Campania, due to its pedo-climatic conditions and to its large varietal heritage, is able to produce oils with high typicity, each different from the other. In this study a “minor” autochthonous cultivar of Campania “Oliva Bianca” was analyzed. In autumn 2020, on drupes from trees belonging to the Campania germplasm collection a varietal characterization through physical, chemical and chromatic parameters at the harvest was carried out. Phenolic compounds profile, fatty acids composition and volatile organic compounds have been investigated in the resulting oil. Quality indices, organoleptic and sensory qualities (panel test) were also determined on the oil. Drupe weight was 4.31 g, flesh/pit ratio was 3.68 and the accumulation of oil content at harvest in drupes was 18.63% FW. The drupes showed high anthocyanins content equal to 116.10 mg/kg. In the oil studied, the secoiridoids represented the 82.25% of total phenolic compounds, the concentration of oleic acid was 74.82% and the most present volatile compound was trans-2-hexenal (72.30%). High secoiridoid derivatives concentrations such as oleuropein (85.93 mg/kg) and ligstroside (122.43 mg/kg) aglycones were showed. This study showed a good content of qualitative and quantitative parameters of “Oliva Bianca” oil and drupe, that can have important beneficial effects on human health. Olea europaea L. subsp. europaea), which originated in the Eastern Mediterranean area, has been cultivated throughout the Mediterranean basin since ancient times for its fruit and oil. It is believed to have been domesticated as far back as 3500–3700 BC and references to the use and trade of olive oil date back to 2000–3000 BC [The olive , due to a high cumulative production per plant (43.47 kg per plant) and a reduced trunk cross-section area (130 cm2) [A previous study polyannual was conducted from 2003 to 2009 on the germplasm of Campania involving 20 autochthonous olive cultivars from Campania including the “Oliva Bianca” cultivar. In this study the cultivar “Oliva Bianca” has shown a cumulative production efficiency greater than the other cultivars analyzed 0.67 kg/cm kg/cm2, In terms of fruit size, the “Oliva Bianca” shows a high weight drupe with 4.31 ± 0.90 g, formed for 78% by flesh, flesh weight equal to 3.36 ± 0.80 (g), pit weight of 0.95 ± 0.23 (g) and a flesh/pit ratio equal to 3.68 ± 1.00 .2) at veraison.The “Oliva Bianca” drupes have a spherical fruit (L/I = 1.25–1.45) and rounded base with a polar diameter mean of 21.41 ± 1.75 (mm) and transversal diameter mean of 17.53 ± 1.29 (mm). Regarding pulp firmness, this cultivar generally showed high resistance to penetration, in fact, the value for this parameter was 460.45 ± 34.98 (kg/cmThe “Oliva Bianca” is characterized by both a late flowering (25–28 May) and late veraison (10–30 Nov).The ripening of the fruits at harvest was determined by the Jaén-index, according to which the optimal harvest time is when the value lies between 2 and 3, in our samples of the cultivar “Olive Bianca” showing (PI) value of 2.41 ± 0.35. The peel color was also determined by chromatic parameters (L* a* b* and IC), L* showed value of 46.45 ± 12.2, a* (red direction) of 6.34 ± 9.62 and major value b* (yellow direction) of 16.9 ± 15.56, these data show weak skin veraison, index color showed the value of -32.86 ± 1072.93. The chemical profile of the fruits showed a high anthocyanins content equal to 116.1 ± 0.4 (mg/kg), carotenoids equal to 2.1 ± 0.01(mg/kg) and total chlorophyll of 5.7 ± 0.01 (chlorophyll a: 3.6 ± 0.03 and chlorophyll b: 2.1 ± 0.01).The accumulation of oil content at harvest in Oliva Bianca drupes was 18.63 ± 0.28 (%) in agreement with previous studies on the same cultivar which showed high values of 21.25% (%) [2/ kg oil, K232 equal to 1.64, delta K less than 0.01 and K270 equal to 0.09. In The individual phenolic compounds were identified and quantified by UHPLC coupled with high resolution mass spectrometry (HRMS) by means of comparison with available standards. As some standards were not available (the case of secoiridoids), quantitation was carried out employing calibration curves of available standards belonging to the same chemical group and with similar response (oleuropein) while for the identification MS/MS experiments had to be used. UHPLC-HRMS analysis allowed the separation and identification of 17 phenolic compounds, which may be grouped in the phenolic alcohols, phenolic acids, secoiridoids and flavonoids. In In the oil studied, the secoiridoids represented the 82.25% of total phenolic compounds, however, hydroxytyrosol and tyrosol accounted together for 4.37% of total polyphenolic content. The dialdehydic form of elenoic acid linked to the tyrosol (p-HPEA-EDA) known as oleocanthal and responsible of anti-inflammatory activity was the main secoiridoid with a content of 255.20 mg/kg together with p-HPEA-EA (ligstroside aglycone) and DHPEA-EA (oleuropein aglycone) that were found at level of 122.43 and 85.93 mg/kg, respectively. DHPEA-EDA (oleacein), 3,4-DHPEA-AC (hydroxytyrosol acetate) and hydroxy oleuropein aglycon were detected in low amounts with concentrations of 33.43, 35.45 and 2.35 mg/kg, respectively.The concentration of elenolic acid was 66.70 mg/kg, tyrosol and hydroxytyrosol, deriving from the hydrolysis of ligstroside and oleuropein respectively, were detected in the investigated oil in low concentration equal to 16.45 and 11.98 mg/kg, respectively. A good content of the flavonoids (luteolin and luteolin rutinoside) was observed with concentration of 17.37 mg/kg.The fatty acid (FA) profile in The concentrations of total saturated fatty acids (SFAs) and polyunsaturated fatty acids (PUFAs) were 15.70% and 8.63%, respectively. The MUFA/PUFA ratio was 8.77, while MUFA/SFA ratio was 4.82.In The most present compounds were trans-2-hexenal that represented 72.30% of total VOCs, trans-2-hexen-1-ol (7.75%), hexanol (3.34%), ethanol (2.93%), ethyl acetate (3.60%), 1-penten-3-one (2.52%), ethyl-1,5-octadiene (1.83%) and β-ocimene. Compounds that were present below 1% were  2,4-hexadienal, 4,8-dimethyl-1,7-nonadiene, cis-3-hexenyl acetate, nonanal, 1,7-octadien-3-one, 2 methyl-6-methylene and α-cubebene, which have also been found in other oils deriving from different cultivars and that influence the flavor of olive oil ,18,19,20Regarding the panel test analysis, the oil must be considered as an extra virgin olive oil (EVOO) since the median of the fruitiness of 5.2 (medium fruity), 3.3 of the bitterness (medium bitterness) and 4.7 of the pungent of 4.7 (medium pungent) and that the median of the defects is 0, in fact according to the Regulation (EC Reg. 1604/2019) an oil in order to be defined extra virgin must have a median of defects equal to 0 and a fruitiness greater than 0.“Oliva Bianca” is a variety very appreciated for its productivity, yield and some agronomic characteristics. In the present study, in agreement with the UPOV method, the “Oliva Bianca” drupes are considered to be of medium size (from 2 to 4 g), of oval-shaped and with rounded apex. Due to its high weight and the pulp/pit ratio (very close to 4), although this cultivar is mainly used for oil production, the drupes are also suitable and potentially marketable as table olives. When used for this purpose, olives are harvested after complete maturation, which gives to them a naturally black color due to anthocyanin accumulation . The hig“Oliva bianca” cultivar is so called because at the veraison the fruits get a very pale color (white) before the appearance of the violet color. This cultivar is considered excellent all for its quality of the oil and it is characterized by a high oil content, in agreement with a previous study carried out on the same cultivar, which showed an oil content of fruits of 20–21% (FW) .Our results were under the limits reported by Regulation EEC 1604/2019 of the European Union Commission, showing that the “Oliva Bianca oil” obtained has all the characteristics to be considered EVOO .2/kg oil), K232 and K270 absorbance at specific wavelengths  and acidity up to 0.8%.EVOO is the highest quality of olive oil; edible olive oils are graded into EVOO with acidity up to 0.8%, calculated as oleic acid. Furthermore, an EVOO must have the following parameters: peroxide value PV , stearic 2.32%) and linolenic acid (0.74%)  was simi%, steari% and linThe difference in FAs composition could be derived from pedoclimatic conditions, variety, altitude and climatic conditions that influence drupe ripening and composition . Yun andThe MUFA/PUFA ratio was similar to data of ,35 that Finally, FA composition influences the sensorial properties of oil and it is also an important marker for biodiversity and quality of product .The aroma of olive oil is attributed to aldehydes, alcohols, esters, hydrocarbons, ketones and furans . As for Ethyl acetate resulting from anaerobic fermentation and influencing the flavor described as vinegar, wine and sweet was well correlated to the winey-vinegar defect ,19. Bactrocera oleae [Among ketones, 1-penten-3-one was identified and it could be derived from a contact with metal surfaces and 13-alcoxy radical  the flavra oleae ,20 but ira oleae  and its ra oleae . Methyl ra oleae ,19,44.The study was conducted in 2020 on olive trees belonging to the germplasm collection of Campania grown at the ‘Improsta’ experimental farm , situated about 100 m above sea level . The studied olive genotype was a Campania minor cultivar called “Oliva Bianca”. Cultural practices at the orchard are usual in the production area, and no irrigation is supplied. In October from 4 trees in full production were picked by hand 120 kg of healthy olives and carefully stored in ventilated boxes and processed within 4 h.2) by a penetrometer with a point of 1 mm in diameter. The ripening index (0–7) for olives was determined according to the method proposed by the “Estación de Olivicultura of Spain” [On a sample of 100 olives, drupe and pit weight with an electronic digital balance , equatorial and polar diameters using a digital vernier caliper  were determined. The same sample was used to determine pulp firmness  that was capable of quantifying colors according to international standards and expressed in define color spaces. The instrument was calibrated with “white” managed by the light source on a white tile, before each measurement. The L* a* b* (CIELAB) color space is the most common for measuring the color of an object or materials of different origins and it is widely used in all sectors. In this color space, L * indicates brightness, while a* and b* the chromaticity coordinates: +a * is the direction of red, −a * is the direction of green, +b* is the direction of yellow and −b * is the direction of blue  subsequeOil extraction was performed using a micro-mill , kneading the fresh olive paste at 28 °C for 30 min. Subsequently, the oil was obtained using a Soxhlet extractor  with n-hexane as a solvent. After 4 h of extraction, consisting in two discontinuous cycles at 130 °C, the sample was weighed for oil yield determination. The oil was filtered and stored at 15–18 °C in absence of light prior to analysis.2/kg oil), spectrophotometric indices  and sensory profile by panel test according to the EC Reg. 2568/1991 and later amendments and International Olive Council (IOC) standard methods. The parameters K232 and K270 are the oil absorbance at 232 and 270 nm, respectively, and ΔK was calculated from the absorbances detected at 262, 268 and 274 nm using a Shimadzu UV-1601 spectrophotometer .The olive oil extract was analyzed for quality indices: acidity (% oleic acid per 100 g oil), peroxide  and EC Reg. 1604/2019. Panel test was performed in the Department of Agriculture, University of Naples Federico II , using the evaluation form regulated by EC Reg. 640/2008 and reported in −1 ramp to 175 °C for 20 min and then 3 °C min−1 ramp to 240 °C for 20 min. The PTV program was set such as follow: 60 °C for 0.1 min, ramp to 500 °C min−1 to 260 °C for 5 min. The split ratio was 15:1, and the flame detector temperature was set at 260 °C, while the injector temperature