triage System color (red, orange, yellow, green, and blue) using an interrupted time series analysis. The prepandemic period corresponded to the months from January 2017 to February 2020 and the pandemic period to the months from March 2020 to July 2021.

Results

We observed over 26 million ED visits, the majority in general EDs (74.0%) and triaged yellow (48.4%) or green (38.4%). During the pandemic period, ED visits decreased 45.7% (95% confidence interval [CI]: -39.8% to -51.2%) and pediatric ED visits decreased by 72.4% (95% CI: -64.6% to -78.6%). A decrease was observed for all colors but tended to be progressively smaller as the priority increased. There was an increase in ED visits during the pandemic period (2.3%; 95% CI: 1.4% to 3.2%), eventually returning to prepandemic values.

Conclusion

Our data indicate a considerable and long-lasting effect of the COVID-19 pandemic affecting mainly pediatric and milder cases, which were returning toward prepandemic values as the pandemic progressed. In a country with frequent use of EDs, the health system may need to be prepared to respond to prepandemic baseline ED demand, together with additional demand because of long-term sequels of COVID-19 cases and delayed care for chronic and acute conditions.

The Pandemic-Related Factors Associated with Emergency Department Visits in Portugal throughout Two Years of the Pandemic: A Retrospective Population-Based Study

The COVID-19 pandemic has affected the use of emergency departments (ED) worldwide. This study identifies the pandemic-related factors associated with the number of ED visits in mainland Portugal and each of its regions. We collected data on ED visits from March 2020 to March 2022. Data on incidence, vaccination, mobility, containment index, and Google search volume were retrieved from open online sources at different time points. We fitted a quasi-Poisson generalized linear regression model, and each variable was modeled separately and adjusted for time and month. There was a positive ED trend throughout the two years of the pandemic in mainland Portugal and each of its regions. In the mainland, during months with high workplace mobility, there were 10.5% more ED visits compared to months with average mobility. ED visits decreased in months with low mobility for retail and recreation, groceries and pharmacies, and transit compared to months of medium mobility. Portugal saw a reduction in ED utilization during the pandemic period, but with a positive trend from March 2020 to March 2022. The change in the population's behavior of seeking the ED throughout the pandemic might be associated with mobility, incidence, and pandemic fatigue.

Unintended intrapleural insertion of an epidural catheter in thoracic surgery: regional analgesia game over, or is there another way out?

In thoracic surgery, optimized pain control is crucial to prevent dysfunction in cardiorespiratory mechanics. Epidural anesthesia (EA) and paravertebral block (PVB) are the most popular techniques for analgesia. Unintended intrapleural insertion of an epidural catheter is a rare complication. Our report presents a case of a patient submitted to pulmonary tumor resection by video-assisted thoracoscopic surgery (VATS). There was difficulty in epidural insertion related to patient's obesity, but after general anesthesia induction, no additional intravenous analgesia was needed after epidural injection. Surgery required conversion to thoracotomy, with intrapleural identification of epidural catheter. At the end of surgery, surgeons reoriented catheter to paravertebral space, with leak absence confirmation after local anesthetic injection through the catheter. In postoperative period, pain control was efficient, with no complications. It was a successful case that shows that when we find unexpected complications, we can look for alternative solutions to give our patient the best treatment.

Association between perception of COVID-19 risk, confidence in health services and avoidance of emergency department visits: results from a community-based survey in Portugal

OBJECTIVES

To examine the association between the perception of COVID-19 risk, confidence in health services and avoidance of emergency department (ED) visits in Portugal during the COVID-19 pandemic.

DESIGN

Community-based, cross-sectional survey.

SETTING

Volunteer sample that completed the online survey between April 2020 and May 2021.

PARTICIPANTS

987 participants who perceived needing ED care. Of those, 242 reported avoiding ED visits.

OUTCOME MEASURES

Logistic regression models for ED avoidance were conducted to estimate the effect of risk perception and confidence in health services, adjusted for sociodemographics, health status and time.

RESULTS

The adjusted odds for ED avoidance were higher for participants lacking confidence in health service response to non-COVID-19 conditions (adjusted OR: 6.39; 95% CI 3.19 to 12.82) and COVID-19 (1.81; 1.19 to 2.77) and lower for those perceiving a low risk of being infected at a health provider (0.16; 0.07 to 0.38).

CONCLUSION

In our sample, confidence in health services and risk perception of infection at a health provider were associated with the decision to avoid the ED. These results suggest that policymakers and care providers need to mitigate the negative consequences of delayed healthcare; be aware of the implications of distrust and fear from those in need of healthcare and provide equally distributed safe alternatives to ED care.

Exosomal glypican-1 discriminates pancreatic ductal adenocarcinoma from chronic pancreatitis

BACKGROUND AND AIMS

Pancreatic ductal adenocarcinoma (PDAC) diagnosis can be difficult in a chronic pancreatitis (CP) background, especially in its mass forming presentation. We aimed to assess the accuracy of glypican-1-positive circulating exosomes (GPC1+crExos) to distinguish PDAC from CP versus the state-of-the-art CA 19-9 biomarker.

METHODS

This was a unicentric prospective cohort. Endoscopic ultrasound with fine-needle aspiration or biopsy and blood tests (GPC1+crExos and serum CA 19-9) were performed.

RESULTS

The cohort comprised 60 PDAC and 29 CP (7 of which mass forming - MF) patients. Median levels of GPC1+crExos were significantly higher in PDAC (99.7%) versus CP (28.4%; p<0.0001) with an AUROC of 0.96 with 98.3% sensitivity and 86.2% specificity for a cut-off of 45.0% (p<0.0001); this outperforms CA 19-9 AUROC of 0.82 with 78.3% sensitivity and 65.5% specificity at a cut-off of 37 U/mL (p<0.0001). The superiority of% GPC1+crExos over CA 19-99 in differentiating PDAC from CP was observed in both early (stage I) and advanced tumors (stages II-IV).

CONCLUSION

Levels of GPC1+crExos coupled to beads enable differential diagnosis between PDAC and CP including its mass-forming presentation.

Mastering new technologies: does it relate to teleworkers’ (in)voluntariness and well-being?

Purpose

This study aims to examine the associations among mastering new technologies, teleworkers’ voluntariness and involuntariness and employee well-being (i.e. work engagement and exhaustion). To the best of the authors’ knowledge, no studies have explored the relationships among these constructs in the same conceptual model.

