the incomplete process of an action research in the hospital

Health professionals are at high risk for developing burnout symptoms. Directed at reducing the organizational variables affecting professionals’ burnout, an action research was developed in a specific sector of a large hospital, with 59 doctors, 66 nurses, and 42 ancilliary professionals. Researchers conducted 11 interviews, one focus group, and 20 h of in loco observation. Professionals report demotivation and the need to address the emotional part of their job. Nonetheless, the hierarchy blocked the proposed intervention possibilities. Organizational factors are unequivocally relevant, particularly in complex settings with emotionally charged interactions, and the direct hierarchy is pivotal for facilitating organizational change.publishersversionpublishe

Different antibody-associated autoimmune diseases have distinct patterns of T follicular cell dysregulation

© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.Autoantibodies are produced within germinal centers (GC), in a process regulated by interactions between B, T follicular helper (Tfh), and T follicular regulatory (Tfr) cells. The GC dysregulation in human autoimmunity has been inferred from circulating cells, albeit with conflicting results due to diverse experimental approaches. We applied a consistent approach to compare circulating Tfr and Tfh subsets in patients with different autoimmune diseases. We recruited 97 participants, including 72 patients with Hashimoto's thyroiditis (HT, n = 18), rheumatoid arthritis (RA, n = 16), or systemic lupus erythematosus (SLE, n = 32), and 31 matched healthy donors (HD). We found that the frequency of circulating T follicular subsets differed across diseases. Patients with HT had an increased frequency of blood Tfh cells (p = 0.0215) and a reduced Tfr/Tfh ratio (p = 0.0338) when compared with HD. This was not observed in patients with systemic autoimmune rheumatic diseases (RA, SLE), who had a reduction in both Tfh (p = 0.0494 and p = 0.0392, respectively) and Tfr (p = 0.0003 and p = 0.0001, respectively) cells, resulting in an unchanged Tfr/Tfh ratio. Activated PD-1+ICOS+Tfh and CD4+PD-1+CXCR5-Tph cells were raised only in patients with SLE (p = 0.0022 and p = 0.0054), without association with disease activity. Our data suggest that GC dysregulation, assessed by T follicular subsets, is not uniform in human autoimmunity. Specific patterns of dysregulation may become potential biomarkers for disease and patient stratification.This work was supported by the Fundação para a Ciência e Tecnologia, Portugal (EJPRD/0003/2019).info:eu-repo/semantics/publishedVersio

Population genomics of Bombus terrestris reveals high but unstructured genetic diversity in a potential glacial refugium

Ongoing climate change is expected to cause an increase in temperature and a reduction of precipitation levels in the Mediterranean region, which might cause changes in many species distributions. These effects negatively influence species gene pools, decreasing genetic variability and adaptive potential. Here, we use mitochondrial DNA and RADseq to analyse population genetic structure and genetic diversity of the bumblebee species Bombus terrestris (subspecies Bombus terrestris lusitanicus), in the Iberian Peninsula. Although this subspecies shows a panmictic pattern of population structure across Iberia and beyond, we found differentiation between subspecies B. t. lusitanicus and B. t. africanus, probably caused by the existence of barriers to gene flow between Iberia and North Africa. Furthermore, the results revealed that the Iberian Peninsula harbours a large fraction of B. terrestris intraspecific genetic variation, with the highest number of mitochondrial haplotypes found when compared with any other region in Europe studied so far, suggesting a potential role for the Iberian Peninsula as a glacial refugium. Our findings strengthen the idea that Iberia is a very important source of diversity for the global genetic pool of this species, because rare alleles might play a role in population resilience against human- or climate-mediated changes.info:eu-repo/semantics/publishedVersio

COVID-19 symptoms at hospital admission vary with age and sex: results from the ISARIC prospective multinational observational study

