Local Health Unit Research Articles

Weight loss in patients with severe obesity after bariatric surgery-the potential role of the chrono-nutrition, chronotype and the circadian misalignment: A study protocol of the ChronoWise prospective cohort.

Despite the potential effectiveness of bariatric surgery in promoting weight loss, a considerable proportion of patients still face the challenge of achieving optimal post-surgery outcomes. The timing of eating, in addition to the content of what is eaten, as well as chronotype and social jetlag (a marker of circadian misalignment), have been implicated in weight regulation. However, the current understanding of these chrono-related behaviours in individuals undergoing bariatric surgery is still scarce. Thus, this study aims to evaluate the role of chrono-nutrition, chronotype, and circadian misalignment in the weight-loss trajectory among individuals living with severe obesity who underwent bariatric surgery. The ChronoWise project is a prospective single-centre cohort study designed to follow patients experiencing bariatric surgery at the Santo António Local Health Unit (ULSSA), Porto, Portugal. Participants will be recruited and evaluated at pre-surgery and followed-up over 3 and 6 months after surgery. The baseline evaluation will be conducted face-to-face during the hospital stay and by telephone or video call on the subsequent evaluations, following standard procedures. Data collection includes sociodemographics, food intake, chrono-nutrition behaviours, sleep time behaviour, sleep quality, screen time, physical activity and exercise behaviours, anthropometric measurements, and biochemical parameters. The 'Munich Chronotype Questionnaire' will be used to assess chronotype and social jet lag. Chrono-nutrition dimensions will be measured by the 'Chrononutrition Profile-Questionnaire' in all evaluations. Weight and height will be self-reported and retrieved from medical registries. trajectories of weight-loss will be obtained. This study will add important evidence on the role of chrono-nutrition, chronotype and social jetlag profile in weight-loss outcomes after bariatric surgery. Identifying novel approaches to change the paradigm of post-surgical weight management towards a tailored treatment aligned with circadian rhythm may be useful to strengthen the existing treatments and improve patients' response to bariatric surgery.

Pros and cons of digital access to healthcare services and healthcare utilization: a quasi-experiment

ObjectivesWe study the introduction of a web portal allowing women to manage their appointments in the public cervical cancer screening program of an Italian Local Health Unit (LHU). We investigate how this intervention affects program participation and the ability of the LHU to collect information on women's screening outside the program.MethodsWe use administrative data from the LHU and a difference-in-differences design to compare outcomes of women in the treated group (n=870), who could reschedule appointments either through phone calls or through the portal, and the control group (n=768), who could only reschedule by phone.ResultsThe portal reduces the number of appointments rescheduled by phone (b = −0.176, 95% CI = −0.228 to −0.114, p < 0.001). It also makes women more likely to report both screenings outside the program (b = 0.049, 95% CI = 0.006–0.912, p < 0.05) and the various reasons for canceling their appointments. However, the portal also decreases the probability of screening (b = −0.156, 95% CI = −0.216–0.096, p < 0.001). Two-thirds of this reduction is due to increased unjustified no-shows (b = 0.099, 95% CI = 0.043–0.155, p < 0.001).ConclusionsDigital innovations increase efficiency of screening programs. However, they may discourage screening, by triggering behavioral biases such as limited attention and procrastination. Pairing portals with frequent reminders may help to boost participation.

A study of the enablers and barriers to the collection of sociodemographic data by public health units in Ontario, Canada during the COVID-19 pandemic

BackgroundCollection and use of sociodemographic data (SDD), including race, ethnicity and income, are foundational to understanding health inequities. Ontario’s public health units collected SDD as part of COVID-19 case management and vaccination activities. This research aimed to identify enablers and barriers to collecting SDD during COVID-19 case management and vaccination.MethodsAs part of a larger mixed-method research study [1], qualitative methods were used to identify enablers and barriers to SDD collection during the COVID-19 pandemic. Purposive sampling was used to recruit participants from Ontario’s 34 public health units. Sixteen focus groups and eight interviews were conducted virtually using Zoom. Interview data were transcribed and analyzed using inductive and deductive qualitative description.ResultsSDD collection enablers included: legally mandating SDD collection and having dedicated data systems, technological and legal supports, senior management championing SDD collection, establishing rapport and trust between staff and clients, and gaining insight from the experiences from local communities and other jurisdictions. Identified barriers to SDD collection included: provincial data systems being perceived as lacking user-friendliness, SDD collection “was not a priority,” time and other constraints on building staff and client rapport, and perceived discomfort with asking and answering personal SDD questions.ConclusionA combination of provincial and local organizational strategies including supportive data systems, training, and frameworks for data collection and use, are needed to normalize and scale up SDD collection by local health units beyond the context of the COVID-19 pandemic.

