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- Telehealth for integrated cardiovascular and diabetes management: a scoping reviewPublication . Estêvão, Maria Dulce da Mota Antunes de Oliveira ; Teotónio Fernandes, Mónica Alexandra; De Sousa-Coelho, Ana Luísa; Neto Espírito-Santo, Margarida de Fátima; Nascimento, Tânia; Alfredo CaturanoCardiovascular disease (CVD) and diabetes mellitus represent major global health challenges, frequently co-occurring and mutually exacerbating. Telehealth interventions offer a promising approach for their management, with potential to improve patient outcomes, enhance access to care, and increase cost-effectiveness. This review synthesized existing evidence from randomized controlled trials (RCTs) and observational studies to evaluate the effectiveness of telehealth interventions for the management of diabetes, focusing on CVD risk, and to identify critical research gaps. A systematic literature search was conducted across major databases (PubMed, Web of Science, and Scopus) to identify studies meeting predefined eligibility criteria, considering digital tools for remote monitoring, consultation, education, and medication management. After the screening of 3041 articles, six studies met the inclusion criteria. Telehealth interventions utilized a range of digital health tools, including mobile applications, artificial intelligence–powered clinical decision aids, electronic consultations, and integrated remote monitoring platforms. Although direct assessment of composite cardiovascular risk was largely absent, the included studies reported several clinical parameters associated with cardiovascular health, namely, blood pressure, lipid profile, and glycated hemoglobin. Telehealth interventions implemented for individuals with Type 2 diabetes mellitus demonstrated promising potential in improving glycemic control and supporting self-management. However, their effectiveness in managing broader cardiovascular risk factors remains less clear due to inconsistent reporting and heterogeneous intervention designs.
- How artificial intelligence can enable personalized mesenchymal stem cell–based therapeutic strategies in systemic lupus erythematosusPublication . Kumar, Sushmitha Rajeev; He, Khor Kai; Lokanathan, Yogeswaran; Gaurav, Anand; Yusoff, Khatijah; Macedo, M. Fatima; Bhassu, SubhaMesenchymal Stromal Cells (MSCs) are increasingly recognized as promising candidates for treating Systemic Lupus Erythematosus (SLE) due to their immunomodulatory and regenerative properties. However, their therapeutic efficacy remains inconsistent, largely due to the heterogeneity of MSC origins, culture conditions, cell quality, host immune interactions, and the influence of immunosuppressive treatments. Artificial Intelligence (AI) offers powerful tools to address these challenges by optimising MSC modification and application. This review explores how AI can identify optimal genetic and epigenetic targets, predict MSC behaviour under different environmental and priming conditions, and design personalise therapies tailored to individual patients. Moreover, AI enables the analysis of extensive datasets to refine dosing strategies and improve the integration of MSC therapy with immunosuppressants. By enhancing the precision, consistency, and personalisation of MSC-based interventions, AI has the potential to significantly improve therapeutic outcomes in SLE, advancing the field toward more effective and patient-centred autoimmune disease management.
- Characterization of knowledge, attitudes, comfort, and perception of discrimination regarding sexual and/or gender minoritized people: comparison between two cohorts of medical students - 2018–2023Publication . Macedo, Ana; Ferreira, João; Gutierrez, Ana Rita; Gato, JorgeObjectives: Despite progress made in the medical field to address the health concerns ofsexual and gender minoritized identities, LGBTQIAþ individuals continue to experience dis-crimination in healthcare. This study aims to evaluate the effects of incorporating a seminaron gender identity and sexual orientation into the medical curriculum of a PortugueseMedical School, after 5 years. The study’s main objective was to compare the changes in stu-dents’ knowledge, attitudes, comfort, and perception of discrimination against LGBTQIAþ,pre and post-intervention.Methods: A total of 313 students in their third, fourth, fifth, and sixth year at a PortugueseMedical School were assessed in 2018 (pre-intervention) and 2023 (post-intervention). Thedata collected were analyzed regarding age, gender identity, sexual orientation, number offriends or family members who identify themselves as LGBTQIAþ, and level of religiosity.Results: The overall knowledge regarding LGBTQIAþ people specific health aspects improvedfrom the 2018 cohort to the 2023 cohort, with significant differences in questions regardinggender identity (OR ¼ 2.0, p ¼ .007), sexual orientation (OR ¼ 2.9, p <.001), and mentalhealth (OR ¼ 3.2, p <.001). The perceived discrimination against homosexual patients wassimilar in both cohorts, with approximately 60% of respondents from both groups agreeingthat homosexual patients were discriminated against in healthcare.Conclusion: Although the perception of discrimination against LGBTQIAþ people in health-care remained high across the two cohorts, positive changes were observed regarding stu-dents’ overall knowledge of LGBTQIAþ individuals’ health, clinical preparation and comfortin treating LGBTQIAþ people, and attitudes toward lesbian women and gay men. Theseresults reinforce the need to develop training and information strategies targeting medicalstudents, promoting greater knowledge and, above all, increasing contact and clinical prac-tice with LGBTQIAþ people, since relationships and personal contact are the most differenti-ating aspects for nondiscrimination.