Background: The ISARIC prospective multinational observational study is the largest cohort of hospitalized patients with COVID-19. We present relationships of age, sex, and nationality to presenting symptoms. Methods: International, prospective observational study of 60 109 hospitalized symptomatic patients with laboratory-confirmed COVID-19 recruited from 43 countries between 30 January and 3 August 2020. Logistic regression was performed to evaluate relationships of age and sex to published COVID-19 case definitions and the most commonly reported symptoms. Results: ‘Typical’ symptoms of fever (69%), cough (68%) and shortness of breath (66%) were the most commonly reported. 92% of patients experienced at least one of these. Prevalence of typical symptoms was greatest in 30- to 60-year-olds (respectively 80, 79, 69%; at least one 95%). They were reported less frequently in children (≤ 18 years: 69, 48, 23; 85%), older adults (≥ 70 years: 61, 62, 65; 90%), and women (66, 66, 64; 90%; vs. men 71, 70, 67; 93%, each P < 0.001). The most common atypical presentations under 60 years of age were nausea and vomiting and abdominal pain, and over 60 years was confusion. Regression models showed significant differences in symptoms with sex, age and country. Interpretation: This international collaboration has allowed us to report reliable symptom data from the largest cohort of patients admitted to hospital with COVID-19. Adults over 60 and children admitted to hospital with COVID-19 are less likely to present with typical symptoms. Nausea and vomiting are common atypical presentations under 30 years. Confusion is a frequent atypical presentation of COVID-19 in adults over 60 years. Women are less likely to experience typical symptoms than men

Genetic variation in two littorinid gastropods along the East African coast: comparison with morphological data