Design/methodology/approach

Data were collected from a sample of 451 individuals performing telework in Portugal. AMOS was used to test all hypotheses of the study.

Findings

The findings showed a positive relationship between mastering new technologies and teleworkers’ voluntariness and a negative relationship between mastering new technologies and teleworkers’ involuntariness. However, contrary to expectations, voluntariness in teleworking was not significantly related to either work engagement or exhaustion. However, consistent with the theoretical background of self-determination theory, involuntariness in teleworking was negatively related to work engagement and positively related to exhaustion.

Originality/value

This study contributes to the literature by addressing the analysis of telework-related variables that may impact workers’ well-being. Implications for human resource management policies and knowledge management are discussed.

Emergency department and hospital utilisation and expenditures in the last year of life: retrospective chronic diseases cohort study

OBJECTIVES

We aimed to examine the influence of chronic diseases in emergency department (ED) and inpatient utilisation and expenditures in the 12 months before death.

METHODS

Retrospective cohort study of ED and inpatient database. Adults deceased at a hospital in Portugal in 2013 were included. We tested the influence of chronic diseases on the number of ED visits, hospital admissions and expenditures using generalised linear models.

RESULTS

The study included 484 patients (81.8% ≥65 years, median two chronic diseases). Nearly all (91.3%) attended the ED in the 12 months before death. The median number of admissions was 1, median expenditure was €6159. Adjusting for confounders, chronic pulmonary disease increased ED and inpatient utilisation (1.49; 95% CI: 1.22 to 1.83; 95% CI 1.29, 1.09 to 1.51). Increased ED utilisation was observed for patients with renal disease, dementia and metastatic solid tumour (1.40, 95% CI 1.15 to 1.71; 1.39, 95% CI 1.11 to 1.75; 1.31, 95% CI 1.07 to 1.60). Other malignancies showed increased inpatient utilisation (1.24, 95% CI 1.09 to 1.42). The number of chronic conditions had a considerable effect on expenditures (3: 2.08, 95% CI 1.44 to 2.99; ≥4: 4.02, 95% CI 2.51 to 6.45).

CONCLUSION

We found a high use of hospitals at the end of life, particularly EDs. Our findings suggest that people with cancer, renal disease, chronic pulmonary disease and dementia are relevant when developing cost-effective alternatives to hospital care.

Tell me who your friends are?! The mediating role of friends use in cannabis abuse

OBJECTIVE

To evaluate the relationship between onset age of cannabis use and cannabis abuse testing the mediating role of the number of friends using cannabis with a sample of Portuguese cannabis users. Comparing men and women regarding these relationships.

METHOD

A sample of 529 Portuguese cannabis users, composed of 276 men and 244 women, aged from 14 to 21 years, completed a sociodemographic questionnaire, the Cannabis Abuse Screening Test and four questions related to cannabis use. Data were analyzed using the PROCESS macro in SPSS version 26.0.

RESULTS

The onset age of cannabis use was negatively related to the number of friends using cannabis, while the number of friends using cannabis showed a positive relationship with cannabis abuse. As predicted, the number of friends using cannabis seems to have a mediating role in the relationship between the onset age of cannabis use and cannabis abuse since the indirect effect was found to be significant. The pattern of the relationships among the variables observed was found to be similar both for the male and women' samples. However, males reported higher cannabis abuse than females.

CONCLUSION

Results highlight the mediating role of the friends' using cannabis in the relationship between the onset age of cannabis use and users' abuse. Results highlight the importance of early intervention to cannabis use. Particularly, the pattern of the relationships observed among the studied variables emphasized the need to monitor and peer training intervention or the promotion of social skills.

Healthcare system delay and utilization in tuberculosis patients in Portuguese high-incidence region

Background

In Portugal, the Tâmega e Sousa region (TeS) has a high incidence of tuberculosis (TB) [27.4 and 43.8 per 100.000 inhabitants in sub-regions Baixo Tâmega (BxT) and Vale do Sousa Sul (VSS), 2017]. Delay in TB diagnosis leads to increased transmission, which may lead to more people infected. This study aimed to describe healthcare system delay among TB patients and healthcare utilization from symptoms onset to diagnosis in TeS.

Methods

We analysed pulmonary TB cases notified in BxT and VSS in 2014-7 in the national surveillance system (SVIG-TB). Concomitantly, we analysed healthcare utilisation from patients in a retrospective study (URBAN-TB) about TB delays in 2019-20. We characterised demographics of patients from each data source and comorbidities from SVIG-TB. We calculated median overall delay until diagnosis (days); and healthcare delay overall and by patient characteristics, for each sub-region. Delay was calculated only when relevant dates were recorded. Healthcare utilisation from symptoms onset to diagnosis was described using the frequency of each first contact provider and the average number of visits until diagnosis.

Results

Included 139 patients from BxT and 206 from VSS (83% male, 53% aged 40-59y, and 17% with silicosis). Global delays were 48 and 75 days (n = 57/132; BxT and VSS). Healthcare delays were 7 and 8 days (n = 76/180; BxT and VSS). In both ACES, healthcare delays were longer for patients aged 60-79y, with COPD and aged 0-19y. Healthcare utilisation analysis included 38 patients (89% male; 55% aged 40-59y; n = 17/21). Primary care (n = 15; 39%) and emergency department (ED) (n = 9; 24%) were frequent points of first contact. The average number of visits until diagnosis was higher for patients from ED (3.9) and lower for patients from TB specialised units (1.3).

Conclusions

Our results suggest that in TeS it is important to avoid ED as a point of first contact of TB patients and to facilitate the diagnosis in young, older and COPD patients.

Key messages

Emergency department is a relevant point of first contact and may be included in efforts to reduce tuberculosis delay. Policies to reduce tuberculosis delay may target younger, older and COPD patients.

Factors associated with avoidance of emergency department visits in Portugal during the pandemic

Background

Avoiding an emergency department (ED) visit risks irreversible negative consequences for patients' health. EDs are a frequent access point to the Portuguese health system. Previous studies have shown that patients may avoid visiting ED during the pandemic. This study aims to identify factors associated with avoidance of ED visits in Portugal during the COVID-19 pandemic.

Methods

We used data from a community-based survey, “COVID-19 Barometer: Social Opinion”, which includes healthcare utilisation, health status, and risk perception in Portugal from 11th April 2020 to 16th April 2021. We included respondents that reported having needed ED care. Data were collected on sociodemographics, health status (comorbidities, mental health), risk perception (COVID-19 and complications), level of trust in health services and self-assessment of the severity of the reason for ED visit. The outcome of interest was the decision to avoid ED care. We used logistic regression to identify factors associated with the decision to avoid ED.