Towards integration of care in Portugal: Expansion of a new management model for the NHS

Abstract Introduction In 1999, the first Local Health Unit (LHU) was created in the Northern region of Portugal to improve management, share resources and integrate care. The LHU integrated a National Health Service (NHS) hospital and primary healthcare (PHC) services located within the same geographic area and became responsible for public health activities and the provision of care. Over the next few years, 7 LHUs were created, the last one in 2012. In 2024, the government expanded this model to the entire territory, creating 39 LHUs. This research analyses the objectives, characteristics and expected outcomes of the scale-up of LHUs. Methods This study utilised a mixed methods approach based on the 6 Ps - Problem, People (policy stakeholders), Process (policy development), Price tag (Resource allocation), Paper (policies, laws, regulations), Programmes (policy implementation); and the political, social and economic setting of the Policy Circle Framework. Findings A 2015 assessment revealed that LHUs did not differ from non-LHUs in terms of access, waiting times, clinical excellency, patient safety or patient centeredness. The degree of integration of care in LHUs seemed lower compared with non-LHUs. However, there was no systematic evaluation of the creation of the first LHU. Despite this, the government announced the intention to expand LHUs to the entire national territory, which culminated with the creation of 39 LHUs in 2024 to deliver integrated care, with an emphasis on the proximity and continuity of health services and promotion. Conclusions Despite the existing knowledge gap on the impacts of LHUs in health outcomes and management efficiency, LHUs can provide opportunities to advance integrated and patient-centred care and develop strategies for managing scarce resources, including the health workforce. Nevertheless, the integration of hospitals and PHC can threaten the centrality of primary health care both in terms of delivery of care and resource allocation.

Chrono-nutrition and post-bariatric weight loss: insights from the Portuguese ChronoWise cohort

Abstract Background Post-bariatric weight loss varies substantially, and a large proportion of patients respond poorly. The literature highlights the importance of chrono-nutrition for weight regulation. This study aims to explore the chrono-related factors associated with poorer weight loss. Methods This study was conducted within the ChronoWise project, an ongoing prospective cohort study following patients undergoing bariatric surgery at the Santo António Local Health Unit, Porto. The sample included patients evaluated at both pre-surgery and 3 months post-surgery. Baseline information on meal timing was gathered through the Chrononutrition Profile-Questionnaire. The eating midpoint (midpoint between first and last meal) was calculated for work and free days. Chronotype was determined using the Munich Chronotype Questionnaire. Weight loss was expressed as the percent of total weight loss (%TWL = [(initial weight − current weight)/(initial weight)]×100). Chrono-related variables were compared according to %TWL (dichotomized by the median) using the Mann-Whitney test. Results Sixty patients were included (72% female; mean age 45±11.8). The mean baseline BMI was 44±5.6 kg/m2, which decreased to 35±5.3 kg/m2 at 3 months post-surgery, resulting in an average 20±3.9 %TWL. On free days, participants with lower %TWL tend to do the first meal later in the day (9h45 vs. 9h10, р=0.367), and later lunch on workdays (12h45 vs 12h30, р=0.531) compared with individuals with higher %TWL. Lower %TWL is typically observed in individuals having later eating midpoints (15h00 vs. 14h15 for workdays, р=0.011; 15h07 vs. 14h44 for free days, р=0.205). A later chronotype (3h37 vs 3h30, р=0.347) was also linked with poorer weight loss. Conclusions Eating later during the day and later chronotype may contribute to poorer post-bariatric weight loss. Funding: This work was supported by FCT - Fundação para a Ciência e Tecnologia [2021.01096.CEECIND, UIDB/04750/2020,LA/P/0064/2020&SGITR2023/EPIUnit]. Key messages • Recognizing meal timing as a modifiable lifestyle factor may optimize current approaches by aligning food intake with circadian clock. • A later chronotype, i.e. a behavioural expression of an individual’s internal circadian clock system as a preference for eveningness or later sleep timing, may negatively influence weight loss.