Tese de mestrado. Biologia (Biologia Evolutiva e do Desenvolvimento). Universidade de Lisboa, Faculdade de Ciências, 2011Um dos principais focos da Biologia Evolutiva é compreender a origem e os processos pelos quais as populações de organismos divergem e se tornam distintas. A diversidade a nível intra-específico pode afectar os processos ecossistémicos, existindo evidências empíricas de que a estabilidade dos ecossistemas pode ser aumentada se existir uma elevada diversidade genética ou fenotípica das espécies. Como tal, a diversidade genética nas populações é importante, não apenas para o potencial evolutivo de uma espécie a longo prazo, mas também para a existência de flexibilidade face a alterações ambientais que afectam os processos ecológicos. Esta possibilidade tem implicações importantes em termos conservacionistas e merece um estudo mais aprofundado, sendo importante ter em conta que a análise da diversidade e diferenciação genética das populações irá providenciar informação fundamental para a conservação, permitindo a preservação da biodiversidade e uma melhor gestão dos recursos vivos. Nos ambientes marinhos, a estrutura genética populacional é influenciada pelos requisitos ecológicos específicos e pelo padrão de história vital dos organismos. Assim sendo, a diferenciação genética em organismos marinhos é altamente influenciada pela sua capacidade de dispersão e, consequentemente, pelo seu modo de reprodução. Para a maioria dos invertebrados marinhos, a chave para a compreensão da estrutura populacional, baseia-se, em parte, no conhecimento da sua dispersão, que, em geral, é muito limitada quando adultos. Dessa forma, a presença ou ausência de uma fase larvar planctónica tem-se mostrado um factor importante na determinação do grau de estruturação espacial das populações nestes organismos. A dispersão de estados larvares permite a troca de indivíduos e genes ao longo da extensão geográfica natural das populações, que pode ser contínua se não houver restrições à dispersão. Uma população distribuída continuamente pode aproximar-se da panmixia, ou pode ser caracterizada por um isolamento por distância, onde a troca de indivíduos e genes ocorre localmente. No entanto, pouco se sabe sobre a prevalência de isolamento por distância em diferentes espécies marinhas, e de que forma é que a variação no fluxo genético e distâncias de dispersão podem afectar a sua expressão a diferentes escalas geográficas. É necessário também ter em conta que factores ambientais podem influenciar a presença ou ausência de estruturação nas populações marinhas. Por exemplo, os padrões de circulação de massas de água, os regimes de temperatura e a topografia costeira afectam grandemente a estrutura populacional em ambientes costeiros, e podem oferecer muitas oportunidades de dispersão passiva. Os eventos de afloramento costeiro, regime de marés, e fluxo estuarino também podem influenciar a dispersão, a uma menor escala espacial. No entanto, muitos destes factores ambientais podem ter um efeito duplo: podem ser responsáveis pela dispersão de larvas planctónicas, actuando como corredores ao fluxo genético ou, alternativamente, podem funcionar como barreiras físicas ao fluxo genético. Assim, um elevado potencial de dispersão nem sempre se traduz em elevados níveis de fluxo genético, e as espécies podem não atingir o seu potencial de dispersão devido a mecanismos de retenção local. Pensa-se, actualmente, que é possível que o nível de estruturação genética se reflicta em diferenças a nível fenotípico. No entanto, a contribuição relativa de factores genéticos e ambientais para a expressão fenotípica não foi ainda resolvida. O mesmo se verifica em relação a factores físicos e biológicos que se pensa promoverem a diferenciação morfológica entre populações contíguas, e que são ainda pouco compreendidos. As espécies exibem, muito frequentemente, variações espaciais e temporais nas suas características morfológicas, e, uma vez que têm sido detectadas grandes diferenças entre populações que habitam locais e ambientes diferentes, a determinação das bases para a diferenciação fenotípica é fundamental para a compreensão da evolução dos organismos. Neste sentido, neste estudo recorreu-se ao uso de dados genéticos e morfológicos, que permitem fazer a interpretação de padrões de variabilidade, permitindo investigar-se a fonte duma possível variação inter-populacional e, também, reconhecer (ou não) a existência de grupos discretos de indivíduos ao longo de áreas costeiras. Mais especificamente, pretendeu-se inferir sobre o fluxo genético na espécie Cerithidea decollata, nos mangais costeiros do Leste Africano, à luz dos padrões putativos de transporte pelas correntes marinhas. A análise separada destes dois tipos de dados irá ajudar a estabelecer até que ponto é que os factores ambientais influenciam a expressão de variabilidade fenotípica em C. decollata, assim como melhorar a compreensão da biogeografia da espécie. O foco da investigação resume-se na avaliação dos padrões filogeográficos da espécie através da análise de marcadores genéticos (sequências parciais do gene mitocondrial da citocromo oxidase I - COI) e de informação quantitativa morfométrica da concha, revelando os níveis de diversidade populacional. O estudo foi realizado ao longo de um gradiente geográfico latitudinal: toda a costa leste Africana (desde o Quénia à República da África do Sul). A informação sobre a estrutura das populações destes gastrópodes dos mangais irá contribuir para um progresso na área da biologia evolutiva, uma vez que os factores mais importantes na formação das estruturas filogeográficas actuais deste género são ainda pouco conhecidos. Esta tese é constituída por 3 partes distintas: uma introdução geral (capítulo 1), uma investigação específica (capítulo 2) e as conclusões finais (capítulo 3). O trabalho científico desenvolvido resultou num artigo científico, a submeter numa revista internacional indexada. No capítulo 2, averiguou-se as diferenças na forma da concha dos espécimes das 32 localidades amostradas através de técnicas de morfometria geométrica, recorrendo a análise de imagem e análises estatísticas. Os resultados indicam que existe