Results

Preliminary data showed that 914 respondents reported needing ED care (74.8% female; mean age 43 years). From those, 224 (25%) decided to avoid ED care. ED visits avoidance was higher during lockdowns (28%). People reporting specific comorbidities (cardiac, autoimmune, respiratory) avoided ED more than those without them. Perception of no severe reason for ED visit, poor mental health, perception of higher risk of COVID-19 and complications, and low trust in health services response to the pandemic were associated with higher odds of ED visit avoidance.

Conclusions

People avoiding ED visits represented a considerable share. The decision to avoid ED visit was associated with clinical characteristics, but the perception of risk and assessment of the context and health system response also played a role in decision making.

Key messages

The effect of avoided ED visits on health should be a research and policy concern. People with certain comorbidities or perception of high risk of COVID-19 and complications may be closely monitored.

Resistant hypertension must be defined by ambulatory blood pressure and pulse pressure is best predictor of new cardiovascular events

Introduction

Resistant Hypertension (RH) defined by Ambulatory blood pressure monitoring (ABPM) isn't so common. Prognostic CV by ABPM of RH is uncertain.

Objective

RH Population defined by ABPM, followed 5.9±5.0 years and prognostic value of ABPM for new CV events (CVe).

Design and method

ABPM-collected 1999–2019. Identified RH patients by ABPM. Obtained anthropometric, clinic, laboratorial data from the patient and clinical records. CVe defined by: stroke (ST) (Ischemic (STisq), haemorrhagic (SThs)), Coronary Event (CD), Other CV events (OCV) (acute heart failure (HF), peripheral arterial disease (PAD). Follow-up finished with event, last evaluation of the patient or death.

Results

258 patients, follow-up – 5.9±5.0 years,158 males, mean age – 60.4±11 years. Diabetes Mellitus (DM) 45.3%, Dyslipidaemia 74.4%, Obesity 45.3%, Chronic Kidney Disease 37.2%, previous CVe (PCVe) 34.5%. Observed 68 CVe: 26 ST (21 STisq, 5 SThs), 21 CD, 21 OCV (15 HF, 6 PAD). 18 death (8 unknown, 1 infection, 2 cancer, 1 sudden death, 2 STisq, 1 CD, 3 HF). When compared those with event vs no-event (fig. 1), in T student to independent samples, those with event had larger left atrium (42.6±5.7 vs 40.2±4.7, p&lt;0.05), lower creatinine clearance (mL/min/1.73m2) (63.6±34 vs 74.5±33). PCVe was significantly more prevalent on those with event (c 9.8, p&lt;0.01). In a multivariate Cox analysis for the risk of CVe (adjusted to age, gender, DM, PCVe, glycemia, creatinine, number of antihypertensive), Day Pulse Pressure with cut-off 60mmHg was statically significant (HR 2.46 (95% CI 1.26–4.83), p&lt;0.01). In Kaplan-Meier survival curve free of events, the best CV predictor obtained was the cut-off 60mmHg of PP (24h, Day, night PP), mostly Day PP-60mmHg (log rank 9.27, p&lt;0.01) (fig. 2A). When analyzed for those who had Stroke, in the multivariate Cox analysis 24h SBP (p&lt;0.05, HR 1.04 (95% CI 1.00–1.07), and night SBP (p&lt;0.05, HR 1.03 (95% CI 1.00–1.06) were statically significant on top of age, gender, DM, PCVe, glycemia, creatinine, number of antihypertensive. In Kaplan-Meier survival curve free of events, the best CV predictor obtained was the cut-off 60mmHg PP, mostly Day PP 60mmHg (log rank 8.5 p&lt;0.01) (fig. 2B). For those who had CD in the multivariate Cox analysis, adjusted for other variables, 24h SBP (p&lt;0.05, HR 1.04 (95% CI 1.00–1.07), and night SBP (p&lt;0.05 HR1.03 (95% CI 1.00–1.06) were statically significant. In Kaplan-Meier survival curve free of events, night PP 60mmHg predicted CD events (log rank 4.42 p&lt;0.05) (fig. 2C). For OCV the multivariate Cox analysis, adjusted for other variables, 24h PP (p&lt;0.05, HR 1.04 (95% CI 1.00–1.07) and night SBP (p&lt;0.05, HR 1.03 (95% CI 1.00–1.06) were statically significant for new OCV. In Kaplan-Meier survival curve free of events, best predictor was mostly night PP 60mmHg (log rank 19, p&lt;0.001) (fig. 2D).

Conclusion

In our sample of RH the definition by ABPM is essential. PP is the key prognosis for future CVe, special if analysed by the cut of PP-60 mmHg.

Funding Acknowledgement

Type of funding sources: None. Kaplan-Meier survival curves

Aerobic exercise training reduces blood pressure, angiotensin II and oxidative stress of patients with resistant hypertension: the EnRiCH trial

Introduction

Resistant hypertension is a major challenge of modern cardiovascular medicine, as it is a puzzling problem without a clear solution. Exercise training clearly reduces blood pressure (BP) and oxidative stress in patients with hypertension, however evidence is limited regarding resistant hypertension.

Purpose

To determine the effect of an aerobic exercise training program in BP, angiotensin II and oxidative stress in patients with resistant hypertension.

Methods

EnRicH is a prospective, two-center, single-blinded, randomized controlled trial with a parallel two-arm group. Sixty patients with resistant hypertension were randomly assigned in a 1:1 ratio to undergo a 12-week aerobic exercise training program (exercise) or usual care (control). The powered primary efficacy measure was 24-hour ambulatory systolic BP change from baseline. Secondary outcome measures included daytime and nighttime ambulatory BP, office BP, cardiorespiratory fitness, and oxidative stress and inflammatory biomarkers: Interferon-gamma (IFN-y), Angiotensin II, vascular endothelial growth factor (VEGF), and superoxide dismutase (SOD).

