The epidemiology of infective endocarditis in Portugal : Prevalence, incidence, risk factors, management and prognosis of infective endocarditis in a general population

Infective endocarditis (IE) is an infrequent clinical condition with a challenging diagnosis and management. An infection of the endocardium, prosthetic or intracardiac devices predominantly caused by bacteria occurs, with a multisystemic involvement and heterogeneous clinical presentation. A long hospitalization course is usually mandatory. Despite several advances in the fields of medical imaging, microbiology techniques, antibiotic and cardiac surgery, complications are common, with fatal outcome still being a frequent finding. Its incidence rate in developed countries from Europe and North America is estimated between 3 and 12 per 100000 people. A progressive shift in the epidemiology of affected patients has been observed. Older patients, with a higher burden of comorbidities and long-term survivors of repaired structural or congenital heart disease have been progressively replacing the former stereotype of younger patients with rheumatic valve disease described in medical conferences more than one century ago. Likewise, more aggressive infectious agents such as Staphylococcus or Enterococcus have been replacing the dominance of Streptococcus in the last decades. Early aggressive surgical management of such patients has become the new standard. Still, prognosis continues poor with an in-hospital mortality rate ranging between 15 and 25%. In industrialized countries, a generalized growing trend noted in the incidence rate of IE and a shift in its epidemiology have been a consequence of the evolution in Medicine itself. Ageing of the population, with an increasing exposure to more invasive medical interventions, that in the case of structural heart disease have led to an increase in the prevalence of intracardiac devices and prosthesis carriers, have been in the cornerstone of these findings. In Portugal, ageing of the population has been well noted, consequently leading to a higher prevalence of comorbidities and structural heart disease. Nevertheless, there is limited understanding on the epidemiology and outcome of patients hospitalized with IE. Its impact, mainly assessed by the publication of single centre retrospective cross-sectional cohorts, lacks a populational perspective. International populational based analyses although useful, reveal significant variability. Prudence is required on the application of their conclusions in the Portuguese clinical setting. The main objectives in this thesis were: i) to provide a population-based analysis on the epidemiological and prognosis of IE in Portugal; ii) to identify temporal trends and predictors of incidence and mortality due to IE in Portugal; iii) to identify indicators of cardiac surgery for IE in Portugal and outcome (mortality); iv) to characterize the use of IE prophylaxis among physicians caring for high-risk patients in Portugal. With the purpose of understanding the published evidence on the epidemiology of IE in Portuguese hospital centres, we undertook a thorough systematic review of all relevant scientific publications concerning cohort studies of hospitalized patients with IE in Portuguese hospitals in the last three decades. The search resulted in the analysis of eighteen retrospective cohort studies, three of them exclusively surgical. One thousand eight hundred seventy two patients were described. Older patients, predominantly men with a higher involvement of native left heart valves were identified. Staphylococcus and Streptococcus were the most frequent infectious agents involved. Nearly 30% of total cohort underwent surgical intervention. Short-term mortality rate averaged 21.9% in the overall cohort, ranging between 13.1 to 16% in the post-operative subgroup. Afterwards, we conducted a nationwide retrospective temporal trend study on the incidence of IE in Portugal, between 2010 and 2018. Additionally, we analysed clinical characteristics, involved infectious agents, heart valve surgical intervention and outcomes of patients hospitalized with IE in that period. We used an administrative medical database derived from the Central Administration of Health System of the Portuguese Ministry of Health. The database included information derived from medical discharge reports of hospitalization episodes, including demographic and clinical diagnoses (coded using International Classification of Disease versions 9 and 10). Seven thousand five hundred seventy four patients were hospitalized with IE in Portuguese public hospitals between 2010 and 2018. Anonymised clinical data was used. Statistical analysis included univariate analysis and multivariate logistic regression models to evaluate factors associated with surgical intervention and all cause in hospital mortality. Odds Ratio (OR) and 95% confidence intervals (CIs) were reported for categorical variables. The analysis was conducted at a 5% level of significance. Between 2010 and 2018, 7574 episodes of hospitalization with IE were analysed. The annual incidence of IE in Portugal that period was 8.3 per 100000 people, higher in men (9.9 versus 6.8 in women per 100000 people) and peaking in patients older than 79 years old (40.6 per 100000 people). 12.4% of patients underwent cardiac valve surgery during the index hospitalization and one fifth of the total cohort died. Men were predominant (56.9% versus 43.1%). Women were older (76 versus 69 years old) and were less likely to undergo cardiac surgery (OR 0.48 – 95%CI 0.40-0.57, p< 0.001), but with a higher odd of dying in the postoperative period (OR 1.84, 95%CI 1.19-2.84, p=0.006). The sub-analysis of patients submitted to cardiac surgery (n= 937 patients) revealed that patients younger than 60 years old, with previous valve or congenital heart disease, infection with Streptococcus spp or the presence of heart failure, systemic embolization or acute renal failure were associated with a higher rate of intervention. In addition, the initial admission of a patient with a diagnosis of IE in a tertiary hospital with cardiac surgery unit was also related with cardiac surgery during the hospitalization. Nearly 74% of patients underwent single valve surgical intervention, with aortic valve being the most frequently involved. In-hospital all-cause postoperative mortality rate was 15.6%. Also, factors linked with in-hospital mortality were older age, female gender, liver, kidney and coronary disease, cardiac valve prosthesis, Staphylococcus spp, acute renal failure and sepsis during hospitalization. Furthermore, we conducted a retrospective temporal trend analysis of all patients whose basic cause of death was IE, in Portugal, between 2002 and 2018. Data was gathered from national death certificates. Three thousand six hundred thirty four people died from IE throughout the 17-year study period with an annual specific mortality rate of 2.1 per 100 000 people. 89% were at least 60 years old, and most were women (55%). Mortality rate was higher in colder months. Finally, we performed a cross sectional study based on a self-completed online questionnaire distributed to physicians, members of the Portuguese Society of Cardiology, evaluating the current practice regarding IE prophylaxis. 253 valid questionnaires were replied. 83% follow the European scientific orientations. 61% find IE prophylaxis challenging. Discrepancy between scientific orientations and some high-risk cardiac conditions or procedures was noted among responders. These findings provide novel insight into the epidemiology and prognosis of IE in Portugal. Additionally, they raise concern regarding temporal incidence, surgical management, and mortality trends compared to other developed countries settings. Our results support the implementation of a national multicentric clinical registry for further evaluation

