Journal of Statistics on Health Decision

The dimension reduction power of ClustOfVar: application of the variable cluster analysis technique in a mixed data health database

Natacha Oliveira — 2023-05-31

Background/Objective: Technological evolution is increasingly making real the elements necessary for the daily practice of personalized medicine, an improved vision of health care whose decisions regarding prognosis, diagnosis and therapeutic strategies depend on the patient's various characteristics. This approach leads to the collection and use of information that is broad in extension and complexity, for which dimensionality reduction techniques are imperative, in order to simplify and understand it. This paper aims to show the value of the ClustOfVar technique, a variable clustering technique capable of dealing with mixed data, resulting in data reduction. Through its hierarchical and non-hierarchical approaches, it replaces sample variables with representative synthetic variables. This dimensional reduction can be extended to individuals by applying Ward's method.

Methods: The cleaning process of anthropometric, obstetric, vital signs and pubertal status data from 700 participants of the Generation XXI cohort and/or their mothers led to variables being removed (181 down to 105 variables, 82 quantitative and 23 qualitative). Then, the hierarchical technique of the ClustOfVar package was applied, which started by building a hierarchy of variables. The optimal number of clusters was then determined, considering the aggregation level plot and the bootstrap methodology, and each cluster was characterized. The partition into clusters was then tried with the non-hierarchical process. Once the partition was defined, Ward's method was applied, dividing the participants into clusters. We finished with their description according to the synthetic variables.

Results: The partition in 8 clusters of variables suggested by the hierarchical technique was chosen, with the first and third cluster being filled mainly by maternal characteristics (relating mainly to menstruation and physical measurements, respectively). While cluster 2 mixes maternal and individual characteristics, cluster 4 contains only patient variables at birth. Cluster 5 is the most diverse, with anthropometric and related measurements of vital signs and blood macromolecules. Cluster 6 has total mass and fat measurements. Finally, cluster 7 is related to pubertal status variables, and cluster 8 includes cholesterol variables. The clustering of individuals results in the creation of specific profiles for each of the 8 clusters of individuals.

Conclusions: The ClustOfVar technique accomplishes a data transformation relevant to the dispersion of personalized medicine. However, it lacks the ability to deal with high proportions of missing data and its bootstrap process is very time-consuming.

Coping strategies and psychosocial factors at work of Dietitians/Nutritionists: a multivariate analysis approach

Raquel Simões — 2023-05-30

Background/Objective: Dietitians and nutritionists, like many healthcare professionals, frequently experience stress, which can be influenced by coping strategies (BriefCOPE) and the psychosocial work environment (COPSOQ-II) and their impact on work ability and stress levels (WAI). The main objective of this short paper is to examine how BriefCOPE and COPSOQ-II scales can be used to study coping with work-related stress among dietitians and nutritionists (n=301), with a focus on exploring the relationship among these scales and WAI.

Methods: BriefCOPE is a self-report measure of coping strategies, and it evaluates various coping strategies, including problem-solving, positive reframing, and avoidance coping. COPSOQ-II is a questionnaire that assesses various psychosocial factors related to the work environment, including job demands, job control, social support, and rewards. WAI is a tool used to assess an individual's work ability, considering their health status, physical and mental demands, and work-related resources. BriefCOPE and COPSOQ-II multivariate outliers were removed based on Mahalanobis distance. The sociodemographic characteristics, the BriefCOPE (n=285) and COPSOQ-II (n=233) scales association with WAI scores were analysed through Chi-Square, Kruskal-Wallis and one-way Analysis of Variance (ANOVA) tests. Exploratory (EFA) and confirmatory (CFA) factor analyses were conducted for both scales. Data was analysed using the R software.

Results: BriefCOPE and COPSOQ-II dimensions were obtained, and the WAI scores was reduced to three levels: “Poor/Moderate” (n=69; 22.9%), “Good” (n=158; 52.5%), and “Excellent” (n=74; 24.6%). About BriefCOPE and COPSOQ-II dimensions, association with WAI scores revealed 8 and 22 dimensions, respectively, with statistically different distribution among WAI categories. In exploratory factor analysis, for BriefCOPE scale the best model selected was constituted by 4 factors and explained 57% of variance, and for COPSOQ-II scale the best model was constituted by 7 factors and explained 64% of variance. In confirmatory factor analysis, the best models selected for each scale demonstrated better fit values in comparison with the theoretical models.