Results

Fifty-three patients (exercise n=26, control n=27) completed the study. Patients were mainly women (54.7%), with an office BP of 140.7±15.9/84.2±9.4 mm Hg and taking an average of 4.6 antihypertensive medications (median, 5; range, 3 to 7). At baseline, no differences were found between groups for the study outcomes and patient characteristics. Ambulatory systolic BP was reduced −7.1 mm Hg (95% CI, −12.8 to −1.4; P=0.015) in the exercise group (127.4±12.2 to 121.2±12.2, p=0.007) compared to control group (126.1±17.2 to 126.9±15.2, p=514) over 24-hour. In addition, 24-hour ambulatory diastolic BP (−5.1 mm Hg, −7.9 to −2.3, P=0.001), daytime ambulatory systolic (−8.4 mm Hg, −14.3 to −2.5, P=0.006), and diastolic BP (−5.7 mm Hg, −9.0 to −2.4, P=0.001) were also reduced in the exercise group compared to the control group. There were no differences in the change of nighttime ambulatory BP between groups. Cardiorespiratory fitness improved in the exercise group by 14% (4.7 ml.kg-1.min-1, P&lt;0.001), while it remained unchanged in the control group (−0.37 ml.kg-1.min-1, P=0.442). A significant between-group difference in favor of exercise group was found for IFN-y (−4.3 pg/mL, 95% CI: −7.1 to −1.5; P=0.003), Angiotensin II (−157.0 pg/mL, 95% CI: −288.1 to −25.9; P=0.020), VEGF (10.53 pg/mL, 95% CI: 0.60 to 22.54; P=0.035), and SOD (0.35 pg/mL, 95% CI: 0.10 to 0.58; P=0.009).

Conclusions

A 12-week moderate intensity aerobic exercise program reduced ambulatory BP, angiotensin II and oxidative stress in patients with resistant hypertension. The antihypertensive effects of exercise in patients with resistant hypertension may be mediated by positive changes in oxidative stress and inflammatory biomarkers.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): European Union through European Regional Development Fund – Operational Competitiveness Factors Program (COMPETE)Portuguese Government through FCT - Foundation for Science and Technology

Perceived overqualification and contact center workers’ burnout: are motivations mediators?

Purpose

The purpose of this paper is to test the direct effect of the perceived overqualification on the burnout syndrome and the indirect effect through the workers’ autonomous and controlled motivation.

Design/methodology/approach

The hypotheses were tested with a sample of 3,256 contact center operators from one Portuguese company and data were analyzed using the software package Mplus to conduct structural equation models.

Findings

The results revealed that workers’ perceived overqualification is positively related to burnout and that both autonomous and controlled motivation partially mediates this relationship.

Research limitations/implications

The cross-sectional design should be regarded as a limitation. Moreover, each variable was only assessed with self-reported measures, the sample comprised call center employees from only one company and one country (Portugal), and the workers were all employed in commercial services of telecommunications, energy, banking or insurance companies, which may constrain the generalization of these results.

Practical implications

Workers’ perceived overqualification should be avoided to prevent their burnout. Furthermore, an increase in workers’ skills and competencies, enhanced decision latitude, and the task variety and quality should be crucial for employees to develop more autonomous motivation to work in a contact center and the promotion of their well-being at work. More precisely, as overqualification concerns the employees’ perceptions of surplus education, experience and knowledge, from a practical perspective, enhancing the decision latitude, task variety and quality of these individuals’ work may contribute to decreasing individuals’ perception of overqualification and, therefore, contribute to increasing workers’ autonomous motivations and well-being.

Originality/value

This study provides evidence concerning the mediating role of both workers’ autonomous and controlled motivation to explain the relationship between perceived overqualification and burnout.

May the brief physical activity assessment tool accurately measure physical activity in patients with resistant hypertension?

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): FEDER Funds through the Operational Competitiveness Factors Program—COMPETE National Funds through the Portuguese Foundation for Science and Technology (FCT) “PTDC/DTP-DES/1725/2014”. SL is a PhD fellow supported by the FCT (Grant Ref: SFRH/BD/129454/2017).

Introduction

Resistant hypertension is a major health problem due to the increased risk of cardiovascular events and mortality. Physical activity and exercise reduces blood pressure in resistant hypertension and is associated with lower cardiovascular risk and mortality. It is presently recommended that physical activity assessment should be a priority in all visits to health settings

Purpose

This study aims to determine if the Brief Physical Activity Assessment Tool (BPAAT), a 2-question tool to assess physical activity, is a valid instrument to detect inactive patients with resistant hypertension. 

Methods

Sixty patients with a diagnosis of resistant hypertension were recruited. Outcome measures included clinical data, blood pressure and daily physical activity. Physical activity was objectively measured over a 7-day period with an accelerometer and subjectively assessed (self-assessment) by the BPAAT. The association between the BPAAT and accelerometry, according to the BPAAT scoring categories, was assessed bythe percentage of agreement, Cohen’s Kappa and sensitivity and specificity.

Results

Patients (33 were male) had a mean age of 59.4 ± 9.1years, were on average overweight (BMI 29.5 ± 4.5 kg/m2) and on an average of 4.5 ± 0.7 antihypertensive medications. Forty-two patients (70%) were classified as insufficiently active by the BPAAT compared to the 38 (63.3%) insufficiently active patients identified by the accelerometry data. Regarding the questionnaire’s specificity and sensitivity, the BPAAT correctly identified 32 [84.2 (73.1 – 95.3) %] of the 38 ‘insufficiently active’ patients and 12 [54.5 (34.3 – 74.7) %] of the 22 ‘sufficiently active’ patients identified by accelerometry. The agreement between BPAAT and accelerometry to identify sufficiently/insufficiently active patients, according to the BPAAT’s cut-off values was fair to moderate (Kappa = 0.403 (0.162 – 0.674), with a percentage of agreement of 73.3%.

Conclusion

The BPAAT, a 2-question tool to assess physical activity, seems to be a valid and fast solution to identify insufficiently active adults with resistant hypertension during routine clinical visits.

Higher levels of physical activity is associated with lower arterial stiffness in patients with resistant hypertension

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Portuguese Foundation for Science and Technology (FCT) European Regional Development Fund – Operational Competitiveness Factors Program (COMPETE)

Background

 Physical activity has been associated with reduced arterial stiffness in patients with hypertension. However, in resistant hypertension, a specific population with an increased risk for target organ damage, cardiovascular morbidity, and mortality, the evidence is sparse. 

Purpose

 The present study aimed to determine the association between daily physical activity and arterial stiffness in patients with resistant hypertension.

Methods

 Fifty-seven patients with resistant hypertension were recruited. Physical activity was objectively assessed during 7 consecutive days with accelerometers. Arterial stiffness was evaluated using carotid-femoral pulse wave velocity (cf-PWV) . 