Foregone care in the Italian elderly population: a new challenge for the National Health System

Abstract Background The avoidance of medical care among the elderly in Italy has been exacerbated during the COVID-19 pandemic and today, according to data from the Passi d’Argento surveillance, it involves over 3 million elders. The study analyzes the medical care avoidance among the elderly in Italy, the motivations behind it and the changes over time. Methods Passi d’Argento surveillance system, coordinated by the Italian National Institute of Health and conducted by Local Health Units, continuously collects information on health and lifestyles, as well as care and assistance needs, of the population aged over 65 residing in Italy, through interviews with representative samples by gender and age. Results Between 2021 and 2022, 1 in 4 individuals over the age of 65 (24%) reported avoiding, in the 12 months before the interview, a medical visit or diagnostic test they needed. The phenomenon is higher among those reporting significant economic difficulties (37%). Among those who have waived, 31% said they did so for fear of Sarsv-Cov-2 infection; 22% due to suspension of service and/or closure of the practice because of the restrictions imposed by the COVID-19 pandemic; 36% declared that the avoidance reason was due to long waiting lists; 7% due to difficulty reaching the facility. With the end of the pandemic, this phenomenon has decreased overall (from 34% in 2020 to 23% in 2022), however, there is an increase of individuals who report renouncing due to long waiting lists or difficulties accessing services. Conclusions Data clearly highlights the difficulties of National Health System in meeting the health needs of elderly citizens, which persist even after the pandemic. It is important to preserve the right and the access to prevention and care for the elderly, for which timeliness is crucial. In this perspective, these data can provide important guidance for action at both national and regional levels. Key messages • Having national data on foregone care allows to see the burden of the phenomenon. • Even after the pandemic, the phenomenon of medical care avoidance among the elderly continues to be observed.

Anxiety, depression, and poor sleep quality in COVID-19 survivors of the first year of the pandemic

Abstract Background Psychological outcomes after SARS-CoV-2 infection have been reported primarily among patients with post-COVID-19 condition followed at COVID-specific clinics who may not represent the population of COVID-19 survivors. This study compares the frequency, 2 years after infection, of symptoms of anxiety and depression and poor sleep quality between COVID-19 survivors from the first year of the pandemic and comparison groups matched for sex, age, and level of care. Methods Participants are users of the Local Health Unit of Matosinhos (comprising almost all citizens of this municipality) classified according to hospitalization and SARS-CoV-2 infection between March, 2020 and February, 2021 in 4 groups: group#1, hospitalized due to COVID-19 (n = 101); group#2, hospitalized, uninfected (n = 87); group#3, infected, non-hospitalized (n = 252); group#4, uninfected, non-hospitalized (n = 258). They were evaluated between July, 2022 and October, 2023, with the Hospital Anxiety and Depression Scale (HADS-A, anxiety, and HADS-D, depression) and the Pittsburgh Sleep Quality Index (PSQI). Logistic regression was used to compute OR and 95%CI adjusted for sex, age, education, marital status, employment, smoking, and level of care of the associations between the study group and clinically significant symptoms of anxiety (HADS-A scores>10), depression (HADS-D scores>10) and poor sleep (PSQI scores>5). Results No significant differences (p < 0.05) were observed for the prevalence of clinically significant symptoms of depression (overall 9.2%) and poor sleep quality (overall 59.8%) between SARS-COV-2 infected participants and comparison groups, but HADS-A scores>10 were more frequent in infected individuals (19.3% vs. 13.6%; OR = 1.92; 95%CI:1.21,3.05). Conclusions Healthcare services should pay special attention to COVID-19 survivors from the first year of the pandemic to identify and treat anxiety symptoms. Funding: FCT UIDB/ 04750/2020 LA/P/0064/2020 PTDC/SAU-EPI/6275/2020 Key messages • COVID-19 survivors from the 1st year of the pandemic present more frequently high levels of anxiety than the general population 2 years after COVID-19. • Specific care for anxiety symptoms are needed for COVID-19 survivors from the 1st year of the pandemic

Comorbidity, Treatment, and Service Utilization Patterns in Difficult-to-Treat Depression Patients: A Retrospective Study in a Portuguese Community Mental Health Team

