Portuguese Hospital Research Articles

Transaction costs in healthcare: empirical evidence from Portuguese hospitals

Transaction Cost Economics has been used in the healthcare context to discuss the make-or-buy dichotomy, focusing on minimizing production or governance costs, respectively. Nevertheless, it is important to recognize that there are other relevant costs, which influence these decisions in health care. Thus, the purpose of this research project was to study such additional variables which may significantly influence the dynamics of transaction costs in hospitals. Semi-structured interviewing was used to collect the data, complemented by some document analysis and observation in the visits made to the hospitals studied. The interviews were conducted during a period of three months, with directors and administrators of four Portuguese hospitals. A deeper study was developed in one of the hospitals where it was possible to get information from additional interviews and documents. Two important findings should be highlighted. Firstly, the internal transaction costs derived from the hospital’s own internal contracting process which generates retention costs of medical personnel and costs of control of the internal contract itself. Secondly, they were studied the intangible costs, particularly those related to the decision of carrying out a process that could deteriorate the patient’s health or her/his critical situation, making the total cost, including treatment and possible re-hospitalizations higher than the cost of having treated the patient internally since the initial cost was considered greater than treating the patient outside hospital facilities. These variables should be considered when studying or using TCE in hospitals, complementing and extending the traditional framework as it is discussed here.

39 - Renal carcinoma associated with end-stage renal disease: The experience of a tertiary Portuguese hospital

39 - Renal carcinoma associated with end-stage renal disease: The experience of a tertiary Portuguese hospital

SECONDARY HYPERTENSION IN THE INTERNAL MEDICINE OUTPATIENT DEPARTMENT OF A PORTUGUESE HOSPITAL

Objective: Secondary hypertension is an uncommon form of hypertension and universal screening is not beneficial or cost-effective. Consequently, investigation is reserved for selected cases, according to clinical suspicion, and is often referred to a specialist. The aim of this study was to characterize the evaluation of secondary hypertension in the Internal Medicine Outpatient Department of a portuguese hospital. Design and method: This longitudinal retrospective study analysed patients referred to our Internal Medicine Outpatient Department for hypertension evaluation in 2021. Patient records and results were analysed, focusing on indication for evaluation, testing performed and identified causes of secondary hypertension. Results: A total of 147 patients were referred for hypertension evaluation, 7 (4,76%) of which were explicitly referred for secondary hypertension screening. Testing was conducted in 105 patients (71,43%), with basic evaluation (CBC, renal function, thyroid function) in 71 patients (48,30%) and additional testing (such as endocrine, renovascular, obstructive sleep apnoea screening) performed in 34 patients (23,13%). Considering age criteria, resistant hypertension, and other clinical clues, 60 patients (40,82%) had a documented indication for additional testing for secondary hypertension. Additional testing was requested in 5 patients (3,40%) not meeting these criteria, most of whom needed testing to follow-up investigations ordered in primary care without clear indication. Conversely, a small proportion (6,12%) met criteria for additional testing that wasn’t requested: 22% already had a previous screening ordered in primary care negative for secondary hypertension; 44% were evaluated for hypertension-mediated organ damage without further screening. Patients in which specific evaluation was complete at the time of this study, a secondary cause was identified in 9 patients (6.12%), all with a previous diagnosis of Obstructive Sleep Apnea. Conclusions: The prevalence of secondary forms identified didn’t significantly differ from the described 5-10% overall prevalence of secondary hypertension and reiterated the identification of OSA as an exceedingly common recognized cause of hypertension. This study emphasised that extensive testing was mostly non-diagnostic and was associated with inconclusive results leading to further investigations, raising costs and risks. This suggests that careful selection of patients and method of screening by a specialist is beneficial.

The role of ethical leadership and social networks in the promotion of workplace happiness and quality of care: A cross-sectional study.