Results

 Participants (50.9% men), aged 58.8 ± 9.4 years, were mainly overweight and were taking in average 4.5 antihypertensive medications. The cf-PWV showed an inverse correlation with light-intensity physical activity (r = -0.290, p = 0.029) and total daily physical activity (r = -0.287, p = 0.030). Additionally, cf-PWV tended to be inversely associated with the number of steps per day (r = -0.242, p = 0.069). Patients with higher risk of cardiovascular events (cf-PWV ≥ 10 m/s) tended to spend less time in light-intensity physical activity (324.0 ± 129.4 vs. 380.5 ± 103.1 min/day, p = 0.090) and to perform less total daily physical activity (351.5 ± 141.7 vs. 411.7 ± 109.1 min/day, p = 0.091) than participants with cf-PWV below the risk threshold value.

Conclusions

 Higher levels of total physical activity and daily levels of light-intensity were associated to lower arterial stiffness. These results emphasize the importance of physical activity as a nonpharmacological tool for patients with resistant hypertension.

Risk assessment of wildlife-watching tourism in an important endangered loggerhead turtle rookery

Wildlife-watching tourism is a non-exploitative activity that can contribute to sustainable economic development of coastal communities. However, it is important to assess the potential impact and implement best practices to mitigate any negative effects of such tourism. We studied this issue on Boa Vista (Cabo Verde), which supports around 60% of nesting activity of one of the most endangered loggerhead turtle rookeries globally. Between 2013 and 2016, authorized turtle watching involved 4942 tourists, generating a mean annual direct income of >USD 289000 and the direct creation of >250 jobs. On João Barrosa beach, which supports around 20% of nests and 48% of turtle-watching activity on the island, we tested the influence of turtle watching on nesting behavior, reproduction and nest-site fidelity. Nesting females observed by tourists spent significantly less time on nest-camouflaging behavior, although all other phases of nesting were unaffected. There were no statistically significant differences between the re-nesting frequency of females watched (n = 187) and non-watched (n = 972) by tourists. We found no evidence that the current turtle-watching intensity has an effect on turtle reproduction. Turtle poaching remains a severe threat on beaches with no turtle watching, although it has strongly decreased on beaches with tourist visits. We suggest tour guides follow best practice guidelines to minimize disturbance, specifically retreating from the immediate vicinity of a female during nest camouflaging to mitigate the observed impact.

Hospitalizations at the End of Life Among Chronic Obstructive Pulmonary Disease and Lung Cancer Patients: A Nationwide Study

CONTEXT

Patients with chronic obstructive pulmonary disease (COPD) and lung cancer report several symptoms at the end of life and may share palliative care needs. However, these disease groups have distinct health care use.

OBJECTIVES

To compare the frequency and length of hospitalizations during the last month of life between patients with COPD and lung cancer, assessing the main characteristics associated with these outcomes.

METHODS

Data were retrieved from the Portuguese Hospital Morbidity Database. Deceased patients in a public hospital from mainland Portugal (2010-2015), with COPD as the main diagnosis of the last hospitalization (n = 2942) were sex and age matched (1:1) with patients with lung cancer. The association of patients' main diagnosis, and individual, hospital and area of residence characteristics, on frequency (>1) and length (>14 days) of end-of-life hospitalizations were quantified through adjusted odds ratio (OR) and respective 95% confidence intervals (CIs).

RESULTS

Hospitalizations for >14 days during the last month of life were more likely for lung cancer patients than COPD patients (OR = 1.12; 95% CI = 1.00-1.25). Among patients with COPD, male sex (OR = 1.50; 95% CI = 1.25-1.80) and death in a large hospital (OR = 1.82; 95% CI = 1.41-2.35) were positively associated with longer hospitalizations; the occurrence of >1 hospitalization and hospitalizations for >14 days were less likely among those from rural areas (OR = 0.72, 95% CI = 0.55-0.94; OR = 0.67, 95% CI = 0.54-0.83, respectively). In patients with lung cancer, male sex was negatively associated with longer hospitalizations (OR = 0.82; 95% CI = 0.69-0.98).

CONCLUSION

At the end of life, patients with lung cancer had longer hospitalizations than patients with COPD, and the main characteristics associated with the frequency and length of hospitalizations differed according to the patients' main diagnosis.

Post-Traumatic Stress Disorder in the Military Police of Rio de Janeiro: Can a Risk Profile Be Identified?

Background: Significant exposure to critical incidents characteristic of military police work has a potentially traumatic effect and multiple consequences for the mental health of these professionals, such as Post Traumatic Stress Disorder (PTSD). This study aims to investigate the occurrence of PTSD in this occupational group and its correlations with socio-demographic and occupational variables. Methods: This is a cross-sectional study of Rio de Janeiro’s Military Police officers (n = 3.577). Data was collected from self-reported questionnaires applied in an institutional health program. Post-Traumatic Stress Disorder Checklist—Civilian version was used to assess PTSD. Results: Rates of 16.9% for full PTSD and 26.7% for partial PTSD were found. Based on logistic regression analysis, female officers and police officers in lower ranks of the military hierarchy and performing administrative duties were found to be at most risk of developing PTSD. Conclusions: These results suggest the need to further understand the predictive organizational and individual variables of PTSD correlated with the increased vulnerability of professionals in order to contribute to institutional policies for the prevention and rehabilitation of these cases.

Inpatient Hospitalizations during the First Wave of COVID-19 in Portugal

The objective of this study was to analyze the impact of the pandemic on inpatient hospital admissions during the first wave in Portugal. Data from hospital admissions in mainland Portugal from 2008 to 2017 were used to forecast inpatient hospital admissions for March to May 2020. The observed number of hospitalizations and their characteristics were compared to forecasted values. Variations were compared by hospital and region. Statistical analysis was used to investigate whether patterns of variations existed according to hospital characteristics. There were 119,315 fewer hospitalizations than expected during March to May 2020 in Portugal, which represented a 57% reduction. Non-COVID-19 hospitalizations had a higher mean length of stay and proportion of inpatient deaths than forecasted values. Differences between observed and forecasted values varied greatly among regions and hospitals. These variations were not associated with COVID-19 hospital admissions, region, forecasted number of hospitalizations, type of hospital, or occupation rate. The impact on inpatient hospital admissions for each hospital was not consistent or proportional to the expected use across Portugal, as indicated by variations between forecasted and observed values. The appropriate planning of future responses may contribute to improving the necessary balance between the level of hospital admissions for usual health needs of the population and the response to COVID-19 patients.