- Editorial: Endocrine regulation and physiological adaptation of stress response in aquatic organisms, volume IIPublication . Li, Yi-Feng; Li, Yiming; Campinho, Marco António; Fuentes, JuanAt the individual level, organisms develop many complex morphological and physiological adaptations to maintain homeostasis, of which endocrine regulation is the key. By adjusting physiological mechanisms, organisms adapt their response to the external environment, enabling the acquisition of new homeostatic equilibrium that allows survival. The physiological adaptative mechanism plays an important role in maintaining homeostasis and adapting to changes in the external environment. Well-known environmental factors such as ambient temperature, pH, ammonia nitrogen, salinity, and exposure to new pollutants can disrupt homeostasis, resulting in growth and physiological and endocrine disorders. Thus, in a rapidly changing climate, it is important to explore the biological adaptive regulation mechanism and endocrine regulation strategy under stress, which has an important impact on the protection of aquatic ecology. The main purpose of the Research Topic is to explore and discuss these potential physiological and molecular mechanisms to provide new insights for developing new green ecological activities.
- Portuguese recommendations on transthyretin amyloid cardiomyopathy: a step toward disease awareness, prompt referral and early diagnosis and treatmentPublication . Marques, Nuno; Azevedo, OlgaTransthyretin amyloidosis (ATTR) is caused by the extracellular deposition of amyloid fibrils of wild-type (ATTRwt) or variant (ATTRv) transthyretin (TTR). While ATTRwt amyloidosis is essentially a cardiac disease, ATTRv amyloidosis may present with different phenotypes, ranging from predominantly cardiac to predominantly neurologic, or even mixed phenotypes, depending on the TTR gene variant.1---3 Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive cardiomyopathy that causes heart failure, dysrhythmias and conduction block, which eventually lead to death.1 Median survival following diagnosis in untreated patients with ATTR-CM is 3.6---4.8 years in the wild-type form, 2.6 years in ATTR-CM due to the Val142Ile variant and 5.8 years in ATTR-CM caused by other TTR variants.4,5 To improve the prognosis of ATTR-CM, it is important to implement strategic measures that (i) increase awareness of ATTR amyloidosis, (ii) ensure early referral of cases with suspicion of ATTR-CM, (iii) promote early screening, diagnosis and treatment of ATTR-CM, and (iv) assure appropriate symptomatic management of the disease. However, some questions remain concerning who should be screened for ATTR-CM, and international recommendations differ regarding the red flags that should prompt screening for ATTR-CM.6
- Portuguese recommendations for the management of transthyretin amyloid cardiomyopathy (Part 1 of 2): screening, diagnosis and treatment. Developed by the task force on the management of transthyretin amyloid cardiomyopathy of the working group on myocardial and pericardial diseases of the portuguese society of cardiologyPublication . Marques, Nuno; Rosa, Sílvia Aguiar; Cordeiro, Filipa; Fernandes, Raquel Menezes; Ferreira, Catarina; Bento, Dina; Brito, Dulce; Cardim, Nuno; Lopes, Luís; Azevedo, OlgaThe Portuguese recommendations for the management of transthyretin amyloid cardiomyopathy (ATTR-CM) evaluate and summarize the available evidence and provide evidence-based recommendations on the best management of patients with ATTR-CM. These recommendations represent the official position of the Working Group on Myocardial and Pericardial Diseases (WGMPD) of the Portuguese Society of Cardiology. The Portuguese WGMPD selected the members of this Task Force as expert professionals involved in the care of patients with this disease. The Task Force performed a critical evaluation of the available evidence on the diagnostic procedures and therapeutic options for ATTR-CM, including an assessment of risk-benefit ratios. The strength of every recommendation and its level of evidence were weighed and scored according to predefined scales, usually those used by the European Society of Cardiology (ESC) in their guidelines, as outlined below in Tables 1 and 2. This Task Force followed voting procedures, and all approved recommendations were subject to a vote and achieved at least 75% agreement among voting members. The experts of the writing panels provided declaration of interest forms for all relationships that might be perceived as actual or potential sources of conflicts of interest. These recommendations were developed without any financial support or involvement of the healthcare industry. The Portuguese WGMPD supervised and coordinated the preparation of these recommendations and was responsible for the approval process. After appropriate revisions, the recommendations were signed off by all the experts involved in the Task Force. The WGMPD submitted the final document for publication in the official journal of the Portuguese Society of Cardiology, Revista Portuguesa de Cardiologia (Portuguese Journal of Cardiology). The recommendations were developed after careful consideration of the scientific knowledge and evidence available at the time of writing. Tables of recommendations are provided in this document along with the corresponding class of recommendation and level of evidence for each statement. Specific areas on which there are uncertainties concerning the existing evidence for the recommendation were also identified. The Task Force members carried out systematic reviews of the literature on these topics, which will be provided in separate publications. These recommendations do not override the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each individual patient’s health condition.