This study examines the sequential effects of perceived ethical leaders and the strength of social networks among healthcare professionals on the perceived workplace happiness of healthcare professionals and its impacts on the quality of provided care. We conduct a partial least squares (PLS) analysis to estimate the relationship between the variables. Data comes from a survey conducted to 321 healthcare professionals with primary/direct contact with patients working at Portuguese hospitals. We use previously validated scales in the literature for measuring the variables; ethical leadership, social network in the context of the workplace; satisfaction, engagement, and commitment as proxies of workplace happiness, and, quality of care provided to patients (the outcome of the research model). Results show that ethical leadership positively influences social networks, workplace happiness, and quality of provided care. Social networks also have a positive relationship with workplace happiness and quality of provided care. Additionally, the workplace happiness of healthcare professionals positively influences the quality of provided care to patients. Our work addresses a diverse research gap regarding hospitals' ethical and social environment and hospital performance. Specifically, the empirical operationalisation of ethical leadership fights a literature gap in healthcare management. Moreover, we report evidence on the influence of antecedents, but also the performance consequences, of workplace happiness in healthcare environments. Our findings contribute to the literature while providing managerial implications for healthcare settings.

Cardiac arrest in patients with acute left main coronary artery occlusion: a real-world multicenter registry

Abstract Funding Acknowledgements Type of funding sources: None. Introduction and objective Acute coronary syndrome (ACS) patients with unprotected left main coronary artery (LMCA) occlusion are at increased risk of mortality. Most studies have shown an association between LMCA occlusion and cardiac arrest. We aimed to evaluate the clinical characteristics and the prognosis of patients with ACS due to LMCA occlusion with cardiac arrest at presentation. Methods We performed a retrospective multicenter study of 128 consecutive patients with ACS due to LMCA occlusion admitted in three Portuguese tertiary hospitals between 2008 and 2020. Patients were divided according to the presentation with cardiac arrest. Results Among this cohort, 26% patients presented with cardiac arrest. Regarding baseline characteristics, they were younger (58 vs 65 years; p=0.001) but no other significant differences were found. Cardiac arrest was associated to shorter symptoms-to-balloon time (150 vs 195 minutes; p=0.042) and higher recourse to fibrinolysis (12.1% vs 0%, p=0.004). They also had higher prevalence of cardiogenic shock (88% vs 51%; p<0.001) and need for aminergic support (91% vs 64%; p=0.004). Furthermore, in-hospital (79% vs 45%; p=0.001) and 5-year (97% vs 73%; p=0.008) mortality were significantly higher, as predicted by Kaplan-Meier survival curves (p=0.002; log-rank test). Finally, in multivariable analysis, younger age [odds ratio (OR),1.12;95% CI,1.04-1.20] and lower median symptoms-to-balloon time (OR, 1.35;95% CI,1.02-1.82) were independently associated to cardiac arrest at presentation. Conclusion In our real-world cohort, more than one quarter of patients with ACS due to LMCA occlusion presented with cardiac arrest, which correlates to a higher incidence of cardiogenic shock, as well as higher short- and long-term mortality. Only younger age and lower symptoms-to-balloon time were independently associated to cardiac arrest. Despite cardiac care improvements, technological evolution, and better patient/system-delay times, this is still a subpopulation with poor prognosis. Further studies are needed to find innovative strategies that can make a difference in this subgroup of patients.

Practice of debriefing of critical events: a survey-based cross-sectional study of Portuguese anesthesiologists.

We performed a national cross-sectional online survey exploring the practice of anesthesiologists' debriefing practice after critical events in Portuguese hospitals. The questionnaire was distributed using a snowball sampling technique from July to September 2021. Data were descriptively and comparatively analyzed. We had replies from 186 anesthesiologists (11.3% of the Portuguese pool). Acute respiratory event was the most reported type of critical event (96%). Debriefing occurred rarely or never in 53% of cases, 59% of respondents needed more training in debriefing, and only 4% reported having specific tools in their institutions to carry it out. There was no statistical association between having a debriefing protocol and the occurrence of critical events (P=.474) or having trained personnel (P=.95). The existence of protocols was associated with lower frequencies of debriefing (P=.017). Portuguese anesthesiologists know that debriefing is an essential process that increases patient safety, but among those surveyed, there is a need for an adequate debriefing culture or practice. Research registry 7741 (https://www.researchregistry.com/browse-the-registry#home).

Spontaneous reporting of adverse reactions associated with the COVID-19 vaccine in health care professionals: A descriptive observational study conducted in a Portuguese hospital.

