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- Comparison of hypothesis- and data-driven asthma phenotypes in NHANES 2007–2012: the importance of comprehensive data availabilityPublication . Amaral, Rita; Pereira, Ana M.; Jacinto, Tiago; Malinovschi, Andrei; Janson, Christer; Alving, Kjell; Fonseca, João A.Half of the adults with current asthma among the US National Health and Nutrition Examination Survey (NHANES) participants could be classified in more than one hypothesis-driven phenotype. A data-driven approach applied to the same subjects may allow a more useful classification compared to the hypothesis-driven one. To compare previously defined hypothesis-driven with newly derived data-driven asthma phenotypes, identified by latent class analysis (LCA), in adults with current asthma from NHANES 2007–2012. Adults (≥ 18 years) with current asthma from the NHANES were included (n = 1059). LCA included variables commonly used to subdivide asthma. LCA models were derived independently according to age groups: < 40 and ≥ 40 years old. Two data-driven phenotypes were identified among adults with current asthma, for both age groups. The proportions of the hypothesis-driven phenotypes were similar among the two data-driven phenotypes (p > 0.05). Class A < 40 years (n = 285; 75%) and Class A ≥ 40 years (n = 462; 73%), respectively, were characterized by a predominance of highly symptomatic asthma subjects with poor lung function, compared to Class B < 40 years (n = 94; 25%) and Class B ≥ 40 years (n = 170; 27%). Inflammatory biomarkers, smoking status, presence of obesity and hay fever did not markedly differ between the phenotypes. Both data- and hypothesis-driven approaches using clinical and physiological variables commonly used to characterize asthma are suboptimal to identify asthma phenotypes among adults from the general population. Further studies based on more comprehensive disease features are required to identify asthma phenotypes in population-based studies.
- Combined image-based approach for monitoring the adherence to inhaled medicationsPublication . Vieira-Marques, Pedro; Teixeira, João Fonseca; Valente, José; Pinho, Bernardo; Guedes, Rui; Almeida, Rute; Jácome, Cristina; Pereira, Ana; Jacinto, Tiago; Amaral, Rita; Gonçalves, Ivânia; Sousa, Ana Sá; Couto, Mariana; Magalhães, Manuel; Bordalo, Diana; Silva, Luís Nogueira; Fonseca, J. AlmeidaThe adherence to inhaled controller medications is of critical importance to achieve good clinical results in patients with chronic respiratory diseases. To objectively verify the adherence, a detection tool was previously developed and integrated in the mobile application InspirerMundi, based on image processing methods. In this work, a new approach for enhanced adherence verification was developed. In a first phase template matching is employed to confirm the inhaler positioning and to locate the dose counter. In a second phase Google ML Kit framework is used for the detection of each numerical dose in the dose counter. The proposed approach was validated through a new detection tool pilot implementation, using a set of images collected by patients using the application in their daily life. Performance of each of the two phases was evaluated for a set of commonly used inhaler devices. Promising results were achieved showing the potential of mobile embedded sensors without the need for external devices.
- Having concomitant asthma phenotypes is common and independently relates to poor lung function in NHANES 2007-2012Publication . Amaral, Rita; Fonseca, João A; Jacinto, Tiago; Pereira, Ana M; Malinovschi, Andrei; Janson, Christer; Alving, KjellEvidence for distinct asthma phenotypes and their overlap is becoming increasingly relevant to identify personalized and targeted therapeutic strategies. In this study, we aimed to describe the overlap of five commonly reported asthma phenotypes in US adults with current asthma and assess its association with asthma outcomes. Data from the National Health and Nutrition Examination Surveys (NHANES) 2007–2012 were used (n = 30,442). Adults with current asthma were selected. Asthma phenotypes were: B-Eos-high [if blood eosinophils (B-Eos) ≥ 300/mm3]; FeNO-high (FeNO ≥ 35 ppb); B-Eos&FeNO-low (B-Eos < 150/mm3 and FeNO < 20 ppb); asthma with obesity (AwObesity) (BMI ≥ 30 kg/m2); and asthma with concurrent COPD. Data were weighted for the US population and analyses were stratified by age (< 40 and ≥ 40 years old). Of the 18,619 adults included, 1059 (5.6% [95% CI 5.1–5.9]) had current asthma. A substantial overlap was observed both in subjects aged < 40 years (44%) and ≥ 40 years (54%). The more prevalent specific overlaps in both age groups were AwObesity associated with either B-Eos-high (15 and 12%, respectively) or B-Eos&FeNO-low asthma (13 and 11%, respectively). About 14% of the current asthma patients were “non-classified”. Regardless of phenotype classification, having concomitant phenotypes was significantly associated with (adjusted OR, 95% CI) ≥ 2 controller medications (2.03, 1.16–3.57), and FEV1 < LLN (3.21, 1.74–5.94), adjusted for confounding variables. A prevalent overlap of commonly reported asthma phenotypes was observed among asthma patients from the general population, with implications for objective asthma outcomes. A broader approach may be required to better characterize asthma patients and prevent poor asthma outcomes.