- High vs low protein intake in chronic critical illness: a systematic review and meta-analysisPublication . Castro, Sílvia; Tome, Ana Maria; Granja, C.; Macedo, A.; Binnie, AlexandraBackground & aims: Patients with persistent organ dysfunction after the first week of intensive care unit (ICU) admission are considered to have chronic critical illness (CCI). Acquired muscle weakness is a common feature of CCI that is accompanied by loss of muscle mass and electromyographic features of myopathy. Optimizing protein intake may help prevent acquired muscle weakness and/or promote muscle recovery, however, the optimal level of protein intake in CCI is uncertain and there is a lack of consensus in published nutritional guidelines. This systematic review focuses on the impact of high versus low protein intake as part of a nutritional strategy for patients with CCI. Methods: The terms “protein intake” and “critically ill” were systematically searched in PUBMED, CENTRAL (Cochrane Central Register of Controlled Trials), and WEB OF SCIENCE on 06/01/2023. We included studies that (1) enrolled critically ill adults (aged 18 years or over) who were in the ICU for more than 7 days and that compared (2) protein intake above and below 1.3 gr/kg administered by any route (enteral and/or parenteral), (3) had an intervention period that occurred primarily after the first 7 days of critical illness and (4) reported clinical outcomes including length of ICU and hospital stay, duration of invasive mechanical ventilation (IMV), mortality, ICU acquired infections, muscle mass and physical function. Studies pertaining to elective surgery, those with intervention periods shorter than 7 days or occurring primarily within the first 7 days of critical illness, those measuring only laboratory parameters as outcomes, and safety and feasibility studies were excluded. Results: Four studies were included (N ¼ 1730) in the meta-analysis and systematic review. Higher (>1.3 g/kg/d) versus lower protein intake was associated with a decrease in early mortality (defined as ICU or 28-day mortality) hazard ratio (HR) 0.42 (95 % confidence interval (CI): 0.26e0.70, P < 0.001), but had no impact on late mortality (defined as the latest mortality timepoint in each study): HR 0.93 (95 % CI 0.76e1.15, P ¼ 0.51). There was no significant difference between intervention and control groups with respect to duration of IMV, duration of ICU or hospital stay, muscle mass, or the incidence of ICUacquired infections. One study reported improvements in physical function at 3 and 6 months in the intervention group. Conclusion: After the first week of critical illness, increasing protein intake to >1.3 g/kg/d may improve early mortality but not late mortality or other clinical outcomes. The small number of relevant studies and the heterogeneity of outcomes assessed, weaken these conclusions. Further studies are warranted to discern whether higher protein intake is beneficial in chronic critical illness. PROSPERO registration number: CRD42023403554; PROSPERO registration name: “The effect of higher than 1,3 g/kg of protein versus lower intake in chronic critically ill patients”
- Predictive factors driving positive awake test in carotid endarterectomy using machine learningPublication . Pereira-Macedo, Juliana; Duarte-Gamas, Luís; Pereira Pias, Ana Daniela; Myrcha, Piotr; Andrade, José P.; António, Nuno; Marreiros, Ana; Rocha-Neves, JoãoBackground: Positive neurologic awake testing during the carotid cross-clamping may be present in around 8% of patients undergoing carotid endarterectomy (CEA). The present work aimed to assess the accuracy of an artificial intelligence (AI)-powered risk calculator in predicting intraoperative neurologic deficits (INDs). Methods: Data was collected from carotid interventions performed between January 2012 and January 2023 under regional anesthesia. Patients with IND were selected along with consecutive controls without IND in a case-control study design. A predictive model for IND was developed using machine learning, specifically Extreme Gradient Boosting (XGBoost) model, and its performance was assessed and compared to an existing predictive model. Shapley Additive exPlanations (SHAP) analysis was employed for the model interpretation. Results: Among 216 patients, 108 experienced IND during CEA. The AI-based predictive model achieved a robust area under the curve of 0.82, with an accuracy of 0.75, precision of 0.88, sensitivity of 0.59, and F1Score of 0.71. High body mass index (BMI) increased contralateral carotid stenosis, and a history of limb paresis or plegia were significant IND risk factors. Elevated preoperative platelet and hemoglobin levels were associated with reduced IND risk. Conclusions: This AI model provides precise IND prediction in CEA, enabling tailored interventions for high-risk patients and ultimately improving surgical outcomes. BMI, contralateral stenosis, and selected blood parameters emerged as pivotal predictors, bringing significant advancements to decision-making in CEA procedures. Further validation in larger cohorts is essential for broader clinical implementation.