The coronavirus disease 2019 (COVID-19) was classified as a pandemic in March 2020 by the World Health Organization. The Pfizer-BioNTech COVID-19 vaccine was the first to be authorized in the European Union, based on data from phase 1, 2, and 3 clinical trials of limited duration. Concerns have been raised regarding the vaccine's safety profile. Some of the adverse drug reactions (ADRs) associated with vaccines may not have been identified during clinical trials. This study aimed to identify ADRs associated with the Pfizer-BioNTech vaccine in health care professionals at a Portuguese tertiary university hospital. The data used in this analysis consist of ADRs reported through a spontaneous notification system from vaccines administered between December 27, 2020, and January 31, 2021. ADRs were categorized according to the MedDRA terminology. A total of 8,605 Pfizer-BioNTech vaccines were administered to 4568 health care professionals. ADRs were reported among 520 of the vaccines, with an incidence of 13.56% in women and 5.31% in men. The mean age of the population reporting ADRs was 41.52 years, with a standard deviation of 9.83 years. The most frequent ADRs were myalgia (n = 274), headache (n = 199), pyrexia (n = 164), injection site pain (n = 160), fatigue (n = 84), nausea (n = 81), chills (n = 65), lymphadenopathy (n = 64), and arthralgia (n = 53). Hypersensitivity reactions occurred in 15 health care professionals, with no anaphylactic reactions observed. A total of four Important Medical Events were observed, which consisted of two cases of syncope, one case of sudden hearing loss, and one case of transverse myelitis. The vaccine was well-tolerated among the study participants. Reactogenicity was greater after the second dose. The incidence of ADRs was higher in women and individuals aged between 40 to 49 years. Systemic adverse reactions were most frequently reported. Systematic monitoring of ADRs of COVID-19 vaccines in real-life context is essential for a more robust establishment of its safety profile.

LOCUS (LOng Covid-Understanding Symptoms, events and use of services in Portugal): A three-component study protocol.

Approximately 10% of patients experience symptoms of Post COVID-19 Condition (PCC) after a SARS-CoV-2 infection. Akin acute COVID-19, PCC may impact a multitude of organs and systems, such as the cardiovascular, respiratory, musculoskeletal, and neurological systems. The frequency and associated risk factors of PCC are still unclear among both community and hospital settings in individuals with a history of COVID-19. The LOCUS study was designed to clarify the PCC's burden and associated risk factors. LOCUS is a multi-component study that encompasses three complementary building blocks. The "Cardiovascular and respiratory events following COVID-19" component is set to estimate the incidence of cardiovascular and respiratory events after COVID-19 in eight Portuguese hospitals via electronic health records consultation. The "Physical and mental symptoms following COVID-19" component aims to address the community prevalence of self-reported PCC symptoms through a questionnaire-based approach. Finally, the "Treating and living with Post COVID-19 Condition" component will employ semi-structured interviews and focus groups to characterise reported experiences of using or working in healthcare and community services for the treatment of PCC symptoms. This multi-component study represents an innovative approach to exploring the health consequences of PCC. Its results are expected to provide a key contribution to the optimisation of healthcare services design.

Cardiovascular and respiratory events following COVID-19 hospitalisation: a cohort study in Portuguese hospitals

Cardiovascular and respiratory events following COVID-19 hospitalisation: a cohort study in Portuguese hospitals

Perspectives on the Person-Centered Practice of Healthcare Professionals at an Inpatient Hospital Department: A Descriptive Study.

The characteristics of health professionals and their understanding of person-centeredness may have important implications for the development of person-centered practice in specific care settings. In this study, we characterized the perceptions of the person-centered practice of a multidisciplinary team of health professionals working in the internal medicine inpatient unit of a Portuguese hospital. Data were collected using a brief sociodemographic and professional questionnaire and the person-centered practice inventory-staff (PCPI-S), and the effect of different sociodemographic and professional variables on each PCPI-S domain was determined using an analysis of variance (ANOVA). The results showed that a person-centered practice was positively perceived in the major constructs of prerequisites (M = 4.12; SD = 0.36), the practice environment (M = 3.50; SD = 0.48), and person-centered process (M = 4.08; SD = 0.62) domains. The highest scored construct was developed interpersonal skills (M = 4.35; SD = 0.47), and the lowest was supportive organization systems (M = 3.08; SD = 0.80). Gender was found to influence the perceptions of knowing self (F(2,75) = 3.67, p = 0.03, partial η2 = 0.089) and the physical environment (F(2,75) = 3.63, p = 0.03, partial η2 = 0.088), as was profession on shared decision-making systems (F(2,75) = 5.38, p < 0.01, partial η2 = 0.125) and commitment to the job (F(2,75) = 5.27, p < 0.01, partial η2 = 0.123), and the educational level on being professionally competent (F(1,75) = 4.99, p = 0.03, partial η2 = 0.062) and having commitment to the job (F(2,75) = 4.49, p = 0.04, partial η2 = 0.056). In addition, the PCPI-S proved to be a reliable instrument for characterizing healthcare professionals' perceptions of the person-centeredness of care in this context. Identifying personal and professional variables that influence these perceptions could provide a starting point for defining strategies to move practice toward person-centeredness and for monitoring changes in healthcare practice.