- Profiling persistent asthma phenotypes in adolescents: A longitudinal diagnostic evaluation from the INSPIRERS StudiesPublication . Amaral, Rita; Jácome, Cristina; Almeida, Rute; Pereira, Ana M.; Alves-Correia, Magna; Mendes, Sandra; Rodrigues, José C.; Carvalho, Joana; Araújo, Luís; Costa, Alberto; Silva, Armandina; Teixeira, Maria F.; Ferreira-Magalhães, Manuel; Alves, Rodrigo R.; Moreira, Ana S.; Fernandes, Ricardo M.; Ferreira, Rosário; Pinto, Paula L.; Neuparth, Nuno; Bordalo, Diana; Bom, Ana T.; Cálix, Maria J.; Ferreira, Tânia; Gomes, Joana; Vidal, Carmen; Mendes, Ana; Vasconcelos, Maria J.; Silva, Pedro M.; Ferraz, José; Morête, Ana; Pinto, Claúdia S.; Santos, Natacha; Loureiro, Carla C.; Câmara, Raquel; Vieira, Inês; Silva, Sofia D.; Silva, Eurico; Rodrigues, Natalina; Fonseca, João A.We aimed to identify persistent asthma phenotypes among adolescents and to evaluate longitudinally asthma-related outcomes across phenotypes. Adolescents (13–17 years) from the prospective, observational, and multicenter INSPIRERS studies, conducted in Portugal and Spain, were included (n = 162). Latent class analysis was applied to demographic, environmental, and clinical variables, collected at a baseline medical visit. Longitudinal differences in clinical variables were assessed at a 4-month follow-up telephone contact (n = 128). Three classes/phenotypes of persistent asthma were identified. Adolescents in class 1 (n = 87) were highly symptomatic at baseline and presented the highest number of unscheduled healthcare visits per month and exacerbations per month, both at baseline and follow-up. Class 2 (n = 32) was characterized by female predominance, more frequent obesity, and uncontrolled upper/lower airways symptoms at baseline. At follow-up, there was a significant increase in the proportion of controlled lower airway symptoms (p < 0.001). Class 3 (n = 43) included mostly males with controlled lower airways symptoms; at follow-up, while keeping symptom control, there was a significant increase in exacerbations/month (p = 0.015). We have identified distinct phenotypes of persistent asthma in adolescents with different patterns in longitudinal asthma-related outcomes, supporting the importance of profiling asthma phenotypes in predicting disease outcomes that might inform targeted interventions and reduce future risk.
- Development of a mobile health app for the management of hypertension, including treatment adherence assessment,using image detection technology - inspirers-HTNPublication . Nogueira-Silva, Luís; Viera-Marques, Pedro; Valente, José; Holtkötter, Jannis; Amaral, Rita; Jácome, Cristina; Ferreira, Ana; Almeida, Rute; Almeida Fonseca, JoãoWe aim to develop a mHealth smartphone app with a novel strategy to support the management of hypertension, including the measurement of adherence to treatment, taking advantage of the widespread use of smartphones and using only their embedded sensors. We have designed and developed a cross-platform, multi-language app which allows to register a pharmacological treatment and to customize alerts for the patient to take his/her medication and to measure his/her blood pressure (BP). Moreover, the app will be able to identify the number of pills in a blister and to capture the BP values from the screen of BP measuring devices, using the smartphone's camera. Thus, the app will quantify adherence to therapy and generate automatic BP reports. Blister photos and BP values collected by the users are enhanced using standard image processing methods for contrast increase, gap filling and relevant elements location. Classification strategies allow to count the pills present in the blisters, while the Google MLKit text mining API is employed for BP values recognition. Health Level Seven International (HL7) Fast Health Interoperability Resources (FHIR) standard is used for health care data modeling and exchange, promoting interoperability while guaranteeing data quality and security. Evaluation of the app's performance by real users will be presented, regarding its usability and the offline validity of the data acquisition. The user interface concept of the app has been defined and the mockups have been produced. Regarding pill counting, blisters with diverse materials and textures were considered. Different processing strategies are used depending on blisters’ characteristics, which has allowed an accuracy above 95% for most of the tested blisters. Extracting the BP measures from smartphone acquired images using the MLKIT app seems to be feasible. Further improvements and evaluations are ongoing. We will show preliminary results regarding usability and offline validity. We propose a new smartphone app that will support the management of hypertension, including an innovative image detection tool that will allow to objectively measure adherence to therapy and will facilitate the capture of BP values.