Higher age, female gender, osteoarthritis and blood transfusion protect against periprosthetic joint infection in total hip or knee arthroplasties: a systematic review and meta-analysis

PURPOSE

The goal of this systematic review and meta-analysis was to identify the main risk factors for periprosthetic joint infection (PJI) in patients undergoing total hip or knee arthroplasties.

METHODS

A systematic review was conducted of the potential risk factors for PJI in total hip or total knee arthroplasty. Risk factors were compared and grouped according to demographics, comorbidities, behavior, infections, native joint diseases and other patient-related and procedure-related factors. Meta-analysis (random-effects models) was conducted using odds ratio (OR) and mean difference (MD). Risk of bias (ROBBINS-I) and strength of the evidence (GRADE) were assessed.

RESULTS

The study included 37 studies (2,470,827 patients). Older age was a protective factor (MD = - 1.18). Male gender (OR 1.34), coagulopathy (3.05), congestive heart failure (2.36), diabetes mellitus (1.80), obesity (1.61), systemic neoplasia (1.57), chronic lung disease (1.52), and hypertension (1.21) increased the risk for PJI. Behavioral risk factors comprised alcohol abuse (2.95), immunosuppressive therapy (2.81), steroid therapies (1.88), and tobacco (1.82). Infectious risk factors included surgical site infections (6.14), postoperative urinary tract infections (2.85), and prior joint infections (2.15). Rheumatoid arthritis, posttraumatic native joint disease, high National Nosocomial Infections Surveillance (NNIS) system surgical patient index score, prior joint operation, American Society of Anesthesiologists score ≥ 3 and obesity were also significantly associated with higher risk of PJI. Osteoarthritis and blood transfusion were protective factors.

CONCLUSIONS

The main risk factors for PJI in each category were male gender, coagulopathy, alcohol abuse, surgical site infection (highest score) and high NNIS system surgical patient index score. Protective factors were age, female gender in TKA, osteoarthritis and blood transfusion. Optimization of modifiable risk factors for PJI should be attempted in clinical practice.

LEVEL OF EVIDENCE

II.

Structural, spectroscopic, and photochemical study of ethyl propiolate isolated in cryogenic argon and nitrogen matrices

Ethyl propiolate (HC ≡ CCOOCH₂CH₃, EP) was studied experimentally by infrared spectroscopy in argon and nitrogen cryomatrices (15 K) and by quantum chemical calculations (at the DFT(B3LYP) and MP2 levels of theory). Calculations predict the existence of four conformers: two low-energy conformers (I and II) possessing the carboxylic moiety in the cis configuration (O=C-O-C dihedral equal to ~0°) and two higher-energy trans forms (O=C-O-C dihedral equal to ~180°; III and IV). The conformation of the ethyl ester group within each pair of conformers is either anti (C-O-C-C equal to 180°; in conformers I and III) or gauche (C-O-C-C equal to ±86.6° in II, and ± 92.5° in IV). The two low-energy cis conformers (I and II) were predicted to differ in energy by less than 2.5 kJ mol^-1 and were shown to be present in the studied cryogenic matrices. Characteristic bands for each one of these conformers were identified in the infrared spectra of the matrix-isolated compound and assigned taking into account the results of normal coordinate analysis, which used the geometries and harmonic force constants obtained in the DFT calculations. The two trans conformers (III and IV) were estimated to be 17.5 kJ mol^-1 higher in energy than the conformational ground state (form I) and were not observed experimentally. The unimolecular photochemistry of matrix-isolated EP (in N₂ matrix) was also investigated. In situ irradiation with UV light (λ > 235 nm) leads mainly to decarbonylation of the compound, with generation of ethoxyethyne, which in a subsequent photoreaction generates ketene (plus ethene).

Frequency and patient attributes associated with ED visits within 30 days after discharge

Background

About 20%-25% of patients return to the emergency department (ED) within 30 days after inpatient discharge. This outcome is relevant since it may signal failures in inpatient care and care transitions. However, literature on the topic is still scarce. Our study aims to describe frequency and patient attributes associated with ED visits within 30 days (30d) of inpatient discharge in one public Portuguese hospital.

Methods

The study included adult patients discharged in 2016. Admissions of deceased or transferred patients were excluded. The rate of 30d ED visits after discharge was computed for selected patient (gender and age) and admission attributes [urgent, Major Diagnostic Category (MDC)]. Number of days from discharge to ED visit was determined. Logistic regression was used to compute crude and age-gender adjusted odds-ratios (cOR, aOR) for each selected admission attribute.

Results

From the 21744 admissions included (median age: 58y; 40% male), for 5058 there was at least one ED visit within 30d after discharge (23%). The majority of ED visits were triaged urgent (n = 2286; 45%) or very urgent (n = 1499; 30%). Time to first ED visit was, on average, 11 days. The risk of ED visit was increased among men (cOR = 1.180; 95% confidence interval - 95%CI: 1.103-1.262) and patients aged 75 or older (cOR = 1.704; 95%CI: 1.557-1.866). After controlling for gender and age differences, admissions with mental diseases (aOR = 1.807; 95%CI: 1.452-2.247), respiratory diseases (aOR = 1.786; 95%CI: 1.535-2.078), endocrine diseases (aOR = 1.758; 95%CI: 1.374-2.250) showed increased risk of visiting ED after discharge.

Conclusions

ED visits after inpatient discharge are frequent and mostly due to urgent and very urgent needs. Older age, mental, respiratory and endocrine conditions are relevant patient risk factors for returning hospital for ED care shortly after discharge.

Key messages

Improved quality of inpatient care and care transitions that reduce ED visits after discharge may benefit a significant part of patients. Future initiatives to reduce adverse events after discharge may target patients with older age or with mental conditions.

Regional analysis of pediatric admissions with complex chronic conditions in mainland Portugal

Background

The expected rise in the number of children living longer with complex chronic conditions (CCC) and the social relevance of this group prompt the study of the patterns of their inpatient care utilization. We aimed to compare the utilization of inpatient care by children with CCC between regions of mainland Portugal.