was set to 120 °C.The determination of fatty acid profile was performed by analyzing the fatty acid methyl esters (FAMEs) obtained after trans-esterification . A 1% sw/w.The identification of the compounds was carried out by comparison with a mixture of standards: FAME C4-C24, (Sigma-Aldrich fatty acid methyl esters 37 components). The results were expressed as % All the standards used were for the analysis were from Sigma Aldrich St. Louis, MO, USA, while hydroxytyrosol was purchased from Indofine , secologanoside from ChemFaces Biochemical Co., Ltd.  and oleuropein form Extrasynthese . Acetonitrile and water (LC-MS grade) were acquired from Carlo Erba reagents , whereas acetic acid (98–100%) was purchased from Fluka .v/v) to extract polar compounds. Subsequently, the three supernatants were combined and counter-extracted with 25 mL of hexane. The solvent was dried in a rotary evaporator  at 40 °C. Finally, the residue was resuspended in 1 mL of methanol, filtered through 0.2 mm nylon filer and kept at 18 °C until analysis.The extraction of phenolic compounds was carried out in accordance with that reported by Dini et al. 2020 . Briefly2O 0.1% of acetic acid) and phase B (Acetonitrile). The flow used to elute the phenols was 0.4 mL/min while gradient was as follows: 0–5 min 5% phase B, 6–25 min 40% phase B, 25.1–27 min 100% phase B, 27.1–35 min 5% phase B and 35.1–45 min 0% phase B. To identify the phenolic compounds a comparison was made between retention time and mass spectra of the respective standards. As regards secoiridoids, they have been quantified using the oleuropein standard, due to the lack of the commercial standard. Mass experiments have been done with a Q Exactive Orbitrap LC-MS/MS  equipped with an ESI source  operating in the negative ion mode (ESI-). The ion source parameters were spray voltage −3.0 kV, sheath gas (N2 > 95%) 30, auxiliary gas (N2 > 95%) 15, capillary temperature 200 °C, S-lens RF level 50 and auxiliary gas heater temperature 305 °C. The detection of the MS (Mass) was carried out in two acquisition modes, one in full scan (negative-ion modes) and the other in targeted selected ion monitoring. The parameters of the full scan acquisition mode were: mass resolving power 35,000 full width at half maximum (at m/z 200), scan range 100–1500 m/z, scan rate 2s−1, and the automatic gain control target 1 × 105 ions for a maximum injection time of 200 ms. The parameters of the targeted selected ion monitoring acquisition mode were: 15 s-time window, resolution power 35,000 full width at half maximum (at m/z 200), and quadrupole isolation window 1.2 m/z. The mass list containing exact masses and expected retention times of the target polyphenolic compounds are reported in To identify and quantify the phenols was used an Ultra-High-Performance Liquid Chromatography  equipped with a degassing system (Dionex Ultimate 3000), a quaternary UHPLC pump working at 1250 bar, an autosampler device, and a thermostated column compartment (T = 30 °C). The column was an Accucore a Q 2.6 µm (100 mm × 2.1 mm)  and the injection volume was 5 µL. About the mobile phases they were phase A (HVolatile organic compounds (VOCs) were extracted and analyzed from extra virgin olive oil following the method proposed by ,45 with Subsequently, the SPME fiber was introduced directly into the GC injector, where the thermal desorption of the analytes was performed at 250 °C for 10 min. A 6890N GC system equipped with a 5973 mass detector was used. VOCs were separated on a 30 m × 0.250 mm capillary column coated with a 0.25 μm polymer of 5% diphenyl 95% dimethylpolysiloxane. Splitless injection was used for the samples.The oven temperature was held at 40 °C for 5 min and increased from 40 °C to 80 °C at 5 °C/min, from 80 to 200 °C at 10 °C/min and from 200 to 270 to 10 °C/min, the temperature of 270 °C was maintained for 4 min. The injection source and ion temperatures were 250 and 230 °C, respectively. Helium was used as a carrier gas at a flow rate of 1 mL/min. The ionizing electron energy was set to 70 eV and the scanned mass range was set to 40–450 amu in the full scan acquisition mode.Compounds were identified comparing the mass spectra fragmentation patterns with the spectra data from the NIST Atomic Spectra Database version 1.6 and the retention indices with those reported in literature. The relative content of VOCs was calculated on the basis of peak area ratios. All the analyses were performed in triplicate. All the analyzed parameters are presented as mean ± standard deviation and calculated by using XLStat version 2009.3.02 software .The results obtained from the study about cv “Oliva Bianca” highlighted interesting qualitative and quantitative aspects; in particular, the drupes showed physical parameters, such as the weight and flesh/pit ratio, suitable also for use as table olives, also showing a high content of anthocyanins, compounds important for their antioxidant effect. Additionally, “Oliva Bianca” oil has shown positive characteristics on human health, such as a high content of oleic acid, in fact recent findings revealed that oleic acid, the main olive oil’s monounsaturated fatty acid, plays a key role in the prevention of various human cancers .Oil extracted has all the characteristics to be considered extra virgin olive oil and the estimated aromatic profile is characterized by a high content of trans-2-hexenal that influences the taste of green, pungent, bitter fruity, apple, almond and cut grass. The high level of oleocanthal attributes to the oil interesting nutraceutical properties considering its considerable positive biological effects. Oliva Bianca is only one of “minor” indigenous cultivars of Campania that due to the region’s pedo-climatic conditions and to its large varietal heritage are able to produce oils with high typicity, each significantly different from the other. Our trial is only a starting point for the local olive trees varietal characterization, which allows one to enhance little known cultivars. Nevertheless, additional studies during next years are required to better characterize olive genetic resources in Campania.


Transradial access (TRA), which has a minimal risk of problems such as radial artery occlusion (RAO), hemorrhage, spasm, and so on, is now considered the standard procedure for cardiac catheterization. The aim of the study is to present the distal transradial access (d-TRA) as a possible promising novel technique in the field of cardiac coronary interventions comparing it to the standard conventional TRA using primary and secondary endpoints, exploring its benefits and drawbacks as a new experience in Alexandria University. One hundred cases with variable indications for coronary interventions were randomized to two arms using systematic random sampling method, coronary interventions in the first one were done via d-TRA (50 patients) and in the second arm via conventional TRA group (50 patients).Technically, there were highly statistically significant differences between the two arms in favor of TRA regarding procedural success, number of punctures taken, Access time, Total procedural time, vasodilator used, and crossover to another access site; meanwhile safety profile parameters have showed statistically significant differences in favor of d-TRA regarding post-operative hematoma, AV fistula, post-operative pain and compression time, and there were no statistically significant differences regarding RAO although it occurred more in TRA group.In the realm of cardiac intervention, the distal radial approach is a promising technique. When compared to TRA, we found it to be a viable and safe method for coronary angiography and interventions and it could be a real option for the interventionists in the near future, with a lower risk of radial artery blockage and no significant differences in wrist hematoma and radial artery spasm. The success rate of d-TRA is proportional to the steepness of the operator's learning curve and the quality of the examples chosen. Many developments have happened in the treatment of ischemic heart disease over the last few years, one of which is the arterial access route for both coronary angiography and percutaneous coronary procedures . The traTraditional radial arterial access (TRA) was initially used to perform interventional treatments in 1993. Some interventional experts were originally ecstatic about the technique's feasibility and safety . TRA hasTo address these constraints, interventionists across the world have tried a variety of TRA modifications, including achieving patent hemostasis to prevent RA occlusion, utilizing mean artery pressure-guided compression, and obtaining TRA more distally in the anatomical snuff-box (ASB) or at the palm .Recently, a novel technique called the "distal transradial approach (d-TRA) (snuffbox approach)" was developed to solve these constraints while simultaneously providing an advantage over the transfemoral approach. Kiemeneij suggested the first publication in 2017, and since then, a huge number of researches have examined the safety and practicality of this novel technique .The distal radial artery (DRA), cephalic vein, and superficial branches of the radial nerve are among the contents of the anatomical snuffbox. The radial pulse can be detected in two places: the anatomic snuffbox and the first inter-metacarpal space; these two locations are alternate puncture sites for TRA . By the The most prevalent problem in TRA is termed as radial artery occlusion (RAO). RAO is caused by damage to the intima of the radial artery and local blood flow stoppage, which results in thrombosis at the puncture site. However, because the d-TRA puncture site is farther away from the wrist and a smaller sheath  is used the intimal damage in the traditional TRA site is minimal .In comparison to traditional TRA, left d-TRA provides a few significant benefits. First and foremost, right-handed individuals will no longer be disturbed by their right hand's restricted mobility following catheterization . PatientFurthermore, interventionists will be able to operate on the right side of the patient rather than bending over the patient, which is inconvenient. As a result, the doctor could work at a safe distance from the source of radiation .One hundred patients were randomized into two arms using systematic random sampling method, coronary interventions in the first arm were done via d-TRA (50 patients) and in the second arm via TRA (50 patients).Cases aged more than 18 years, intentional for coronary intervention either in acute or elective settings, and having palpable radial pulse at wrist and at anatomical snuff-box (ASB).Those with the history of undergoing coronary intervention through radial access, history of hand surgery, history of Peripheral arterial diseases, history of carpal tunnel syndrome, history of infection or inflammation at access site, renal inadequacy  and history of contrast allergy or Lignocaine hypersensitivity be excluded.After approval of the ethics committee of the faculty of medicine, university of Alexandria with serial number 0106762, A prospective, single-center, study was done, comparing two methods of obtaining radial access in patients undergoing coronary intervention. Written informed consents were signed by the patients or their guardians.After full assessment of our study population and applying inclusion and exclusion criteria, we fully explain the goals of the study and the procedure technically to the study participants and their guardians and obtain a written formal consent from them. We choose the systematic random sampling method to divide the whole 100 cases into two groups (d-TRA and TRA), as we start using the d-TRA approach for the first case then the second one via the conventional TRA approach automatically and so on, ending with 50 patients for each group.Patients enrolled with at least 2-month follow-up in the form of assessment of the access site and clinical palpation of the radial artery pulse at both sites after the index procedure of the last patient. Direct contacts (phone numbers or E-mails) were