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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.

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.

This work was funded by ERDF (European Regional Development Fund) through the operations: POCI- -01-0145-FEDER-029130 (“mINSPIRERS—mHealth to measure and improve adherence to medication in chronic obstructive respiratory diseases - generalisation and evaluation of gamification, peer support and advanced image processing technologies”) co-funded by the COMPETE2020 (Programa Operacional Competitividade e Internacionalização), Portugal 2020 and by Portuguese Funds through FCT (Fundação para a Ciência e a Tecnologia). © 2020, Sociedade Portuguesa de Alergologia e Imunologia Clinica. All rights reserved. Aims: To identify distinct asthma control clusters based on Control of Allergic Rhinitis and Asthma Test (CARAT) and to compare patients’ characteristics among these clusters. Methods: Adults and adolescents (≥13 years) with persistent asthma were recruited at 29 Portuguese hospital outpatient clinics, in the context of two observational studies of the INSPIRERS project. Demographic and clinical characteristics, adherence to inhaled medication, beliefs about inhaled medication, anxiety and depression, quality of life, and asthma control (CARAT, >24 good control) were collected. Hierarchical cluster analysis was performed using CARAT total score (CARAT-T). Results: 410 patients (68% adults), with a median (percentile 25–percentile 75) age of 28 (16-46) years, were analysed. Three clusters were identified [mean CARAT-T (min-max)]: cluster 1 [27(24-30)], cluster 2 [19(14-23)] and cluster 3 [10(2-13)]. Patients in cluster 1 (34%) were characterised by better asthma control, better quality of life, higher inhaler adherence and use of a single inhaler. Patients in clusters 2 (50%) and 3 (16%) had uncontrolled asthma, lower inhaler adherence, more symptoms of anxiety and depression and more than half had at least one exacerbation in the previous year. Further-more, patients in cluster 3 were predominantly female, had more unscheduled medical visits and more anxiety symp-toms, perceived a higher necessity of their prescribed inhalers but also higher levels of concern about taking these inhalers. There were no differences in age, body mass index, lung function, smoking status, hospital admissions or specialist physician follow-up time among the three clusters. Conclusion: An unsupervised method based on CARAT--T, identified 3 clusters of patients with distinct, clinically meaningful characteristics. The cluster with better asthma control had a cut-off similar to the established in the validation study of CARAT and an additional cut-off seems to distinguish more severe disease. Further research is necessary to validate the asthma control clusters identified. publishersversion published

Copyright © 2018 Ana Sá-Sousa et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited., The Portuguese Severe Asthma Registry (Registo de Asma Grave Portugal, RAG) was developed by an open collaborative network of asthma specialists. RAG collects data from adults and pediatric severe asthma patients that despite treatment optimization and adequate management of comorbidities require step 4/5 treatment according to GINA recommendations. In this paper, we describe the development and implementation of RAG, its features, and data sharing policies. The contents and structure of RAG were defined in a multistep consensus process. A pilot version was pretested and iteratively improved. The selection of data elements for RAG considered other severe asthma registries, aiming at characterizing the patient's clinical status whilst avoiding overloading the standard workflow of the clinical appointment. Features of RAG include automatic assessment of eligibility, easy data input, and exportable data in natural language that can be pasted directly in patients' electronic health record and security features to enable data sharing (among researchers and with other international databases) without compromising patients' confidentiality. RAG is a national web-based disease registry of severe asthma patients, available at asmagrave.pt. It allows prospective clinical data collection, promotes standardized care and collaborative clinical research, and may contribute to inform evidence-based healthcare policies for severe asthma., RAG was financed by an unrestricted grant from Novartis Farma-Produtos Farmacêuticos, S.A., which had no participation in any part of the development and implementation of the registry and has no access to the stored data for any purpose. The first author is financed by a PhD Grant (PD/BD/113665/2015) and financed by the European Social Fund and national funds of MCTES (Ministério da Ciência, Tecnologia e Ensino Superior) through FCT (Fundação para a Ciência e Tecnologia, I.P) PhD Programme Ref. PD/0003/2013-Doctoral Programme in Clinical and Health Services Research (PDICSS). Te publication of this article was supported by ERDF (European Regional Development Fund) through the operation POCI-01-0145- FEDER-007746 funded by the Programa Operacional Competitividade e Internacionalização – COMPETE2020 and by National Funds through FCT - Fundação para a Ciência e a Tecnologia within CINTESIS, R&D Unit (reference UID/IC/4255/2013).