Endocardite infecciosa: ainda mais desafios que certezas

© Sociedade Brasileira de Cardiologia - SBC. This is an open-access article distributed under the terms of the Creative Commons Attribution LicenseAfter fourteen decades of medical and technological evolution, infective endocarditis continues to challenge physicians in its daily diagnosis and management. Its increasing incidence, demographic shifts (affecting older patients), microbiology with higher rates of Staphylococcus infection, still frequent serious complications and substantial mortality make endocarditis a very complex disease. Despite this, innovations in the diagnosis, involving microbiology and imaging, and improvements in intensive care and cardiac surgical techniques, materials and timing can impact the prognosis of this disease. Ongoing challenges persist, including rethinking prophylaxis, improving the diagnosis criteria comprising blood culture-negative endocarditis and prosthetic valve endocarditis, timing of surgical intervention, and whether to perform surgery in the presence of ischemic stroke or in intravenous drug users. A combined strategy on infective endocarditis is crucial, involving advanced clinical decisions and protocols, a multidisciplinary approach, national healthcare organization and health policies to achieve better results for our patients.Após catorze décadas de evolução médica e tecnológica, a endocardite infeciosa continua a desafiar médicos no seu diagnóstico e manejo diário. O aumento da incidência, alterações demográficas (afetando pacientes mais idosos), microbiologia com taxas de infeção por Staphylococcus mais elevadas, com complicações graves ainda frequentes e uma mortalidade substancial tornam a endocardite uma doença muito complexa. Apesar de tudo, a inovação no seu diagnóstico, nomeadamente na área da microbiologia e imagem, e a melhoria nos cuidados intensivos e na cirurgia cardíaca (quanto às técnicas, materiais usados e momento de intervenção) podem ter um impacto no seu prognóstico. Os desafios persistem, incluindo repensar a profilaxia, melhorar os critérios de diagnóstico incluindo a endocardite com culturas negativas e endocardite de prótese valvar, o timing para a intervenção cirúrgica, e sua realização ou não na presença de acidente vascular cerebral isquêmico e em usuários de drogas intravenosas. Uma estratégia combinada na endocardite infeciosa é fundamental, incluindo decisões e protocolos clínicos avançados, um manejo multidisciplinar, organização e políticas de saúde que culminem em melhores resultados para os nossos pacientes.info:eu-repo/semantics/publishedVersio