Methods

Observational longitudinal retrospective study using anonymized administrative data for mainland Portuguese public hospitals. We selected admissions within the pediatric age limit (&lt;18yo), 2011-15. The variable of interest was the patient region of residence [Alentejo, Algarve, Centre, Lisbon Metropolitan Area (Lisbon MA), or North]. Variables related to condition (number and categories of CCC) and to care utilization [admission type, hospital type (I- community, II- regional, III- tertiary & university, IV- specialized), inpatient days, expenses] were described by region.

Results

A total of 64,918 pediatric admissions with CCC were included (ranging from 2,839 to 23,194 by region). The percentage of admissions with 2 or more CCC ranged from 16% to 22%. Haematologic & Immunologic and Metabolic categories were the ones with the highest range between regions (8%-19%; 5%-10%); the smallest range was seen in Cardiovascular (15%-18%). Urgent admissions ranged from 48% to 70%. Hospital type varied considerably, especially for type II (8%-69%). Median length of stay was 4-5 days, and median expense ranged from €1,256 to €1,467.

Conclusions

The utilization of inpatient care by children with CCC in mainland Portugal varied by region, mainly on type of admission, type of hospital, and distribution of CCC categories. Possible explanatory factors may include differences in CCC prevalence, patterns of care, and available care in each region.

Key messages

Differences in the percentage of urgent admissions require further analysis, aiming at reducing the disruption that healthcare needs may cause in the life of children with CCC and their families. There are considerable differences in the type of hospital where children with CCC in each region receive care. Healthcare system must ensure appropriate resources are available where needed.

Effect of a therapeutic exercise program (FisioPausa) on the quality of life of employees from CESPU

Introduction In the context of work, labouring time is mainly spent in the sitting position and in a continuous way. This reality contributes for the increase of a sedentary lifestyle of workers, leading to health-related diseases and consequently decreasing they quality of life (QoL).

Objectives Verify the effect of a therapeutic exercise program in quality of life, and evaluate the association between different components of QoL, with back pain, physical activity and Body Mass Index (BMI).

Methodology A pré-post interventional study was realized in workers from the Cooperativa de Ensino Superior Politécnico Universitário. Fourteen participants were included and submitted to evaluations with a preliminary survey, the SF-36v2 (before and after 8 weeks of intervention) to assess the effects of the program in QoL. All the participants were submitted to a specific therapeutic exercise program of 20 minutes, twice a week, and during 8 weeks.

Results There was a general improvement in Health-Related Physical and Mental Quality of Life. These improvements were especially observed in the functional capacity with a higher median of 5.00 (p = 0,015). Although it was less evident, Vitality was the domain with higher improvements amongst all the four Mental domains (increase of 10.00 points across time, p = 0.341). Associations were observed between pain and functional capacity (p = 0,027) BMI and Mental Health (p = 0,027) and finally between Age and Mental Health (p = 0,028).

Conclusion Our therapeutic exercise program seems to have positive effect on quality of life, especially regarding functional capacity of workers. Participants with the highest pain were associated with decreased functional capacity and older people or those with higher BMI showed weaker mental health.

Differences in Clinical Characteristics and Utilization of Emergency Department by High-Frequency Users

BACKGROUND

Knowing the distinctive features of patients with the highest utilization of the emergency department (ED) is paramount to finding adequate alternatives to ED care for selected patients and improving health care quality and efficiency.

OBJECTIVE

This study aimed to identify ED high-frequency users and compare their clinical and utilization characteristics with other ED users.

METHODS

Secondary data analysis of ED visits and patients database from a Portuguese public urban hospital. Retrospective study of adults visiting the ED in 2016 (61,403 patients; 95,643 visits), comparing demographic and clinical characteristics of patients and clinical and temporal characteristics of ED visits between high-frequency users (>10 ED visits in 2016) and frequent (4-10 ED visits) and nonfrequent (1-3 ED visits) users.

RESULTS

We identified 169 high-frequency users (0.3% of patients and 3.0% of ED visits) with an average number of 16.9 visits in 2016. Patients in this group were older (61.8 years; frequent users: 61.2 years; nonfrequent users: 53.4 years; p < 0.01) and required immediate and mental health care more frequently (18.6% of high-frequency users, 17.4% of frequent users, 13.5% of nonfrequent users, and 6.6%; 3.3%, 2.3%; p < 0.01). High-frequency users also used the ED for nonurgent reasons more than remaining groups (6.1%, 3.5%, 3.1%; p < 0.01).

CONCLUSION

High-frequency users are an aged and heterogeneous group, requiring tailored interventions to improve care.

Linking perceptions of organizational support to temporary agency workers’ well-being

Purpose

This research focused on agency work. Previous studies highlighted the importance of motivations to understand workers’ attitudes, behaviors and well-being. Thus, the purpose of this paper is to analyze the contribution of perceptions of support from organizations to autonomous motivation for temporary agency employment, the relationship of motivations with workers’ well-being and the mediating role of motivations between perceptions of organizational support (POS) and workers’ well-being.

Design/methodology/approach

The hypotheses were tested with a sample of 3,983 temporary agency workers and using structural equation modeling.

Findings

The authors verified that POS from the agency contributed to both autonomous motivation and controlled motivation for temporary agency employment, whereas POS from the client company only contributed to autonomous motivation for temporary agency employment. Moreover, autonomous motivation for temporary agency employment was positively associated with workers’ well-being. Contrary to expectations, controlled motivation for temporary agency employment was not significantly associated with workers’ well-being. As predicted, autonomous motivation for temporary agency employment was a mediator in the relationship between POS and workers’ well-being.

Research limitations/implications

The study relies on self-reported data, and it does not have a longitudinal design.

Practical implications

An important implication of this research study is that organizations, through the support provided to the workers, may contribute positively to increase workers’ autonomous motivation for temporary agency employment, and, in turn, more autonomous motivation for temporary agency employment relates to higher levels of workers’ well-being.

Originality/value

The study innovates by including in the same model variables that may contribute to workers’ motivation for temporary agency employment as well as the outcomes that may arise from workers’ motivation for temporary agency employment.

Low Golimumab Trough Levels at Week 6 Are Associated With Poor Clinical, Endoscopic and Histological Outcomes in Ulcerative Colitis Patients: Pharmacokinetic and Pharmacodynamic Sub-analysis of the Evolution Study

BACKGROUND AND AIMS

Golimumab has an established exposure-response relationship in patients with ulcerative colitis [UC]. However, the association of serum golimumab trough levels [TL] with objective markers of disease activity, such as endoscopic and histological activity scores and concentrations of biomarkers, remains less understood. This report describes the relationship of serum golimumab TL at the end of the induction period [Week 6] with clinical, endoscopic, histological, and biomarker parameters.

