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- Symptoms of anxiety and depression in patients with persistent asthma: a cross-sectional analysis of the INSPIRERS studiesPublication . Cunha, Mafalda Simões; Amaral, Rita; Pereira, Ana Margarida; Almeida, Rute; Alves-Correia, Magna; Loureiro, Cláudia Chaves; Lopes, Cristina; Carvalho, Joana; Ribeiro, Carmelita; Vidal, Carmen; Antolín-Amérigo, Dario; Pinto, Diana; Ferreira-Magalhães, Manuel; Vasconcelos, Maria João; Lozoya, Carlos; Santos, Natacha; Cardia, Francisca; Taborda-Barata, Luís; Ferreira, Rosário; Silva, Pedro Morais; Ferreira, Tania Monteiro; Câmara, Raquel; Silva, Eurico; Bordalo, Diana; Guimarães, Cristina; Calix, Maria José; Silva, Sofia da; Marques, Maria Luís; Morete, Ana; Nunes, Carlos; Vieira, Cláudia; Páscoa, Rosália; Alves, Adelaide; Marques, José Varanda; Reis, Bruno; Monteiro, Luís; Monteiro, Rosário; Cepa, Margarida; Valentim, Bruno; Coelho, Daniela Sousa; Fernandes, Sara; Meireles, Patrícia; Aguiar, Margarida Abreu; Mourão, Ana Rita; Fonseca, João A; Jácome, CristinaAnxiety and depression are relevant comorbidities in asthma, but, in Portugal and Spain, data on this topic are scarce. We assessed, in patients with asthma, the frequency of anxiety and depression using the Hospital Anxiety and Depression Scale (HADS) and the European Quality of Life Five Dimension Questionnaire (EQ-5D); the level of agreement between these questionnaires, and the factors associated with these symptoms. This is a secondary analysis of the INSPIRERS studies. A total of 614 adolescents and adults with persistent asthma (32.6±16.9 years, 64.7% female) were recruited from 30 primary care centres and 32 allergy, pulmonology and paediatric clinics. Demographic and clinical characteristics, HADS and EQ-5D were collected. A score ≥8 on Hospital Anxiety and Depression Scale-Anxiety/Hospital Anxiety and Depression Scale-Depression or a positive answer to EQ-5D item 5 indicated the presence of these symptoms. Agreement was determined by Cohen’s kappa. Two multivariable logistic regressions were built. According to HADS, 36% of the participants had symptoms of anxiety and 12% of depression. According to EQ-5D, 36% of the participants had anxiety/depression. The agreement between questionnaires in identifying anxiety/depression was moderate (k=0.55, 95% CI 0.48 to 0.62). Late asthma diagnosis, comorbidities and female gender were predictors of anxiety/depression, while better asthma control, health-related quality of life and perception of health were associated with lower odds for anxiety/depression. At least 1/3 of the patients with persistent asthma experience symptoms of anxiety/depression, showing the relevance of screening these disorders in patients with asthma. EQ-5D and HADS questionnaires showed a moderate agreement in the identification of anxiety/depression symptoms. The identified associated factors need to be further investigated in long-term studies.
- Development and validation of a digital image processing-based pill detection tool for an oral medication self-monitoring systemPublication . Holtkötter, Jannis; Amaral, Rita; Almeida, Rute; Jácome, Cristina; Cardoso, Ricardo; Pereira, Ana; Pereira, Mariana; Chon, Ki H.; Fonseca, João AlmeidaLong-term adherence to medication is of critical importance for the successful management of chronic diseases. Objective tools to track oral medication adherence are either lacking, expensive, difficult to access, or require additional equipment. To improve medication adherence, cheap and easily accessible objective tools able to track compliance levels are necessary. A tool to monitor pill intake that can be implemented in mobile health solutions without the need for additional devices was developed. We propose a pill intake detection tool that uses digital image processing to analyze images of a blister to detect the presence of pills. The tool uses the Circular Hough Transform as a feature extraction technique and is therefore primarily useful for the detection of pills with a round shape. This pill detection tool is composed of two steps. First, the registration of a full blister and storing of reference values in a local database. Second, the detection and classification of taken and remaining pills in similar blisters, to determine the actual number of untaken pills. In the registration of round pills in full blisters, 100% of pills in gray blisters or blisters with a transparent cover were successfully detected. In the counting of untaken pills in partially opened blisters, 95.2% of remaining and 95.1% of taken pills were detected in gray blisters, while 88.2% of remaining and 80.8% of taken pills were detected in blisters with a transparent cover. The proposed tool provides promising results for the detection of round pills. However, the classification of taken and remaining pills needs to be further improved, in particular for the detection of pills with non-oval shapes.
