European Portuguese Language and Cultural Validation of the Chronic Obstructive Pulmonary Disease Assessment Test.

INTRODUCTION: The chronic obstructive pulmonary disease assessment test (CAT) is a self-administered questionnaire that measures health-related quality of life. GOLD proposes using this questionnaire, since it provides thorough coverage of the impact of chronic obstructive pulmonary disease (COPD) on well-being. This questionnaire has been widely used in daily clinical practice in Portugal, but it lacks validation for European Portuguese. The aim of this study was to carry out the cultural adaptation and validation of the CAT questionnaire so that the most appropriate version can be made available to Portuguese researchers and clinicians. MATERIAL AND METHODS: A cross-sectional descriptive study was performed involving 65 patients with COPD aged 40 years or older. CAT and the previously validated Portuguese-language version of the Clinical Questionnaire for COPD were applied between January 2019 and June 2019. The agreement between the two questionnaires was determined with Kappa agreement with a 95% confidence interval. Spearman correlation was used to find the correlation between two scores. RESULTS: The 65 patients included in the study were observed in a hospital-based pulmonology clinic [aged 68 ± 7 years; forced expiratory volume in 1 sec (FEV1) 49.86% ± 16.5% predicted]. CAT correlated significantly with all the domains and the overall score of the CCQ (0.47 < r < 0.75; p < 0.001). The bilingual patient interclass correlation coefficient was 0.922; Pearson's r = 0.928; p < 0.001. The Cronbach's alpha coefficient was 0.96 (p < 0.001). CONCLUSION: The European Portuguese version of the COPD Assessment Test is a valid instrument for measurement of health-related quality of life in COPD patients. The use of validated questionnaires is of great importance since it generates reliable and reproducible evidence for use either in research or clinical practice.

Introdução: O teste de avaliação da doença pulmonar obstrutiva crónica (CAT) é um questionário autoaplicável que mede a qualidade de vida relacionada com a saúde. As normas internacionais GOLD propõem o uso deste questionário, uma vez que traduz o impacto da doença pulmonar obstrutiva crónica (DPOC) no bem-estar. Este questionário tem sido amplamente utilizado na prática clínica diária em Portugal, mas carece de validação para o português europeu. Assim, o objetivo deste estudo foi realizar a adaptação cultural e validação do questionário CAT para que a sua versão mais adequada possa ser disponibilizada a investigadores e clínicos portugueses. Material e Métodos: Foi realizado um estudo transversal descritivo com 65 doentes com DPOC com 40 anos ou mais. O CAT e a versão em português previamente validada do questionário clínico para DPOC foram aplicados entre janeiro de 2019 e junho de 2019. A concordância entre os dois questionários foi determinada com o teste de concordância de Kappa com intervalo de confiança de 95%. A correlação de Spearman foi usada para avaliar a presença de uma correlação entre os dois scores. Resultados: Os 65 doentes incluídos no estudo foram observados em consulta de pneumologia hospitalar [idade 68 ± 7 anos; volume expiratório máximo no 1º segundo (FEV1) 49,86% ± 16,5% do previsto]. O CAT correlacionou-se significativamente com todos os domínios e com a pontuação geral do CCQ (0,47 < r < 0,75; p < 0,001). O coeficiente de correlação interclasse de doentes bilíngues foi de 0,922; R de Pearson = 0,928; p < 0,001. O coeficiente alfa de Cronbach foi de 0,96 (p < 0,001). Conclusão: A versão em português europeu do CAT é um instrumento válido para medir a qualidade de vida relacionada com a saúde em doentes com DPOC. A aplicação de questionários validados é fundamental, visto que gera evidência confiável e reprodutível para uso em ensaios clínicos ou na prática clínica.

Confirmatory Evaluation of the Modified Medical Research Council Questionnaire for Assessment of Dyspnea in Patients with Chronic Obstructive Pulmonary Disease in Portugal.