Background and Objectives: Observational studies with data from real-world clinical practice with patients with difficult-to-treat depression (DTD) are rare. This study aims to collect observational data from the real-world clinical practice of a Portuguese community mental health team (CMHT) on the prevalence of DTD and to explore differences between DTD and non-DTD groups. Materials and Methods: We conducted a retrospective chart review study using data from Electronic Health Records (EHRs) of adult patients with psychiatric disorders followed by a CMHT from the Department of Psychiatry of the Coimbra Local Health Unit (between 1 December 2020–31 December 2022). The Dutch Measure for quantification of Treatment Resistance in Depression (DM-TRD) was used to assess the degree of treatment resistance and the Charlson Comorbidity Index (CCI) to measure medical comorbidity. Results: A quantity of 473 patients were referred to Cantanhede CMHT for a first assessment. Of these, 219 patients met the criteria for a primary diagnosis of any depressive disorder. Assistant psychiatrists identified 57 patients with DTD during follow-up (approximately 26%). The DTD group had higher rates of depressive episodes, greater depression severity, increased service use, higher DM-TRD scores, and a higher prevalence of comorbid anxiety symptoms, personality disorders, and severe medical comorbidities. The DTD group also had a higher prescription rate of antidepressants. Differences were observed in the use of antidepressant augmentation strategies and in the prescription of anticoagulant/antiplatelet drugs and analgesics, with higher prescription rates in the DTD group. We found correlations between DM-TRD and CCI scores, and between DM-TRD scores and all service use variables. Conclusions: Our results are consistent with a similar study in the United Kingdom, highlighting the need for a different approach to the management of DTD patients, who continue to live with a significant burden despite usual pharmacological and non-pharmacological treatments.

The association between surgical complications and compliance to the World Health Organization Surgical Safety Checklist: A retrospective analysis of hospital records.

The World Health Organization Surgical Safety Checklist (SSC), now used by healthcare providers worldwide, has proved to be useful in the improvement of patients' health through the reduction of mortality and morbidity after surgery. In the Emilia-Romagna region in Italy the SSC is accompanied by a document that registers any non-conformity (NC) identified during SSC completion. This study aimed to investigate the association between surgical complications and checklist compliance, in terms of incompleteness and presence of NCs, using data from the Modena Local Health Unit (LHU). We used data from surgeries performed in the Modena LHU between 2018 and 2022, with their SSC and related NC document. We estimated relative risks (RRs) of complications fitting three modified Poisson regression models. Model 1 included checklist incompleteness and NC presence, Model 2 adjusted Model 1 for patients' sex and age group, and Model 3 adjusted Model 2 for the other potential confounders. We also performed a sensitivity analysis estimating the same three models including death outcomes as complications. We found an increased risk of complications for both checklist incompleteness (unadjusted RR [uRR]= 2.04; 95% confidence interval [CI]: 1.17 to 3.54) and presence of NCs (uRR = 2.35; 95% CI: 1.71 to 3.22). Results were consistent after adjustment and in the sensitivity analysis. Improving checklist compliance can reduce the risk of surgical complications. In particular, NCs are a risk factor that must be further investigated to better understand their relationship with complications. We believe that NCs data recording is helpful for both researchers in the scope of surgical complications, and healthcare professionals in the operating room.

Telemedicine for Outpatients: A Case Study of the First Experience with Diabetic Patients in the Local Health Authority of Modena.