- The use of remote care during the Coronavirus disease 2019 pandemic: a perspective of Portuguese and Spanish physiciansPublication . Jácome, C.; Pereira, A. M.; Amaral, Rita; Alves-Correia, M.; Almeida, R.; Mendes, S.; Mendes, S.; Fonseca, J. Almeida; INSPIRERS groupThis study aimed to characterise how the follow-up of outpatients was done during the first months of COVID-19 pandemic by a multidisciplinary group of physicians involved in an asthma mHealth project. A cross-sectional study based on a web survey was conducted. The survey was sent to 123 physicians working at secondary care centres of Portugal and Spain, that participate in the INSPIRERS project. A total of 65 physicians completed the survey (53% response rate). They had a mean of 18 (11) years of clinical practice and 14% were residents. More than half were allergists (58%), 22% pulmonologists and 20% paediatricians. Most were working in Portugal (89%) and in public hospitals (88%). All were conducting consultations: 71% presential (median [p25 , p75] duration 30 [20, 30] min), 91% telephonic (15 [10, 20] min) and 20% video consultations (20 [10, 28] min). The median duration of presential consultations was significantly higher than pre-COVID-19 (20 [20, 30] min; p = 0.021). From the physicians conducting video consultations, 92% were allergists and only 54% considered that their institution provided adequate conditions. The physicians of the INSPIRERS group used telephonic consultations as the main alternative to presential ones and 1/5 used video consultations. These results suggest the need to rethink clinical follow-up services for outpatients in the near future increasing the use of telemedicine, especially
- Multidisciplinary development and initial validation of a clinical knowledge base on chronic respiratory diseases for mHealth decision support systemsPublication . Pereira, Ana Margarida; Jácome, Cristina; Jacinto, Tiago; Amaral, Rita; Pereira, Mariana; Sá-Sousa, Ana; Couto, Mariana; Vieira-Marques, Pedro; Martinho, Diogo; Vieira, Ana; Almeida, Ana; Martins, Constantino; Marreiros, Goreti; Freitas, Alberto; Almeida, Rute; Fonseca, João A.Most mobile health (mHealth) decision support systems currently available for chronic obstructive respiratory diseases (CORDs) are not supported by clinical evidence or lack clinical validation. The development of the knowledge base that will feed the clinical decision support system is a crucial step that involves the collection and systematization of clinical knowledge from relevant scientific sources and its representation in a human-understandable and computer-interpretable way. This work describes the development and initial validation of a clinical knowledge base that can be integrated into mHealth decision support systems developed for patients with CORDs. A multidisciplinary team of health care professionals with clinical experience in respiratory diseases, together with data science and IT professionals, defined a new framework that can be used in other evidence-based systems. The knowledge base development began with a thorough review of the relevant scientific sources (eg, disease guidelines) to identify the recommendations to be implemented in the decision support system based on a consensus process. Recommendations were selected according to predefined inclusion criteria: (1) applicable to individuals with CORDs or to prevent CORDs, (2) directed toward patient self-management, (3) targeting adults, and (4) within the scope of the knowledge domains and subdomains defined. Then, the selected recommendations were prioritized according to (1) a harmonized level of evidence (reconciled from different sources); (2) the scope of the source document (international was preferred); (3) the entity that issued the source document; (4) the operability of the recommendation; and (5) health care professionals’ perceptions of the relevance, potential impact, and reach of the recommendation. A total of 358 recommendations were selected. Next, the variables required to trigger those recommendations were defined (n=116) and operationalized into logical rules using Boolean logical operators (n=405). Finally, the knowledge base was implemented in an intelligent individualized coaching component and pretested with an asthma use case. Initial validation of the knowledge base was conducted internally using data from a population-based observational study of individuals with or without asthma or rhinitis. External validation of the appropriateness of the recommendations with the highest priority level was conducted independently by 4 physicians. In addition, a strategy for knowledge base updates, including an easy-to-use rules editor, was defined. Using this process, based on consensus and iterative improvement, we developed and conducted preliminary validation of a clinical knowledge base for CORDs that translates disease guidelines into personalized patient recommendations. The knowledge base can be used as part of mHealth decision support systems. This process could be replicated in other clinical areas.