Standardizing Corneal Transplantation Records Using openEHR: Case Study.

Corneal transplantation, also known as keratoplasty, is a widely performed surgical procedure that aims to restore vision in patients with corneal damage. The success of corneal transplantation relies on the accurate and timely management of patient information, which can be enhanced using electronic health records (EHRs). However, conventional EHRs are often fragmented and lack standardization, leading to difficulties in information access and sharing, increased medical errors, and decreased patient safety. In the wake of these problems, there is a growing demand for standardized EHRs that can ensure the accuracy and consistency of patient data across health care organizations. This paper proposes the use of openEHR structures for standardizing corneal transplantation records. The main objective of this research was to improve the quality and interoperability of EHRs in corneal transplantation, making it easier for health care providers to capture, share, and analyze clinical information. A series of sequential steps were carried out in this study to implement standardized clinical records using openEHR specifications. These specifications furnish a methodical approach that ascertains the development of high-quality clinical records. In broad terms, the methodology followed encompasses the conduction of meetings with health care professionals and the modeling of archetypes, templates, forms, decision rules, and work plans. This research resulted in a tailored solution that streamlines health care delivery and meets the needs of medical professionals involved in the corneal transplantation process while seamlessly aligning with contemporary clinical practices. The proposed solution culminated in the successful integration within a Portuguese hospital of 3 key components of openEHR specifications: forms, Decision Logic Modules, and Work Plans. A statistical analysis of data collected from May 1, 2022, to March 31, 2023, allowed for the perception of the use of the new technologies within the corneal transplantation workflow. Despite the completion rate being only 63.9% (530/830), which can be explained by external factors such as patient health and availability of donor organs, there was an overall improvement in terms of task control and follow-up of the patients' clinical process. This study shows that the adoption of openEHR structures represents a significant step forward in the standardization and optimization of corneal transplantation records. It offers a detailed demonstration of how to implement openEHR specifications and highlights the different advantages of standardizing EHRs in the field of corneal transplantation. Furthermore, it serves as a valuable reference for researchers and practitioners who are interested in advancing and improving the exploitation of EHRs in health care.

Machine learning prediction of mortality in Acute Myocardial Infarction

BackgroundAcute Myocardial Infarction (AMI) is the leading cause of death in Portugal and globally. The present investigation created a model based on machine learning for predictive analysis of mortality in patients with AMI upon admission, using different variables to analyse their impact on predictive models.MethodsThree experiments were built for mortality in AMI in a Portuguese hospital between 2013 and 2015 using various machine learning techniques. The three experiments differed in the number and type of variables used. We used a discharged patients’ episodes database, including administrative data, laboratory data, and cardiac and physiologic test results, whose primary diagnosis was AMI.ResultsResults show that for Experiment 1, Stochastic Gradient Descent was more suitable than the other classification models, with a classification accuracy of 80%, a recall of 77%, and a discriminatory capacity with an AUC of 79%. Adding new variables to the models increased AUC in Experiment 2 to 81% for the Support Vector Machine method. In Experiment 3, we obtained an AUC, in Stochastic Gradient Descent, of 88% and a recall of 80%. These results were obtained when applying feature selection and the SMOTE technique to overcome imbalanced data.ConclusionsOur results show that the introduction of new variables, namely laboratory data, impacts the performance of the methods, reinforcing the premise that no single approach is adapted to all situations regarding AMI mortality prediction. Instead, they must be selected, considering the context and the information available. Integrating Artificial Intelligence (AI) and machine learning with clinical decision-making can transform care, making clinical practice more efficient, faster, personalised, and effective. AI emerges as an alternative to traditional models since it has the potential to explore large amounts of information automatically and systematically.