taken from them to facilitate the communications and the follow-up.Demographic data , risk factors history , history of previous MI, previous PCI, previous bypass surgery, cerebrovascular disease, peripheral arterial disease, clinical indication , acute coronary syndrome (ACS), lab investigations: renal functions, Complete blood count (CBC), Coagulation profile, echocardiography to measure the left ventricular systolic function and history of drug intake of anticoagulants.After defining the accessing part of the radial artery either proximally or distally, a local anesthesia is injected following proper sterilization. A 20-G cannula-needle is used for puncturing the RA, and after getting free blood backflow 0.025 inch sheath wire is introduced carefully before placement of the 5Fr or 6Fr radial sheath, followed by injection of 5 mg verapamil and 5000 IU unfractionated Heparin.In case of difficulty of advancing the 0.025 in. sheath wire, we may use 0.14 in. wire and then replace it with the 0.025 in. sheath wire.Adding 100 mg Nitroglycerin directly through the sheath may be considered in case of RA spasm has occurred, provided that the blood pressure measurement is maintained.When the procedure is finished and after sheath removal a manual compression was applied for the d-TRA group to maintain hemostasis, while a radial band was used for TRA group and removed gradually over 2–3 h and radial artery pulse was assessed for each patient on both sides.Major local complications or any patients' complaints during or post-procedure were noticed and recorded for each case Figs. , 2.Fig. Procedural success, successful cannulation (sheath placement), site of the procedure (right or left), successful radial artery puncture, number of punctures used, access time (min), total procedure time (min), sheath size, frequency of vasodilator administration in sheath, quantity of catheter handed through the access site during the process, crossover to another access site, contrast volume used (ml), major complications, including Post-catheterization radial artery occlusion, hematoma, infection, arteritis, dissection, rupture of access artery and A-V fistula, post-procedure puncture site pain, post-procedure compression time and post-procedure assessment of radial artery pulse at both sites.. . Qualitative data were described using number and percent. The Kolmogorov–Smirnov test was used to verify the normality of distribution Quantitative data were described using range (minimum and maximum), mean, SD, median and (IQR). Significance of the obtained results was judged at the 5% level.Data were fed to the computer and analyzed using IBM SPSS software package version 20.0Results were obtained and tabulated under two groups; group I represents patients in whom d-TRA was used and group II represents patients selected for conventional TRA.P = 0.424.Table P = 0.295.Age in group I was ranged between 45 and 69 years with mean ± S.D. 56.34 ± 6.08 years, while in group II was ranged between 49 and 69 years with mean ± S.D. 57.56 ± 5.49 years. There were no statistically significant differences between groups where Table Table P = 0.012.Table P < 0.001.No. of punctures in group I was ranged between 1 and 6 with mean ± S.D. 2.56 ± 1.42, while in group II was ranged between 1 and 5 with mean ± S.D. 1.66 ± 0.89. There was statistically significant differences between groups where P < 0.001.Table P = 0.013.Total procedural time in group I was ranged between 18.0 and 30.0 min with mean ± S.D. 24.0 ± 2.91 min, while in group II was ranged between 12.0 and 30.0 min with mean ± S.D. 22.28 ± 3.83 min. There was statistically significant differences between groups where Sheath size in group I and group II shows that all patients in both groups had sheath size = 6Fr.Table P = 0.424.Table P = 952.Contrast volume in group I was ranged between 80.0 and 300.0 ml with mean ± S.D. 189.4 ± 51.25 ml, while in group II was ranged between 80.0 and 280.0 ml with mean ± S.D. 190.0 ± 49.16 ml. There were no statistically significant differences between groups where P = 0.749.Table P < 0.001.Post-procedural compression time in group I was ranged between 2.0 and 7.0 min with mean ± S.D. 5.14 ± 0.88 min, while in group II was ranged between 19.0 and 40.0 min with mean ± S.D. 24.50 ± 4.02 min. There was statistically significant differences between groups where In cardiac catheterization, TRA is now considered the standard of care. Because of the low frequency of problems and the comfort provided to both the patient and the operator, (d-TRA) has gained significant interest in the field of interventional cardiology.Because of the growing interest in this unique vascular access, numerous studies addressing the technique have been published; nevertheless, a complete and up-to-date comparison of conventional (TRA) and d-TRA is scarce .P = 0.013 indicated that there were statistically significant differences between the groups. It's interesting to know that in d-TRA, both access time and total process time were strongly connected to the learning curve's progression. In all cases of both arms, a 6 Fr sheath was utilized.Starting with the most statistically significant results in our study, access time in group I (d-TRA) varied from 3.0 to 9.0 min with a mean S.D. of 5.10 ± 1.61, whereas access time in group II (TRA) ranged from 1.0 to 5.0 min with a mean S.D. of 2.28 ± 1.16. P0.001 indicated that there were statistically significant differences between the two groups. Total procedural time varied from 18.0 to 30.0 min in group I, with a mean S.D. of 24.0 ± 2.91, and 12.0–30.0 min in group II, with a mean S.D. of 22.28 ± 3.83. p = 0.008); these findings were consistent with those of Koutouzis et al., [p = 0.001). The time of cannulation was equivalent in the two techniques in the research by Hammami et al. [p 0.001). In the AS, the average number of attempts for distal TRA was 1.8, with ultrasonography being employed in 34.2% of patients. For traditional TRA, there was no data on attempts and ultrasonic usage.The findings of studies comparing cannulation times were controversial. According to Kis and Soydan , the acc et al.,  .According to our findings, Wang et al. , the meaP = 0.424 indicated that there were no statistically significant differences between groups. It is important to clarify that the low sample size of female sex in both groups wasn't intentional and success percentage was 100% in both groups. The age ranged from 45 to 69 years old in group I, with a mean S.D. of 56.34 ± 6.08 years, and 49–69 years old in group II, with a mean S.D. of 57.56 ± 5.49 years. There were no statistically significant differences between groups in terms of age and sex (P = 0.295) or success rate between males and females.According to the findings, d-TRA (group I) had 43 (86.0%) males and 7 (14.0%) females, whereas group II had 40 (80.0%) males and 10 (20.0%) females. According to our findings, Rigatelli et al.  showed aWang et al.  also fouP = 0.012 indicated that there were statistically significant differences between groups, the selection of the side (whether right or left) of the procedure in both groups was randomized at the start of the study, but while proceeding we noticed that the left distal radial approach was more comfortable to the patient and the operator simultaneously than performing via the right side, while in group II we didn’t notice much comfort from the left side explaining the low left side radial intervention. Group I had 1–6 punctures with a mean S.D. of 2.56 ± 1.42, whereas group II had 1–5 punctures with a mean S.D. of 1.66 ± 0.89. (P 0.001) indicated that there were statistically significant differences between groups.In our hands, group I had 35 (70.0%) right hands and 15 (30.0%) left hands, whereas group II had 45 (90.0%) right hands and 5 (10.0%) left hands in the study. p 0.001).The puncture was effective in two patients from the d-TRA group, but the wire could not be pushed towards the forearm section of the radial artery; whereas the puncture failed in the rest, according to Hammami et al. . For botFurthermore, according to Kis and Soydan , the lefP > 0.05).Wang et al.  found noVasodilator usage, Crossover to another access site, and post-operative puncture pain all exhibited highly statistically significant differences across groups, but radial artery blockage, hematoma, and A-V Fistula did not.P > 0.05) between the comparisons for intraoperative radial artery spasm, postoperative hematoma, arterial aneurysm, and A-V fistula.According to our findings, Wang et al.  found thp 0.001); however, hematoma was uncommon and not statistically significant .Also, according to Aoi et al. , post-prNo significant problems were reported in the research by Hammami et al. . While sP = 0.424 indicated that there were no statistically significant differences between groups. Contrast volume was measured between 80.0 and 300.0 in group I, with a mean S.D. of 189.4 ± 51.25, and between 80.0 and 280.0 in group II, with a mean S.D. of 190.0 ± 49.16. When P = 952 was used, there were no statistically significant differences between the groups.Our findings revealed that in group I, 23 (46.0%) used two catheters and 27 (54.0%) used three, but in group II, 27 (54.0%) used two catheters and 23 (46.0%) used three. p = 0.008). Despite similar doses of administered heparin between distal TRA and conventional TRA, Aoi et al. [p 0.001) and PCI , with (pint 0.001). Furthermore, when compared to traditional TRA that had diagnostic catheterization, d-TRA that underwent PCI had a similar time to remove the TR band.In contrast to our findings, Hammami et al.  found thi et al.  found thP = 0.749 indicated that there were no statistically significant differences between groups.Finally, post-operative radial artery pulse was found in 45 (90.0%) of patients in group I and 44 (88.0%) of patients in group II. P 0.001 indicated that there were statistically significant differences between groups. We need to clear out that manual compression post-procedure was used in group I patients, while radial band was used in group II patients denoting the major advantage of the d-TRA approach in post-procedural hemostasis.The post-procedural compression time in group I was 2.0–7.0 with a mean S.D. of 5.14 ± 0.88, whereas the post-procedural compression time in group II was 19.0–40.0 with a mean S.D. of 24.50 ± 4.02 p = 0.646, I2 = 51.1%), and that there is a more incidence of RAO with TRA than d-TRA , but we don’t share the same agreement related the access success rate as they reported that there is no much difference between both groups  0.924–1.007, p = 0.1, I2 = 81.4%), which made us highlighting the value of operator experience and good selection of cases and their relation with the access success rate using d-TRA [Comparing our study results with the meta-analysis study done by Cao et al., which was published in November 2021, we both agree that there is no significant difference between d-TRA and TRA regarding post-operative hematoma . But on contrary they didn’t report any case with RAO on both groups as we found 7 cases with conventional TRA arm. [And on the other hand, comparing our work results with randomized clinical trial done by Lucreziotti S, et al., published in March 2021, we both agree on the concept of reduced access success rate with d-TRA group compared with the conventional TRA group. Vascular access failure was more frequent in d-TRA patients than in conventional TRA patients  and post-operative complications.In the field of cardiac intervention, the distal radial approach is a promising technique. In our study, we establish that it is a feasible and safe approach for coronary angiography and interventions, and that it is more comfortable for both the patient and the operator, especially when using the left d-TRA approach, which has a lower risk of radial artery occlusion. When compared to conventional TRA, there were no significant changes in wrist hematoma and radial artery spasm. The success rate of d-TRA is proportional to the steepness of the operator's learning curve and the quality of the examples chosen.