- Avaliação objetiva no diagnóstico de broncoconstrição induzida pelo exercícioPublication . Couto, Mariana; Jacinto, TiagoA broncoconstrição induzida pelo exercício (BIE) define -se como o aumento transitório da resistência das vias aéreas resultante da obstrução brônquica que ocorre após esforço físico. É uma entidade clínica muito frequente, que importa diagnosticar corretamente de forma a prevenir a resposta broncoconstritora ao esforço, de modo a que esta não constitua restrição à escolha de uma atividade física ou limitação ao nível do desempenho desportivo. A história clínica pode ser extremamente sugestiva, porém, são frequentes tanto situações de sobrediagnóstico de asma como de subdiagnóstico de BIE. Assim sendo, e face à importância do diagnóstico exato, pretende -se com o presente artigo apresentar os exames complementares no diagnóstico de BIE, abordando a sua utilidade e aplicabilidade.
- Measuring adherence to inhaled control medication in patients with asthma: Comparison among an asthma app, patient self-report and physician assessmentPublication . Amaral, Rita; Jácome, CristinaPrevious studies have demonstrated the feasibility of using an asthma app to support medication management and adherence but failed to compare with other measures currently used in clinical practice. However, in a clinical setting, any additional adherence measurement must be evaluated in the context of both the patient and physician perspectives so that it can also help improve the process of shared decision making. Thus, we aimed to compare different measures of adherence to asthma control inhalers in clinical practice, namely through an app, patient self-report and physician assessment. This study is a secondary analysis of three prospective multicentre observational studies with patients (≥13 years old) with persistent asthma recruited from 61 primary and secondary care centres in Portugal. Patients were invited to use the InspirerMundi app and register their inhaled medication. Adherence was measured by the app as the number of doses taken divided by the number of doses scheduled each day and two time points were considered for analysis: 1-week and 1-month. At baseline, patients and physicians independently assessed adherence to asthma control inhalers during the previous week using a Visual Analogue Scale (VAS 0-100). A total of 193 patients (72% female; median [P25-P75] age 28 [19-41] years old) were included in the analysis. Adherence measured by the app was lower (1 week: 31 [0-71]%; 1 month: 18 [0-48]%) than patient self-report (80 [60-95]) and physician assessment (82 [51-94]) (p < 0.001). A negligible non-significant correlation was found between the app and subjective measurements (ρ 0.118-0.156, p > 0.05). There was a moderate correlation between patient self-report and physician assessment (ρ = 0.596, p < 0.001). Adherence measured by the app was lower than that reported by the patient or the physician. This was expected as objective measurements are commonly lower than subjective evaluations, which tend to overestimate adherence. Nevertheless, the low adherence measured by the app may also be influenced by the use of the app itself and this needs to be considered in future studies.