uma convergência na forma da concha, e que os diversos morfotipos se sobrepõem ao longo do gradiente em estudo. No entanto foi revelada uma variação significativa entre localidades, indicando que, para a espécie em causa, existe maior variabilidade morfológica a mesoescalas espaciais do que a macroescalas espaciais. Este padrão é provavelmente uma consequência da similaridade de condições ambientais a que os indivíduos estão expostos ao longo do gradiente, levando a uma convergência de formas entre as diversas regiões geográficas – a uma macroescala geográfica (norte, centro e sul do gradiente), mas a acção de factores mais locais pode levar a alguma diferenciação entre localidades. Relativamente à análise genética, utilizaram-se sequências parciais do gene COI, sequenciadas a partir de 172 indivíduos distribuídos por 30 populações ao longo da costa. Uma primeira análise exploratória revelou elevada variação nas diversidades haplotípica e nucleotídica consoante a população. A rede de haplótipos revelou a existência de relações complexas entre haplótipos, resultando numa estruturação genética populacional moderada ao longo da costa, o que foi confirmado pelas análises de variância molecular (AMOVAs). Investigou-se também a história demográfica dos grupos filogeográficos definidos, através de testes de neutralidade e análises da distribuição das frequências das diferenças genéticas encontradas. Os resultados foram consistentes com a hipótese de expansão demográfica recente a norte do gradiente (Quénia, Tanzânia, Moçambique norte), o que tem sido verificado também para outras espécies do oceano Índico. Para as zonas centro (Moçambique centro) e sul do gradiente (Moçambique sul e Républica da África do Sul), os resultados sugerem vários eventos de colonização. Verificou-se ainda a existência de uma correlação significativa entre distâncias genéticas e geográficas. Visto que se prevê uma elevada capacidade de dispersão para esta espécie, por possuir estados larvares planctónicos de 2-3 semanas, estes resultados indicam a possibilidade de um isolamento por distância devido a barreiras físicas, havendo um factor de interacção entre a hidrologia costeira e a conectividade das populações. Combinando os resultados provenientes da análise de morfometria geométrica e da análise genética, observa-se que estes apontam para a existência de uma certa independência entre a variabilidade genética e morfológica observadas. Na realidade, as diferenças genéticas obtidas não se traduziram em diferenças significativas na forma da concha, sendo que a variação desta última se pode dever à existência de plasticidade na expressão de fenótipos, ainda que isso não seja possível de demonstrar recorrendo apenas ao dados deste estudo. A combinação de métodos morfométricos com a genética molecular mostrou ser uma ferramenta robusta para analisar a diferenciação das populações em diversos aspectos, permitindo aumentar o conhecimento sobre diferenciação populacional desta espécie marinha, que poderá eventualmente fornecer uma base para o desenvolvimento de outros estudos relacionados. Foram evidenciados os possíveis factores que levam à divergência genética e morfológica das populações, numa escala espacial muito abrangente, fornecendo informação sobre os padrões de diversidade na costa Leste Africana. Por fim, recomenda-se que este estudo, e outros estudos do mesmo tipo, possam ser aprofundados através de análises complementares que permitam estudar os níveis de diferenciação ecológica e adaptativa entre populações, para que se possa compreender melhor a influência de factores ambientais na evolução das espécies.In this study I aimed to investigate the sources of a possible inter and intra population variation and the existence of discrete groups of individuals in the mangrove gastropod Cerithidea decollata along the eastern coast of Africa. The combined analysis of morphometric and genetic data helped to improve the comprehension of the population genetic structure and phylogeography of the species. The assessment of shell shape variation revealed a convergence of morphological characteristics with an overlap of shape across the latitudinal gradient in study. However, significant differences were found among sampling localities, showing that most variation in shape occurs at meso spatial scales but not at macro spatial scales. This pattern is most likely a consequence of the similarity of environmental conditions to which specimens are exposed along the coast, leading to a convergence of shell shape across the gradient. Nevertheless the action of specific local pressures may lead to some shape variation among locals. Regarding the genetic analysis, I used partial sequences of the mitochondrial gene cytochrome oxidase I (COI) sequenced from 172 individuals distributed by the populations along the coast. The network analysis showed the existence of a moderate population genetic differentiation along the coast, which was confirmed by the molecular variance analyses. The demographic history of the defined groups was also investigated using neutrality tests and mismatch distributions. The results were consistent with the sudden expansion hypothesis for the northern region of the gradient, which has also been observed for other species inhabiting in the Indian Ocean. A correlation between genetic and geographic distances was also observed. Once it was predicted a high dispersal ability for C. decollata, due to its planktonic larval stage of 2-3 weeks, these results indicate the possibility of isolation by distance as consequence of physical barriers with the existence of a correlation between coastal hydrology and population connectivity. The predominant mechanisms that lead to population differentiation include a combination of factors, such as dispersal ability of the species, ocean currents, habitat discontinuities, phenotypic plasticity, physical barriers and geographical distance. The information about the population structure of this mangrove gastropod will contribute to a progress in evolutionary biology, once the determinant factors in the formation of the actual phylogeographic structures of this kind still remain unsettled