Surveillance of surgical site infection after colorectal surgery: comprehensiveness and impact of risk factors.

The incidence of surgical site infection (SSI) is highest after colorectal surgery. We assessed the impact of risk factors for SSI using the population attributable fraction (PAF). Retrospective cohort study. Portuguese hospitals performing regular surveillance. We identified patients who underwent colorectal procedures in hospitals that reported colorectal surgeries every year between 2015 and 2019. Among 42 reporting hospitals, 18 hospitals were included. Risk-factor incidence was estimated using the National Epidemiological Surveillance platform from 2015 to 2019. This platform follows the methodology recommended by the European Centre for Disease Prevention and Control. American Society of Anaesthesiologists (ASA) physical classification, wound classification, open surgery, urgent operation, antibiotic prophylaxis, operation time, and male sex were included as risk factors. Measures of association were retrieved from published meta-analyses. PAFs were calculated using the Levin formula. To account for interaction between risk factors, communality of risk factors was used in a weighted-sum approach, providing a combined value that serves as a measure of the comprehensiveness of surveillance. Among 11,219 reported procedures, the cumulative SSI incidence was 16.8%. The proportion of SSI attributed to all risk factors was 61%. Modifiable variables accounted for 31% of procedures; the highest was laparotomy (16.8%), and urgent operations (2.7%) had the lowest value. Nonmodifiable factors accounted for 28.7%; the highest was wound classification (14.3%). A relevant proportion (39%) of SSI remains unaccounted for by current surveillance. Almost one-third of SSI cases have potentially modifiable factors. Interventions focusing on shorter, less invasive procedures may be optimally effective in reducing the SSI incidence.

Incidence and risk factors for neoplasia in inflammatory bowel disease.

Inflammatory Bowel Disease (IBD) patients may have an increased risk of neoplasia. The aim was to evaluate the incidence of malignant neoplasia in IBD patients, associated risk factors and therapy adjustments. Unicentric retrospective cohort study. All patients followed for IBD in a tertiary portuguese hospital and oncological centre during 2015-2020 were included. 318 patients were included female 55.0%, age at diagnosis = 37.24(±15,28), Crohn's disease 52.5%, Primary Sclerosing Cholangitis n = 7, family history of cancer n = 12, previous diagnosis of neoplasia n = 23(7.2%). 42 cancers were diagnosed in 35 patients (11.0%) - median of 12.0(IQR = 7.5-21.0) years after IBD diagnosis. Most affected organs were the skin (n = 15 in 11 patients; melanoma = 1), colon/rectum (n = 8 in 6 patients), prostate (n = 4), breast (n = 3) and anal canal (n = 2). In those with non-melanoma skin cancer, 6 were under active treatment with azathioprine and 2 had stopped it for more than two years. In the univariate analysis, the occurrence of neoplasia was positively associated with tobacco exposure (p = 0.022), age at IBD diagnosis (p = 0.021), and negatively with infliximab exposure (p = 0.046). In 9 cases, cancer treatment was different because of the IBD, while IBD treatment was changed in 9 patients. In those affected by cancer, in the univariate analysis, its cure/remission was negatively associated with tobacco exposure (p = 0.004) and positively with salicylates use (p = 0.007). In IBD patients, cancer mostly affected the skin and the lower digestive system. As in the general population, tobacco exposure was a risk factor for the development of neoplasia.

Promotion of tracheostomy self-care: a qualitative study based on the nurses' perspective

Aim: To describe nurses&#8217; perspectives on promoting tracheostomy self-care. There is little information on the nurses&#8217; perspective as care providers with knowledge of clinical contexts. Design: A qualitative descriptive study was conducted. Methods: A purposeful sample of nurses was selected from eight Portuguese hospitals. Recruitment ended once data saturation was reached (n = 12). Data were collected using semi-structured interviews and analysed through content analysis. Results: The nurses described the most important aspects to promote tracheostomy self-care, namely the objectives, the contents to be addressed, the methods and resources to be used, the appropriate moment to intervene, the necessary conditions to promote self-care, the way to ensure the standardisation of interventions among nurses, and the level of tailored planned interventions. Conclusion: From the nurses&#8217; perspective, promoting tracheostomy self-care is critical for regaining autonomy. Therefore, it is crucial to establish an intervention plan sensitive to individual needs and preferences. These results can help elucidate the aspects considered by nurses when promoting tracheostomy self-care so that more meaningful and feasible care models can be designed.