Metastatic upper urinary tract urothelial carcinoma (mUTUC) is a relatively rare urothelial carcinoma, and little attention has been given to it. Our study established a nomogram by analyzing the prognostic factors of mUTUC to predict the survival of patients and revealed that the role of surgery at the primary tumor site. We extracted our data (2010–2016) from the Surveillance, Epidemiology, and End Results (SEER) database, and 628 patients with distant metastasis were identified. Propensity score matching (PSM) was used to balance the clinical variable bias in a 1:1 ratio. After PSM, we enrolled 502 patients in our study cohort. Univariate and multivariate Cox regression analyses and Kaplan–Meier curves showed that T stage, N stage, hepatic metastasis, surgery, and chemotherapy were prognostic factors for mUTUC before and after PSM. Based on the findings, a nomogram was constructed to predict the 12‐month survival of patients with distant metastasis. The analysis of subgroups of T stage, N stage, and different metastatic sites demonstrated that the survival of patients with T1/T2, N0/N1/N2/N3, metastasis including liver, and metastasis including bone could be improved by a combination of surgery and chemotherapy, while for the patients with T3/T4/TX, NX, metastasis including lung, and metastasis including distant lymph nodes, chemotherapy alone was a better choice to improve their overall survival. Radiotherapy has been proven to be useful for patients with N1/N2/N3 stage. We have provided more precise treatment strategies for stage IV patients. Our research fully affirms the role of surgery on primary site in UTUC patients with distant metastasis and the significance of classifying the patients into subgroups by integrating variables including T stage, N stage, and different metastatic sites to select the optimal treatment method. It is a research about prognostic factors of metastatic upper urinary tract urothelial carcinoma (mUTUC) including metastatic patterns, therapy modes, and T/N stage based on the data extracted from SEER database. It reveals that the role of surgery on primary site is significant in the treatment of metastatic upper urinary tract urothelial carcinoma. Our inclusion criteria were as follows: (1) patients were diagnosed with neoplasms of the renal pelvis and ureter between 2010 and 2016 and (2) carcinoma of the renal pelvis and ureter was their first primary malignancy. The exclusion criteria included were as follows: the information about age at diagnosis, race, sex, histologic type, grade, T stage, N stage, M stage, surgery on primary site, surgery for regional lymph nodes, radiotherapy, chemotherapy, the scope of regional lymph node surgery, metastatic information, survival months, and current status were unavailable. It is worth mentioning that the surgery group included patients with surgery at the primary site for codes 30–80, including partial or subtotal nephrectomy  or partial ureterectomy (ureter) , complete/total/simple nephrectomy (kidney parenchyma) or nephroureterectomy , radical nephrectomy , Gerota's fascia, perinephric fat, or partial/total ureter), and any nephrectomy in continuity with the resection of other organ(s) .2.2th edition) including TX/T0/Ta/Tis/T1/T2/T3/T4/NX/N0/N1/N2/N3/M0/M1, metastatic information, and treatment modalities including surgery on primary site, surgery on the regional lymph nodes, radiotherapy, chemotherapy, and the scope of regional lymph nodes surgery. Metastatic information included the distant metastatic sites that were identified at the time of diagnosis and the number of metastatic sites. The study endpoint was the overall survival (OS). According to the European Association of Urology Guidelines on Upper Urinary Tract Urothelial Cell Carcinoma (2020 Update), upper urinary tract tumors with variant histology (UTVH) are one of the high‐risk factors.The variables extracted from the SEER database contained age at diagnosis, race, sex, pure or variant histology, grade, the AJCC Staging Manual tumor stage  was performed to filter the variables that could be included in the regression model. We set a 1:1 ratio to reduce bias by the ‘MatchIt’ R package using a propensity score matching (PSM) method. The chi‐squared test and the Fisher's exact test were used to make comparisons for categorical variables. A 33.1We enrolled 6724 patients diagnosed with upper urinary tract urothelial carcinoma. Among the final cohort, 628 (9.34%) were recorded as having distant metastasis at the time of diagnosis. The demographic and clinicopathological characteristics of the metastatic group and nonmetastatic group are shown in Table p < 0.0001, Figure Furthermore, univariate and multivariate Cox regression analyses showed that distant metastasis was an independent prognostic factor for OS Table . The K–M3.23.2.1p = 0.0136, Figure p < 0.0001, Figure p < 0.0001, Figure Lung metastasis was the most common site , followed by bone 203, 32.32%), liver , distant lymph nodes , and brain , but the brain was not included in this study because the sample was too small , followed by two sites 147, 23.41%), three sites , and four sites . Figure 3.41%, thp = 0.0005, Figure p = 0.0068, p = 0.0443, Figure p = 0.0032, Figure Through Kaplan–Meier curves, we found that OS l of patients varied with the number of metastatic sites , metastasis including bone, metastasis including liver, and the number of metastatic sites were balanced, while the differences in grade, T stage, and the scope of regional lymph node surgery were still significant. The clinicopathological features of the two groups before and after PSM are shown in Table Univariate and multivariate Cox regression analyses suggested that OS was associated with T stage, N stage, metastasis including liver, and treatment patterns (surgery and chemotherapy) after PSM Table . Accordi3.4p = 0.0430, Figure Because the sample sizes of T1 and T2 were both relatively small and the Kaplan–Meier analysis suggested no diversity of OS between them Figure , we comb3.5p < 0.0001, Figure p = 0.0027, Figure p = 0.0196, Figure p < 0.0001, Figure p = 0.0079, Figure Univariate and multivariate Cox analyses showed that surgery, chemotherapy, and histological types were independent prognostic factors in N0 stage patients Table . Further3.6p < 0.0001, Figure p < 0.0001, Figure First, we performed univariate and multivariate Cox analyses on the liver metastasis group, which indicated that prognostic indicators for this group were surgery and chemotherapy Table . The KapFor the metastasis including lung group, chemotherapy and liver metastasis were clearly related to OS Table . And for3.7th edition), stage IV refers to any T/any N/M1, which means that all of the patients with mUTUC were in this range. Therefore, we grouped the stage IV patients according to the previous results, and performed Kaplan–Meier curves with some new combinations. Because the sample size of patients who underwent radiotherapy in each subgroup after stratification was too small, the treatment modalities included only surgery and chemotherapy. Since fewer than two patients with each staging T1/2/NX, TX/N1/2/3, and TX/N0 underwent surgery, K–M analysis could not be performed. The treatment strategies of stage IV patients with different T/N stages are shown in Table p = 0.0185), According to the AJCC Staging Manual tumor stage  accounts for only 10% of UTUCs, but its incidence has been increasing in the past 30 years.Many studies have shown that distant metastasis was associated with much worse OS in UTUC and patients with distant metastasis had a higher probability of receiving chemotherapy instead of surgery at the primary site, which were revealed by our results as well.According to the univariate and multivariate Cox regression analyses after PSM, we found that T stage, N stage, hepatic metastasis, surgery, and chemotherapy were independent prognostic factors for mUTUC. The studies of both Lughezzani G. et al and Margulis V.et al demonstrated that T stage was indeed a significant prognostic factor related to oncologic outcomes.th edition). Therefore, a more precise treatment strategy was established for stage IV patients based on our stratified analysis of T/N stage. For patients with T1/2&N0/1/2/3 and T3&N0, their prognosis could be significantly improved by the combination of surgery and chemotherapy, and for patients with T3/4/X&NX, their prognosis could just be improved by chemotherapy alone. We hope it will provide more personalized options for patients with mUTUC.For patients with metastatic UTUC (mUTUC), chemotherapy has been the optimal choice for a long time, and RNU is recommended for palliative treatment, with the aim of controlling the symptoms of the disease. However, our analysis revealed that both surgery and chemotherapy are treatment methods that can significantly improve the prognosis of patients with mUTUC. It is noteworthy that some study suggested these benefits may be limited to those with only one metastatic site, which was not confirmed by our study.Although this research was performed rigorously, it still has many limitations. First, we cannot know the sequence of chemotherapy and surgery because this information is not recorded in the SEER database. Some studies have shown that neoadjuvant chemotherapy before radical nephroureterectomy might provide better survival outcomes for patients with locally advanced UTUC.5Our SEER database analysis was a retrospective study investigating the influence of surgery on primary site to the metastatic renal pelvis and ureter cancers. Distant metastasis is a factor suggesting a poor OS of renal pelvis and ureter cancer. For patients with mUTUC, there were five independent prognostic factors: T stage, N stage, hepatic metastasis, surgery, and chemotherapy. A nomogram was established to predict the 4, 8, and 12‐months survival of patients with distant metastasis. Although chemotherapy alone can improve the OS of patients with distant metastasis, it was less efficient than combining surgery and chemotherapy for patients with T1/T2, N0/N1/N2/N3 stage, and metastasis including the liver and bone. However, for patients with T3/T4/TX, NX, and metastasis including lung and distant lymph nodes, chemotherapy alone was still the best choice to improve the prognosis. It is worth mentioning that radiotherapy was proven to be useful for patients with N1/N2/N3 disease. Moreover, more precise treatment strategies were provided for stage IV patients with different T/N stages.The authors declare no potential conflict of interest.All data were from the SEER database. The SEER database is publicly available and considered.Fig S1‐15Click here for additional data file.Table S1Click here for additional data file.Table S2Click here for additional data file.Table S3Click here for additional data file.Table S4Click here for additional data file.Table S5Click here for additional data file.Table S6Click here for additional data file.Table S7Click here for additional data file.Table S8Click here for additional data file.Table S9Click here for additional data file.Table S10Click here for additional data file.Table S11Click here for additional data file.Table S12Click here for additional data file.Table S13Click here for additional data file.Table S14Click here for additional data file.