Conclusions: Most of the BriefCOPE and COPSOQ-II dimensions revealed statistically different distribution among WAI categories for the dietitians and nutritionists group. The excellent work capacity is related to the situation of “I almost always do this” for the dimensions of “Active coping”, and “Positive reinterpretation” for BriefCOPE, and with the situations of “Never/almost never” or “Rarely” for the dimensions of “Role conflicts”, “Work/Family conflict”, “Stress”, “Sleeping troubles”, “Depressive symptoms”, and “Bullying” for COPSOQ-II. This indicates that individuals with excellent work capacity frequently experienced active coping and positive reinterpretation, and never or rarely experienced stress, sleeping issues, burnout, and depressive symptoms. For both scales, EFA presented different factor structures when compared to the theoretical ones. Our data do not fit the theoretical models of BriefCOPE and COPSOQ-II scales, but present good results for the models proposed by EFA.

Are coping and workplace psychosocial factors related to work ability in physicians? A PLS-SEM approach

Joana Ricardo Pires — 2023-05-30

Background/Objective: Over the last few years, new statistical techniques have been developed in the context of multivariate analysis, which are proving to be very useful in the social or health sciences, even marketing. The aim of this work was to study the interplay between 3 scales: BriefCOPE for evaluating coping strategies; COPSOQII for assessing psychosocial factors; and WAI for assessing work ability.

Methods: Considering a subpopulation of physicians (n=35) we applied the Partial Least Squares Structure Equations Modelling (PLS-SEM) technique to study the relation between the 3 scales.

Results: Regarding the analysis of BriefCOPE and WAI, the only BriefCOPE domain significantly related to WAI was ‘Strategies focused on emotions’ (β=0.329;p=0.038). In COPSOQII and WAI analysis, the COPSOQII domain ‘Health and wellness’ was significantly associated with WAI (β= 0.599; p<0.001) with a strong effect. In final model regarding the three scales, we could observe that the apparent relationship between WAI and ‘Strategies focused on emotions' (BriefCOPE) is mediated by the COPSOQII domain ‘Health and wellness’ (p = 0.047), which shows that there is small effect between the BriefCOPE and WAI.

Conclusions: This study is the first to test relationships between these three scales simultaneously. Using a PLS-SEM approach to analyse the data, the results of the present study highlight the central role of ‘Health and wellness’ in work ability and in the mediation between coping ‘Strategies focused on emotions’ and work ability. These data suggest that employers should implement organizational policies that enhance health and well-being in order to achieve better performance from their employees.

Occupational health, well-being and ability to work in a sample of Portuguese Nurses

Diana Lucas — 2023-05-31

Background/Objective: Occupational health is a multidisciplinary activity aiming to keep people mentally and physically well and safe at work. In nurses, it has deserved a particular attention, considering the complexity and demanding nature of the job. The current study aims to investigate the association between psychosocial variables, including coping with work (BriefCOPE) and psychosocial factors of work (COPSOQ-II), and ability to work (WAI) among Portuguese nurses.

Methods: An observational cross-sectional study with 111 Portuguese nurses was conducted and the outcome measures include socio-demographical variables, COPSOQ, BriefCOPE and WAI. To study the variables presented in the original database, a sociodemographic characterization was performed, followed by an exploratory factor analysis (EFA) to the COPSOQ and BriefCOPE dimensions. To quantify, test and confirm the results obtained in the previous analyses, a confirmatory factor analysis (CFA) was performed.

Results: Key coping dimensions were closely associated with better ability to work among nurses, particularly the use of instrumental support, planning, quantitative demands, and emotional demands. The EFA for BriefCOPE suggested a 5-factor structure, which is a slightly different factor structure for the corresponding 3 theoretical dimensions, and the CFA results show that the model is not fit to the data. Regarding the COPSOQ-II scale, the EFA suggested the same 8-factor structure of the original scale’s theoretical model. For this scale, most of values obtained in CFA are consistent with the cut-off values, so a fit of the model to the data is possible.