- Association of epigenetic age and outcome in critically Ill patientsPublication . Sharma-Oates, Archana; Sullivan, Jack; Pestana, Daniel; Santos, Claudia C. dos; Binnie, Alexandra; Lord, Janet M.OBJECTIVES: DNA methylation can be used to determine an individual’s biological age, as opposed to chronological age, an indicator of underlying health status. This study aimed to assess epigenetic age in critically ill patients with and without sepsis to determine if higher epigenetic age is associated with admission diagnosis or mortality. DESIGN: Secondary analysis of whole blood DNA methylation data generated from a nested case–control study of critically ill septic and nonseptic patients. SETTING: Four tertiary care hospitals in Canada. INTERVENTIONS: None. PATIENTS: Critically ill patients with and without sepsis. MEASUREMENTS AND MAIN RESULTS: Epigenetic age was derived from DNA methylation data using the Hannum and PhenoAge algorithms and deviation from the patient’s chronological age in years was determined. Of the 66 patients with sepsis, 34 were male (51.5%), the mean age was 65.03 years and 25 patients (37.8%) died before discharge. Of the 68 nonseptic patients, 47 were male (69.1%), the mean age was 64.92 years and 25 (36.7%) died before discharge. Epigenetic age calculated using the PhenoAge algorithm showed a significant age acceleration of 4.97 years in septic patients (p = 0.045), but no significant acceleration in nonseptic patients. Epigenetic age calculated using the Hannum algorithm showed no significant acceleration in the septic or nonseptic patients. Similarly, in the combined septic and nonseptic cohorts, nonsurvivors showed an epigenetic age acceleration of 7.62 years (p = 0.004) using the PhenoAge algorithm while survivors showed no significant age acceleration. Survivor status was not associated with age acceleration using the Hannum algorithm.
- The burden of COVID-19 care in community and academic intensive care units in Ontario, Canada: a retrospective cohort studyPublication . Pestana, Daniel; Joshi, Divya; Duan, Erick; Fowler, Robert; Tsang, Jennifer; Binnie, AlexandraDuring the COVID-19 pandemic, neighbourhoods with high material deprivation and high proportions of racialized Canadians were disproportionately affected by COVID-19. Many of these neighbourhoods were served by community hospitals. We sought to compare the burden of COVID-19 care in community and academic intensive care units (ICUs) in Ontario, Canada. We included all adult patients admitted to Ontario ICUs with COVID-19 between 1 March 2020 and 31 July 2021 in a retrospective cohort study. We compared patient volumes, demographics, interventions, and outcomes between community hospital corporations (CHCs) and academic hospital corporations (AHCs). During the first three waves of the pandemic, 9,651 adult ICU admissions for COVID-19 were reported across 72 hospital corporations in Ontario: 6,902 (71.5%) in CHCs and 2,749 (28.5%) in AHCs. Days of ICU care per baseline ICU bed were highest in large CHCs ([ 10 baseline ICU beds) relative to AHCs and small CHCs (median [interquartile range], 73.7 [53.8–110.6] vs 42.2 [32.7–71.8] vs 21.4 [7.2–40.3]; Kruskal–Wallis test, P \ 0.001). Among direct ICU admissions, CHC patients had greater severity of illness whereas among transfer ICU admissions, AHC patients were more severely ill. In a multivariable logistic regression model, mortality was similar among patients with index admission to a CHC or AHC; however, patients with index admission to an AHC were more likely to receive extracorporeal membrane oxygenation (adjusted odds ratio, 6.16; 95% confidence interval, 4.72 to 8.11). During the pandemic, Ontario’s large CHCs provided significantly more days of ICU COVID-19 care per baseline ICU bed compared with AHCs and small CHCs. Equipping large CHCs to handle ICU surges during future emerging disease outbreaks should be a priority for pandemic preparedness.