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- A Portuguese expert panel position paper on the management of heart failure with preserved ejection fraction - part I: pathophysiology, diagnosis and treatmentPublication . Silva-Cardoso, José; Moreira, Emília; Melo, Rachel Tavares de; Moraes-Sarmento, Pedro; Cardim, Nuno; Oliveira, Mário; Gavina, Cristina; Moura, Brenda; Araújo, Inês; Santos, Paulo; Peres, Marisa; Fonseca, Cândida; Ferreira, João Pedro; Marques, Irene; Andrade, Aurora; Baptista, Rui; Brito, Dulce; Cernadas, Rui; Santos, Jonathan dos; Leite-Moreira, Adelino; Gonçalves, Lino; Ferreira, Jorge; Aguiar, Carlos; Fonseca, Manuela; Fontes-Carvalho, Ricardo; Franco, Fátima; Lourenço, Carolina; Martins, Elisabete; Pereira, Hélder; Santos, Mário; Pimenta, JoanaHeart failure (HF) with preserved ejection fraction (HFpEF) affects more than 50% of HF patients worldwide, and more than 70% of HF patients aged over 65. This is a complex syndrome with a clinically heterogeneous presentation and a multifactorial pathophysiology, both of which make its diagnosis and treatment challenging. A Portuguese HF expert panel convened to address HFpEF pathophysiology and therapy, as well as appropriate management within the Portuguese context. This initiative resulted in two position papers that examine the most recently published literature in the field. The present Part I includes a review of the HFpEF literature covering pathophysiology, clinical presentation, diagnosis and treatment, including pharmacological and non-pharmacological strategies. Part II, the second paper, addresses the development of a holistic and integrated HFPEF clinical care system within the Portuguese context that is capable of reducing morbidity and mortality and improving patients’ functional capacity and quality of life.
- Perturbação de hiperatividade/défice de atenção no adulto: um posicionamento de peritos portugueses sobre diagnóstico e tratamentoPublication . Madeira, Nuno; França, Gustavo; Jesus, Gustavo; Fernandes, João M.; Almeida, Susana S.; Filipe, Carlos N.A perturbação de hiperatividade e défice de atenção (PHDA) é uma perturbação do neurodesenvolvimento que frequentemente persiste na vida adulta, afetando aproximadamente 1,5% - 3% da população adulta em Portugal. A PHDA não tratada em adultos está ligada a um risco aumentado de abuso de substâncias, criminalidade, baixo desempenho académico e profissional. Menos de 20% dos adultos com PHDA são diagnosticados e tratados adequadamente, devido a sintomas sobrepostos com outras perturbações mentais, à existência de comorbilidades, ou ao desconhecimento e preconceitos sobre esta perturbação. Este documento de posicionamento resulta da realização de reuniões de peritos envolvendo seis psiquiatras portugueses experientes na gestão da PHDA em adultos. Visa orientar estratégias de diagnóstico e tratamento, bem como abordar as principais barreiras e limitações no acompanhamento destes doentes no contexto português, ao nível do diagnóstico e tratamento. Este documento pretende ainda esclarecer e desmistificar preconceitos, aumentar a consciencialização médica e promover a discussão para a elaboração de diretrizes para melhorar o diagnóstico, tratamento e qualidade de vida dos adultos com PHDA em Portugal.
- Correction to: worsening heart failure: progress, pitfalls, and perspectives (Heart Failure Reviews, (2025), 10.1007/s10741-025-10497-z)Publication . Fonseca, Cândida; Baptista, Rui; Franco, Fátima; Moura, Brenda; Pimenta, Joana; Sarmento, Pedro Moraes; Cardoso, José Silva; Brito, DulceThe order of the authors' first and last names was reversed in the original publication. The correct author names are as follows: Incorrect Author List: Fonseca Cândida · Baptista Rui · Franco Fátima · Moura Brenda · Pimenta Joana · Pedro Moraes Sarmento · Silva Cardoso José · Brito Dulce Correct Author List: Cândida Fonseca · Rui Baptista · Fátima Franco · Brenda Moura · Joana Pimenta · Pedro Moraes Sarmento · José Silva Cardoso · Dulce Brito The original article has been corrected.