INTRODUCTION: The Modified British Medical Research Council Questionnaire is considered an adequate and simple measure of breathlessness in chronic obstructive pulmonary disease. It is widely used in clinical practice in Portugal, but it still lacks confirmatory evaluation for the Portuguese setting. The aim of this study was to perform a cultural adaptation and validation of the Modified British Medical Research Council Questionnaire so that its most suitable version can be made available to researchers and clinicians in Portugal. MATERIAL AND METHODS: We performed a cross-sectional descriptive study involving patients with chronic obstructive pulmonary disease aged 40 years or older. We applied the Modified British Medical Research Council Questionnaire and the previously validated Portuguese-language version of the clinical questionnaire for chronic obstructive pulmonary disease between January and June 2019. We determined the agreement between the two questionnaires with kappa agreement, with a 95% confidence interval, and we used Spearman correlation to find a correlation between two scores. RESULTS: The study included 65 patients managed in a hospital pulmonology clinic (aged 68 ± 7 years; with predicted FEV1 of 49.86% ± 16.5%). The Modified British Medical Research Council scale correlated significantly with all the domains and the overall score of the clinical questionnaire for chronic obstructive pulmonary disease (0.46 < r < 0.68; p < 0.001). In bilingual patients, interclass correlation coefficient was 0.912 (p < 0.001). DISCUSSION: Our study showed that the Portuguese-language version of the Modified British Medical Research Council Questionnaire is feasible and externally valid when compared with a traditional and previously validated instrument. CONCLUSION: The Portuguese version of the Modified British Medical Research Council Questionnaire is a valid instrument for measurement of breathlessness in chronic obstructive pulmonary disease.

Introdução: O Questionário British Medical Research Council (mMRC) Modificado é considerado um instrumento adequado e simples para a medição da dispneia na doença pulmonar obstrutiva crónica (DPOC). Tem sido amplamente usado na prática clínica em Portugal, mas carece de avaliação confirmatória para o cenário português. O objetivo deste estudo é realizar a adaptação cultural e validação do Questionário British Medical Research Council Modificado para que a versão mais adequada possa estar disponível a investigadores e clínicos em Portugal. Material e Métodos: Realizamos um estudo descritivo e transversal com doentes com doença pulmonar obstrutiva crónica e idade ≥ 40 anos. Aplicamos o Questionário British Medical Research Council Modificado e o questionário clínico para a doença pulmonar obstrutiva crónica previamente validado para a língua portuguesa, entre janeiro e junho de 2019. Determinámos a concordância entre os dois questionários com kappa agreement, com 95% de intervalo de confiança, e usámos o coeficiente de correlação de Spearman para determinar a correlação entre os dois scores. Resultados: O estudo incluiu 65 doentes seguidos em consulta hospitalar de Pneumologia (idades de 68 ± 7 anos; com FEV1 49,86% ± 16,5% do predito). A Escala Modificada do British Medical Research Council correlacionou-se significativamente com todos os domínios e pontuação total do questionário clínico (0,46 < r < 0,68; p < 0,001). Nos doentes bilingues, o coeficiente de correlação interclasse foi 0,912 (p < 0,001). Discussão: O nosso estudo mostrou que a versão portuguesa do Questionário Modificado do British Medical Research Council apresenta exequibilidade e validade externa quando comparado com um instrumento tradicional e previamente validado. Conclusão: A versão portuguesa do Questionário Modificado do British Medical Research Council é um instrumento válido para a medição da dispneia na doença pulmonar obstrutiva crónica.

Determinants of the Use of Health and Fitness Mobile Apps by Patients With Asthma: Secondary Analysis of Observational Studies.