- Unsupervised algorithms to identify potential under-coding of secondary diagnoses in hospitalisations databases in PortugalPublication . Portela, Diana ; Amaral, Rita; Rodrigues, Pedro P. ; Freitas, Alberto ; Costa, Elísio ; Fonseca, João A. ; Sousa-Pinto, BernardoQuantifying and dealing with lack of consistency in administrative databases (namely, under-coding) requires tracking patients longitudinally without compromising anonymity, which is often a challenging task. This study aimed to (i) assess and compare different hierarchical clustering methods on the identification of individual patients in an administrative database that does not easily allow tracking of episodes from the same patient; (ii) quantify the frequency of potential under-coding; and (iii) identify factors associated with such phenomena. We analysed the Portuguese National Hospital Morbidity Dataset, an administrative database registering all hospitalisations occurring in Mainland Portugal between 2011–2015. We applied different approaches of hierarchical clustering methods (either isolated or combined with partitional clustering methods), to identify potential individual patients based on demographic variables and comorbidities. Diagnoses codes were grouped into the Charlson an Elixhauser comorbidity defined groups. The algorithm displaying the best performance was used to quantify potential under-coding. A generalised mixed model (GML) of binomial regression was applied to assess factors associated with such potential under-coding. We observed that the hierarchical cluster analysis (HCA) + k-means clustering method with comorbidities grouped according to the Charlson defined groups was the algorithm displaying the best performance (with a Rand Index of 0.99997). We identified potential under-coding in all Charlson comorbidity groups, ranging from 3.5% (overall diabetes) to 27.7% (asthma). Overall, being male, having medical admission, dying during hospitalisation or being admitted at more specific and complex hospitals were associated with increased odds of potential under-coding. We assessed several approaches to identify individual patients in an administrative database and, subsequently, by applying HCA + k-means algorithm, we tracked coding inconsistency and potentially improved data quality. We reported consistent potential under-coding in all defined groups of comorbidities and potential factors associated with such lack of completeness. Our proposed methodological framework could both enhance data quality and act as a reference for other studies relying on databases with similar problems.
- Efeito do envelhecimento cronológico na função pulmonar. Comparação da função respiratória entre adultos e idosos saudáveisPublication . Ruivo, Susana; Viana, Paulo; Martins, Cristiana; Baeta, CristinaO sistema respiratório sofre alterações inerentes ao envelhecimento e o conhecimento dessas modificações contribui para a detecção e prevenção de disfunções respiratórias em idosos. O objectivo deste estudo foi comparar o padrão respiratório entre adultos e idosos saudáveis, não fumadores, confrontando os valores espirométricos e de expansibilidade torácica, de forma a confirmar a acção do envelhecimento na função pulmonar. A espirometria foi utilizada para medir as variáveis capacidade vital forçada, volume expiratório máximo ao primeiro segundo, débitos expiratórios máximos e ventilação máxima voluntária. A cirtometria foi utilizada para medir a expansibilidade torácica. As medidas foram registadas em repouso, com os sujeitos posicionados em decúbito dorsal a 45º de inclinação do tronco. A análise estatística aplicada foi o teste t de Student para amostras independentes e o teste não paramétrico Mann-Whitney considerando significativo p <0,05. Com o mesmo nível de significância, foi aplicada a análise de regressão linear e determinada a correlação entre as variáveis em estudo e a idade. Estudaram-se 35 idosos e 35 jovens/adultos. Dos primeiros, 15 eram homens (43%) e 20 mulheres (57%), constando 16 homens (46%) e 19 mulheres (54%) no grupo dos jovens adultos. Foram recolhidas características da amostra, como idade, peso, altura, perímetro abdominal, bem como dados clínicos, para excluir factores de enviesamento dos resultados. Para os homens e mulheres estudados, a diferença entre os dois grupos foi estatisticamente significativa, para todas as medidas avaliadas. A relação linear foi, também, significativa entre a idade e todos os parâmetros e observou-se correlação negativa e significativa. A expansibilidade torácica no género feminino revelou ser a medida mais inversamente correlacionada com a idade (60,37%). A variável espirométrica com maior diferença entre os grupos foi o débito expiratório máximo instantâneo (35,77% no género feminino e 36,17% no género masculino). Os resultados mostraram que houve diferenças do padrão respiratório entre jovens adultos e idosos saudáveis, sugerindo que a função pulmonar é influenciada pelo envelhecimento cronológico. Em ambos os géneros, os indivíduos idosos apresentaram valores espirométricos mais baixos do que os indivíduos adultos, sendo esta diferença maior no género feminino.