Characterization and prognosis of very elderly patients with anemia, cardio-cerebrovascular disease, and iron deficiency in four Portuguese hospitals.

To the Editor Cardiovascular disease (CVD) is the leading cause of death in Portugal.1 Anemia and iron deficiency (ID) are commonly present in the elderly and associated with adverse clinical outcomes.2,3 Portuguese data describing elderly and very elderly (VEP) patients are scarce, making it critical to characterize this population and obtain data on the actual dimension of their major clinical issues. This study aimed to characterize and evaluate the prognosis of VEP with anemia and CVD in four Portuguese hospitals. Data from all patients admitted to the internal medicine wards in 2017 who fulfilled the study inclusion criteria, including being VEP (≥aged 80 years or older) and diagnosed with anemia and CVD at the time of admission, were obtained. Authorizations were obtained from all the ethics committees/institutional review boards from all the hospitals involved in this study. Of the 16 446 patients admitted to the hospitals, 514 met the inclusion criteria. The median age of VEP was 86 years (interquartile range [IQR]: 83–89), 64.4% were female, and 81.5% resided in their homes. At admission, median hemoglobin was 10.7 g/dL [IQR: 9.57–11.5], median serum iron was 34 µg/dL [IQR: 25–50.5], median ferritin was 117.8 µg/dL [IQR: 59.73–246.5], and median transferrin saturation was 12% [IQR: 7–17.7]. The median hospitalization length was 8.5 days [IQR: 5–13]. The mortality rate for 18 months after discharge was 39.9%, and the 30-day readmission rate was 16.5%. Only 302 patients (59.0%) had serum iron and ferritin levels data. Globally, 7.0% of patients (n = 36) had ferritin levels below 30 µg/L, and 21% were on iron supplements. Mortality had a significant association with length of hospitalization (odds ratio [OR], 1.057, 95% confidence interval [CI]: 1.030–1.084, P = .001, calculated with multiple logistic regression model), age at admission (OR, 1.508, 95% CI: 1.033–2.201, P = .033, calculated with multiple logistic regression model), and hemoglobin levels (OR, 0.667, 95% CI: 0.414–1.073, P = .019, calculated with multiple logistic regression model). Regarding prognosis, the mortality rates of patients with and without ID were 25.7% and 46.5% (P = .028, calculated with the Fisher exact test). Although anemia is a widely recognized risk factor for morbidity and mortality, it remains underestimated and unexplored in VEP. Accordingly, iron parameters were unavailable in this study for many patients hospitalized with anemia and CVD. Our study revealed that VEP at a higher age, with more prolonged hospitalizations and lower hemoglobin levels, were more likely to die within 18 months after discharge. ID was associated with a worse prognosis, but further studies are needed. Notably, the authors acknowledge the limitations of this study because of its retrospective nature and the consequent inability to control the recording of data in the clinical reports. In conclusion, our study suggests that VEP with anemia and CVD may have higher mortality, which may be predicted from admission. We consider these results to warrant further investigation. Contributors RR was responsible for data curation, draft preparation, and final revision. MM, AB, and SP were responsible for data curation and draft preparation. EG was responsible for conceptualization and draft preparation. DB and AV were responsible for methodology and draft preparation. MS was responsible for the investigation and draft preparation. AM was responsible for the formal analysis. Funding Financial support and sponsorship: Vifor Pharma provided support for third-party medical writing assistance for this manuscript. The sponsor had no role in the study design, data analysis and interpretation, report writing, or the decision to submit this study. Conflicts of interest The authors report no conflicts of interest.