Conclusions: The current study focus on potential factors playing a role in key well-being and coping with work outcomes on the psychosocial characterization of Portuguese nurses.

Exploratory and Inferential Analysis of Children's Eye Defects Screening in the Region of Aveiro

Diana Lucas Almeida — 2023-05-31

Background/Objective: Amblyopia is one of the leading causes of monocular vision loss in children in Portugal, affecting 1 to 4% of children. Diagnosis and treatment of amblyopia at an early stage can prevent visual impairment, and thus the Children's Eye Defects Screening (CEDS) was implemented in primary care health centres nationwide with the aim to identify children with eye changes capable of causing amblyopia.The primary objectives of this study were to compare the proportion of screenings conducted in the different municipalities and the possible interference of the typology of functional units in adherence to screening.

Methods: An exploratory analysis using R Software was performed on the standardised screening data to identify differences between the 11 primary care health centres in the Region of Aveiro. In addition, an inferential analysis was performed using non-parametric tests such as the Kruskal-Wallis test and the Wilcoxon test, both used to verify whether there are significant differences between the analysed groups.

Results: It is possible to observe that the results obtained in 2021 were abnormal because of the COVID-19 pandemic, which lead to an increase in the number of screenings in 2022. The family health units had higher numbers of requests generated, screening attendances, and reports than personalised health care units, especially in 2021 and 2022. Most of the screening results were negative, with approximately 10% of screenings being positive and roughly 1% of scans being inconclusive. There also appears to be a growing trend of positive results in some municipalities, which may result from a higher reach to the target population of this screening.

Conclusions: The purpose of our statistical analysis was to identify differences between the primary health centres in Region of Aveiro. Our results show that might be useful to perform further studies in order to address potential inequities regarding CEDS access.

Self-perceived functioning in relation to existing symptoms 12 months after SARS-COV-2 infection in workers of an industrial facility in Aveiro Region – an observational study.

Ana Rita Pádua — 2023-05-30

Background/Objective: Most individuals recover after acute SARS-CoV-2 infection, but some may suffer persistent symptoms with potential medium and long-term consequences. The present study aims to analyze self-perceived functioning concerning existing symptoms 12 months after SARS-CoV-2 infection in workers of an industrial facility in the Aveiro Region.

Methods: Observational study, including workers with a positive SARS-CoV-2 RT-PCR/TRAg test. After 12 months of the infection, the occupational health team collected information on sociodemographic variables, manifested symptoms, and perceived functioning assessed using the WHODAS-2.0–12 items - where '12 points' means the highest functioning. Data analysis included descriptive statistics and univariate and multivariate linear regression.

Results: Eighty-five workers were infected with SARS-CoV-2, 77.7% were male, with a mean age of 36y1m±9y8m, 36.8% have a higher education level and 17.7% reported at least one chronic condition. Thirty workers (35.3%) reported persistent symptoms, with fatigue (27.7%) and arthralgia (14.4%) being the most described. Whodas 2.0 mean score was 15,7±5,0, and items most frequently reported as presenting limitations were difficulties in working (43.5%), concentrating (35.3%), and walking one kilometer (35.3%). Self-perceived functioning depended on educational level (β=-2.37, CI95% -4.53 ; -0.21) or the existence of a chronic illness (β=3.53, CI95% 0.81 ; 6.24), and the level of functioning is associated with the persistence of symptoms of fatigue (β=4.02, CI95% 1.75 ; 6.29), headache (β=4.13, CI95% 0.84 ; 7.42), and myalgia (β=3.30, CI95% 0.14 ; 6.45).

Conclusions: Persistent symptoms 12 months after symptomatic SARS-CoV-2 infection have an influence on self-perceived functioning. Occupational health services should regularly address the assessment of persistent symptoms of SARS-CoV-2 infection to prevent possible impacts on daily activities and participation.

Relationship between WAI, BriefCOPE and COPSOQII scales: a multivariate analysis on health care professionals

Alina Humenyuk — 2023-05-30

Background/Objective: Individual health and organizational performance are strongly influenced by how people manage stress, or how they cope. Analysis and understanding of bidirectional association of BriefCOPE and COPSOQII and a unidirectional association of these two with “Índice de Capacidade para o Trabalho (ICT)”, a Portuguese version of Work Ability Index (WAI) in a health care professionals (e.g. Physicians, Nurses…) database (incomplete cases: n=909, complete cases: n=652).