- Real-time clinical decision support at the point of carePublication . Pereira, Ana Margarida; Jácome, Cristina; Amaral, Rita; Jacinto, Tiago; Fonseca, João A.This chapter starts by introducing the complex process of shared clinical decision-making, the value of incorporating patient-reported outcome measures into clinical decisions and the increasing usefulness of clinical decision support systems to enhance the quality and safety of healthcare. It then gives examples of three tools for clinical decision support at the point of care, which were designed to support health professionals and patients in the assessment, treatment and long-term management of chronic respiratory diseases.
- Allergen sensitization associates with worse lung function parametersPublication . Gonçalves, I.; Pereira, A. M.; Jacinto, Tiago; Amaral, Rita; Fonseca, J. de Almeida Lopes daTo assess the association between the number of allergen sensitizations and lung function variables in individuals with airway symptoms. Methods. Retrospective study with all individuals who performed lung function and skin-prick tests at CUF-Porto (01/2011-06/2016). Six allergen groups were considered. % predicted Pre-Bronchodilator test (BD) and % change after BD were analysed for spirometry and plethysmography parameters. Results. A total of 1293 individuals were included, 54% (n = 698) adults and 69% (n = 891) with sensitization to ≥ 1 allergen group. % FEV1 was significantly higher and % change in FEV1 significantly lower in non-sensitized individuals. % sRaw was higher in polysensitized (vs non-sensitized). Conclusions. The presence of allergen sensitizations was significantly associated with worse key lung function parameters.
- Feasibility and acceptability of an asthma app to monitor medication adherence: mixed methods studyPublication . Jácome, Cristina; Almeida, Rute; Pereira, Ana Margarida; Amaral, Rita; Mendes, Sandra; Alves-Correia, Magna; Vidal, Carmen; Freire, Sara López; Brea, Paula Méndez; Araújo, Luís; Couto, Mariana; Antolín-Amérigo, Darío; Caballer, Belén de la Hoz; Castro, Alicia Barra; Gonzalez-De-Olano, David; Bom, Ana Todo; Azevedo, João; Pinto, Paula Leiria; Pinto, Nicole; Neves, Ana Castro; Palhinha, Ana; Bom, Filipa Todo; Costa, Alberto; Loureiro, Cláudia Chaves; Santos, Lilia Maia; Arrobas, Ana; Valério, Margarida; Cardoso, João; Emiliano, Madalena; Gerardo, Rita; Rodrigues, José Carlos Cidrais; Oliveira, Georgeta; Carvalho, Joana; Mendes, Ana; Lozoya, Carlos; Santos, Natacha; Menezes, Fernando; Gomes, Ricardo; Câmara, Rita; Alves, Rodrigo Rodrigues; Moreira, Ana Sofia; Bordalo, Diana; Alves, Carlos; Ferreira, José Alberto; Lopes, Cristina; Silva, Diana; Vasconcelos, Maria João; Teixeira, Maria Fernanda; Ferreira-Magalhães, Manuel; Taborda-Barata, Luís; Cálix, Maria José; Alves, Adelaide; Fonseca, João AlmeidaPoor medication adherence is a major challenge in asthma, and objective assessment of inhaler adherence is needed. The InspirerMundi app aims to monitor adherence while providing a positive experience through gamification and social support. This study aimed to evaluate the feasibility and acceptability of the InspirerMundi app to monitor medication adherence in adolescents and adults with persistent asthma (treated with daily inhaled medication). A 1-month mixed method multicenter observational study was conducted in 26 secondary care centers from Portugal and Spain. During an initial face-to-face visit, physicians reported patients’ asthma therapeutic plan in a structured questionnaire. During the visits, patients were invited to use the app daily to register their asthma medication intakes. A scheduled intake was considered taken when patients registered the intake (inhaler, blister, or other drug formulation) by using the image-based medication detection tool. At 1 month, patients were interviewed by phone, and app satisfaction was assessed on a 1 (low) to 5 (high) scale. Patients were also asked to point out the most and least preferred app features and make suggestions for future app improvements. A total of 107 patients (median 27 [P25-P75 14-40] years) were invited, 92.5% (99/107) installed the app, and 73.8% (79/107) completed the 1-month