O peso da endocardite infeciosa em Portugal nos últimos 30 anos : uma revisão sistemática de estudos observacionais

© 2021 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. Este é um artigo Open Access sob uma licença CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).Introduction: Infective endocarditis affects cardiac valves or devices and has a potentially uncertain prognosis. Little information is available on the epidemiology of this disease in Portugal. Objective: A systematic review of all evidence published in the last 30 years to assess epidemiological data in patients hospitalized with infective endocarditis in Portuguese hospital centers. Methods: Extensive search of all published evidence using Medline, Scopus, general search databases and in addition Portuguese medical journals was performed. All relevant studies in Portuguese or English that reported short- or long-term mortality were included. Results: Eighteen retrospective cohort studies (15 medical and three surgical series) were included with a total of 1872 patients assessed. The medical series included 1279 patients. Older males with predominant native left heart valve involvement were identified. Staphylococcus and streptococcus were the most frequent reported pathogens. Surgical intervention was performed on average in 29.8% of cases. The short-term mortality rate ranged from three to 37.2% (average 21.9%). Surgical cases involved older males with affected native left heart valves, emergent/urgent indication was dominant and short-term mortality ranged from 13.6 to 16%. Conclusions: The current study provides a descriptive analysis of the published series of infective endocarditis in Portugal over the last 30 years. Therefore, it may serve as a starting point for the development and implementation of a multicentric prospective registry on infective endocarditis patients in Portugal that will allow a better and more accurate characterization of this special patient population.Introdução: A endocardite infeciosa afeta válvulas ou dispositivos cardíacos e tem um prognóstico potencialmente incerto. Pouca informação está disponível sobre a sua epidemiologia em Portugal. Objetivo: Revisão sistemática de todos os estudos publicados nos últimos 30 anos que avaliaram dados epidemiológicos em pacientes hospitalizados com endocardite infeciosa em centros hospitalares portugueses. Métodos: Uma pesquisa detalhada de todos os estudos publicados, usando a Medline, Scopus, motores de busca generalistas e também revistas médicas portuguesas, foi realizada. Todos os estudos relevantes em português ou inglês que relataram mortalidade em curto ou longo prazo foram incluídos. Resultados: Dezoito estudos de coorte retrospetivos (15 séries médicas e 3 cirúrgicas) foram incluídos com um total de 1872 pacientes avaliados. As séries médicas incluíram 1279 doentes. Identificaram-se homens mais velhos com envolvimento predominante de válvulas cardíacas esquerdas nativas. Staphylococcus e Streptococcus foram os agentes envolvidos mais frequentemente. A intervenção cirúrgica foi realizada em 29,8% dos casos (valor médio). A taxa de mortalidade em curto prazo variou entre 3 e 37,2% (média 21,9%). Os casos cirúrgicos incluíram homens mais velhos com envolvimento das válvulas esquerdas nativas, a indicação emergente/urgente dominou e a mortalidade em curto prazo variou entre 13,6 e 16%. Conclusões: O estudo atual fornece uma análise descritiva de todas as séries de endocardite infeciosa publicadas em Portugal nos últimos 30 anos. Pode servir como ponto de partida para o desenvolvimento de um registo prospetivo multicêntrico em pacientes com endocardite infeciosa em Portugal, que permitirá uma caracterização mais rigorosa desta população específica de doentes.info:eu-repo/semantics/publishedVersio