- Worsening heart failure: progress, pitfalls, and perspectivesPublication . Cândida, Fonseca; Rui, Baptista; Fátima, Franco; Brenda, Moura; Joana, Pimenta; Sarmento, Pedro Moraes; José, Silva Cardoso; Dulce, BritoFor most patients with chronic heart failure (HF), the clinical course of the disease includes periods of apparent clinical stability punctuated by episodes of clinical deterioration with worsening signs and symptoms, a condition referred to as worsening heart failure (WHF). Over time, episodes of WHF may become more frequent, and patients may enter a cycle of recurrent events associated with deterioration in their quality of life and functional capacity, hospitalizations, and ultimately death. WHF is apparently an old concept but seems to have acquired new boundaries in terms of definition and clinical and prognostic value due to the fast-paced evolution of the HF treatment landscape and the emergence of new drugs in this setting. As a result, the management of WHF is being reshaped. In the present paper, a group of HF experts gathered to discuss the concept, prevention, detection, and treatment of WHF.
- Arrhythmic risk stratification in patients with left ventricular ring-like scarPublication . Parisi, Vanda; Graziosi, Maddalena; Lopes, Luis R.; Luca, Antonio De; Pasquale, Ferdinando; Tini, Giacomo; Targetti, Mattia; Cueto, Maria R.; Moura, Ana R.; Ditaranto, Raffaello; Torlasco, Camilla; Taglieri, Nevio; Nardi, Elena; Lovato, Luigi; Augusto, João B.; Galiè, Nazzareno; Crotti, Lia; Gasperetti, Alessio; Biffi, Mauro; Autore, Camillo; Merlo, Marco; Olivotto, Iacopo; Sinagra, Gianfranco; Elliott, Perry M.; Biagini, ElenaAims Left ventricular (LV) ring-like scar on cardiac magnetic resonance (CMR) has been linked to malignant arrhythmias in patients with non-ischaemic cardiomyopathy. This study aimed to perform a comprehensive evaluation of this phenotype and to identify risk factors for life-threatening arrhythmic events (LAEs), a composite of sudden cardiac death (SCD), aborted SCD, and sustained ventricular tachycardia. Methods and results One hundred and fifteen patients [median age 39 (interquartile range, IQR, 28–52), 42% females] were identified at 6 referral centres. Inclusion criteria were ring-like LV scar [≥3 contiguous segments with sub-epicardial/midwall late gadolinium enhancement (LGE) in the same slice] and one among: pathogenic/likely pathogenic genetic variant, family history for cardiomyopathy, or arrhythmogenic cardiomyopathy diagnosis. During the study follow-up, survival free from LAEs was 60% (3.8 events/100 patients/year); at a median follow-up of 4.6 years (IQR 1.7–8.4) it was 84%. On multivariable analysis, anterior Q waves [hazard ratio (HR): 1.030, 95% confidence intervals (CI): 1.014–1.046, P < 0.001], QRS width (HR: 4.642, 95% CI: 1.296–16.628, P = 0.018), and LV end-diastolic volume index (LVEDVi; HR: 1.011, 95% CI: 1.001–1.021, per mL/m2 increase, P = 0.040) were independently associated with LAEs; with good discrimination power (Harrell’s C-index = 0.796). Three risk categories were identified: normal electrocardiogram (ECG), abnormal ECG and no LAEs predictive variables, abnormal ECG and ≥1 LAEs predictive variables, with a decreasing survival from 100 to 65% and 49%, respectively (Log-rank test = 0.015). Conclusion In this study, the LV ring-like scar phenotype was associated with a high rate of malignant arrhythmias in presence of anterior Q waves, QRS prolongation, and increased LVEDVi. A normal ECG identified a lower risk sub-group.