Methods: The Brief-COPE is a 28 item self-report questionnaire designed to measure effective and ineffective ways to cope with a stressful life event. The psychosocial factors of work were evaluated using the COPSOQII. This questionnaire comprises 76 items divided into 29 scales. The WAI assesses the work ability, considering their health status, physical and mental demands, and work-related resources. To explore the association between Sociodemographic variables, BrieCOPE and COPSOQII with WAI, the chi-squared test (for categorical variables) and the Kruskal-Wallis test (for quantitative variables) were applied. Exploratory Factorial Analysis (EFA) and Confirmatory Factorial Analysis (CFA) methods todetermine the model structure and fitness were also used.

Results: The WAI classification for the health care professionals was: poor/moderate (n=123; 18.9%), good (n=349, 53.5%), excellent (n=180, 27.6%). The sociodemographic variables showed no significant association with WAI categories. For the BriefCOPE scale, significant results were found with WAI categories in 8 of 14 dimensions (e.g active coping, denial, and substance use). For the COPSOQII scale, significant results were found with WAI categories in 28 of 29 dimensions (e.g work pace, burnout, and bullying). By EFA, the best model of BriefCOPE (oblimin rotation) with 4 dimensions was obtained, explaining in total 55% of the data variance. The best resulting model for COPSOQII, composed of 7 dimensions (varimax rotation), explains 63% of the total variance. These best models were used to be compared to the respective CFA. The results for the CFAs were not satisfactory given that the CFI and TLI indices were not good.

Conclusions: The main conclusion is that the fitting of the models does not have good results, even considering the models proposed by EFA. This might be explained due to the aggregation of all heath care professionals since different types of healthcare professionals have different work environments and demands.

Physicians' perceptions of psychosocial factors and coping strategies in their ability to work: a multivariate analysis

Ana Messias — 2023-05-31

Background/Objective: Physicians play a crucial role in healthcare systems but face negative impacts from a challenging work environment, leading to burnout. Burnout has negative effects on physician health and patient care. Understanding psychosocial aspects of work and coping strategies used by physicians is essential. Validated tools, including COPSOQ-II, BriefCOPE, and WAI scales, can provide insight into the psychosocial impact of the medical profession. The study aims to use these scales to explore the relationship between job demands (COPSOQ-II), coping strategies (BriefCOPE), and work ability (WAI) among Portuguese physicians.

Methods: Participants were recruited through professional associations and organizations with access to physicians, and data was collected via a self-administered web-based questionnaire. Participants’ sociodemographic characteristics were associated with WAI scores through Chi-Square analysis and One-way ANOVA. Outliers were detected through sensitivity analysis, and exploratory and confirmatory factor analyses were performed for the COPSOQ-II and BriefCOPE scales. Associations between WAI scores and COPSOQ-II and BriefCOPE scales were also analyzed.

Results: The study surveyed 55 physicians and found that except for sex, there were no significant differences in the work ability index (WAI) by sociodemographic characteristics. Significant differences were found between WAI and higher scores in job purpose, quality of management, and general health, while higher stress, sleep issues, and depressive symptoms were associated with lower WAI groups. Exploratory (EFA) and confirmatory factorial analyses (CFA) were conducted on the BriefCOPE and COPSOQ-II scales, revealing disconnection with the theoretical model. Under EFA, the BriefCOPE items related to theoretical dimension of "dysfunctional coping" are scattered into other coping dimensions, and the empirical model of the COPSOQ-II scale presented a different configuration from its theoretical model, either in the number of dimensions or in the distribution of items by their dimensions. Under CFA, these differences between the theoretical and empirical models are even clearer, as neither dataset fits to its theoretical counterpart without changes. In BriefCOPE, removing self-blaming is sufficient to correct this, while in COPSOQ, a minimum of 9 dimensions needed to be excluded. Even then this result presents unacceptable CFI(Comparative Fit Index), TLI(Tucker-Lewis Index) and RMSEA(Root Mean Square Error of Approximation) values.