During the COVID-19 pandemic, telemedicine had the opportunity to demonstrate its potential. In Italy, after an initial period of mistrust, it became clear that remote medicine can provide significant benefits for both healthcare professionals and patients. In the Local Health Unit of Modena (Emilia Romagna region, Northern Italy), great importance was placed on developing, promoting, and managing all telemedicine activities. In particular, it was decided to prioritize the activation of tele-visit services in accordance with the guidelines of the Emilia-Romagna region. This case study aims to illustrate the activities planned and developed at the Local Health Authority of Modena for the implementation of the first service of this kind, the tele-visit service for outpatients suffering from type 1 diabetes mellitus, and to analyze data from the first 12 months of activity (from May 2023 to April 2024) to share reflections on the strengths and critical points encountered. For the activation of tele-visits at the Local Health Authority of Modena, a dedicated working group was established with the mandate to manage all clinical, organizational, and IT aspects. Before starting the service, various preliminary activities were carried out, including selecting the clinical specialty to be activated, defining patient inclusion criteria, implementing IT systems, assessing clinical risks, preparing and distributing information materials, training healthcare personnel, and planning outpatient activities. During the first year of experimental activation of the service (May 2023-April 2024), a total of 72 patients were enrolled in the project, with 103 tele-visits provided. The patients were predominantly women (67%), and the most represented age groups were 30-39 (26%) and 40-49 (21%). Half of the specialists in the Diabetology Service (9/19) participated in the initiative by providing tele-visits, most of whom were young and all of whom were women. The main issues identified through regularly scheduled meetings with professionals, to which the working group is seeking the most appropriate solutions, include poor adherence by many patients who still have doubts about this modality, the habit of many patients rescheduling appointments multiple times, a habit not diminished by this visit method, the non-uniform adherence of professionals, and uneven territorial diffusion of the service. Lastly, professionals reported various IT difficulties. Although the number of tele-visits was not high, the initiative has sparked the interest of several specialists, some of whom have already proposed activating other telemedicine services, with some even suggesting innovative new projects. The next steps will involve extending diabetes monitoring to pregnant women with gestational diabetes and developing tele-visit services for endocrinology, neurology, hematology, and gastroenterology. Implementing a tele-visit service in a Local Health Unit is a complex process. A thorough evaluation of the issues that emerged during the development phases and the initial delivery period can help us to act proactively to prevent the failure of future projects. Our evaluations suggest a need to act on two fronts: on one hand, we must organize further activities to promote telemedicine to both patients and healthcare providers, while on the other hand, we must work to resolve IT issues.

Ocular Syphilis: The Resurgence of an Old Disease Experience of a Tertiary Centre in Portugal

ABSTRACT Purpose To estimate the number of ocular syphilis (OS) cases diagnosed in a tertiary care centre in Portugal, correlate with increasing syphilis diagnoses and characterize the OS population. Materials and methods Retrospective, observational, single-center study that included patients diagnosed with OS between 2015 and 2023 at the local health unit of Coimbra. Demographic data were collected, and a complete ophthalmological examination was performed with multimodal imaging acquisition. Data on syphilis reports from the National System of Epidemiologic Surveillance were correlated with OS data. Results Fifty-four patients with OS were observed; mean age was 54.17 ± 14.46 years, 38 (70.37%) were male and 18 (47.37%) men who have sex with men. The proportion of OS in syphilis patients per year ranged from 0% to 10.34%. One-quarter were co-infected with HIV. Forty-nine patients (91.84%) complained of decreased visual acuity on presentation. Twenty-two (40.74%) had systemic findings (mostly skin rash). Two-thirds had bilateral disease and half presented with anterior segment involvement. Eighty-five percent had posterior segment involvement, mostly placoid chorioretinitis. Forty-one percent had optic nerve involvement. All patients were admitted and underwent 2-week treatment with intravenous penicillin. Visual acuity improved from logMAR 0.70 to logMAR 0.26 (p < 0.001). Conclusions Ocular syphilis is a heterogeneous disease with a wide range of presentations. The incidence is on the rise and therefore OS must be considered in every patient with anterior and posterior uveitis, panuveitis and optic neuritis, with or without systemic manifestations.

Lung cancer and smoking: years lived with disability in Tuscany (Italy). An analysis from the ACAB study

BackgroundLung cancer (LC) is among the most common neoplasms, mostly caused by smoking. This study, carried out within the ACAB project, aims to provide local, updated and systematic estimates of years lived with disability (YLD) from LC due to smoking in the Tuscany region, Italy.MethodsWe estimated YLD for the year 2022 for the whole region and at subregional level by local health unit (LHU) using data from the Tuscany Cancer Registry and local surveys. YLD were calculated by applying the severity-specific LC prevalence, estimated with an incidence-based disease model, to the corresponding disability weight. The burden from smoking was computed by: modelling the prevalence of smokers with a Bayesian Dirichlet-Multinomial regression model; estimating the distribution of smokers by pack-years simulating individual smoking histories; collecting relative risks from the literature.ResultsIn 2022 in Tuscany, LC caused 7.79 (95% uncertainty interval [UI] = 2.26, 17.27) and 25.50 (95% UI = 7.30, 52.68) YLDs per 100,000 females and males, respectively, with slight variations by LHU, and 53% and 66% of the YLDs were caused by smoking.ConclusionThe updated estimates of the burden of LC attributable to smoking for the Tuscany region as a whole and for each LHU provide indications to inform strategic prevention plans and set public health priorities. The impact of smoking on YLDs from LC is not negligible and heterogeneous by LHU, thus requiring local interventions.