Endocardite Infecciosa como causa de morte: um estudo populacional em Portugal, de 2002 a 2018

Copyright © Ordem dos Médicos 2021Introduction: Infective endocarditis presents a high rate of morbidity and mortality. Population-based studies addressing mortality caused by infective endocarditis in Portugal are scarce. We aimed to study deaths caused by Infective endocarditis, as well as corresponding demographics and temporal trends. Material and methods: Retrospective cohort study of all patients whose main cause of death was Infective endocarditis in Portugal from 2002 to 2018. The data was obtained from the national death certificate information system. Results: In Portugal, 3634 people died from infective endocarditis throughout the 17-year study period - infective endocarditis specific mortality rate of 2.1 per 100 000 habitants. Of all deceased, 89% were at least 60 years old, and most were women (55%). Overall, 72% died in a healthcare institution. An annual 9% increase in the incidence death rate from Infective endocarditis was observed, with a significant upward trend during the colder months. Discussion: In Portugal, mortality by infective endocarditis increased, mainly affecting older patients and women, and which can partially be explained by factors such as ageing of the population. The management of older patients with infective endocarditis is challenging as they present a higher number of comorbidities, more valvular heart disease and valve implants, invasive medical procedures and are less likely to undergo cardiac surgery. Conclusion: In addition to data on the evolution of demographics in Portugal, it is crucial to study the incidence of infective endocarditis over time to help explain these findings. The identification of factors that can be used to better model national health policies to improve clinical outcomes of infective endocarditis in Portugal is also required.Introdução: A endocardite infeciosa apresenta uma taxa substancial de morbilidade e mortalidade. Estudos populacionais que abor- dam a mortalidade por endocardite infeciosa em Portugal são escassos. O nosso objetivo foi estudar as mortes causadas por endo- cardite infeciosa e os dados demográficos e tendências temporais correspondentes. Material e Métodos: Estudo de coorte retrospetivo de todos os doentes cuja causa de óbito foi endocardite infeciosa em Portugal entre 2002 e 2018. Os dados foram obtidos no sistema nacional de informação de certificados de óbito. Resultados: Em Portugal, 3634 pessoas morreram de endocardite infeciosa ao longo de um período de 17 anos - taxa de mortalidade específica da endocardite infeciosa de 2,1 por 100 000 habitantes. De todos os falecidos, 89% tinham pelo menos 60 anos, a maior parte dos quais do género feminino (55%) e morreram por endocardite infeciosa. Globalmente, 72% morreram numa instituição de saúde. Foi demonstrado um aumento anual de 9% na taxa de mortalidade por endocardite infeciosa, com uma tendência ascendente significativa nos meses mais frios. Discussão: Em Portugal, a mortalidade por endocardite infeciosa aumentou, afetando principalmente doentes mais idosos e mulhe- res, o que pode ser parcialmente explicado pelo envelhecimento da população. O manejo de doentes idosos com endocardite infe- ciosa é exigente, pois apresentam maior número de comorbidades, mais valvulopatia e próteses valvulares, procedimentos médicos invasivos e menor probabilidade de serem submetidos a cirurgia cardíaca. Conclusão: Para além dos dados sobre a evolução demográfica de Portugal, é indispensável rever a incidência da endocardite infe- ciosa e a sua tendência, de forma a melhor interpretar estes resultados. É fundamental identificar indicadores que possam ser usados para melhor modelar as políticas nacionais de saúde, de forma a melhorar os resultados clínicos na endocardite infeciosa no nosso país.info:eu-repo/semantics/publishedVersio

Estudo transversal sobre profilaxia da endocardite infecciosa: inquérito a médicos da Sociedade Portuguesa de Cardiologia