Respiratory syncytial virus (RSV) is a major cause of acute lower respiratory tract infection (ALRI) leading to infant hospitalization, morbidity and postnatal mortality in children younger than 5 years of age worldwide. The aim of this study was to collect data on hospitalizations for RSV-related ALRI in children in Spain from 2012 to 2018.We used the discharge reports from the Minimum Basic Data Set (MBDS) to retrospectively analyze hospital discharge data in children ≤ 14 years of age with a diagnosis of acute lower respiratory tract infection, based on the ICD-9-CM and ICD-10-CM diagnosis codes, from 2012 to 2018.A total of 190,474 children, 58.1% boys and 41.9% girls, were admitted for lower respiratory tract infections in Spain, including 118,731 cases of bronchiolitis, 53,972 cases of bronchitis, 3710 cases of RSV-positive pneumonia, and 14,061 cases of RSV infections. Of these, 92,426 children (48.5%) had laboratory-confirmed RSV infection. The mean case fatality rate was almost 6 times higher for pneumonia (0.6%) than for bronchiolitis (0.1%) or bronchitis (0.1%). A significant linear increase in the mean annual hospitalization rate for pneumonia of almost 15% per year was found, with no changes in the trend over the study period.RSV-related respiratory infections remain a leading cause of infant hospitalization in Spain. Effective antiviral treatments and preventive vaccines are urgently needed for the management of RSV infection in children, especially for those aged 6 to 12 months. Respiratory syncytial virus (RSV) is a major cause of acute lower respiratory tract infection (ALRI) leading to infant hospitalization, morbidity and postnatal mortality in children younger than 5 years of age worldwide, especially in developing countries. Data suggest that most RSV-related childhood mortality occurs during the first year of life –9. HospiThe global health and economic burden of RSV-associated disease is considerable and poses a major global health problem. However, clinical data for global RSV-related mortality are scarce. Results from a recent extensive systematic review of both published studies and unpublished data estimated that in 2015, up to 33.1 million episodes of RSV ALRI occurred globally in children younger than 5 years, resulting in about 3.2 million hospital admissions and 59,600  in hospital deaths, 99% of which occurred in developing countries and almost half (45%)  among children under 6 months of age . Data frp = 0.003) and the comorbidity rate was also higher . The case fatality rate among children admitted for RSV was 0.3%  4) for children under 1 year of age and 2 years (IQR 2) for those older than 1 year. Overall, of the three main RSV-related diseases addressed in our study, the most prevalent diagnosis was ‘bronchiolitis’ , that accounted for 62.3% of all hospitalizations , followed by ‘bronchitis’ , 28.3% , ‘RSV infection’ , 7.4% (8009 cases in boys [4.2%] and 6052 cases in girls [3.2%]), and ‘pneumonia’ , 1.9% (1919 cases in boys [1.0%] and 1791 cases in girls [0.9%]). Among children hospitalized for bronchiolitis , 36.5%  were diagnosed with ‘acute bronchiolitis’  and 63.5%  with ‘bronchiolitis due to RSV’ , while among those hospitalized for bronchitis , 94.4%  were diagnosed with ‘acute bronchitis’  and 5.6% (1750 cases in boys [57.8%] and 1279 cases in girls [42.2%]) with ‘bronchitis due to RSV’ (ICD 10 CM J20.5). Almost half of all children, 92,426 (48.5%), had laboratory-confirmed RSV infection.p < 0.05), with no changes in the trend over the study period . No significant sex differences were found for pneumonia  during the study period was 26.7 (95% CI 25.4–27.9) for ‘RSV infection’ (29.4 27.7–31.2] in boys and 23.7 [22.2–25.4] in girls), ranging from 22.1 (95% CI 21.1–23.2) in 2013 to 29.2 (95% CI 27.9–30.4) in 2018. For bronchiolitis diagnosis codes, the mean hospitalization rate  was 80.3 (95% CI 78.2–82.4) for ‘acute bronchiolitis’ (93.0 [90.1–96.1] in boys and 66.8 [64.2–69.4] in girls), ranging from 55.2 (95% CI 53.5–56.9) in 2016 to 101.7 (95% CI 99.5–104.0) in 2015, and 140.7 (95% CI 137.7–143.6) for ‘bronchiolitis due to RSV’ (155.3 [151.5–159.3] in boys and 125.1 [121.5–128.7] in girls), ranging from 115.5 (95% CI 113.2–117. 9) in 2013 to 156.0 (95% CI 153.1–159.00) in 2018  for ‘acute bronchiolitis’ and 2185.2 (95% CI 2168.2–2202.2) for ‘bronchiolitis due to RSV’, rates that were more than 10 times higher than those in children aged one year. In general, an age-related decrease in hospitalization rates was observed, especially in children ≤ 5 years of age, being more pronounced among children diagnosed with bronchiolitis (both ‘acute bronchiolitis’ and ‘bronchiolitis due to RSV’), followed by ‘acute bronchitis’ and ‘RSV infection’, while hospitalization rates due to ‘bronchitis due to RSV’ and ‘pneumonia due to RSV’ remained relatively low in all age groups Table .Table 4HThe case fatality rate among hospitalized children diagnosed with pneumonia due to RSV was almost six times higher than among those diagnosed with bronchiolitis or bronchitis throughout the study period, 0.57% vs. 0.1% (for both diagnoses). Unlike the case fatality rates in children with bronchiolitis and bronchitis, that were comparable throughout the 7-year study period, the case fatality rate in children with pneumonia was more variable, showing maximum values in the years 2013 and 2016  than in children hospitalized with a diagnosis of bronchitis or bronchiolitis . The difference in hospitalization rates between diagnoses was quite variable throughout the study period and, with the exception of 2012, highly relevant. However, we believe there could be a patient selection bias, as previously mentioned. Although viruses are the most common cause of pediatric pneumonia—especially in infants younger than 2 years—, microbiological testing is only performed if the child’s progress during their hospital stay is slow, usually related to the presence of known risk factors or any other pediatric alert that identifies hospitalised children at risk of clinical deterioration. Thus, other patients with RSV-positive pneumonia could be lost in the diagnostic selection due to lack of laboratory tests. Most studies do not report detailed cause of death and clinical details of the fatal cases are often unavailable, limiting our ability to accurately assess RSV-related infant mortality , 51.p < 0.001), but not for cases of viral pneumonia. Male sex is a known risk factor for the development of respiratory tract infections, and generally presents with a more severe course than in females, leading to higher mortality rates. It has been reported that male infants have shorter and narrower airways and therefore are more likely to develop bronchial obstruction after contracting RSV infection [We also found statistically significant sex differences in the rate of hospital admissions for bronchiolitis and bronchitis (1.3 times higher in males than in females for both diagnoses, nfection . Pediatrnfection , 53.This study has several strengths and limitations that should be considered. Its main strength lies in the use of MBDS records that offer a very large sample size that includes practically all admissions to both public and private acute hospitals in Spain, thus increasing the power of the statistical analyses, even for low-prevalence diseases. Furthermore, the methodology used has been well recognized for many years and offers great external validity, making the MBDS a valuable tool for epidemiological research into respiratory diseases . On the In summary, RSV-related diseases represent a heavy burden to children, their families, and the public health system in Spain. To address this problem, there is consensus that early protective measures should be applied, especially in children during their first 6–12 months of life. These measures include general hygienic practices, such as visiting restrictions during the RSV outbreak period and effective handwashing, and, where available, immunotherapy for all children, since it has been shown that the majority of infected children were full-term and otherwise healthy , 58. WitRSV-related respiratory infections remain a leading cause of infant hospitalization in Spain.Effective antiviral treatments and preventive vaccines are urgently needed for the management of RSV infection in children, especially for those aged 6–12 months.