BACKGROUND: Health and fitness apps have potential benefits to improve self-management and disease control among patients with asthma. However, inconsistent use rates have been reported across studies, regions, and health systems. A better understanding of the characteristics of users and nonusers is critical to design solutions that are effectively integrated in patients' daily lives, and to ensure that these equitably reach out to different groups of patients, thus improving rather than entrenching health inequities. OBJECTIVE: This study aimed to evaluate the use of general health and fitness apps by patients with asthma and to identify determinants of usage. METHODS: A secondary analysis of the INSPIRERS observational studies was conducted using data from face-to-face visits. Patients with a diagnosis of asthma were included between November 2017 and August 2020. Individual-level data were collected, including age, gender, marital status, educational level, health status, presence of anxiety and depression, postcode, socioeconomic level, digital literacy, use of health services, and use of health and fitness apps. Multivariate logistic regression was used to model the probability of being a health and fitness app user. Statistical analysis was performed in R. RESULTS: A total of 526 patients attended a face-to-face visit in the 49 recruiting centers and 514 had complete data. Most participants were ≤40 years old (66.4%), had at least 10 years of education (57.4%), and were in the 3 higher quintiles of the socioeconomic deprivation index (70.1%). The majority reported an overall good health status (visual analogue scale [VAS] score>70 in 93.1%) and the prevalence of anxiety and depression was 34.3% and 11.9%, respectively. The proportion of participants who reported using health and fitness mobile apps was 41.1% (n=211). Multivariate models revealed that single individuals and those with more than 10 years of education are more likely to use health and fitness mobile apps (adjusted odds ratio [aOR] 2.22, 95%CI 1.05-4.75 and aOR 1.95, 95%CI 1.12-3.45, respectively). Higher digital literacy scores were also associated with higher odds of being a user of health and fitness apps, with participants in the second, third, and fourth quartiles reporting aORs of 6.74 (95%CI 2.90-17.40), 10.30 (95%CI 4.28-27.56), and 11.52 (95%CI 4.78-30.87), respectively. Participants with depression symptoms had lower odds of using health and fitness apps (aOR 0.32, 95%CI 0.12-0.83). CONCLUSIONS: A better understanding of the barriers and enhancers of app use among patients with lower education, lower digital literacy, or depressive symptoms is key to design tailored interventions to ensure a sustained and equitable use of these technologies. Future studies should also assess users' general health-seeking behavior and their interest and concerns specifically about digital tools. These factors may impact both initial engagement and sustained use.

Is the Nox-T3 device scoring algorithm accurate enough for the diagnosis of obstructive sleep apnea?

INTRODUCTION: Obstructive sleep apnea (OSA) is highly prevalent. Home sleep apnea testing (HSAT) for OSA is rapidly expanding because of its cost effectiveness in the diagnosis of OSA. Type 3 portable monitors are used for this purpose. In most cases, these devices contain an algorithm for automatic scoring of events. We propose to study the accuracy of the automatic scoring algorithm in our population in order to compare it with the manually edited scoring of Nox-T3®. MATERIAL AND METHODS: For five months, a prospective study was performed. Patients were randomly distributed to the available HSAT devices. We collected the data of patients who performed HSAT with Nox-T3®. We used normality plots, the Spearman correlation, the Wilcoxon signed-rank test, and Bland-Altman plots. RESULTS: The sample consisted of 283 participants. The average manual apnea and hypopnea index (AHI) was 23.7 ± 22.1 events/h. All manual scores (AHI, apnea index, hypopnea index, and oxygen desaturation index) had strong correlations with their respective automated scores. When AHI > 15 and AHI > 30 the difference between the values of this index (automatic and manual) was not statistically significant. Also, for AHI values > 15 the mean difference between the two scoring methods was 0.17 events/h. For AHI values > 30, this difference was - 1.23 events/h. CONCLUSIONS: When AHI is < 15, there may be a need for confirmation of automatic scores, especially in symptomatic patients with a high pretest probability of OSA. But, for patients with AHI > 15, automatic scores obtained from this device seem accurate enough to diagnose OSA in the correct clinical setting.

A Rare Mass in the Mediastinum / Una masa extraña en el mediastino

No disponible

Feasibility and Acceptability of an Asthma App to Monitor Medication Adherence: Mixed Methods Study.

BACKGROUND: Poor 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. OBJECTIVE: 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). METHODS: 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. RESULTS: 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%). CONCLUSIONS: 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.

Monitoring Adherence to Asthma Inhalers Using the InspirerMundi App: Analysis of Real-World, Medium-Term Feasibility Studies.

