Identifying subgroups in heart failure patients with multimorbidity by clustering and network analysis.

This study presents a workflow for identifying and characterizing patients with Heart Failure (HF) and multimorbidity utilizing data from Electronic Health Records. Multimorbidity, the co-occurrence of two or more chronic conditions, poses a significant challenge on healthcare systems. Nonetheless, understanding of patients with multimorbidity, including the most common disease interactions, risk factors, and treatment responses, remains limited, particularly for complex and heterogeneous conditions like HF. We conducted a clustering analysis of 3745 HF patients using demographics, comorbidities, laboratory values, and drug prescriptions. Our analysis revealed four distinct clusters with significant differences in multimorbidity profiles showing differential prognostic implications regarding unplanned hospital admissions. These findings underscore the considerable disease heterogeneity within HF patients and emphasize the potential for improved characterization of patient subgroups for clinical risk stratification through the use of EHR data.

Occurrence and molecular characterization of Enterocytozoon bieneusi in wild and domestic animal species in Portugal.

The phylum Microsporidia encompasses a diverse group of obligate, intracellular, and spore-forming organisms able to infect a wide range of animal hosts. Among them, Enterocytozoon bieneusi is the most frequently reported species in humans and animals. Little is known about the presence and epidemiology of E. bieneusi in wildlife. We investigated E. bieneusi occurrence and genetic diversity in wild and domestic mammals, through molecular-detection methods, from different regions across Portugal. A total of 756 samples were collected from 288, 242, and 226 wild carnivores, wild ungulates, and domestic animals, respectively. Overall, eight specimens were E. bieneusi-positive (1.1%, 8/756) obtained from five wild (Iberian lynx, Iberian wolf, red fox, stone marten, and wild boar) and one domestic (sheep) host. Nucleotide sequence analysis identified four genotypes of E. bieneusi, Type IV, Wildboar3, BEB6, and PtEbIX. Three of those genotypes belong to Groups 1 (Type IV and Wildboar3) and 2 (BEB6), which are known to contain genotypes capable of infecting a variety of hosts, including humans, highlighting their public health importance. PtEbIX belongs to the dog-specific Group 11. This study represents the first, largest, and most comprehensive molecular-based epidemiology survey carried out in Portugal in wild and domestic animals to date and the first worldwide identification of E. bieneusi in wolf species. Our study showed that wild carnivores and ungulates may act as reservoirs of zoonotic genotypes of E. bieneusi, establishing their role in maintaining the sylvatic cycle of this parasite while representing a potential source of infection for humans and domestic animals.

The identification of human-pathogenic genotypes of fungi-related Enterocytozoon bieneusi in wild carnivores and ungulates in Portugal suggests cross-species infection events and overlapping of the sylvatic and domestic transmission cycles, demonstrating a potential transmission risk to humans.

Levosimendan In Single Ventricle Heart Failure After Longterm Survival Of A Modified Blalock-Taussig Shunt.

We report the case of a 44 year-old patient with complex ACHD, admitted with acute decompensated heart failure (ADHF) in hemodynamic profile B. He had a single ventricle with pulmonary atresia, previously submitted to three modified Blalock-Taussig shunts (mBTs) at the age of 2, 12 and 19 years old. Despite conventional treatment with diuretics, ß-blockers (BB) and isosorbide dinitrate the patient progressed to profile C and the transthoracic echocardiogram disclosed a reduced systolic function. Likewise, levosimendan was commenced and an appropriate decongestion and a marked reduction in the NT-proBNP were seen. Treatment with angiotensin-converting-enzyme inhibitor, BB, ivabradine and mineralocorticoid receptor was optimized. The patient was discharged home after 26 days in NYHA class III and referred for heart transplant after right heart catheterization. To our knowledge, this is the first report of successful levosimendan's use in ADHF in a mBTs long-term survivor.

Sugars levels of four sugarcane genotypes in different stem portions during the maturation phase.