P < 0.05), and these indexes were higher for the IVC expansion (IVCE), the respiration variation index (RVI) of IVC (ΔIVC2), the peak flow velocity RVI of brachial artery (ΔVpeakBA), femoral artery (ΔVpeakFA), left ventricular outflow tract (ΔVpeakL), and aorta (ΔVpeakAO), as well as peak flow velocity time integral RVI of aorta (ΔVTIAO) (P < 0.05). In conclusion, early MBTs can elevate survival rate and prognostic living quality and alleviate the atrophy degree of IVC, peripheral artery, and blood vessel of patients with severely injured trauma. Furthermore, bedside ultrasound scanning demonstrated superb capabilities in quantitatively displaying hemodynamics and outcomes of MBTs of patients with severely injured trauma.The focus of the study was to quantitatively analyze the influence of early massive blood transfusions (MBTs) on the hemodynamics and prognostic living quality of patients with severely injured trauma. 114 patients with severely injured trauma were enrolled into MBT group (67 cases) and nonmassive blood transfusions (NBT) group (47 cases) according to whether they accepted MBTs within 24 hours after the admission. All patients had bedside ultrasound technology scanning. Furthermore, the indexes were calculated for inferior vena cava (IVC), peripheral arteries, and heart. The prognostic deaths were recorded. It was found that, in the MBT group, the mortality was lower (7.55% vs. 24.23%) ( Trauma refers to the destruction of tissues or organs caused by mechanical factors. Due to the differences in injured parts, injured tissues, and skin integrity, the severity of trauma is also different , 2. AmonWith the advancement of imaging, there are various imaging examination methods used in clinical practice. However, being time-consuming, the routine imaging scan is not suitable for the diagnosis of trauma and bleeding patients, such as ultrasound, conventional CT, X-ray, and angiography . Plain XIn summary, bedside ultrasound demonstrated superb capabilities in clinical diagnosis and treatment of severely injured trauma patients. Based on this, 114 patients with severely injured trauma were enrolled into MBT group (67 cases) and NBT group (47 cases) according to whether they accepted MBTs within 24 hours after the admission. All patients had bedside ultrasound technology scanning. Furthermore, the indexes were calculated for IVC, peripheral arteries, and heart, to quantitatively analyze the influence of early MBTs on the hemodynamics and prognostic living quality of patients with severely injured trauma.114 patients with severely injured trauma, who were admitted to the hospital between November 25, 2017, and February 10, 2020, were selected for analysis, with an average age between 20 and 67. All of them had bedside ultrasound scanning. The study has been approved by the Medical Ethics Committee of the hospital. The patient and his/her family members have been informed of the study and signed the consent letters.Inclusion criteria: (i) patients older than 18 years; (ii) patients who underwent bedside ultrasound within 12 hours after trauma; (iii) patients with an abbreviated injury scale (AIS) score greater than 3; (iv) patients who can cooperate with the doctors.Exclusion criteria: (i) patients with unstable hemodynamics; (ii) patients with congenital heart disease; (iii) patients with severe kidney disease; (iv) patients with aortic and great vessel split; (v) patients with incomplete clinical data; and (vi) patients with head trauma.114 patients with severely injured trauma were enrolled into MBT group (67 cases) and NBT group (47 cases) according to whether they accepted MBTs within 24 hours after the admission. The standard of massive blood transfusions no less than 20 U red blood cells were injected within 24 hours after admission.2, ΔVpeakBA, ΔVpeakFA, ΔVpeakL, ΔVpeakAO, and ΔVTIAO were recorded. IVCE refers to the difference between the maximum diameter (IVCmax) and the minimum diameter (IVCmin) of IVC at 2 cm of the opening of right atrium which was then divided by IVCmin. The equation is as follows:Patients accepted bedside ultrasound scanning before and after treatment by Sono ultrasonic machine (USA). A 2.5 MHz heart probe was used. The patient was in a supine position. The long axis of the left heart next to the sternum was selected, that is, the long axis of the left ventricle. The heart probe was placed between 3 and 4 intercostals of the left edge of the sternum. The detection direction was parallel to the right sternoclavicular joint to center the transverse section of the thoracic aorta. The probe was slightly upward on the basis of the four-chamber heart at the apex of the heart, and the scanning plane passed through the aortic root to obtain the transverse section of the aortic root, the longitudinal section of the left ventricle, the longitudinal section of the right atrium, the longitudinal section of the right ventricle, and the longitudinal section of the right atrium, namely, the image of the five-chamber heart at the apex. IVCE, ΔIVCs) illustrated how to calculate the measurement data. Count data were expressed as a percentage (%). Age, BMI, length of hospital stays, male-female ratio, and mortality were compared using independent t-test. The analysis of variance was applied to compare indexes for IVC, peripheral arteries, and heart. P < 0.05 indicated statistically significant differences.The data were processed by SPSS19.0. The mean ± standard deviation .Figures P < 0.05).2. It was evident that, in the MBT group, IVCE (21.54 ± 4.11 vs. 13.52 ± 3.27) and IVC2 (13.52 ± 3.27 vs. 13.17 ± 2.86) were obviously higher (P < 0.05).L. It was evident that, in the MBT group, ΔVpeakL was obviously higher (19.56 ± 2.76 vs. 14.11 ± 1.85) (P < 0.05).AO and ΔVTIAO. It was evident that, in the MBT group, ΔVpeakAO (15.77 ± 1.48 vs. 12.75 ± 1.51) and ΔVTIAO (18.88 ± 1.62 vs. 13.47 ± 1.36) were obviously higher (P < 0.05).BA and ΔVpeakFA. It was evident that, in the MBT group, ΔVpeakBA (21.55 ± 1.42 vs. 14.92 ± 1.36) and ΔVpeakFA (17.53 ± 1.38 vs. 13.66 ± 1.51) were obviously higher (P < 0.05).P < 0.05). This was in line with the research results of Nolte et al. [2 (13.52 ± 3.27 vs. 13.17 ± 2.86) were obviously higher (P < 0.05). This was inconsistent with the research results of Cui and Wu [2.Patients with severely injured trauma should see a doctor in time to determine the degree of trauma as quickly as possible, so as to provide targeted clinical treatment. Although the domestic diagnostic technology has been greatly improved in recent years, the shock and mortality caused by severely injured trauma are still high, so it is very important to adopt effective diagnostic methods , 15. In e et al. . ExistinL was obviously higher (19.56 ± 2.76 vs. 14.11 ± 1.85) (P < 0.05). This was different from the research results of Endo et al. [AO (15.77 ± 1.48 vs. 12.75 ± 1.51) and ΔVTIAO (18.88 ± 1.62 vs. 13.47 ± 1.36) were obviously higher (P < 0.05). This illustrated that the early MBTs greatly affected the abdominal aortic vessels, which may be due to the fact that the abdominal aortic vessels mainly regulate blood flow through changes in tube diameter and distal resistance and will supplement the overall capacity of human body by reducing its own blood flow when there is trauma [BA (21.55 ± 1.42 vs. 14.92 ± 1.36) and ΔVpeakFA (17.53 ± 1.38 vs. 13.66 ± 1.51) were obviously higher (P < 0.05). This was aligned with the research results of Roden-Foreman et al. [In the MBT group, ΔVpeako et al. , which mn et al. . ArterieIn the study, 114 patients with severely injured trauma were enrolled into MBT group (67 cases) and NBT group (47 cases) according to whether they accepted MBTs within 24 hours after the admission. They all had bedside ultrasound scanning. The results revealed that early MBTs can elevate survival rate and prognostic living quality and alleviate the atrophy degree of IVC, peripheral artery, and blood vessel of patients with severely injured trauma. Furthermore, bedside ultrasound scanning demonstrated superb capabilities in quantitatively displaying hemodynamics and outcomes of MBTs of patients with severely injured trauma. However, some limitations should be noted in the study. The sample size is relatively small, which may reduce the power and increase the margin of error of the study. A study with an expanded sample size is necessary to strengthen the findings. In summary, the results obtained provide a theoretical basis for the application of bedside ultrasound scanning in diagnosis of patients with severely injured trauma.


Evidence-based practice (EBP) is considered the “holy grail” to manage patients by health practitioners . However, sometimes, patients are not treated with the best interventions for their condition. Although studies already explored the facilitators and barriers for this issue, they increase in the level of importance if the information gathered are context appropriated. As the profession is relatively new in Portugal, currently little is known about the implementation of EBP in Portuguese physical therapists context. So, the aim of this study is to know if the Portuguese physical therapists use an EBP, and collect and deeper understand the factors, barriers and facilitators associated with EBP.verbatim transcribed, and the texts explored by the thematic approach.This study incorporated a mixed-methods design . In an attempt to ensure the correct population sample, a national professional association e-mail database and the e-mails of past students from national schools were requested. For the quantitative data it was choose an e-survey, adapted from the EBP: Beliefs, Attitudes, Knowledge, and Behaviors of Physical Therapists Portuguese version questionnaire, consisted of 55 close-ended questions. It was analyzed response frequencies and associations between variables with logistic regression analyses. For the qualitative data, it was choose to perform semi-structured interviews in purposefully selected physical therapists to include different sociodemographic factors  and survey responses regarding the physical therapists’ beliefs, attitudes, knowledge, and behaviors. The interviews were performed in an online software, where only audio contact was performed. The audios were anonymized and From the 277 physical therapists that shown interest in participating in the study, 193 fully completed the questionnaire and, from those, 10 participated in the interviews. The Portuguese physical therapists reported positive beliefs, attitudes, knowledge, and behaviors regarding EBP. Among the physical therapists characteristics it seems that age (younger therapists), education , and workplace  are the main factors in the Portuguese EBP implementation. The Portuguese physical therapists, beyond the physical therapists individual characteristics and workplace, also stated that evidence, patients, clinical experience, schools, country and physical therapy characteristics, may behave as facilitators or barriers when performing an EBP. Originally developed at the McMaster Medical School in Canada in the 1980s, EBP can be defined as the conscientious, explicit and judicious use of current relevant available evidence combined with the health-care providers’ clinical expertise and the patients’ preferences, guiding clinical decisions about patients’ care . Despitem an EBP . Personam an EBP . As the m an EBP , currentm an EBP . Therefom an EBP : by 2020So, the aim of this study is to know if the Portuguese PTs use an EBP, and collect and deeper understand the factors, barriers and facilitators associated with EBP.This study followed the Ethical Principles of the Helsinki Declaration  and was This study incorporated a concurrent mixed-methods design , collectIn an attempt to ensure the correct population sample, a national PT professional association–Associação Portuguesa de Fisioterapeutas (APFISIO)–e-mail database was requested for the Portugal PTs working class recruitment. Also, in an attempt to increase the number of enrolled participants, the e-mails of past students from 19 PT national schools were requested. According to the APFISIO, the number of participants would be around 12,000 PTs .For the quantitative data, it was chosen to apply a self-administered e-survey. The e-survey was evaluated, designed, administered, conducted and collected according to established guidelines .The e-survey was e-mailed to all PTs in the APFISIO database in the regular online newsletter and to past PT students as a formal e-mail with a cover letter containing a small study’s information . Additionally, after reading the study’s information, the participants were invited to click in the e-survey link.Before initiating the e-survey (in the front page), the purpose and context of the study, the data protection rights and how the results will be used , the criteria for selecting the participants and the reasons for non-participation, the possibility to terminate the