Factors influencing community engagement approaches used in Aedes aegypti management in Cairns, Australia.

An important part of preventing and managing Aedes-borne mosquito disease outbreak risk is engaging the community. Research shows that high-income countries tend to use top-down measures for Aedes mosquito management, favouring educational approaches to engage the community over participatory approaches that actively involve and empower the community in addressing disease risk. Little is known about the reasons behind the use of these approaches and how they could be strengthened. This research explores the community engagement approaches used in Aedes mosquito management in Cairns, Queensland, Australia and the factors influencing the choice of these approaches. A case study design was used, drawing on two qualitative methods-key informant, semi-structured interviews (n = 25), and a document review (n = 20). Thematic analysis was used to identify, analyse and attribute meaning from the data. Various approaches were used to engage the community, including direct interaction through door-to-door inspections, broad outreach via mass media campaigns, and community participation in a novel mosquito replacement strategy. Factors influencing the choice of these approaches included government legislative responsibilities, research-related ethical obligations, work norms within local government and public health units, the perceived importance of gaining community trust, constraints on workforce capacity, time and funding. There were multiple factors influencing the community engagement approaches used in this study. Resource constraints, institutional norms and prevailing attitudes and beliefs were identified as hindering the use of more empowering approaches to engaging the community. These barriers should be considered and addressed in the planning of Aedes mosquito management to better support community engagement in this setting. SO WHAT?: Community engagement is an important aspect of managing the Aedes mosquito disease threat. With the global increase in Aedes mosquito-borne disease risk, these findings can help other at-risk settings understand potential organisational impediments to engaging the community. This is particularly important when advocating for the inclusion of bottom-up approaches in policy, and to ensure sufficient resources are allocated to strengthen community engagement in Aedes mosquito management.

High-Risk HPV Detection in Paraffin-Embedded Tissue from Cervical Lesions.

Human papillomavirus (HPV), a leading cause of cervical cancer, is present in most cases of the disease and ranks as the fourth most common cancer in women globally. Among the HPV types, fourteen (HPV 16/18/31/33/35/39/45/51/52/56/58/59/66/68) are recognized as high-risk (hrHPV), each with varying levels of oncogenic potential. Detecting and genotyping these hrHPV types in cervical lesions is crucial, requiring the development of new diagnostic methods. This study focuses on a retrospective analysis conducted on 44 women from the Cova da Beira Local Health Unit. We used the Anyplex™ II hrHPV Detection kit for hrHPV genotyping from paraffin-embedded cervical tissue samples. hrHPV types were identified in 38 out of the 44 women. Genotyping revealed HPV-16 (55.3%), HPV-18/39/56/58/59 (5.3%), HPV-31 (21.1%), HPV-35 (7.9%), HPV-51/66 (2.6%), and HPV-52 (10.5%). This study demonstrates that the Anyplex™ II hrHPV Detection kit, originally designed for cervical cancer screening, is also effective for hrHPV genotyping in histological analyses. This methodology offers a simpler and more cost-effective approach for cervical cancer risk stratification. Its implementation in clinical practice could enhance the detection of hrHPV in cervical lesions, thereby contributing to more precise diagnoses and potentially more informed treatment strategies.

The Economic Burden of Atherosclerotic Cardiovascular Disease in Italy.

Atherosclerotic cardiovascular diseases remain the primary cause of mortality in Italy. Individuals with a history of acute coronary syndrome, peripheral arterial disease, and ischemic stroke/transient ischemic attack face an elevated risk of recurrent major adverse cardiovascular events, including mortality. The population aging, coupled with increasing risk factors such as diabetes mellitus and obesity, exacerbates the disease's economic impact. This study aims to comprehensively assess the economic burden of atherosclerotic cardiovascular diseases in Italy, specifically focusing on direct healthcare costs. We analyzed real-world data from administrative databases in the Marche region and Local Health Unit Umbria 2. The economic burden of patients discharged with acute coronary syndrome, peripheral arterial disease, and ischemic stroke/transient ischemic attack was evaluated, with a focus on direct costs associated with hospitalizations, drugs, and outpatient visits. Results were stratified by age, sex, comorbidities at baseline, and adherence to lipid-lowering therapy and antihypertensive agents. Annually, nearly 350,000 patients were hospitalized for peripheral arterial disease, acute coronary syndrome, or ischemic stroke/transient ischemic attack. Direct health costs averaged €7190 per patient over a 2-year follow-up, with hospitalizations accounting for nearly 70% of the total. Male patients incurred significantly higher costs (€7467) than female patients (€6625). Costs correlated positively with age and with the number of baseline comorbidities, with a range from €5259 (0-1 comorbidities) to €17,095 (4+ comorbidities). Costs were significantly lower in adherent subjects (€6813) compared with non-adherent subjects (€7757). This study provides valuable insights into the economic implications of atherosclerotic cardiovascular diseases in Italy, emphasizing the necessity of a comprehensive approach to preventive measures, optimal medication adherence, and lifestyle modifications to mitigate its impact.