Maturation is a characteristic of sugarcane plant (Saccharum spp.) and even when grown under the same soil and climate conditions the varieties differ on the maturation curve. Thus, studies that allow establishing maturation curves of different sugarcane genotypes in the local soil and climate may indicate the proper harvesting period to ensure better quality of the raw material. This study aimed to analyze the levels of soluble sugars during the maturation phase and assess the technological and productivity indexes of four irrigated sugarcane genotypes in the region of Rio Largo, Alagoas. The experiment was conducted in randomized blocks in a 4 x 2 x 5 factorial: four genotypes (RB92579, RB98710, RB99395 and RB961003), two stem portions (internodes 1-4 and internodes 5-8) and five seasons (82, 49, 25, 13 and 3 days before harvesting), each treatment with three replications. Internodes 1-4 showed the highest levels of reducing sugars, while the largest accumulation of sucrose and total soluble solids occurred in internodes 5-8. RB99395 genotype showed more stability in the sugar levels during sugarcane maturation, which can indicate early maturation and high agricultural yield.

Impact of bacterial cellulose on the physical properties and printing quality of fine papers.

Bacterial nanocellulose (BNC), due to its inherent nanometric scale and strength properties, can be considered as a good candidate to be used in papermaking. This work explored the possibility of using it in the production of fine paper as a wet-end component and for the paper coating. Filler-containing handsheet production was performed with and without the presence of common additives typically used in the furnish of office papers. It was found that, under optimized conditions, BNC mechanically treated by high-pressure homogenization could improve all the evaluated paper properties (mechanical, optical and structural) without impairing the filler retention. However, paper strength was improved only to a small extent (increase in the tensile index of 8 % for a filler content of ca. 27.5 %). On the other hand, when used at the paper surface, remarkable improvements in the gamut area of >25 % in comparison to the base paper and of >40 % in comparison to starch-only coated papers were achieved for a formulation having 50 % BNC and 50 % of carboxymethylcellulose. Overall, the present results highlight the possibility of using BNC as a paper component, particularly when applied at the paper substrate as a coating agent aiming at improving printing quality.

conTemporary reflectiOns regarding heart failure manaGEmenT - How to ovERcome the PorTuguese barriers (TOGETHER-PT).

INTRODUCTION AND OBJECTIVES: Heart failure (HF) is a complex clinical syndrome that is a significant burden in hospitalisations, morbidity, and mortality. Although a significant effort has been made to better understand its consequences and current barriers in its management, there are still several gaps to address. The present work aimed to identify the views of a multidisciplinary group of health care professionals on HF awareness and literacy, diagnosis, treatment and organization of care, identifying current challenges and providing insights into the future. METHODS: A steering committee was established, including members of the Heart Failure Study Group of the Portuguese Society of Cardiology (GEIC-SPC), the Heart Failure Study Group of the Portuguese Society of Internal Medicine (NEIC-SPMI) and the Cardiovascular Study Group (GEsDCard) of the Portuguese Association of General and Family Medicine (APMGF). This steering committee produced a 16-statement questionnaire regarding different HF domains that was answered to by a diversified group of 152 cardiologists, internists, general practitioners, and nurses with an interest or dedicated to HF using a five-level Likert scale. Full agreement was defined as ≥80% of level 5 (fully agree) responses. RESULTS: Globally, consensus was achieved in all but one of the 16 statements. Full agreement was registered in seven statements, namely 3 of 4 statements for patient education and HF awareness and 2 in 4 statements of both HF diagnosis and healthcare organization, with proportions of fully agree responses ranging from 82.9% to 96.7%. None of the HF treatment statements registered full agreement but 3 of 4 achieved ≥80% of level 4 (agree) responses. CONCLUSION: This document aims to be a call-to-action to improve HF patients' quality of life and prognosis, by promoting a change in HF care in Portugal.

Portuguese Heart Failure Prevalence Observational Study (PORTHOS) rationale and design - A population-based study.