e-survey at any time, instructions about how to fill and complete the e-survey, and the e-mail address for possible clarifications were explicitly stated. The consent for participation in the study was obtained through a informed consent statement. The e-survey was an adaptation of the Evidence-Based Practice: Beliefs, Attitudes, Knowledge, and Behaviors of Physical Therapists Portuguese version questionnaire , develophttp://www.raosoft.com/samplesize.html), the sample size goal for this study was 373 responses, based in a 95% confidence level, a margin of error of 5% and a 50% response distribution , where only audio-recorded was performed–excluding any face-to-face or written contact. Furthermore, there was no relationship between the interviewers and the PTs prior to the study, and the interviewees were recruited by completing the study previous stages where, at the end of the e-survey, the respondents were invited to fill a space where a personal e-mail could be inserted. With this filling, they consent to be later contacted, if desired to continue to be studied. Following a review of questionnaire responses, the sample was purposefully selected to include different sociodemographic factors  and survey responses regarding the PTs’ beliefs, attitudes, knowledge, and behaviors. To ensure a high participation rate, after 1, 2 and 4 weeks respectively, a thank you note, a reminder containing the interview objectives and a request to provide their most convenient dates for the interview, were e-mailed. The interview script had 12 core questions , construResponse frequencies for the survey questions were determined and displayed in tabular and graphic formats, using the Microsoft Excel  and the IBM SPSS 26.0  software.Before examining the associations between variables, some categories were collapsed in order to use them as dependent measures in logistic regression analyses. Using a similar strategy as For some of the sociodemographic data, where subsamples were smaller, we collapsed categories in an effort to derive stable models. For example, our sample included only 1 PT who indicated a professional Post-Doctorate degree, so we included him/her with others Philosophy Doctors (PhD) degrees. Furthermore, we combined the Certificate and Baccalaureate degrees into the same category , as in Portugal they are the minimum required professional entry-level.After item categories were collapsed, logistic regression analyses were conducted to examine the associations with the PTs’ characteristics. It was used an α of 0.05 to define whether a model needed to be reported. Odds ratios (ORs) and their 95% CIs were determined for each level of the independent variables. CIs including 1.0 were considered as not statistically significant .verbatim transcribed. Then, the texts were explored by the six phases of thematic approach  . The audapproach . Data coapproach .From the 277 PTs that shown interest in participating in the study, only 193 (69.7%) fully completed the questionnaire .The average time to complete the e-survey was 12 min. The majority of the PTs that completed the questionnaire were females (73.1%), within the 30–39 years age group (44.6%), with a valid PT working license obtained between 5 to 10 years ago (32.1%). Furthermore, despite the majority only had the baccalaureate degree (61.1%), they shown interest in pursuing a higher academic degree in the future (66.3%). Most of them obtained the Certificate/Baccalaureate in the Escola Superior de Saúde de Alcoitão (20.7%) and were clinical instructors for PT students (51.3%). Additionally, they reported belonging to a practice-oriented organization (78.8%) and participate, at least once per year, in continuing education courses (89.1%). Regarding their practice, most of the PTs worked more than 40 h per week (44.6%), focusing their time taking care of patients (57.9%), leaving research and teaching as a low priority . Typically, the PTs treated more than 15 adult patients per day, with orthopedic conditions . The majority worked in Lisbon (35.2%), in an urban environment (82.9%), for someone else’s account, with 5 to 10 PTs, in the private sector –private clinics (21.2%). For a more detailed data analysis, the descriptive statistics of the PTs personal and practice characteristics are presented in Concerning the items sub-group Attitudes and Beliefs About EBP, respondents stated they held generally positive attitudes and beliefs regarding EBP. The only exception was in the item 32, where they Disagreed (45.1%) that EBP may increase their reimbursement. Moreover, there is the necessity to highlight the item 31 , where the PTs’ answers were very balanced between Agree (44.6%) and Disagree (44.0%). The respondents’ answers are presented in p = 0.033 and p = 0.040, respectively). Also, PTs that treat 11 to 15 patients per day were 2.5 times more likely to agree that “EBP Doesn’t Account for Practice Settings Limitations”, in comparison with those who treated more than 15 patients per day (p = 0.036). Furthermore, PTs that belong to a practice-orientated organization were 4.1 and 4.2 more likely to agree that “EBP Improves Care Quality” and that “EBP Helps Decision Making” in comparison to those that do not belong to a practice-orientated organization . Moreover, male PTs were 2.6 times more likely to agree that “EBP Will Increase Reimbursement” and 55% less likely to agree that “EBP Creates Unreasonable Demands” in comparison to their female peers . Likewise, PTs that work by their own account were 91% less likely to agree that “EBP is Necessary to Practice” (p = 0.044). Regarding the statistically significant associations between PTs’ characteristics and their perceived Attitudes and Beliefs About EBP, therapists that participate at least once per year in continuing education courses were 2.9 and 3.7 more likely to agree that “EBP Doesn’t Account for Practice Settings Limitations” and that “Evidence is Lacking to Support Interventions” in comparison to those that do not participate in continuing education courses  for “Public” – p = 0.009; and OR 0.401 (95% CI [0.172–0.936]) for “Own Account” – p = 0.035). Overall, the responders shown interest in learning or improving the skills necessary to incorporate EBP into practice (64.8%). The PTs’ characteristics that were more likely to agree with the overall findings were therapists that have a Certificate/Baccalaureate degree (OR 8.850 (95% CI [1.734–45.178]) – p = 0.009), that devote most of their time treating several patients (OR 0.089 (95% CI [0.010–0.786]) for “1–5 Patients Day” – p = 0.029; and OR 0.009 (95% CI [0.000–0.272]) for “0% Patient Care” – p = 0.007; OR 0.016 (95% CI [0.002–0.162]) for“5–25% Patient Care” – p = 0.000; OR 38.333 (95% CI [3.958–371.244]) for “0% Teacher” – p = 0.002; and OR 27.333 (95% CI [1.890–395.245]) for “5–25% Teacher” – p = 0.015) and do not work in the academic sector (OR 31.111 (95% CI [3.248–297.981]) for “Public” – p = 0.003; and OR 16.389 (95% CI [3.734–71.938]) for “Private” – p = 0.000) . The PTs’ characteristics that were more likely to agree were female therapists that worked in the public sector, for someone else account (OR 0.427 (95% CI [0.187–0.977]) for “Male” – = 0.000) .p = 0.022, p = 0.010 and p = 0.022, respectively). Similarly, younger PTs were more likely to read and search professional literature in comparison to more experienced therapists (OR 4.105 (95% CI [1.556–10.830]) – p = 0.004; and OR 3.778 (95% CI [1.448–9.856]) – p = 0.007, respectively). In contrast, it was found that PTs with lower level academic degrees read and search less literature in comparison with Doctorate level peers . Furthermore, PTs that spend moderate time in patient care were more likely to read and search literature in comparison with PTs who spend 80–100% of their time treating patients (30–50% – OR 3.181 (95% CI [1.122–9.020]) (p = 0.030) and 55–75% – OR 3.054 (95% CI [1.533–6.085]) (p = 0.002) in “Articles Read per Month”; and 5–25% – OR 7.540 (95% CI [1.873–30.359]) (p = 0.004) and 30–50% – OR 6.786 (95% CI [2.201–20.922]) (p = 0.001) in “Databases Searches Performed per Month”). Similarly, PTs that spend moderate time as researchers were more likely to search literature in comparison with PTs who spend no time in that activity (OR 2.379 (95% CI [1.230–4.601]) – p = 0.010 for “5–25%”; and OR 6.825 (95% CI [2.294–20.306]) – p = 0.001 for “30–50%”). Still, PTs that belong to a practice-orientated organization were 2.5 times more likely to read more articles in comparison to those that do not belong to a practice-orientated organization (p = 0.030). Moreover, it was found that younger PTs were more likely to have good levels in professional literature searched in comparison to their older peers (OR 4.529 (95% CI [1.676–13.017]) – p = 0.005). Also, PTs that pursue a higher academic degree were more likely to search professional literature (OR 0.328 (95% CI [0.115–0.932]) – p = 0.036 for “No”; and OR 0.350 (95% CI [0.155–0.793]) – 0.012 for “Do Not Know”). Furthermore, those who work in the public sector were 80% less likely to search it in comparison to PTs who work primarily in the academic context (p = 0.011). About the items sub-group Level of Attention to and Use of the Literature, PTs read, use and search a small number of professional literature  . Regardip = 0.004) and were 3.1 time more likely to use them in their practice (p = 0.012). Additionally, PTs that pursue a higher academic degree and participate at least once a year in continuing education courses were more likely to use practice guidelines (OR 0.158 (95% CI [0.059–0.427]) – p = 0.000 for “No”; and OR 6.039 (95% CI [2.251–16.206]) – p = 0.000 for “Yes”, respectively). Furthermore, it was found that PTs that spend no time as teachers were 9.1 times more likely to be in agreement that practice guidelines incorporate patients’ preferences in comparison with those who spend 80–100% (p = 0.025). Within the items sub-group Access to Practical Guidelines, most of the PTs know, seek, use, and access practice guidelines, and incorporate them with patient preferences   and 4. Cp = 0.007 for “Yes”; and OR 25.250 (95% CI [2.651–240.495]) – p = 0.005 for “0%”, respectively). Additionally, male therapists were the ones who have an easier access to online databases at work (p = 0.018). Nevertheless, in general, PTs Agreed that the facility supports the use of research in practice (42.5%) (p = 0.005), treating 6–10 patients per day (OR 2.350 (95% CI [1.087–5.079]) – p = 0.030), 30–50% as researcher (OR 6.963 (95% CI [1.884–25.736]) – p = 0.04), working by their own account (OR 3.444 (95% CI [1.623–7.310]) – p = 0.001), in either the academic or private work sector. , since the majority assumed that they do not have access to current research through professional journals in their paper form (77.7%) . From th (42.5%) . From th sector. .p = 0.001) and 30–39 – OR 3.547 (95% CI [1.395–9.015]) (p = 0.008) in “Learned Foundations”; and 20-29 – OR 5.262 (95% CI [1.941–14.260]) (p = 0.001) and 30–39 – OR 3.577 (1.521–8.410) (p = 0.003) in “Search Strategies”). Similar comparison was found for formal training in critical appraisal, where PTs in the 20–29 and in the 30–39 age group were 4.2 and 2.6 times more likely to agree in contrast with the older therapists . As a complementation, PTs that had less years of license report a similar pattern as younger therapists in the “Formal Training in Search Strategies” (OR 3.832 (95% CI [1.276–11.508]) – p = 0.017 for “<5”; and OR 3.283 (95% CI [1.475–7.307]) – p = 0.04 for “5–10”). In contrast, more experienced therapists were more likely to agree that they were confident in search skills (OR 0.254 (95% CI [0.078–0.824]) – p = 0.023 for “5–10”; and OR 0.267 (95% CI [0.078–0.916]) – p = 0.036 for “11–15”). Still, clinical instructors were 3.3 and 2.3 times more confident in searching and critically reviewing professional literature, in comparison to non-clinical instructors . Additionally, not knowing if the PT wants to pursue a higher academic degree had a negative impact in learning his foundations for EBP as part of the academic preparation, received formal training in search strategies, and help them to be more familiar with medical search engines, since therapists who pursue it are more likely to agree (OR 0.286 (95% CI [0.122–0.699]) – p = 0.004; OR 0.370 (95% CI [0.177–0.772]) – p = 0.008; and OR 0.233 (95% CI [0.092–0.541]) – p = 0.001, respectively). Additionally, PTs that work in the Public and Private sectors were 4.7 and 7.1 times more likely to agree that “I learned the foundations for EBP as part of my academic preparation”, in comparison with the academic sector peers . In the same item, therapists that are not teachers were 13.1 times more likely to agree, in contrast with PTs that are teachers (p = 0.007). Concerning the items sub-group Educational Background, Knowledge and Skills Related to Accessing and Interpreting Information, most Agreed that they learned