Mental Illness Stigma among professionals at a Portuguese Medical Center

IntroductionMental Illness Stigma is a barrier in access to healthcare. Stigma also influences population health outcomes by worsening, undermining adequate processes. The healthcare professionals show several stigmatising behavirous and cognitions, which may impair the adequate provision of care of this population with mental illness.ObjectivesWe aimed to measure mental health stigma in healthcare professionals at a portuguese hospital center.MethodsA cross-sectional study of health profissionals was performed using a survey that included socio-economic and job related questions, personal and familiar questions regarding mental health, and Attribution Questionnaire 27 (AQ-27), a translated and validated stigma questionnaire with nine stigma sub-scales (Responsability, Pity, Anger, Dangerousness, Fear, Help, Coercion, Segregation and Avoidance).ResultsThe sample included a total of 388 participants. The majority of the respondants were female (82,5%). The age ranged from 22 to 69 (mean = 40,05). According to the job place distribution, we found statistically significant differences in various stigma subscales among several healthcare settings within our center. The inpatient unit professionals showed lesser stigmatising attitudes in anger, coercion, segregation and avoidance domains; and higher stigmatising attitudes in pity and help domains. However, professionals who work at surgery room showed higher stigmatising attitudes in danger and fear, but lesser levels of help domains. We also found differences in five stigma subscales among various health professions. The study didn’t show differences in stigma domains regarding personal or professional contact with mental illness, neither academic studies in mental health.ConclusionsOur findings suggest that workplace environment and profession may impact mental ilness stigma levels in healthcare professionals. We propose that future studies could be done to investigate methods to mitigate mental illness stigma, tailored to address different stigma domains in different workplace settings.Disclosure of InterestNone Declared

Time for implementation of local observational studies.

To the Editor The importance of improving clinical research is a consensual topic. Observational studies represent a practical approach to measuring real-world outcomes and responding to health policy directives by their descriptive nature and hypothesis generators. Thus, in the era of evidence-based medicine, the prompt approval of these studies would benefit their implementation and data collection. This pilot study evaluated the approval times for eight observational studies in the fields of hematology, psychiatry, oncology, and immunology, in 43 Portuguese hospitals, between 2018 and 2021. Study objectives range from effectiveness, outcomes measurements, quality-of-life research, or patient pathway analyses. We considered 112 records corresponding to submissions to ethics committees (EC) and approval requests to administration boards. A descriptive analysis of the approval times was performed. The mean time to obtain EC authorization was 67 days (SD = 55; median = 46.5; 6–253), and the time for financial contracts' approval was 71 days (SD = 56; median = 53; 1–226). In 10% of the cases, the time to EC authorization was higher than 165 days, and financial contracts' approval surpassed 148 days. The mean time to final approval was 118 days (SD = 62; median = 99; 41–276). Among the considered records, 29% were approved in less than 30 days (6–29), 27% in less than 60 days (32–54), and 44% in more than 60 days (62–253). There were no differences between approval times in public vs private hospitals or central vs secondary hospitals. Still, university hospitals had a significantly longer median time for EC authorization (94 days vs 42 days in non-university hospitals, P = 0.008, calculated using the Mann-Whitney U test) (Fig. 1). While the increased approval times might either be a direct consequence of the hospitals' high internal flow or be due to the need to clarify submission-related issues raised by the hospitals, remarkably, the submissions approval rate is 100%.Figure 1.: Time comparison until EC opinion between private vs public hospitals (A), non-university vs university hospitals (B), and central hospitals vs others (local, IPOs, and islands: Madeira and Azores; C).A similar scenario was observed by Eichler et al, who analyzed the necessary time for institutional review boards to approve noninterventional studies in Germany and found that university hospitals needed more than three times the days that state medical chambers required (72.4 vs 20.3 days, respectively).1 Another analysis that described the differences in the processes to obtain EC approval for one study in 16 European/European-affiliated countries showed that time from application until first national approval ranged from less than a week (in Greece and the Netherlands) to more than 300 days (in Portugal).2 Although preliminary, these results suggest high heterogeneity among hospitals, highlighting the need to adopt improved strategies to standardize procedures across sites. Simultaneously, stakeholders involved in clinical studies (sponsors, clinical research organizations, investigators, and regulatory agencies) should implement preventive methods to meliorate EC authorization time and financial contracts' approval process. Study limitations include the small number of observations and the fact that some submissions coincided with the COVID-19 pandemic, which may have interfered with the usual procedures and times. Contributors G.M.C.R. and M.J.S. were responsible for the conceptualization, investigation, data curation, and editing. A.R.J. was responsible for the conceptualization and editing. A.P.F. performed data curation and editing. A.M. was responsible for the conceptualization, methodology, and initial draft preparation. M.S. was responsible for the conceptualization, supervision, formal analysis, and review. Financial support and sponsorship This research was sponsored by the pharmaceutical laboratory Janssen-Cilag.