INTRODUCTION AND OBJECTIVES: Current epidemiological data on heart failure (HF) in Portugal derives from studies conducted two decades ago. The main aim of this study is to determine HF prevalence in the Portuguese population. Using current standards, this manuscript aims to describe the methodology and research protocol applied. METHODS: The Portuguese Heart Failure Prevalence Observational Study (PORTHOS) is a large, three-stage, population-based, nationwide, cross-sectional study. Community-dwelling citizens aged 50 years and older will be randomly selected via stratified multistage sampling. Eligible participants will be invited to attend a screening visit at a mobile clinic for HF symptom assessment, anthropomorphic assessment, N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing, one-lead electrocardiogram (ECG) and a sociodemographic and health-related quality of life questionnaire (EQ-5D). All subjects with NT-proBNP ≥125 pg/mL or with a prior history of HF will undergo a diagnostic confirmatory assessment at the mobile clinic composed of a 12-lead ECG, comprehensive echocardiography, HF questionnaire (KCCQ) and blood sampling. To validate the screening procedure, a control group will undergo the same diagnostic assessment. Echocardiography results will be centrally validated, and HF diagnosis will be established according to the European Society of Cardiology HF guidelines. A random subsample of patients with an equivocal HF with preserved ejection fraction diagnosis based on the application of the Heart Failure Association preserved ejection fraction diagnostic algorithm will be invited to undergo an exercise echocardiography. CONCLUSIONS: Through the application of current standards, appropriate methodologies, and a strong research protocol, the PORTHOS study will determine the prevalence of HF in mainland Portugal and enable a comprehensive characterization of HF patients, leading to a better understanding of their clinical profile and health-related quality of life.

Impact of COVID-19 lockdown measures on waste production behavior in Lisbon.

The recent restrictions on mobility and economic activities imposed by governments due to the COVID-19 pandemic have significantly affected waste production and recycling patterns in cities worldwide. This effect differed both between cities and within cities as the measures of confinement adopted by governments had diverse impacts in different areas of cities, depending on their characteristics (e.g., touristic, or residential). In the present work, mixed waste collection areas were created, based on waste collection points, that define spatial units in which contextual data such as tourism and residential characteristics were aggregated. The difference in mixed waste collected compared with previous years was analyzed along with the impacts on recycling due to the modification in operations regarding waste collection during the lockdown. The results showed that despite the suspension of the door-to-door recycling system during the lockdown, this did not translate into an increase in the production of mixed waste, and the recycling levels of previous years have not been reached after the lockdown, indicating a possible change in recycling habits in Lisbon. The touristic and non-residential mixed waste circuits presented significantly reduced mixed waste production compared to the non-pandemic context. Also, tourist, mobility, and economic activity were measured to understand which factors contributed to waste production changes during the COVID-19 pandemic. While little evidence of a relationship with these exogenous variables was found at the citywide level, evidence was found at the waste collection circuit level.

Serological and Molecular Survey of Leishmania infantum in a Population of Iberian Lynxes (Lynx pardinus).

Leishmania infantum, the sand fly-transmitted protozoan parasite responsible for leishmaniasis in humans, dogs, and cats, is endemic in the Iberian Peninsula. However, the impact of L. infantum infection on the conservation of the endangered Iberian lynx (Lynx pardinus) is unknown. Herein, we describe for the first time the occurrence of L. infantum infection among a population of reintroduced and wild-born L. pardinus living in the Portuguese Guadiana Valley Park. The presence of infection was addressed by molecular detection of Leishmania kinetoplast DNA (kDNA) in 35 lynxes, with further confirmation of L. infantum species performed by an internally transcribed spacer (ITS)-1 sequencing. Eight blood samples were positive for kDNA, and ITS-1 sequencing confirmed the presence of L. infantum in two of those samples. Exposure to Leishmania was screened in a group of 36 lynxes using an immunofluorescence antibody test (IFAT) and a multi-antigen enzyme-linked immunosorbent assay (ELISA), using SPLA, rK39, and CPX as Leishmania-specific antigens. Four animals presented a positive IFAT at a dilution of 1:40. Eight samples were considered seropositive to all ELISA Leishmania-specific antigens. Agreement between PCR, IFAT, and all ELISA antigens was found for 1 in 27 samples. These results highlight the susceptibility of autochthonous L. pardinus to L. infantum infection. Further investigation is required to assess the impact of L. infantum infection on this wild species conservation.