the foundations for EBP (48.2%), and receive training for finding and critically appraise research literature , as part of their academic preparation. Furthermore, they were self-confident in their skills to critical appraisal and find research . They were also familiar with medical search engines (44.6%). p = 0.024 for “Clinical Instructor”; and OR 3.339 (95% CI [1.205–9.252]) – p = 0.020 for “Own Account”, respectively). The understanding levels of the terms associated with EBP are described in The positive findings in the Educational Background, Knowledge and Skills Related to Accessing and Interpreting Information sub-group was further confirmed, as most the PTs Understand Completely (62.2%) the presented scientific terms. Nevertheless, the most understood scientific term was “Systematic Review” (17.4%) and the least was “Odds Ratio” (9.7% in Understand Somewhat and 39.6% in Do Not Understand). The only term that had statistically significant associations was “Publication Bias”. The PTs who do not understand the term were non-clinical instructors working by their own account (OR 0.262 (95% CI [0.082–0.836]) – p = 0.022). At the same time, they were 62% less likely to choose “Lack of collective support among my colleagues in my facility” as a barrier, in comparison with their peers (p = 0.022). Less experienced PTs were more likely to choose “Insufficient Time” as a barrier in comparison with more experienced therapists (OR 3.106 (95% CI [1.031–9.356]) – p = 0.044 for “<5”; and OR 2.941 (95% CI [1.297–6.668]) – p = 0.010 for “5-10”). Furthermore, non-clinical female therapists’ instructors were more likely to choose “Insufficient Time” in comparison with their male clinical instructors peers . It was also found that the number of PTs in the facility might influence the “Inability of Apply Research to Individual Patients” barrier, as in facilities with more than 15 PTs, this barrier was less chosen (OR 3.491 (95% CI [1.096–11.124]) – p = 0.0034 for “0”; OR 4.945 (95% CI [1.654–14.790]) – p = 0.004 for “1–5”; and OR 12.800 (95% CI [2.545–64.372]) – p = 0.002 for “11–15”). Additionally, PTs that treat 1–5 patients per day were 72% less likely to choose the “Lack of Collegial Support” in comparison with the ones that treat more than 15 patients per day (p = 0.041). Finally, differences were found between public and academic work sector, as academic therapists were more likely to have restrictions to apply research to individual patients (OR 0.271 (95% CI [0.076–0.986]) – p = 0.044 for “Public”) , followed by “Inability to apply research findings to individual patients with unique characteristics” (17.8%), and finally “Lack of generalizability of the literature findings to my patient population” (15.7%). In the ranking, “Insufficient time” was the most chosen for 1st (49.7%), and “Inability to apply research findings to individual patients with unique characteristics” for 2nd and 3rd . The barriers distribution is exhibited in Public”) .For a more detailed data analysis, the descriptive statistics of the PTs EBP responses are presented in From the 193 PTs that completed the e-survey, only 67 (34.7%) volunteered for the interviews. From those, 23 PTs were selected, but only 10 responded to the emails. The participants’ characteristics in the qualitative study are outlined in The interviews were made from January to April 2020. At the end, 313 minutes of recordings were obtained , which generated 71 transcript pages . The interviews offered compelling fragments of PT’s experiences, opinions and beliefs about evidence-based practice. In most cases, the qualitative data underpins the survey findings. The most often spoken word by PTs was “persons”, followed by “evidence” and “practice” . The With the interviews, six main themes were identified: EBP definition; EBP concept origin; Main actors and their individual importance; Relations between the main actors; EBP in the workplace; EBP national wide. The classification tree is illustrated in The overall findings and their conceptual map are present in the The aim of this study was to know if the Portuguese PTs use an EBP, to collect and deeper understand the factors, barriers and facilitators associated to EBP. The overall results shown that the Portuguese PTs have positives beliefs, attitudes, knowledge and behaviors regarding EBP. Most of the PTs answer Agree or Yes to the questionnaire questions, except in the item “Application of EBP is necessary in the practice of physical therapy”, where the majority of the PTs answered Strongly Agree. There were some negative items such as “I have access to current research through professional journals in their paper form”, “EBP does not take into account patient preferences”, “My reimbursement rate will increase if I incorporate EBP into my practice”, “The adoption of EBP places an unreasonable demand on PTs”, and “Strong evidence is lacking to support most of the interventions I use with my patients”, where the answers were Disagree or No. Still, there was the item “EBP does not take into account the limitations of my clinical practice setting” where the answers balanced between Agree (44.6%) and Disagree (44.0%). Despite the answers to these items were negative, they shown progressive attitudes regarding EBP, as disagreeing to the majority of these statements is considered as positive . The onlAdditionally, increasing the academic degree may have a positive influence in EBP. The advantages pointed out by the PTs were better search and critical analyze literature skills, as for the lectures and dissertation it is needed to constantly base their options on the most recent and higher quality evidence and to perform studies. In our quantitative data, Baccalaureate degree PTs were 9 times more likely to Agree that “I am interested in learning or improving the skills necessary to incorporate EBP into my practice” and were 80% less likely to search and read studies per month, in comparison to PhD PTs. Moreover, for the oldest PT interviewed, increasing the academic degree was very important to do an EBP. This is evidenced in the Another suggested facilitator was having frequent trainings/courses/workshops provided by professional bodies. It could not only be a good way to receive summarized evidence and have the possibility to be in contact with new treatments, but it could also exist more specialized workshops or lectures to give older PTs the necessary skills to search in online databases. Evidence has been showing that directed educational meetings have a positive impact in the EBP . For exap = 0.001); sufficient EBP knowledge in the graduate or postgraduate degree (p = 0.004); EBP core elements understanding (p = 0.004); ability to critically analyze a scientific paper (p = 0.005); and access online databases frequency (p = 0.009). Other factors that may help to decrease the evidence interest for older PTs include: evidence is often inconclusive or in certain areas non-existent; lack of high quality physical therapy studies; recommendations are difficult to apply in practice and do not respond to the clinical practice “real” problems; most of the papers are written in English and difficult to read/understand. Similar evidence-related barriers were reported in other studies . HoweverAlthough it seems that Portuguese physical therapy schools are getting better in preparing their students for EBP, it was also recommended to regularize and update their academic contents, and continuing to insist in EBP contents until doing EBP becomes almost a habit for the PTs. This facilitator was identified as early as 2005  and reinOther researchers found, as we did, that the primary barrier to implement EBP is lack of time  and, altAlthough no statistically significant association was found, “Insufficient time” was further related in the qualitative data with workplace, especially in Physical Therapy Medicine and Rehabilitation Centers. In those workplaces, the PTs pointed out that there are excessive patients “treated” per hour (it was referred 10 patients/hour), sometimes the work is very bureaucratic (time is more spent in filling paper forms and less in treating patients), and the PTs have to respect what is prescribed by the physiatrist . Belgians PTs reported similar barriers, but still added that some doctors are influenced by commercial firms that promote certain products, prejudicing an EBP . So, as An explanation for the barriers may relay on the image that other health professional and the Portuguese society have regarding physical therapy. The bad image could be from: some discredit and disrespect of the Portuguese PTs on using an EBP ; the profession focuses mainly on providing quality of life and not quantity of life ; the number of PTs involved in top health policy makers is still scarce ; the profession in Portugal is considered as new (54 years); and the fullness of its work areas is unknown . Related barriers were also reported by Belgians PTs . There wAs showed in the qualitative data, for the interviewed PTs, EBP is not a “fixed” concept. This was already shown in the literature, where other factors were added to the early EBP definition proposed by In conclusion, the Portuguese PTs reported positive beliefs, attitudes, knowledge, and behaviors regarding EBP. Among the PTs characteristics it seems that age (younger therapists), education , and workplace  are the main factors in the Portuguese EBP implementation. The Portuguese PTs, beyond the PTs individual characteristics and workplace, also stated that evidence, patients, clinical experience, schools, country and physical therapy characteristics, may behave as facilitators or barriers when performing an EBP.e.g., adding the language factor to the barriers). Another factor may be the PTs lack of interest in participating in national studies. Although the quantitative data shows that the Portuguese PTs have positive beliefs, attitudes, knowledge and behaviors regarding EBP, in our qualitative data all the PTs interviewed agreed that EBP was still not widely practiced in Portugal. So, it is possible that therapists with more positive attitudes, or those who are more confident in their evidence-based practice knowledge and practice, are more likely to return surveys and could correspond to the majority of the PTs sample (There were found some limitations in our study. One limitation was the number of valid questionnaires. From the potential 12,000 Portuguese physical therapists only 1.6% returned the completed questionnaire, the minimal 373 sample size goal was not reached and 26% of the questionnaires were incomplete. This is may be due to the questionnaire extension and complexity. As no reward was given to the responders PTs, they may felt tired after answering some of the questions. Additionally, although the questionnaire was anonymous, as many of the questions were clinical practice related, some of the PTs may not felt comfortable to answer them. Moreover, as the questionnaire has 32 questions EBP related, the sociodemographic questions should have appeared after the EBP related questions, since the PTs, even if tired, could be more enthusiastic in answering more individual questions, possibly increasing the number of complete questionnaires. Additionally, after combining quantitative and qualitative data, we also believe that the questionnaire may be revise, in an attempt to approximate to the Portuguese reality (s sample . For exas sample . In surv10.7717/peerj.12666/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.12666/supp-2Supplemental Information 2Click here for additional data file.10.7717/peerj.12666/supp-3Supplemental Information 3Click here for additional data file.10.7717/peerj.12666/supp-4Supplemental Information 4Click here for additional data file.10.7717/peerj.12666/supp-5Supplemental Information 5a Nagelkerke R2; b In logistic regression, one level of the independent variable serve as reference against which the odds of the other levels occurring are determined.Instructions for Submissions Click here for additional data file.10.7717/peerj.12666/supp-6Supplemental Information 6Instructions for Submissions a–Relative risk; b–Absolute risk; c–Systematic review; d–Odds ratio; e–Meta-analysis; f–Confidence interval; g–Heterogeneity; h–Publication bias; α–Insufficient time; β–Lack of information resources; γ–Lack of research skills; δ–Poor ability to critically appraise the literature; ε–Lack of generalizability of the literature findings to my patient population; θ–Inability to apply research findings to individual patients with unique characteristics; σ–Lack of understanding of statistical analysis; ψ–Lack of collective support among my colleagues in my facility; ω–Lack of interest; NA–Not Applicable.Click here for additional data file.10.7717/peerj.12666/supp-7Supplemental Information 7Click here for additional data file.10.7717/peerj.12666/supp-8Supplemental Information 8Raw Data-SPSSClick here for additional data file.