- World Heart Federation cholesterol roadmap: the Portuguese casePublication . Abreu, Ana; Dores, Hélder; Gonçalves, Lino; Franco, Fátima; Silveira, Conceição; Proença, Gonçalo; Timóteo, Ana Teresa; Cardim, Nuno; Pedro, Mónica; Fiuza, Manuela; Ferreira, Daniel; Bento, Luísa; Patrício, Lino; Caldeira, Daniel; Baptista, Sérgio Bravo; Santos, José; Rocha, Evangelista; Raimundo, Anabela; Catarino, Carlos; Carrageta, Manuel; Mexia, Ricardo; Araújo, Francisco; Pereira, Hélder; Santos, Raul; Pinto, Fausto J.Atherosclerotic cardiovascular disease (ASCVD) remains the major cause of premature death and disability; effective cardiovascular (CV) risk prevention is fundamental. The World Heart Federation (WHF) Cholesterol Roadmap provides a framework for national policy development and aims to achieve ASCVD prevention. At the invitation of the WHF, a group of experts from the Portuguese Society of Cardiology (SPC), addressed the cholesterol burden at nationally and discussed possible strategies to include in a Portuguese cholesterol roadmap. The literature review showed that the cholesterol burden in Portugal is high and especially uncontrolled in those with the highest CV risk. An infographic scorecard was built to include in the WHF collection, for a clear idea about CV risk and cholesterol burden in Portugal, which would also be useful for health policy advocacy. The expert discussion and preventive strategies proposal followed the five pillars of the WHF document: awareness improvement; population-based approaches for CV risk and cholesterol; risk assessment/population screening; system-level approaches; surveillance of cholesterol and ASCVD outcomes. These strategies were debated by all the expert participants, with the goal of creating a national cholesterol roadmap to be used for advocacy and as a guide for CV prevention. Several key recommendations were outlined: include all stakeholders in a multidisciplinary national program; create a structured activities plan to increase awareness in the population; improve the quality of continuous CV health education; increase the interaction between different health professionals and non-health professionals; increment the referral of patients to cardiac rehabilitation; screen cholesterol levels in the general population, especially high-risk groups; promote patient self-care, engage with patients’ associations; use specific social networks to spread information widely; create a national database of cholesterol levels with systematic registry of CV events; redefine strategies based on the evaluation of results; create and involve more patients’ associations – invert the pyramid order. In conclusion, ASCVD and the cholesterol burden remain a strong global issue in Portugal, requiring the involvement of multiple stakeholders in prevention. The Portuguese cholesterol roadmap can provide some solutions to help urgently mitigate the problem. Population-based approaches to improve awareness and CV risk assessment and surveillance of cholesterol and ASCVD outcomes are key factors in this change. A call to action is clearly needed to fight hypercholesterolemia and ASCVD burden.
- Therapeutical usefulness of PD-1/PD-L1 inhibitors in aggressive or metastatic pituitary tumoursPublication . Lopes-Pinto, Mariana; Lacerda-Nobre, Ema; Silva, Ana Luísa; Marques, PedroTherapeutic options for pituitary neuroendocrine tumours (PitNETs) refractory to temozolomide are scarce. Immune checkpoint inhibitors (ICIs), particularly inhibitors of the programmed cell death-1 (PD-1) pathway and its ligand (PD-L1), have been experimentally used in aggressive or metastatic PitNETs. We aimed to study the therapeutic usefulness of anti-PD-1 drugs in patients with aggressive or metastatic PitNETs. Published cases and case series involving patients with PitNETs treated with PD-1/PD-L1 inhibitors were reviewed. Demographic data, clinical–pathological features, previous therapies, drug dosage and posology, and the best radiological and biochemical responses, as well as survival data, were evaluated. We identified 29 cases of aggressive (n = 13) or metastatic (n = 16) PitNETs treated with PD-1/PD-L1 inhibitors. The hypersecretion of adrenocorticotropic hormone (ACTH) was documented in eighteen cases (62.1%), seven were prolactinomas (24.1%), and four were non-functioning PitNETs. All patients underwent various therapies prior to using ICIs. Overall, a positive radiological response (i.e., partial/complete radiological response and stable disease) was observed in eighteen of twenty-nine cases (62.1%), of which ten and four were ACTH- and prolactin-secreting PitNETs, respectively. Hormonal levels reduced or stabilised after using ICIs in 11 of the 17 functioning PitNET cases with available data (64.7%). The median survival of patients treated with ICIs was 13 months, with a maximum of 42 months in two ACTH-secreting tumours. Among 29 patients with PitNETs treated with PD-1/PD-L1 inhibitors, the positive radiological and biochemical response rates were 62.1% and 64.7%, respectively. Altogether, these data suggest a promising role of ICIs in patients with aggressive or metastatic PitNETs refractory to other treatment modalities.