Conclusions: This study analyzed physician perceptions of workplace environment and job-related and psychosocial factors using a questionnaire. However, the results did not provide any significant findings, and only suggested some possible associations between certain workplace factors, coping abilities, and work ability. The study had a small sample size and further research with larger sample sizes is needed to confirm these findings.

Analysis of Cervical Node Metastasis in Oral Cavity Squamous Cell Carcinoma Patients

Leonor Cruz Silva — 2023-05-31

Background/Objective: Oral Cavity Cancer is a frequent type of Head and Neck Cancer, associated with high mortality rates worldwide. One of the main prognostic factors for the disease is regional lymph node metastasis that is associated with survival rate reduction by 50%. Reported tumour sites more frequently associated with regional node metastasis vary throughout literature. Therefore, we aimed to conduct a retrospective study that would allow us to identify the relationship between patient and SCC tumour factors with the rate of neck metastasis and compare our data with the conclusions from similar studies.

Methods: A retrospective study was conducted in the Oral Medicine and Oncology Consultation of the Stomatology Department from Centro Hospitalar Universitário Lisboa Norte, comprehending patients diagnosed with Squamous Cell Carcinoma between January 2015 and April 2021. As eligibility criteria we considered patients which had clinical charts with complete information including sociodemographic variables, tumour site and disease staging at diagnosis. We excluded tumour sites with only two diagnosed cases, considering bias risk. Three groups were defined according to a clinical/pathological reason. The current research was approved by an independent ethics committee.

Results: The sample includes 151 cases, the majority of which were males (≈59%) and with average age at diagnosis (± standard deviation) of 65 ± 13 years-old. Oral tumour sites with highest percentage of cases with clinical positive lymph nodes (cN+) by the time of diagnosis were inferior gingiva (72.7%, n=16), mouth floor (66.7%, n=22), oropharynx (64.7%, n=11), retromolar trigone (58%, n=11) and ventral tongue (57%, n=16). Sites with fewer cases of cN+ were inferior lip (31%, n=4) and superior lip (n=0). Similar results were found in our sample when operated tumors (pN+) were considered: floor of the mouth (65%, n=13), retromolar trigone (63.6%, n=7), inferior gingiva (46.2%, n=6) and ventral tongue (45%, n=9). Tumour sites with fewer pN+ cases were hard palate (25%, n=1), superior gingiva (16.7%, n=1) and inferior lip (0 out of 7 cases). According to Fisher’s exact test there is no statistically significant association (p-value=0.1506) between primary tumour site and cervical node disease (either cN+ or, whenever available, pN+).

Conclusions: Our data seem to indicate an association between primary tumour site and N+, being cervical metastasis more frequent when tumour site was posterior and caudally located. Lower lip had the fewer positive lymph nodes, probably correlated with the inclusion in the same group of oral mucosa and skin cancers. Despite these findings, the association was not statistically significant.

5th Statistics on Health Decision Making: Personalized Medicine

Poster Communication Authors — 2023-05-31

P01 - Analysis of cervical node metastasis in oral cavity squamous cell carcinoma patients
Leonor Cruz Silva, José Cunha Coutinho,Gonçalo Cunha Coutinho, Ricardo Miguel Vieira de São João, Tiago Dias Domingues, Cecília Caldas, Paulo Palmela, Miguel Nobre, Francisco Salvado

P02 - Odontometrics analysis as tool of Legal Medicine discipline to decide about perfil postmortem of cadavers: apply in a commingled archaeological human population related to 1755 Lisbon’s earthquake
Cristiana Palmela Pereira, Valon Nushi, Tatiana Major, Guilherme Borges, Lara Lopes, Lisa Zheng, Ana Rodrigues, Rui Santos

P03 - Forensic dental age assessment: effect size on real age forensic medical report
Cristiana Palmela Pereira, Valon Nushi, Diana Augusto, Adriana Santos, Mafalda Marques, Sakher J. AlQhatani, Rui Santos

P04 - Effect of statins intake in the risk for progression of age-related macular degeneration – a comparison of two Cox regression models applied to the Coimbra Eye Study
Rita Coimbra, Patrícia Barreto, Cláudia Farinha, Rufino Silva