Objective: We aimed to compare patient's and physician's ratings of inhaled medication adherence and to identify predictors of patient-physician discordance. Design: Baseline data from two prospective multicentre observational studies. Setting: 29 allergy, pulmonology and paediatric secondary care outpatient clinics in Portugal. Participants: 395 patients (≥13 years old) with persistent asthma. Measures: Data on demographics, patient-physician relationship, upper airway control, asthma control, asthma treatment, forced expiratory volume in one second (FEV1) and healthcare use were collected. Patients and physicians independently assessed adherence to inhaled controller medication during the previous week using a 100 mm Visual Analogue Scale (VAS). Discordance was defined as classification in distinct VAS categories (low 0-50; medium 51-80; high 81-100) or as an absolute difference in VAS scores ≥10 mm. Correlation between patients' and physicians' VAS scores/categories was explored. A multinomial logistic regression identified the predictors of physician overestimation and underestimation. Results: High inhaler adherence was reported both by patients (median (percentile 25 to percentile 75) 85 (65-95) mm; 53% VAS>80) and by physicians (84 (68-95) mm; 53% VAS>80). Correlation between patient and physician VAS scores was moderate (rs=0.580; p

Introduction: Inadequate control of asthma continues to present as serious problem despite advances in our understanding of the inflammatory basis of asthma. Objective and methods: The aim of this retrospective study was to assess the asthma control using asthma control test (ACT) and to explore the factors that affects the poorly control of this disease among outpatient clinic in out center. Chi-square and Spearman tests were applied, with a 5% significance level. Results: We enrolled 195 adult patients (pts), 77% were women (n=150), with a mean age of 55y (18-86y) and mean duration of asthma of 12±7y. All pts were prescribed ICS/LABA at least. Uncontrolled asthma (ACT 25 kg/m2 (n=59 vs 20, p=0.036), gastroesophageal reflux symptoms (n= 21 vs 13, p=0.01), airflow limitation measured by FEV1 120% of predicted (n=33 vs 32, p=0.046). The extent of asthma control did not have significative correlation with age, smoking, duration of asthma, presence of comorbidities (allergic rhinitis, sinusitis, OSA, depression), peripheral eosinophils count or total IgE measurement. Conclusion: In this population, we identified a high number of UA (41.5%). Despite the advent of novel treatments for severe and UA, our findings enhance the importance to improve the education to the disease, promote healthy lifestyle habits and strategies to guarantee therapeutic adherence, which may have a positive impact on asthma control.

Fungal infections have increased in the last few decades as a result of the use of broad-spectrum antibiotics and the growing number of immunocompromised patients (pts), which have led to changes in the saprophytic microorganisms usually isolated. Fungal empyema (FE) is still a rare entity, with a mortality rate of 70%. Retrospective analysis of fungal pleural effusions diagnosed in our hospital between 2015 and 2018. Aseptic sampling of pleural fluid was performed by thoracentesis, chest drainage (CT) or video-assisted thoracoscopic surgery (VATS). Seventeen fungal isolates were obtained from 15 pts (12 males, mean age 60±19 y). It presented with nonspecific symptoms (respiratory failure, dyspnea and fever). Three-months mortality rate of 53% and high length of stay (50±16 days). Twelve yeasts (3 non-Candida albicans), 3 Aspergillus species, 1 Saccharomyces cerevisiae and 1 Trichosporon asahii were isolated. Twelve pts (80%) had ≥1 immunodeficiency disease: surgery in the 4 weeks before (n=6), cancer (n=4), alcoholism (n=2) and hepatic transplant (n=1). CT placement and antifungal therapy were used in 10 pts (66%), the most being azole derivatives. Seven pts (46%) underwent VATS with wash. The mean overall survival was 375 days. Pts submitted to CT placement had a longer survival (mean 520 days, p=0.04), but no significant differences were found in those treated with antifungals (p=0.08) or VATS (p=0.06). In this series of cases, CT placement was the isolated procedure with the greatest impact on survival. The optimal treatment of FE is not yet defined, but combination of drugs can be used due to variable penetration of antifungals into the pleural cavity. The severity of FE and its consequences should not be underestimated.

The paper version of CARAT (pCARAT) is valid to assess asthma control over a 4-week period. For follow-up purposes, assessment through mobile apps (aCARAT) or telephone (tCARAT) may be useful alternatives. We explored the psychometric properties of the aCARAT and tCARAT. Patients with asthma were recruited at secondary care outpatient clinics. During medical visits, patients filled in the pCARAT and were invited to complete the aCARAT in the following days using the app of project Inspirers (InspirerMundi). After 1 week, tCARAT was collected. Patients completing the 3 CARAT versions within 28 days were analysed. CARAT scores (0-worst, 30-best) were calculated. The internal consistency (Cronbach’s α), convergent validity (Spearman correlation-rs) and reliability (intraclass correlation coefficient-ICC, Bland-Altman analysis) were determined. 55 patients (21 male; median 19 [interquartile range 17-37]y) were included. The aCARAT was completed by 82% of patients within 1 week of pCARAT; and by 78% within 1 week of tCARAT. The median pCARAT score was 21[17-24], the aCARAT 21[18-26], and the tCARAT 23[21-26]. Internal consistency was good for all versions (α=.73-.77). pCARAT was more strongly correlated with aCARAT than with tCARAT. Reliability was better for aCARAT than for tCARAT (table 1). App and telephonic CARAT versions are valid and reliable, exhibiting comparable psychometric properties to the paper version. These new CARAT versions are promising alternatives for assessing control in patients with asthma.