Social and economic value of Portuguese community pharmacies in health care

Abstract Background Community pharmacies are major contributors to health care systems across the world. Several studies have been conducted to evaluate community pharmacies services in health care. The purpose of this study was to estimate the social and economic benefits of current and potential future community pharmacies services provided by pharmacists in health care in Portugal. Methods The social and economic value of community pharmacies services was estimated through a decision-model. Model inputs included effectiveness data, quality of life (QoL) and health resource consumption, obtained though literature review and adapted to Portuguese reality by an expert panel. The estimated economic value was the result of non-remunerated pharmaceutical services plus health resource consumption potentially avoided. Social and economic value of community pharmacies services derives from the comparison of two scenarios: “with service” versus “without service”. Results It is estimated that current community pharmacies services in Portugal provide a gain in QoL of 8.3% and an economic value of 879.6 million euros (M€), including 342.1 M€ in non-remunerated pharmaceutical services and 448.1 M€ in avoided expense with health resource consumption. Potential future community pharmacies services may provide an additional increase of 6.9% in QoL and be associated with an economic value of 144.8 M€: 120.3 M€ in non-remunerated services and 24.5 M€ in potential savings with health resource consumption. Conclusions Community pharmacies services provide considerable benefit in QoL and economic value. An increase range of services including a greater integration in primary and secondary care, among other transversal services, may add further social and economic value to the society

Additional file 2: Table S2. of Social and economic value of Portuguese community pharmacies in health care

Future community pharmacist’s services evaluated. (DOCX 24 kb

Additional file 3: Table S3. of Social and economic value of Portuguese community pharmacies in health care

Search strategy. (DOCX 28 kb

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population.The aim of this study was to inform vaccination prioritization by modelling the impact of vaccination on elective inpatient surgery. The study found that patients aged at least 70 years needing elective surgery should be prioritized alongside other high-risk groups during early vaccination programmes. Once vaccines are rolled out to younger populations, prioritizing surgical patients is advantageous

Respiratory support in patients with severe COVID-19 in the International Severe Acute Respiratory and Emerging Infection (ISARIC) COVID-19 study: a prospective, multinational, observational study

Background: Up to 30% of hospitalised patients with COVID-19 require advanced respiratory support, including high-flow nasal cannulas (HFNC), non-invasive mechanical ventilation (NIV), or invasive mechanical ventilation (IMV). We aimed to describe the clinical characteristics, outcomes and risk factors for failing non-invasive respiratory support in patients treated with severe COVID-19 during the first two years of the pandemic in high-income countries (HICs) and low middle-income countries (LMICs). Methods: This is a multinational, multicentre, prospective cohort study embedded in the ISARIC-WHO COVID-19 Clinical Characterisation Protocol. Patients with laboratory-confirmed SARS-CoV-2 infection who required hospital admission were recruited prospectively. Patients treated with HFNC, NIV, or IMV within the first 24 h of hospital admission were included in this study. Descriptive statistics, random forest, and logistic regression analyses were used to describe clinical characteristics and compare clinical outcomes among patients treated with the different types of advanced respiratory support. Results: A total of 66,565 patients were included in this study. Overall, 82.6% of patients were treated in HIC, and 40.6% were admitted to the hospital during the first pandemic wave. During the first 24 h after hospital admission, patients in HICs were more frequently treated with HFNC (48.0%), followed by NIV (38.6%) and IMV (13.4%). In contrast, patients admitted in lower- and middle-income countries (LMICs) were less frequently treated with HFNC (16.1%) and the majority received IMV (59.1%). The failure rate of non-invasive respiratory support (i.e. HFNC or NIV) was 15.5%, of which 71.2% were from HIC and 28.8% from LMIC. The variables most strongly associated with non-invasive ventilation failure, defined as progression to IMV, were high leukocyte counts at hospital admission (OR [95%CI]; 5.86 [4.83-7.10]), treatment in an LMIC (OR [95%CI]; 2.04 [1.97-2.11]), and tachypnoea at hospital admission (OR [95%CI]; 1.16 [1.14-1.18]). Patients who failed HFNC/NIV had a higher 28-day fatality ratio (OR [95%CI]; 1.27 [1.25-1.30]). Conclusions: In the present international cohort, the most frequently used advanced respiratory support was the HFNC. However, IMV was used more often in LMIC. Higher leucocyte count, tachypnoea, and treatment in LMIC were risk factors for HFNC/NIV failure. HFNC/NIV failure was related to worse clinical outcomes, such as 28-day mortality. Trial registration This is a prospective observational study; therefore, no health care interventions were applied to participants, and trial registration is not applicable