- Implementation of a remote symptom monitoring pathway in oncology care: analysis of real-world experience across 33 cancer centres in France and BelgiumPublication . Franzoi, Maria Alice; Ferreira, Arlindo R.; Lemaire, Antoine; Rodriguez, Joseph; Grosjean, Jessica; Ribeiro, Joana M.; Polastro, Laura; Grellety, Thomas; Artignan, Xavier; Du, Katell Le; Pagliuca, Martina; Nouhaud, Élodie; Autheman, Maximilien; André, Fabrice; Basch, Ethan; Metzger, Otto; Ferté, Charles; Palma, Mario Di; Scotté, Florian; Vaz-Luis, InesBackground: Remote patient monitoring (RPM) of symptoms using electronic patient reported outcomes (ePROs) has been shown to reduce symptom burden and hospitalizations, increase dose intensity and improve quality of life of patients during systemic therapy being recommended by international guidelines in routine oncology practice. However, implementation in routine care has been slow and faces several challenges. In this study we report on the real-world multi-center implementation of a RPM pathway encompassing weekly patient symptom ePRO reporting with electronic alert notifications triggered to providers for severe or worsening symptoms. Methods: An RPM pathway was implemented in 33 European cancer centers in France and Belgium between November 2021 and August 2023. The implementation process followed a standardized phasic process of Exploration, Preparation, Implementation and Sustainment. Patient-level and system-level implementation metrics were collected and evaluated according to the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. Findings: Across the 33 cancer centers, the RPM pathway was implemented for 3015 patients cared for by 168 providers. The RPM pathway enabled effective and timely symptom management with 94.6% of all alerts (10,132/10,711) evolving to an improvement two weeks later, among which 88.4% (9468/10,711) showed ≥2 grades of improvement on the 5-point scale of the Patient-Reported Outcomes Common Terminology (PRO-CTCAE). The median time to alert management by the care team was 13 h 41 min (25th percentile: 1 h 42 min, 75th percentile: 1 day + 19 h 54 min), with 80% (36,269/45,334) of alerts managed by a nurse navigator telephone call. Patient adherence with weekly ePRO reporting was 82% (2472/3015). In an experience survey, 87% (32/38) of providers were satisfied with integrating the solution into their organization and 90% (276/307) of the patients felt that ePRO reporting positively impacted their care. As of March 2024, the pathway has been maintained in all participating centers, with activation of an additional 18 centers following data lock, and reimbursement for this RPM pathway approved in France in October 2023. Interpretation: These findings demonstrate the feasibility of implementing and maintaining an RPM pathway during routine care across a diverse group of cancer centers in the European setting, with high levels of patient and provider engagement, and positive clinical impact. Funding: Part of this work was funded Breast Cancer Research Foundation (Career Development Award to Maria Alice Franzoi) and Resilience (nurse navigation and technology support).