EHLERS–DANLOS SYNDROME — A CASE OF MULTIDIRECTIONAL SHOULDER INSTABILITY REHABILITATION

Introduction: Ehlers–Danlos Syndrome (EDS) is a hereditary and heterogeneous syndrome that affects conjunctive tissue, due to collagen production compromise. Hypermobile EDS (hEDS) is the most common subtype of this syndrome and can cause shoulder joint instability, which can lead to chronic pain and significant functional impairment. Methods: A case report of a patient with hEDS followed in our local health unit was made. The authors describe their clinical insight regarding the case, as well as the rehabilitation program the patient was submitted to. Results: Female patient, 32 years old. Functionally autonomous in every daily living activity. Clinically diagnosed with hEDS in 2013, after reporting bilateral shoulder instability. The patient presented herself in a Physical and Rehabilitation Medicine consultation, 6 months after being submitted to the third surgical intervention of the right shoulder. She presented an overall limited range of motion, decreased muscle strength and positive apprehension and drawer tests. An extensive rehabilitation program was prescribed, focusing on joint mobilization, dynamic stabilizers strengthening and proprioceptive training. After 12 weeks, the patient presented reduced shoulder pain and a better functional status. Conclusion: hEDS compromises the integrity of the static and dynamic stabilizers of the shoulder. Clinical management of these cases involves a multidisciplinary approach with early and adequate rehabilitation care treatments.

How do undergraduate nursing students learn to care for families and informal caregivers? A qualitative study with a grounded theory approach

BackgroundNurses play a crucial role in caring for families of ill individuals in care, requiring high-quality relational and communication skills to care for them. Yet these skills remain underutilized, leading to reported issues of inadequate inclusion and communication. Education is crucial to enhance nurses' competencies in caring for families and informal caregivers. AimTo explore the learning process of undergraduate nursing students to care for families and informal caregivers. DesignQualitative study with a grounded theory approach. SettingsBachelor's degree in nursing from two off-sites of a university and four local health units collaborating with the university in North Italy. Participants15 undergraduate nursing students, 10 nurse preceptors, and 10 nurse clinical teachers. MethodsWe adopted initial and theoretical sampling and conducted semi-structured interviews from December 2023 to January 2024, lasting 16 to 62 min. The interviews were audio-recorded, transcribed verbatim, and analysed through open, selective, and theoretical coding. ResultsWe developed a theory of learning for undergraduate nursing students in caring for families and informal caregivers, comprising two themes, “Learning areas” and “Learning antecedents,” and nine categories. Learning areas involve five stages of learning to care for families and informal caregivers and the most frequent opportunities to interact with families and informal caregivers. The five stages are “Seeing and considering families and informal caregivers”, “Assessing the families' and informal caregivers' needs and resources”, “Preparing for and planning intervention with families and informal caregivers”, “Acting with families and informal caregivers”, “Reflecting on the intervention with families and informal caregivers”. Learning antecedents encompass student characteristics, interpersonal relationships, and the clinical training setting. ConclusionsIn this study, we delineate a five-stage learning process for undergraduate nursing students to care for families and informal caregivers, influenced by individual, interpersonal, and contextual factors. We emphasised the importance of relational skill development, tailored learning experiences, and supportive mentorship in enhancing students' preparedness to engage with and support families in healthcare settings. The developed theory provides a foundational framework for designing educational interventions to optimise nursing students' capacities in this domain.

Towards performance governance in healthcare: An analysis of Italian local health units.