Copyright © Ordem dos Médicos 2022Introduction: In the last decade, the downgrading of indications for antibiotic prophylaxis for infective endocarditis caused an uncertain impact on the incidence of this condition. Since no data is available on the practice of infective endocarditis prophylaxis in Portugal, we aimed to characterize the pattern of antibiotic use for infective endocarditis prophylaxis and the compliance/awareness of scientific guidelines among physician members of the Portuguese Society of Cardiology. Material and methods: A cross sectional observational study was conducted. An online self-completed questionnaire with 12 items on infective endocarditis prophylaxis was sent to 1330 physicians, specialists and residents, members of the Portuguese Society of Cardiology. In addition, descriptive statistical analysis was performed. Results: Two hundred and fifty-three valid questionnaires were responded. Eighty-seven per cent of respondents were cardiologists (specialists or residents), mostly between 30 and 40 years old (26.7%) and 50 to 80 years old (44.3%). The majority (83.0%) follow the European scientific guidelines. Still, 61.0% had or may have had doubts regarding prophylaxis of infective endocarditis in certain patients. Variable adherence to scientific guidelines was noted. Further scientific evidence was required by 60.6% of respondents. Conclusion: Infective endocarditis prophylaxis was generally guided by European scientific guidelines among physicians of the Portuguese Society of Cardiology. There was, however, an evident discrepancy between the guidelines and real-world perception of the risk of infective endocarditis. This highlights the sensed gap in accessing more robust scientific evidence.Introdução: Na última década, a restrição das indicações para a profilaxia antibiótica na endocardite infeciosa teve um impacto incerto na incidência desta condição. Uma vez que não existem dados sobre a prática da profilaxia da endocardite infeciosa em Portugal, procurámos caracterizar o padrão de utilização antibiótica para a profilaxia da endocardite infeciosa e a conformidade/sensibilização das orientações científicas entre médicos, membros da Sociedade Portuguesa de Cardiologia. Material e Métodos: Foi realizado um estudo observacional transversal. Um questionário online de autopreenchimento com 12 itens sobre profilaxia da endocardite infeciosa foi enviado a 1330 médicos, especialistas e internos, sócios da Sociedade Portuguesa de Cardiologia. Foi realizada uma análise estatística descritiva. Resultados: Foram validados 253 questionários respondidos. Oitenta e sete por cento dos inquiridos eram cardiologistas (especialistas ou internos), a maioria entre os 30 e os 40 anos (26,7%) e os 50 e 80 anos (44,3%). A maior parte (83,0%) segue as orientações científicas europeias. Ainda assim, 61,0% admitiu ter ou poder ter dúvidas sobre a profilaxia da endocardite infeciosa em determinados doentes. Verificou-se uma adesão variável às orientações científicas. A necessidade de mais evidência científica foi defendida por 60,6% dos respondedores. Conclusão: Entre médicos da Sociedade Portuguesa de Cardiologia, a profilaxia da endocardite infeciosa foi geralmente orientada pelas orientações científicas europeias. Existiu, no entanto, uma evidente discrepância entre as orientações e a perceção do risco de endocardite infeciosa na prática clínica. Isto reforça a necessidade de acesso a dados científicos mais robustos.info:eu-repo/semantics/publishedVersio

Insight into the epidemiology of infective endocarditis in Portugal : a contemporary nationwide study from 2010 to 2018

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/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.Background Nationwide hospital admissions data series have contributed to a reliable assessment of the changing epidemiology of infective endocarditis, even though conclusions are not uniform. We sought to use a recent populational series to describe the temporal trends on the incidence of infective endocarditis, its clinical characteristics and outcome results, in Portugal. Methods A nationwide retrospective temporal trend study on the incidence and clinical characterization of patients hospitalized with infective endocarditis, between 2010 and 2018. Results 7574 patients were hospitalized with infective endocarditis from 2010 to 2018 in Portuguese public hospitals. The average length of hospitalization was 29.3 ± 28.7 days, predominantly men (56.9%), and 47.1% had between 60 and 79 years old. The most frequent infectious agents involved were Staphylococcus (16.4%) and Streptococcus (13.6%). During hospitalization, 12.4% of patients underwent heart valve surgery and 20% of the total cohort died. After a 1-year post-discharge follow-up, 13.2% of the total initial cohort had had heart valve surgery and 21.2% in total died. The annual incidence of infective endocarditis was 8.31 per 100,000 habitants, being higher in men (9.96 per 100,000 in males versus 6.82 in females, p < 0.001) and increased with age, peaking at patients 80 years old or older (40.62 per 100,000). In-hospital mortality rate significantly increased during the analyzed period, the strongest independent predictors being ischemic or hemorrhagic stroke, sepsis, and acute renal failure. Younger age and cardiac surgery had a protective effect towards a fatal outcome. Conclusions In Portugal, between 2010 and 2018, the incidence of infective endocarditis presented a general growth trend with a deceleration in the most recent years. Also, a significant rate of in-hospital complications, a mildly lower than expected stable surgical rate and a still high and growing mortality rate were noted.info:eu-repo/semantics/publishedVersio