DNA-based detection of Mycobacterium avium subsp. paratuberculosis in domestic and municipal water from Porto (Portugal), an area of high IBD prevalence.

Mycobacterium avium subsp. paratuberculosis (MAP) may play a role in the pathology of human inflammatory bowel disease (IBD). Previously, we found a high frequency (98% in patients with active disease) of MAP DNA detection in the blood of Portuguese Crohn's Disease patients, suggesting this cohort has high exposure to MAP organisms. Water is an important route for MAP dissemination, in this study we therefore aimed to assess MAP contamination within water sources in Porto area (the residential area of our IBD study cohort). Water and biofilms were collected in a wide variety of locations within the Porto area, including taps connected to domestic water sources and from municipal water distribution systems. Baseline samples were collected in early autumn plus further domestic water samples in early winter, to assess the effect of winter rainfall. DNA was extracted from all 131 samples and IS900-based nested PCR used to assess the frequency of MAP presence. Our results show high MAP positivity in municipal water sources (20.7% of water samples and 41.4% of biofilm samples) and even higher amongst domestic sources (30.8% of water samples and 50% of biofilm samples). MAP positivity in biofilms correlated with positivity in water samples from the same sources. A significantly higher frequency of MAP-positivity was observed during winter rains as compared with samples collected in autumn prior to the winter rainfall period (61.9% versus 30.8%). We conclude that domestic and municipal water sources of Porto region have a high burden of MAP contamination and this prevalence increases with rainfall. We hypothesize that human exposure to MAP from local water supplies is commonplace and represents a major route for MAP transmission and challenge which, if positively linked to disease pathology, may contribute to the observed high prevalence of IBD in Porto district.

Floating marine litter and their risks to cetaceans off Portugal.

Floating Dangerous Debris For Cetaceans (DDFC) and cetacean abundances were assessed by shipboard visual surveys off continental Portugal. Plastic litter (other than fishing gear) was the most abundant category, corresponding to 56.53% of the total recorded DDFC. Areas of DDFC and cetacean potential overlap suggest that cetaceans are generally exposed to DDFC at different risk levels within the study area. The highest concentration areas of DDFC and cetaceans did not overlap, whereas lower DDFC concentration areas (70% kernel probability contour) overlapped with 45% of the distribution area obtained for cetaceans. Future marine litter management measures (prevention or mitigation) should be focused on the predicted high DDFC-cetacean interaction risk area in the central region of the study. DDFC are representative of the overall floating litter distribution and future floating litter assessments could be based on DDFC categories alone.

Enzymatic nanocellulose in papermaking - The key role as filler flocculant and strengthening agent.

Nanocelluloses have been increasingly used in composites since their reduced size, high aspect ratio and stiffness confer great strength to the materials. In papermaking, it has been proved that harsh and expensive chemical pre-treatments to generate nanofibrils, such as TEMPO-mediated oxidation, are not the most favourable and therefore the use of cellulose microfibrils (CMF) have gained extra attention, especially those produced with the aid of enzymatic hydrolysis. In the present work, strategies to improve filler flocculation and the papermaking properties, by using enzymatic CMF, are provided. The CMF degree of polymerization was found to be directly related to precipitated calcium carbonate flocculation, leading to higher retentions in the fibre matrix. Besides, the paper dry and wet strengths were much improved, allowing in return the production of high-filler loaded handsheets with reduced requirements for common paper additives.

Validity of a discharge diagnosis of heart failure: implications of misdiagnosing.