METHODS

This was an open-label, uncontrolled, prospective and interventional study. Moderate to severely active UC patients naïve to biologic therapy were treated with golimumab. Serum golimumab TL and faecal calprotectin levels were measured at baseline [Week 0 of induction] and Week 6.

RESULTS

A total of 34 patients completed the induction phase [Week 6] and were included in this analysis. Overall, 47.1% and 14.7% of patients achieved clinical response and remission with significantly higher serum golimumab TL in patients with early response or remission [3.7 μg/mL vs 1.3 μg/mL, p = 0.0013; and 3.1 μg/mL vs 1.7 μg/mL, p = 0.0164, respectively]. In addition, golimumab TL were significantly higher in patients achieving histological remission [4.2 μg/mL vs 1.7 μg/mL, p = 0.0049]. Week 6 golimumab TL were inversely correlated with the total Mayo score [rs = -0.546; p = 0.0008], the Mayo endoscopic subscore [rs = -0.381; p = 0.0262], the Geboes histological activity score [rs = -0.464; p = 0.0057], and faecal calprotectin levels [rs = -0.497; p = 0.0044].

CONCLUSIONS

A higher early exposure to golimumab is associated with a better objective response in active UC patients and appears to drive the outcome at Week 6.

Promoting School Engagement in Children with Cerebral Palsy: A Narrative Based Program

This study assessed the efficacy of an educational program focused on the promotion of school engagement in children with Cerebral Palsy. A 9 weeks, narrative-based intervention program, with a pre-post neuropsychological and self-report evaluation, was developed with a dual focus: a self-regulation theoretical model and executive function stimulation. Fifteen children with Cerebral Palsy participated in the study. Results showed a significant main effect of time (F(2.82) = 6.04, p = 0.0066, partial η2 = 0.30; F(2.82) = 9.91, p = 0.0006, partial η2 = 0.41; F(2.82) = 26.90, p < 0.0001, partial η2 = 0.66) in the three dimensions of school engagement. Findings indicate that the program to train self-regulated competences and executive function skills was efficacious in promoting school engagement in children with Cerebral Palsy. Educational implications were discussed.

[The Epidemiological Profile of the Isolation of 'Problem' Microorganisms]

INTRODUCTION

Infections are a major problem and the presence of drug-resistant microorganisms has significant clinical and economic impact. The present study aims to evaluate the epidemiological profile of "problem" microorganisms isolated in a hospital in the north of Portugal.

MATERIAL AND METHODS

All isolated microorganisms were analyzed, between January 2014 and June 2015. Data obtained was then processed using statistical software.

RESULTS

We analyzed 8146 microbiological isolations and found a prevalence of 23% of 'problem' microorganisms (in descending order of frequency: Enterococcus, Pseudomonas, Staphylococcus aureus e Streptococcus pneumonia), 57.55% of which isolated in male patients. The most frequent mechanism of drug resistance for the overall sample was the production of extended-spectrum beta-lactamase, and resistance to oxacillin for 'problem' microorganisms.

DISCUSSION

In this sample, we observed a much higher prevalence of 'problem' microorganisms than that reported in other countries, which shows the need of improvement of surveillance mechanisms and treatment of these cases. Microorganisms that showed higher resistance were Staphylococcus aureus (resistant to oxacillin) and Enterococcus (resistant to vancomycin). Those were isolated in patients with a higher mean age compared to non-resistant microorganisms. Most of these microorganisms were isolated in hospitalized patients or intermediate and intensive care units, what relates them with healthcare associated infections.

CONCLUSION

The prevalence of infection by 'problem' microorganisms during the studied period was 23%. The detection and control of the spread of these microorganisms are paramount due to its impact on health costs, morbidity and survival of patients.

Gamification: focus on the strategies being implemented in interventions: a systematic review protocol

OBJECTIVE

Gamification broadly refers to the use of game design elements in non-game contexts with the goal of promoting users' engagement. Gamification strategies appear as an advantageous tool to increase the motivation and involvement of users. The purpose of this systematic review is to identify studies using gamification strategies in distinct intervention contexts and to describe their impact in each type of intervention. Thus, the focus is on the construct (gamification) rather than on a particular area or population.

RESULTS

To achieve this goal, Scopus, IEEE, Web of Science, MEDLINE, ERIC, and PsycINFO databases will be used to gather data for the systematic review. Both the research and report of results will be based on Cochrane's recommendations and PRISMA guidelines. Data, including the assessment on the quality of the articles, will be conducted by two members of the team independently. Findings will be reported narratively. The ethical approval is not required as the research does not involve data collection. Findings will be submitted to a peer-review journal and the results will be presented on international congresses. Future reviews could consider investigating particular areas of intervention in which gamification strategies are being employed. Trial registration Systematic Review Registration: PROSPERO CRD42017070508.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

The performance of Remicade®-optimized quantification assays in the assessment of Flixabi® levels

BACKGROUND

The advent of Remicade® biosimilars, Remsima®, Inflectra® and, more recently, Flixabi®, has brought along the potential to decrease the costs associated with this therapy, therefore increasing its access to a larger group of patients. However, and in order to assure a soft transition, one must make sure the assays and algorithms previously developed and optimized for Remicade perform equally well with its biosimilars. This study aimed to: (a) validate the utilization of Remicade-optimized therapeutic drug monitoring assays for the quantification of Flixabi; and (b) determine the existence of Remicade, Remsima and Flixabi cross-immunogenicity.

METHODS

Healthy donors' sera spiked with Remicade, Remsima and Flixabi were quantified using three different Remicade-quantification assays, and the reactivity of anti-Remicade and anti-Remsima sera to Remicade and to its biosimilars was assessed.

RESULTS

The results show that all tested Remicade-infliximab-optimized assays measure Flixabi as accurately as they measure Remicade and Remsima: the intraclass correlation coefficients between theoretical and measured concentrations varied from 0.920 to 0.990. Moreover, the interassay agreement values for the same compounds were high (intraclass correlation coefficients varied from 0.936 to 0.995). Finally, the anti-Remicade and anti-Remsima sera reacted to the different drugs in a similar fashion.

CONCLUSIONS

The tested assays can be used to monitor Flixabi levels. Moreover, Remicade, Remsima and Flixabi were shown to have a high cross-immunogenicity, which supports their high similarity but prevents their switching in nonresponders with antidrug antibodies.