interview. Patients interacted with the app a median of 9 (P25-P75 1-24) days. At least one medication was registered in the app by 78% (77/99) of patients. A total of 53% (52/99) of participants registered all prescribed inhalers, and 34% (34/99) registered the complete asthma therapeutic plan. Median medication adherence was 75% (P25-P75 25%-90%) for inhalers and 82% (P25-P75 50%-94%) for other drug formulations. Patients were globally satisfied with the app, with 75% (59/79) scoring ≥4,; adherence monitoring, symptom monitoring, and gamification features being the most highly scored components; and the medication detection tool among the lowest scored. A total of 53% (42/79) of the patients stated that the app had motivated them to improve adherence to inhaled medication and 77% (61/79) would recommend the app to other patients. Patient feedback was reflected in 4 major themes: medication-related features (67/79, 85%), gamification and social network (33/79, 42%), symptom monitoring and physician communication (21/79, 27%), and other aspects (16/79, 20%). The InspirerMundi app was feasible and acceptable to monitor medication adherence in patients with asthma. Based on patient feedback and to increase the registering of medications, the therapeutic plan registration and medication detection tool were redesigned. Our results highlight the importance of patient participation to produce a patient-centered and engaging mHealth asthma app.
- Qualidade de vida em doentes com melanoma cutâneo maligno das extremidades submetidos a perfusão isolada dos membros – estudo longitudinalPublication . Baeta, Cristina; Narciso, Jorge; Amaral, Rita; Ribeiro, Matilde; Araújo, António; Pimentel, FranciscoMelanoma cutâneo maligno (MM) pode ser considerado uma doença crónica, porque a incidência está a aumentar e a mortalidade a diminuir. A Perfusão Isolada dos Membros (PIM) é uma técnica/terapêutica invasiva que permite aos doentes com MM disseminado/volumoso/irressecável nas extremidades evitarem amputação e regredirem estádio da doença. O interesse da comunidade clínica/científica na Qualidade de Vida (QdV) em doentes oncológicos tem aumentado.
- Exhaled NO reference limits in a large population-based sample using the Lambda-Mu-Sigma methodPublication . Jacinto, Tiago; Amaral, Rita; Malinovschi, Andrei; Janson, Christer; Fonseca, João; Alving, KjellAbsolute values are used in the interpretation of the fraction of exhaled nitric oxide (FeNO), but it has been suggested that equations to calculate reference values may be a practical and clinically useful approach. We hypothesize that the application of the Lambda-Mu-Sigma (LMS) method may improve FeNO reference equations and their interpretation. Our aims were to develop FeNO reference equations with the LMS method and to describe the difference between this method and the absolute fixed cut-offs of the current recommendations. We utilized the United States National Health and Nutrition Examination Surveys 2007-2012 and included healthy individuals with no respiratory diseases and blood eosinophils <300/mm3 ( n = 8,340). Natural log-transformed FeNO was modeled using the LMS method, imbedded in the generalized additive models for location, scale, and shape models. A set of FeNO reference equations was developed. The explanatory variables were sex, age, height, smoking habits, and race/ethnicity. A significant proportion of individuals with normal FeNO given by the equations were classified as having intermediate levels by the current recommendations. Further lower predicted FeNO compared with previous linear models was seen. In conclusion, we suggest a novel model for the prediction of reference FeNO values that can contribute to the interpretation of FeNO in clinical practice. This approach should be further validated in large samples with an objective measurement of atopy and a medical diagnosis of asthma and rhinitis. NEW & NOTEWORTHY Novel reference equations and fraction of exhaled nitric oxide (FeNO)-predicted values to improve interpretation of FeNO in clinical practice are presented. These may increase the accuracy of ruling out airway inflammation in patients with asthma or suspected asthma.