P05 - Association between the adrenoreceptor β2 gene and pediatric asthma severity – a study of the PACMAN cohort
Maria Leonor Caleiro, Patricia Soares, Marília Antunes

P06 - Communication strategies used by health professionals and finalist students from health areas with people with aphasia
Daniela Jesus, Ana Rita Pinheiro, Pedro Sá-Couto, Maria A. Matos

P07 - Association of the practice of contact sports with the development of amyotrophic lateral sclerosis
Ana Rita Henriques, Marta Gromicho, Julian Grosskreutz, Magdalena Kuzma-Kozakiewicz, Susanne Petri, Hilmi Uysal, Susana Pinto, Marília Antunes, Mamede de Carvalho, Ruy M. Ribeiro

P08 - Self-perceived functioning in relation to existing symptoms 12 months after SARS-COV-2 infection in workers of an industrial facility in Aveiro Region – an observational study.
Ana R. Pádua, Marco Gama, João Conde, Joaquim Alvarelhão

P09 - Disclosing gene signatures in gliomas via classification and dimensionality reduction methods
João F. Carrilho, Roberta Coletti, Marta B. Lopes

P10 - Explanatory variables consistency and association strengths in sepsis diagnosis: a methods comparison
Vanusa Rocha, Vera Afreixo, Luís Cabral

P11 - Identification of the molecular basis of heart failure through Microarray merging
Sandra Magalhães, Sílvia O. Diaz, Adelino Leite-Moreira, António S. Barros

P12 - What is the predictive value of ambulatory blood pressure monitoring (ABPM) in terms of future cardiovascular events for patients with resistant hypertension?
Simão Carvalho, Carlos Costa, Flávio G. Pereira, Susana Lopes, José Mesquita Bastos

P13 - STOP-Bang questionnaire as a screening tool for obstructive sleep apnea syndrome in the bariatric population: a meta-analysis
Sara Velha, Emília Lima Silva, Maria da Conceição Costa

P14 - Brain protection strategies in the surgical treatment of acute type A aortic dissection and the occurrence of intraoperative brain damage - a systematic literature review and meta-analysis
Carolina Lança Pereira, Tiago Adrega

P15 - Perceived health status of patients in a hyperbaric medicine unit in the north of Portugal
António Pedro Ferreira, Filipe Alvarilhão, Paula Inês Rebelo, Manuel Lopes, Óscar Camacho, Joaquim Alvarelhão

P16 - Relevance of testing proportional hazard assumption in Cox Regression - Sex differences in long-term survival after coronary artery bypass grafting
Inês Sousa, Sílvia Diaz, Rui J. Cerqueira, Ana Filipa Ferreira, Mário J. Amorim, Paulo Pinho, André P. Lourenço, António S. Barros, Francisca Saraiva, Adelino Leite-Moreira

P17 - Exploring the impact of sex differences on atrial fibrillation recurrence after catheter ablation using a data-driven approach
Sílvia O. Diaz, Ana Inês Aguiar Neves, Augusto Sá Carvalho, Mariana Ribeiro Silva, Gualter Santos Silva, João Almeida, Paulo Fonseca, Marco Oliveira, Helena Gonçalves, Francisco Sampaio, João Primo, Francisca Saraiva, António S. Barros; Ricardo Fontes-Carvalho

P18 - Lipidomic profiling of HFpEF patients for the stratification of cardiovascular risk
Sílvia O. Diaz, António S. Barros, Pedro Palma, António Angélico-Gonçalves, Francisco Vasques-Nóvoa, Francisca Saraiva, José A Belo, Otília V Vieira, Adelino F Leite-Moreira

P19 - Assessing the prognostic value of metabolites in patients with heart failure: a systematic review and meta-analysis
Leonel Sousa Neves, Francisca Saraiva, Adelino Leite-Moreira, António S. Barros, Sílvia O. Diaz

P20 - Decoding the genetic architecture behind disease heterogeneity: A genome-wide association study and cluster analysis in COPD
Guilherme Rodrigues, Rui Marçalo, Gabriela Moura, Vera Afreixo, Alda Marques