Background: Poor medication adherence is a major challenge in asthma and objective assessment of inhaler adherence is needed. InspirerMundi app aims to monitor inhaler adherence while turning it into a positive experience through gamification and social support. Objective: We assessed the medium-term feasibility of the InspirerMundi app to monitor inhaler adherence in real-world patients with persistent asthma (treated with daily inhaled medication). In addition, we attempted to identify the characteristics of the patients related to higher app use. Methods: Two real-world multicenter observational studies, with one initial face-to-face visit and a 4-month telephone interview, were conducted in 29 secondary care centers from Portugal. During an initial face-to-face visit, patients were invited to use the app daily to register their asthma medication intakes. A scheduled intake was considered taken when patients took a photo of the medication (inhaler, blister, or others) using the image-based medication detection tool. Medication adherence was calculated as the number of doses taken as a percentage of the number scheduled. Interacting with the app ≥30 days was used as the cut-off for higher app use. Results: A total of 114 patients {median 20 [percentile 25 to percentile 75 (P25-P75) 16-36] years, 62% adults} were invited, 107 (94%) installed the app and 83 (73%) completed the 4-month interview. Patients interacted with the app for a median of 18 [3-45] days, translated on a median use rate of 15 [3-38]%. Median inhaler adherence assessed through the app was 34 [4-73]% when considering all scheduled inhalations for the study period. Inhaler adherence assessed was not significantly correlated with self-reported estimates. Median adherence for oral and other medication was 41 [6-83]% and 43 [3-73]%, respectively. Patients with higher app use were slightly older (p = 0.012), more frequently taking medication for other health conditions (p = 0.040), and more frequently prescribed long-acting muscarinic antagonists (LAMA, p = 0.024). After 4 months, Control of Allergic Rhinitis and Asthma Test (CARAT) scores improved (p < 0.001), but no differences between patients interacting with the app for 30 days or less were seen. Conclusions: The InspirerMundi app was feasible to monitor inhaler adherence in patients with persistent asthma. The persistent use of this mHealth technology varies widely. A better understanding of characteristics related to higher app use is still needed before effectiveness studies are undertaken.

Difficult to treat asthma - The importance of thoracic imaging.

Asthma is a chronic disease with clinical variations throughout its course. Periods of symptom aggravation can occur with the need to escalate therapy. Nevertheless, further investigation should be considered when atypical manifestations appear or when worsening of symptoms occurs. Proximal tracheal/bronchial obstruction can mimic symptoms observed in patients with asthma. Primary benign tracheal tumors are rare, but can constitute the cause for such symptoms. We present a case report of a patient with asthma and a tracheal lesion.

[Rickets: Emerging From the Past]. / Raquitismo: Ressurgimento do Passado.

In the past decade rickets has re-emerged in developed countries due to changes in lifestyles and dietary habits. We describe a case of a 28-month-old black infant with failure to thrive. He was exclusively breastfed until nine months of age, without vitamin supplementation, and never ingested milk products due to alleged cowâÄôs milk intolerance. His examination revealed bowlegs, rachitic rosary and wide wrists. Alkaline phosphatase and intact parathyroid hormone levels were elevated, and calcidiol was decreased. Radiographic images showed bone demineralization, fraying and cupping of the distal radius and ulna. Nutritional rickets was considered and treatment with colecalciferol and calcium carbonate was initiated, with clinical, laboratory and radiologic improvement. In this case, a group of factors contributed to severe nutritional rickets, alerting to the re-emergence of this disease.

Na última década o raquitismo tem ressurgido nos países desenvolvidos, devido a alterações no estilo de vida e hábitos alimentares. Descrevemos o caso de uma criança de 28 meses, raça negra, antecedentes de aleitamento materno exclusivo até aos nove meses sem suplementação vitamínica e ausência de ingestão de produtos lácteos por suspeita de intolerância às proteínas de leite de vaca, internado por má progressão estaturo-ponderal. Apresentava varismo acentuado, rosário costal e punhos de boneca. Analiticamente destacava-se elevação da paratormona intacta e fosfatase alcalina, com diminuição do calcidiol. O estudo radiológico evidenciava desmineralização óssea generalizada, com alargamento das extremidades e metáfises do rádio e cúbito distais em forma de taça. Admitido o diagnóstico de raquitismo carencial, foi instituída terapêutica com colecalciferol e carbonato de cálcio, com progressiva melhoria clínica, laboratorial e radiológica. Neste caso destacam-se vários fatores que, conjugados, contribuíram para um raquitismo carencial grave, alertando para o ressurgir desta patologia.