Heart failure (HF) costs are largely due to hospitalization. The validity of a death/discharge diagnosis of HF (DDHF) is largely unknown. The authors assessed the validity of DDHF and the impact of misdiagnosing. The case notes of patients consecutively admitted to a medical department between January and June 2001 were reviewed. Cases with DDHF or cardiovascular diseases, potential precursors of HF (PPHF), were included. The diagnosis of HF (European Society of Cardiology guidelines) was classified as definite, possible, or miscoded. Of the 1038 patients admitted, 234 were enrolled: 157 with DDHF and 77 with PPHF. One hundred eighty patients had a definite diagnosis of HF. Of the 157 diagnoses coded as definite HF, 130 were correct, 21 had possible HF, and 6 were miscoded. Of the 77 patients classified as having PPHF, 38 had definite HF. The accuracy of the DDHF diagnosis was 72.2%: 21.1% were underdiagnosed and 8.3% overdiagnosed. DDHF failed to capture many HF admissions and therefore alone underestimates the prevalence, burden, and costs of the syndrome.

Translating guidelines into clinical practice: benefits of an acute heart failure unit .

UNLABELLED: Heart failure (HF) is a very prevalent condition, with high mortality, morbidity and costs, despite the development of effective drug therapy. Many patients still do not have access to appropriate treatment. Heart failure clinics have shown success in improving delivery of appropriate HF management, helping to reduce morbidity and mortality and costs. AIMS: To compare the quality of diagnosis and drug therapy at discharge in an unselected population of patients admitted to a medical ward of an urban central teaching hospital before and after the creation of a heart failure unit (HFU) and to evaluate its impact on long-term mortality and morbidity from all causes and from HF. METHODS: We compared a population of 153 patients, aged 75 +/- 12.8 years, 50.3% male, with a diagnosis of HF according to the guidelines of the European Society of Cardiology, NYHA classes II-IV (74% III or IV), admitted consecutively to a medical ward (MW) before the creation of an HFU (Group 1), with a population of 82 patients, aged 73 +/- 12.4 years, 62.2% male, admitted consecutively to the HFU for acute decompensated HF (Group 2). The prescription of diuretics, spironolactone, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, angiotensin receptor antagonists (ARAs) and warfarin in the two groups at discharge was analyzed. The endpoints of the study were: in-hospital mortality (IM), mortality and hospitalization due to all causes (P1), mortality and hospitalization due to HF (P2), all-cause mortality (P3), and mortality due to HF (P4). The follow-up duration was 18 months. RESULTS: The two populations were not statistically different in gender, age or type of HF. HF diagnosis was correct in 67.7% of cases in Group 1, vs. 86% in Group 2. The increase in the prescription of beta-blockers in Group 2 compared with Group 1 was highly significant (4.9% vs. 36.0%, p = 0.000 in all-cause HF patients and 28.9% vs. 56.8%, p = 0.000, in HF due to systolic dysfunction), as was that of warfarin (16.7% vs. 32.6%, p = 0.003 in all-cause HF and 17.6% vs. 44.4%, p = 0.001, in HF due to systolic dysfunction). IM in the MW vs. HFU was 7.7% vs. 8.5% (p = 0.42). The probabilities for the different end-points in MW/HFU at 6, 12 and 18 months were: P1: 55/35% (p = 0.013), 68/46% (p = 0.0005) and 73/51% (p = 0.0004); P2: 26/19% (p = 0.1), 34/20% (p = 0.008) and 39/23% (p = 0.004); P3: 25.5/21% (p = 0.22), 31/30% (p = 0.44) and 38/35% (p = 0.32); P4: 16/19% (p = 0.28), 23/20% (p = 0.3) and 27/33% (p = 0.25). CONCLUSIONS: These results are in agreement with reported morbidity and mortality from the syndrome after hospitalization. There is a tendency for better outcome in all the studied endpoints among the population treated in the HFU, despite greater severity of the disease, compared to those treated in the MW. A statistically significant improvement was found in the composite endpoints of mortality and hospitalization from all causes and due to HF, at 12 and 18 months. The results of the study indicate that the HFU had a better performance in reducing morbidity than mortality compared to the MW. As hospitalization accounts for 60% of HF costs, HFUs are expected to be cost effective.

Post-percutaneous coronary angioplasty atheroembolization--a feared iatrogenic complication.