- Incidência da fibrilação auricular após cirúrgia cardíaca: influência do tipo de cirurgia, da circulação extracorporeal e de fatores pré e intraoperatóriosPublication . Moreira, Soraia; Paulo, Nelson; Vouga, Luís; Jacinto, Tiago; Baeta, CristinaA fibrilação auricular (FA) é a arritmia com maior incidência no pós-operatório da cirurgia cardíaca. Na cirurgia de substituição valvular (CSV) ela ocorre em cerca de 64% dos indivíduos e na cirurgia de revascularização do miocárdio (CRM) ela pode desencadear-se em 30-40% dos indivíduos. A sua incidência no pós-operatório pode ainda ser influenciada por fatores de risco pré e intraoperatórios. Estudar a incidência de FA após cirurgia cardíaca, a sua associação com o tipo de cirurgia, com a realização de circulação extracorporal (CEC), e com fatores de risco/preditores pré e intraoperatórios. Métodos: Estudo observacional retrospetivo longitudinal realizado com os indivíduos submetidos a CRM e CSV em 2014, num hospital central da região norte. Foi avaliado o ritmo cardíaco em quatro momentos do pós-operatório (saída de CEC, Unidade de Cuidados Intensivos (UCI)/internamento, pré-alta e follow-up). Foi explorada a associação entre este ritmo e fatores de risco/preditores pré-operatórios (dimensão das aurículas, cardiomegalia, hipertrofia ventricular esquerda (HVE)) e intraoperatórios (tipo de cirurgia, realização de CEC, duração da CEC, tempo de clampagem aórtica e administração de cardioplegia), através do Odds ratio (OR). Foram estudados 416 indivíduos, 73.6% do sexo masculino, idade média 66.8±10.5 anos. Nas CSV ocorreu incidência de FA nos quatro momentos de avaliação, e na CRM apenas na UCI/internamento e na pré-alta. Em todos os tipos de cirurgia essa incidência foi mais elevada na UCI/internamento, variando entre 3.7% na CRM com CEC e 71.4% na CSV mitral. Os fatores preditores pré-operatórios com OR>1 foram idade superior a 65 anos (2.51 saída de CEC, 10.62 pré-alta), dilatação da aurícula direita (AD) (1.08 follow-up, 3.41 pré-alta), e HVE (1.68 saída de CEC, 2.78 pré-alta). Relativamente aos fatores preditores intraoperatórios, a CEC (2.74 CI/internamento, 3.37 pré-alta) e a cardioplegia (2.93 UCI/internamento, 5.40 pré--alta) foram os que apresentaram OR>1, no pós-operatório. As CSV foram o tipo de cirurgia com maior incidência de FA. Na CRM esta incidência foi superior nas cirurgias sem CEC. A idade superior a 65 anos, a dilatação da AD e a HVE foram os fatores preditores pré-operatórios com associação positiva à incidência de FA, em todos os momentos de avaliação.
- Predictors of acute kidney injury associated with cardiopulmonary bypassPublication . Moreira, Raquel; Jacinto, Tiago; Neves, Paulo; Vouga, Luís; Baeta, CristinaTo study the incidence of acute kidney injury (AKI) in the postoperative period of cardiac surgery in patients without preoperative renal insufficiency who underwent cardiac surgery with cardiopulmonary bypass (CPB), and to explore the association between the incidence of AKI and predictors related to CPB. Observational, cross-sectional study. Participants were divided in two groups, those who developed AKI in the postoperative period and those who did not develop AKI. Kidney Disease: Improving Global Outcomes - Clinical Practice Guideline for Acute Kidney Injury (KDIGO) classification was used to characterize AKI. The analysis included preoperative variables (anthropometric data, cardiovascular risk factors and blood parameters), as well as the type of surgery, intraoperative variables related to CPB, and postoperative creatinine variation. Association between variables was studied with binary logistic regression. We have included 329 patients, of which 62 (19%), developed AKI. There were statistically significant differences between the groups in age (p<0.001; OR (95%)-1.075 (1.037-1.114)), duration of CPB (p=0.011; 1.008 (1.002-1.014)), urine output during CPB (p=0.038; 0.998 (0.996-0.999)), mannitol and furosemide administration during CPB, (respectively, p=0.032; 2.293 (1.075-4.890) and p=0.013; 2.535 (1.214-5.296)). A significant number of patients developed AKI in the postoperative period of cardiac surgery and this incidence was influenced by factors related to CPB, namely: age, duration of CPB, urine output during CPB, mannitol and furosemide administration during CPB.
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