- Magnitude and temporal variations of socioeconomic inequalities in the quality of life after early breast cancer: results from the multicentric French CANTO CohortPublication . Sandoval, José Luis; Franzoi, Maria Alice; Di Meglio, Antonio; Ferreira, Arlindo R.; Viansone, Alessandro; André, Fabrice; Martin, Anne Laure; Everhard, Sibille; Jouannaud, Christelle; Fournier, Marion; Rouanet, Philippe; Vanlemmens, Laurence; Dhaini-Merimeche, Asma; Sauterey, Baptiste; Cottu, Paul; Levy, Christelle; Stringhini, Silvia; Guessous, Idris; Vaz-Luis, Ines; Menvielle, GwennPURPOSE: Socioeconomic status (SES) influences the survival outcomes of patients with early breast cancer (EBC). However, limited research investigates social inequalities in their quality of life (QoL). This study examines the socioeconomic inequalities in QoL after an EBC diagnosis and their time trends. PATIENTS AND METHODS: We used data from the French prospective multicentric CANTO cohort (ClinicalTrials.gov identifier: NCT01993498), including women with EBC enrolled between 2012 and 2018. QoL was assessed using the European Organisation for Research and Treatment of Cancer QoL Core 30 questionnaire (QLQ-C30). summary score at diagnosis and 1 and 2 years postdiagnosis. We considered three indicators of SES separately: self-reported financial difficulties, household income, and educational level. We first analyzed the trajectories of the QLQ-C30 summary score by SES group. Then, social inequalities in QLQ-C30 summary score and their time trends were quantified using the regression-based slope index of inequality (SII), representing the absolute change in the outcome along socioeconomic gradient extremes. The analyses were adjusted for age at diagnosis, Charlson Comorbidity Index, disease stage, and type of local and systemic treatment. RESULTS: Among the 5,915 included patients with data on QoL at diagnosis and at the 2-year follow-up, social inequalities in QLQ-C30 summary score at baseline were statistically significant for all SES indicators (SIIfinancial difficulties = -7.6 [-8.9; -6.2], SIIincome = -4.0 [-5.2; -2.8]), SIIeducation = -1.9 [-3.1; -0.7]). These inequalities significantly increased (interaction P <.05) in year 1 and year 2 postdiagnosis, irrespective of prediagnosis health, tumor characteristics, and treatment. Similar results were observed in subgroups defined by menopausal status and type of adjuvant systemic treatment. CONCLUSION: The magnitude of preexisting inequalities in QoL increased over time after EBC diagnosis, emphasizing the importance of considering social determinants of health during comprehensive cancer care planning.
- Do cognitive subtypes exist in people at clinical high risk for psychosis? Results from the EU-GEI studyPublication . EU-GEI High Risk Study; Gifford, George; Avila, Alessia; Kempton, Matthew J.; Fusar-Poli, Paolo; Mccutcheon, Robert A.; Coutts, Fiona; Tognin, Stefania; Valmaggia, Lucia; Haan, Lieuwe de; Gaag, Mark van der; Nelson, Barnaby; Pantelis, Christos; Riecher-Rössler, Anita; Bressan, Rodrigo; Barrantes-Vidal, Neus; Krebs, Marie-Odile; Glenthoj, Birte; Ruhrmann, Stephan; Sachs, Gabriele; Rutten, Bart P. F.; Os, Jim van; McGuire, PhilipBackground and Hypothesis: Cognition has been associated with socio-occupational functioning in individuals at Clinical High Risk for Psychosis (CHR-P). The present study hypothesized that clustering CHR-P participants based on cognitive data could reveal clinically meaningful subtypes. Study Design: A cohort of 291 CHR-P subjects was recruited through the multicentre EU-GEI high-risk study. We explored whether an underlying cluster structure was present in the cognition data. Clustering of cognition data was performed using k-means clustering and density-based spatial clustering of applications with noise. Cognitive subtypes were validated by comparing differences in functioning, psychosis symptoms, transition outcome, and grey matter volume between clusters. Network analysis was used to further examine relationships between cognition scores and clinical symptoms. Study Results: No underlying cluster structure was found in the cognitive data. K-means clustering produced “spared” and “impaired” cognition clusters similar to those reported in previous studies. However, these clusters were not associated with differences in functioning, symptomatology, outcome, or grey matter volume. Network analysis identifed cognition and symptoms/functioning measures that formed separate subnetworks of associations. Conclusions: Stratifying patients according to cognitive performance has the potential to inform clinical care. However, we did not fnd evidence of cognitive clusters in this CHR-P sample. We suggest that care needs to be taken in inferring the existence of distinct cognitive subtypes from unsupervised learning studies. Future research in CHR-P samples could explore the existence of cognitive subtypes across a wider range of cognitive domains.