What is the real impact of on-site percutaneous coronary intervention? A propensity score analysis of patients admitted with acute coronary syndrome

© 2020 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. Este é um artigo Open Access sob uma licença CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).Introduction: In an era in which coronary heart disease is one of the leading causes of death worldwide, several studies report the persistence of obstacles to accessing revascularization, and percutaneous coronary intervention in particular, which may be associated with worse outcomes. Objectives: To compare cardiovascular outcomes in patients admitted to hospitals with and without on-site percutaneous coronary intervention (PCI) capabilities. Material and methods: A retrospective study based on the National Registry of Acute Coronary Syndromes (ACS) - with data collection from 2010 to 2018. Division of the patients into two groups: with and without ST-elevation. Two subgroups were subsequently created according to the presence/absence of on-site PCI. A propensity score was performed to standardize the results. Patients without information about hospital admission (with/without PCI) were excluded. Results: 6008 patients were included after exclusion criteria and propensity score were applied. We found that patients admitted for ACS with ST-elevation (STE-ACS) had more episodes of sustained ventricular tachycardia (OR 2.14; CI (1.26-3.61); p=0.004) in hospitals without on-site PCI. Regarding ACS without ST elevation (NSTE-ACS), there were more cases of congestive heart failure (OR 0.79; CI (0.65-0.98)) in hospitals with on-site PCI. Conclusion: The incidence of a greater number of major adverse events in hospitalizations without on-site PCI, particularly in the case of STE-ACS, is a consequence of the delay before revascularization. National and local strategies must be established to reduce the negative impact of the absence of on-site PCI and the resulting time before revascularization.Introdução: Numa era em que a doença coronária é uma das principais causas de morte a nível mundial, vários estudos referem a persistência de obstáculos no acesso à revascularização, sobretudo na facilidade de acesso à intervenção coronária percutânea, podendo tal estar asso- ciado a piores outcomes. Objetivos: Comparar os outcomes cardiovasculares dos doentes submetidos a intervenção coronária percutânea (ICP) em hospitais com e sem intervenção on-site. Material e métodos: Estudo retrospetivo baseado no Registo Nacional de Síndromes Coronárias Agudas (SCA) --- com colheita de dados de 2010 a 2018. Divisão dos SCA em dois grupos: com e sem supradesnivelamento do segmento ST. Criados ainda dois subgrupos, de acordo com a presenc ̧a/ausência de ICP on-site, para cada uma destas entidades. Realizado score de pro- pensão (SdP) para uniformização dos resultados. Excluídos doentes sem informação sobre a realização de ICP. Resultados: Admitidos 6008 doentes após aplicação de critérios de exclusão e SdP. Verificamos que os doentes admitidos por SCA com supraST apresentaram mais episódios de taquicardia ventricular mantida (OR 2,14; IC (1,26-3,61); p = 0,004) em hospitais sem ICP on-site. Relativamente aos SCA sem supraST, verificou-se um predomínio de insuficiência cardíaca congestiva (ICC) (OR 0,79; IC (0,65-0,98); p = 0,03) em hospitais com ICP on-site. Conclusão: A ocorrência de um maior número de eventos adversos major nos hospitais sem ICP on-site, em particular no caso do SCA com supraST, é consequência do atraso até a revascularização. Estratégias nacionais e locais devem ser definidas para reduzir o impacto negativo da ausência de ICP on-site e consequente tempo até revascularização.info:eu-repo/semantics/publishedVersio