Bouckaert and Halligan (2008) proposed four ideal types of performance management systems, ranging from a disconnected and input-led approach (performance administration) to a model in which performance management is fully integrated with both the internal and external context of an organisation (performance governance). This article empirically analyzes performance plans issued by Italian Local Health Units (LHUs) to provide a first nationwide snapshot of the different ideal-types of performance management that each (LHUs) have reached, in a 'performance governance'-oriented perspective. This paper employs a qualitative methodology based on document analysis. The model orienting the analysis features six dimensions capturing the ideal-types characteristics and what the Italian performance regulations prescribe. Data was derived from the performance plans adopted by the Italian LHUs on the condition that they made the documentation necessary for the analysis public on their institutional website. For a 'performance governance' oriented approach, two elements are considered relevant: familiarity with the analysis of stakeholders and context. In our sample, consisting of 63 performance plans out of 99 Italian LHUs, it was challenging to identify specific territorial clusters, due tosignificant heterogeneity. The role of strategic objectives, integration between cycles, and context analysis seems to positively influence the orientation towards a 'performance governance' approach. The application of Bouckaert and Halligan's ideal-types has only been episodically investigated in the healthcare sector, mainly at the individual health unit or Region level. This article's innovative contribution consists of conducting a qualitative analysis based on a replicable taxonomy that enables further national comparisons. Furthermore, it highlights the need for public healthcare systems to engage more with external stakeholders to improve the quality of their performance governance.

The Impact of the COVID-19 Pandemic on Staffing Levels in Philadelphia Nursing Homes: Disparities Based on the Racial Composition of Geographical Areas.

Research to assess and inform health policy is an essential component of the policymaking process to advance equity in public health practice. This study investigated health disparities during the COVID-19 pandemic (2020-2022) in older adult institutional settings in Philadelphia, PA, to inform policy initiatives, interventions, and infrastructure development. We first explored the changing patterns of nursing staffing levels (total direct care staff and registered nurses [RNs]) measured by hours per resident per day (HPRD) before and after COVID-19. Our findings revealed that HPRD levels consistently fell below the Centers for Medicare and Medicaid Services recommended standards from 2018 to 2022, with notable declines observed starting from 2021. Results from multilevel modeling showed significant declines in HPRD for total direct care nursing staff in nursing homes located in zip codes with a high proportion of Black residents (≥40%). In contrast, HPRD for RNs significantly declined in nursing homes located in zip codes with a lower proportion of Black residents (<40%). Moreover, higher reported direct care HPRD and RN HPRD were associated with any reported COVID-19 cases only within zip codes with a low proportion of Black residents. These findings indicate the need for additional policies to address these observed patterns in staffing levels. Our study provides a foundation for future policy reviews utilizing a conceptual framework that is health equity-centric for local and state health departments program and units intended for institutional care settings for older adults.

Validity and Reliability of the Greek Version of Adult Vaccine Hesitancy Scale in Terms of Dispositional Optimism in a Community-Dwelling Population: A Cross-Sectional Study.

Vaccine hesitancy is an important public health issue referring to concerns about the safety and efficacy of vaccination. Within a framework, this study aimed to assess the cultural adaptation, validity, and reliability of the Greek version of the adult Vaccine Hesitancy Scale (aVHS) as well as to identify the determinants of vaccine hesitancy among a large regional population in central Greece. A cross-sectional study was conducted enrolling 300 adults who had received primary healthcare services in the Health Centers and Local Health Units of the Magnesia Region from October to December 2022. The aVHS and the Life Orientation Test-Revised (LOT-R) were used to identify vaccine hesitancy and the dispositional level of optimism, respectively. For survey translation, the procedure of forward and backward translation was followed. Also, the aVHS was tested in a pilot study with a sample of 18 responders. Construct validity and internal consistency reliability were investigated via exploratory and confirmatory factor analysis and Cronbach's alpha coefficients, respectively. Simple and multiple linear regression analysis were used to determine predictors for vaccine hesitancy. Factor analyses indicated that the aVHS comprises two constructs ("lack of confidence" and "risk perception") explaining 68.9% of the total variance. The Cronbach's alpha of the total scale was 0.884, indicating its high internal consistency. Participants who lived in rural areas, had a lower annual income, and reported a lower level of optimism showed a higher lack of confidence in vaccination. On the other hand, people aged above 45 years old who had graduated from high school or elementary school and were unemployed showed greater aversion to the risks of side effects. Finally, certain socio-demographic characteristics were associated with vaccine hesitancy. Our data suggest that the aVHS is a valid and reliable instrument for measuring vaccine-related attitudes and perceptions in Greek society, providing meaningful insight into designing vaccination-related preventive interventions in the community.