Atheroembolic disease is a rarely recognized clinical entity. The growing use of antiplatelet and thrombolytic therapy and of invasive cardiovascular procedures in acute coronary syndromes has nevertheless transformed this feared iatrogenic complication into an increasingly frequent diagnosis. The authors review this entity through the case of a 71-year-old man who, fifteen days after undergoing thrombolysis for acute myocardial infarction with ST-segment elevation, followed by elective percutaneous coronary revascularization under triple antiplatelet therapy, came to the emergency department with a clinical setting of mental confusion, gastrointestinal bleeding, oliguria and cutaneous eruptions on the lower limbs; laboratory tests revealed severe azotemia and hyperkalemia. With a diagnostic hypothesis of systemic atheroembolization, a cutaneous lesion biopsy was performed, which confirmed the diagnosis. Supportive treatment led to neurological and cutaneous recovery, but the patient developed chronic renal failure. The pathophysiology, forms of presentation, treatment and prognosis of atheroembolic disease are discussed, highlighting the importance of a high degree of clinical suspicion for diagnosis.

Acutely decompensated heart failure: characteristics of hospitalized patients and opportunities to improve their care.

UNLABELLED: Heart failure (HF) remains a major public health problem in western countries, despite the enormous progress in its diagnosis and treatment. Acute and chronic decompensated HF are leading medical causes of hospitalization among people aged over 65 years in European countries, the USA, Australia and New Zealand. However, there have been few studies on acute and chronic decompensated HF and the European Society of Cardiology (ESC) guidelines on this subject have only just been published. AIM: To evaluate the overall prevalence of hospitalization due to HF according to its subtypes, comorbidities, and decompensating factors, in the Medical Department of a central teaching hospital in an urban area. METHODS: We performed a retrospective observational study of patients admitted consecutively to the Medical Department via the emergency room between January and June 2001. Discharge casenotes on 1038 admissions were reviewed. Those with a diagnosis of HF or cardiovascular conditions associated with or precursors of HF were analyzed. Cases with a final diagnosis of HF according to the criteria of the ESC guidelines were included in the study. We evaluated the overall prevalence of HF and subtypes of cardiac dysfunction, etiological risk factors, patients' demographic characteristics, decompensating factors, comorbidity, mean length of hospital stay, and in-hospital mortality rate. RESULTS: We identified 180 patients with HF (17.4%), mean age 74.6 +/- 14; 87 were male (48%), aged 73.7 +/- 14.2, and 93 female (52%), aged 75.6 +/- 14. Left ventricular systolic dysfunction (LVSD) was present in 42.2% of cases, preserved left ventricular systolic function in 32.6%, and valvular heart disease in 10.6%. Hypertension and coronary artery disease were the main etiological risk factors (62.2% and 42.8% respectively). Atrial fibrillation was recorded in 43.4% of the patients, diabetes was diagnosed in 21.6%, and anemia and chronic obstructive pulmonary disease in about one third. Infection, predominantly respiratory, was the main factor triggering decompensation, followed by uncontrolled hypertension and supraventricular tachyarrhythmia. At admission, 42.2% of the patients were in NYHA class III and 44.8% in NYHA class IV. HF patients had a mean hospital stay of 13.8 days, slightly shorter than the mean overall stay of patients admitted to the Medical Department in the same period (14.5 days). In-hospital mortality for HF patients was 7.7%, with HF being the first cause of admission to the Medical Department, followed by stroke (10.6%). CONCLUSIONS: This study confirms the high prevalence of acute or chronic decompensated HF in patients hospitalized in the Medical Department of a central teaching hospital in an urban area. The patients were mainly elderly, of both genders, with a slightly higher proportion of HF due to LVSD. Most patients were in NYHA classes III and IV. Mean hospital stay was no longer than that of all patients admitted in the same period. The in-hospital mortality rate was low. The age-group affected and the high prevalence of multiple comorbidities emphasize the need to establish HF clinics with multidisciplinary teams to manage these patients, and health authorities must be made aware of the burden of this syndrome.