Knowledge of cytomegalovirus and available prevention strategies in pregnancy: a cross-sectional study in Portugal

Objective Maternal and fetal congenital infection by cytomegalovirus (CMV) during pregnancy is the leading infectious cause of neurologic impairment and hearing loss. Efforts at limiting CMV exposure are based on hygienic measures. This study assessed the relationship between CMV knowledge and pregnant women’s time perspective as per the Zimbardo Time Perspective Inventory (ZTPI) scale. Methods We conducted a prospective descriptive study at a secondary-care Portuguese hospital between October to November 2021. All consecutive pregnant women in antenatal third-trimester appointments were included. The questionnaire included: sociodemographic data, knowledge about CMV, and the ZTPI scale, validated to our population. The number of correct answers in the knowledge section of the questionnaire was tallied to determine the individual knowledge score (KS). We investigated patients subjective perceptions of CMV infection during pregnancy, CMV knowledge, and CMV serologic status of pregnant women. Results We enrolled 96 pregnant women. 81.0% had not previously heard about CMV and only 8.8% had heard about it through their obstetrician. No significant association between awareness of CMV and education level was detected. 16.0% of pregnant women declared that they were aware of the hygienic measures for CMV. The CMV serology was performed in 21.3% of those enrolled in the preconception assessment, and 13.8% proved to be immune. From the time perspective, half of the women displayed a future-oriented attitude. Future-oriented women had significantly higher KS. No significant association was found between KS and education level, age, or previous pregnancy. There was a significant association between KS and women that work in health care. Conclusions Most patients had no knowledge of CMV. Being a medical professional and having a future-oriented outlook increases knowledge about CMV. Primary health care and obstetrics doctors may play a crucial role in informing pregnant women of antenatal appointments. The CMV serology coverage is scarce in this sample. This study constitutes a first step toward raising the awareness of the general population about CMV.

Clozapine in first episode psychosis – the experience of a Portuguese center

IntroductionAntipsychotics are the standard in the treatment of first psychotic episodes. Although the majority of patients respond to the established treatment, it is currently known that there is a subgroup of patients whose response is not satisfactory. In this group, the subsequent response to a new antipsychotic is generally poor. Clozapine is an antipsychotic with a unique profile, with demonstrated efficacy and approval in the treatment of treatment-resistant schizophrenia. Its role in the first psychotic episodes remains unclear and its use is, to say the least, controversial.ObjectivesThis work aims to analyze and evaluate the use of clozapine in patients with a first psychotic episode, taking into account the experience of a Portuguese Hospital Center.MethodsWe carried out a retrospective study, including all patients admitted to the inpatient clinic of adults with a first psychotic episode, in the Department of Psychiatry of Centro Hospitalar Universitário of São João, in Oporto, between 2007 and 2020. Clinical and socio-demographic data were collected.We performed a retrospective analysis of patients who, at discharge, were medicated with clozapine, proceeding to a descriptive analysis.ResultsIn this case series, we intended to describe the cases of patients in whom the use of clozapine in the first psychotic episode was initiated. All patients were discharged with the diagnosis of Schizophrenia. Prior to the introduction of clozapine, patients were treated with other antipsychotics, normally two. Patients taking clozapine were younger and had a longer duration of untreated psychosis. They had also longer length of hospital stay. The pattern of prescribing antipsychotics in the first and subsequent episodes has generally been extensively studied. However, the use of clozapine in the first episodes remains unclear.In the literature, and despite clozapine being considered one of the most effective antipsychotics, there is a high prevalence of polypharmacy and a significant delay in its use in the first episodes.Notwithstanding the unfavorable metabolic and hematological profile of clozapine, compared to other antipsychotics, in terms of hospitalization, mortality and discontinuation rates for all causes, it demonstrates a pattern of superiority.ConclusionsThe superiority in effectiveness of clozapine is well established, despite its underutilization and frequent delay in its introduction.The clinicians attitude remains a significant barrier to the commencement of clozapine, although it is important to define and characterize better potential groups of eligible patients. Education resources for clinicians as well as services specifically dedicated to early identification and management of eligible patients would be beneficial.Disclosure of InterestNone Declared