P21 - Low versus high-resource pulmonary rehabilitation settings in COPD: a retrospective, propensity score-matched, non-inferiority study
Joana Antão, Cátia Paixão, Patrícia Rebelo, Ana Machado, Sara Souto-Miranda, Ana Sofia Grave, Cíntia Dias, Guilherme Rodrigues, Tânia Pinho, M. Aurora Mendes, Ana Oliveira, Alda Marques

P22 - Evolution of the risk perception of infection by COVID-19 – Evidence from the COVID-19 Barometer: Social Opinion
Inês Paixão, Marília Antunes, Patrícia Soares

P23 - Relationship between WAI, BriefCOPE and COPSOQII scales: a multivariate analysis on health care professionals
Alina Humenyuk, Inês Baptista, Rodrigo Antunes, Pedro Sá-Couto, Marco Ramos

P24 - What proportion of women refers moderate to severe pain during office hysteroscopy with a mini- hysteroscope? A systematic review and meta- analysis
Margarida Cordoeiro, Susana Lima Oliveira, Maria Helena Solheiro, António Santos-Paulo, Vera Afreixo

P25 - Fetal hemoglobin level impact on the clinical and laboratory profile of SCA patients
Ariana Freire, Vera Afreixo, Vanusa Rocha, Enrique Martinez, José Raya, João Gonçalves

P26 - Effectiveness of neural mobilization techniques in decreasing pain and improving function in people with low back and neck pain: a systematic review with meta-analysis
Frederico Baptista, Ellen Nery, Eduardo B. Cruz, Vera Afreixo, Anabela G. Silva

P27 - Bacterial co-infections in patients with COVID-19: a retrospective single center study
Raquel Diaz, Vera Afreixo, Filipa Rocha, Gabriela Nogueira, Bruno Gago.

P28 - Forecast model for Performance Indicators, a case of USF Arte Nova
Catarina Cardoso, José P. Antunes

P29 - Hypertensive disorders in pregnancy: association between clinic and ambulatory blood pressure and adverse pregnancy outcomes
Eline S. Barbosa, José M. Bastos

P30 - Patients pain and anxiety in office hysteroscopy
Maria Francisca Vilaça, Catarina Toscano, António Santos Paulo, Vera Afreixo

P31 - Modelling COVID-19 with graph theory and cellular automata as an alternative to overcome the limitations of the SIR model.
Rodrigo Antunes, Sofia J. Pinheiro, Cristiana J. Silva, Vera Afreixo, Pedro Rebelo, Rui Pedro Leitão

P32 - Determinants of surgical site infection in hip and knee arthroplasty: A retrospective cohort study
Catarina Alves Rodrigues, Cristina Nunes, Sandra Linhares, Cristiano Matos

P33 - The dimension reduction power of ClustOfVar: application of the variable cluster analysis technique in a mixed data health database
Natacha Oliveira, Milton Severo

P34 - Coping strategies and psychosocial factors at work of dietitians/ nutritionists: a multivariate analysis approach
Raquel Simões, João Oliveira, Pedro Sá-Couto, Marco Ramos

P35 - Are coping and workplace psychosocial factors related to work ability in physicians? A PLS-SEM approach
Joana Ricardo Pires, Pedro Sá Couto, Pedro Bem-Haja, Marco Ramos

P36 - Occupational health, well-being and ability to work in a sample of Portuguese Nurses
Diana Lucas, Hugo Senra, Vitor Rodrigues, Pedro Sá Couto, Marco Ramos

P37 - Exploratory and inferential analysis of children's eye defects screening in the region of Aveiro
Diana Lucas, Joana C. Santos, Jorge M. S. Marques, Rui P. Leitão

P38 - Physicians’ perceptions of psychosocial factors and coping strategies in their ability to work: a multivariate analysis
Pedro Couto, Ana Messias, Marta Estrela, Pedro Sá Couto, Marco Ramos

P39 - Neutrophil-to-lymphocyte ratio as a prognostic marker in highly PD-L1 expressing advanced non-small cell lung cancer patients in first line treatment with Pembrolizumab
Joana Dias, Lídia Gomes, Ana Figueiredo, Fernando Barata