Ensino Superior depois dos 23 anos: capacitação pessoal, social e profissional

 O estudo que se apresenta realizou-se numa instituição pública portuguesa de Ensino Superior, o XXXX Visa perceber que mudanças ocorreram na vida pessoal, social e profissional dos estudantes que ingressaram nessa instituição, a partir da prova de acesso para maiores de 23 anos, e entender a importância da formação superior para adultos. Para o estudo, de abordagem mista, efetuou-se um inquérito por questionário a 180 diplomados. Os dados mostram a relevância da formação de adultos enquanto razão válida para uma maior realização pessoal e aquisição ou atualização de conhecimentos, ainda que não contribua muito para a mudança de profissão ou progressão da carreira. Os inquiridos também deixam claro que os motivos financeiros são um entrave significativo ao prosseguimento dos estudos.

As Características de Governo Societário versus Estrutura de Capital das Empresas Portuguesas

This study analyzes the relationship between Corporate Governance and the level of leverage of Portuguese companies. The sample consists in 9,170 Portuguese non-financial companies corresponding to 100,870 observations, over a period from 2008 to 2018. The data for this study were collected by consulting the SABI database and were analyzed using random effects regression models, considering the data model in panel, by using the integrated development software program for R – RStudio, version 1.2.5001. The analysis of the results provides evidence that Corporate Governance influence the choice of capital structure of Portuguese companies.O presente estudo analisa a relação existente entre as características de Governo Societário  e o nível de endividamento das empresas portuguesas. A amostra é constituída por 9.170 empresas, não financeiras e corresponde a 100.870 observações, no período de 2008 a 2018. Os dados foram recolhidos por consulta da base SABI e foram analisados através de modelos de regressão de efeitos aleatórios, considerando o modelo de dados em painel, com recurso ao programa de software de desenvolvimento integrado para R – RStudio, versão 1.2.5001. A análise dos resultados fornece evidências no sentido de concluirmos que as características de governo influenciam a escolha da estrutura de capital das empresas portuguesas. Este estudo visa contribuir para o debate e o enriquecimento da discussão sobre as características de Governo e a estrutura de capitais e pode ser muito útil para accionistas, administradores, credores e outros investidores, assim como para académicos e reguladores. 

In-hospital outcomes of Infective Endocarditis from 1978 to 2015: analysis through machine-learning techniques

© 2021 The Authors. Published by Elsevier Inc. on behalf of the Canadian Cardiovascular Society. This is an open access article under the CC BY-NC- ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)Background: Early identification of patients with infective endocarditis (IE) at higher risk for in-hospital mortality is essential to guide management and improve prognosis. Methods: A retrospective analysis was conducted of a cohort of patients followed up from 1978 to 2015, classified according to the modified Duke criteria. Clinical parameters, echocardiographic data, and blood cultures were assessed. Techniques of machine learning, such as the classification tree, were used to explain the association between clinical characteristics and in-hospital mortality. Additionally, the log-linear model and graphical random forests (GRaFo) representation were used to assess the degree of dependence among in-hospital outcomes of IE. Results: This study analyzed 653 patients: 449 (69.0%) with definite IE; 204 (31.0%) with possible IE; mean age, 41.3 ± 19.2 years; 420 (64%) men. Mode of IE acquisition: community-acquired (67.6%), nosocomial (17.0%), undetermined (15.4%). Complications occurred in 547 patients (83.7%), the most frequent being heart failure (47.0%), neurologic complications (30.7%), and dialysis-dependent renal failure (6.5%). In-hospital mortality was 36.0%. The classification tree analysis identified subgroups with higher in-hospital mortality: patients with community-acquired IE and peripheral stigmata on admission; and patients with nosocomial IE. The log-linear model showed that surgical treatment was related to higher in-hospital mortality in patients with neurologic complications. Conclusions: The use of a machine-learning model allowed identification of subgroups of patients at higher risk for in-hospital mortality. Peripheral stigmata, nosocomial IE, absence of vegetation, and surgery in the presence of neurologic complications are predictors of fatal outcomes in machine learning-based analysis.info:eu-repo/semantics/publishedVersio