A 31-year-old black man, previously resident in Angola, was referred to our hospital complaining of 6 months of progressively worsening shortness of breath with exertion and mucous productive cough. During this period, he had a significant weight loss (about 10 kg) and fatigue. His past medical history included suspected pulmonary tuberculosis (TB), for which he had completed 6 months of anti-bacillary treatment in the year before. He is a construction worker and a nonsmoker, with no other environmental exposure or medication. The physical examination was remarkable for slight tachycardia (heart rate 105 beats·min−1), tachypnoea (respiratory rate 20 cycles·min−1), oxygen saturation of 94% and bilateral inspiratory crackles on both lungs. Figure 1 shows the chest radiograph., Can you diagnose this man with progressively worsening shortness of breath, mucous productive cough, weight loss, fatigue and a history of suspected pulmonary tuberculosis? http://bit.ly/2VUdnTr

A 57-year-old Portuguese woman was referred to our hospital for a second opinion due to multiple respiratory infections in the previous year with a recent onset of progressive dyspnoea and wheezing. She indicated there had been no weight loss during this period. She was a former smoker of 15 pack-years who quit 20 years ago. The patient had a medical history of atrial fibrillation and breast cancer that was treated with radiotherapy. These both occurred in the same year, 5 years prior. Moreover, the patient specified that she had “asthma-like” symptoms during childhood. The patient was working as a lawyer and was medicated with bisoprolol 5 mg and montelukast 10 mg, both medications once a day. On examination, wheezes were auscultated in all lung fields, especially in the right upper lobe. Her oxygen saturation was 96% on room air and the chest radiograph revealed no abnormalities (figure 1)., What is the diagnosis of this woman with multiple respiratory infections in the previous year and a recent onset of progressive dyspnoea and wheezing? https://bit.ly/3bLgw2A

Pleural involvement is the most frequent thoracic complication of rheumatoid arthritis (RA), usually occurring in patients with known RA. Typical rheumatoid pleural effusion is an exudate characterized by low pH and glucose levels and high LDH activity. Rarely, it has features of pseudochylothorax. Other uncommon complications are pneumothorax, hydropneumothorax, empyema, and bronchopleural fistula. The case of a 51-year-oldman with a spontaneous, small, and asymptomatic hydropneumothorax with features of pseudochylothorax is presented. After careful clinical and laboratory evaluation, he was diagnosed with rheumatoid arthritis, and we admitted that the pleural changes were secondary to the connective tissue disease. He started immunosuppressive treatment and maintained stability duringfollow-up,without need of specific pleural treatment. We hypothesized that the pleural nodule found on the chest computed tomography scan was related with the simultaneous occurrence of pleural effusion and pneumothorax. This is a rare presentation and complication of RA, highlighting the utility of a comprehensive clinical and laboratory evaluation and focusing on the importance of pleural rheumatoid nodules in the pathogenesis of RA pleural disease.

Introduction: The 6-minute-walk test (6MWT) is a reproducible and commonly used test that evaluates exercise capacity in patients with severe pulmonary disease. The test results are considered predictors of survival in different pulmonary diseases. Objective: To evaluate the preoperative 6MWT results as predictors of postoperative survival in lung transplant recipients. Methods: A retrospective study of 97 consecutive, adult lung transplant recipients transplanted at our centre from 2009 to 2016. Kaplan-Meier methods and log rank test were used to determine the association between preoperative 6MWT results and post-transplant survival. Results: A total of 79 patients were included, with a mean age of 48 years (SD 13), 46 (58.2%) males, with the most common indication being interstitial lung disease (46.8%). Preoperatively, the median FEV1 was 1020 mL (33.8%), median 6-minute-walk distance (6MWD) was 296m (25th–75th percentiles =180-389 m) and oxygen desaturation was 12% (25th–75th percentiles =7-20%). The median survival was 66,46 months. Walking distance 20%) was also associated with lower survival but without statistical significance (mean 55 vs 70 months, p=0.94). Conclusions: In our group 6MWD, but not oxygen desaturation, was significantly associated with post-transplant survival. This finding may have important implications for the assessment and stratification of individual risk/benefit ratio before proceeding to lung transplantation.

Introduction: Lung transplant (LT) is therapeutic option for patients (pts) with end-stage lung disease. However it is still associated with many complications, namely airway complications (AC). Recently, a grading system for central AC after lung transplantation was published, known as the MDS classification – corresponding to macroscopic aspect (M), diameter (D) and appearance of the sutures (S) of the anastomosis. Objectives: Compare the anastomosis diameter according to MDS classification assessed with bronchofibroscopy (BF) and multiplanar reconstructed thoracic computed tomography (CT) in a series of pts submitted to LT in our center between Jan/2012 and Dec/2014. Methods: Retrospective analysis of BF reports and correspondent CT images (max 30 days difference). The anastomosis diameter was classified according to MDS classification as D0: normal to fixed reduction up to 33%; D1: malacia greater than 50%; D2: stenosis from 33% to 66% and D3: stenosis greater than 66%. Results: One hundred and thirty exams (performed 15 days to 34 months after LT) were analyzed and the results were as in table 1. No significant correlation between BF and CT results was found. Moreover, when compared to BF (gold standard), the CT sensitivity in the assessment of significant stenosis (D1 – D3) was 17% and specificity 86%. Conclusions: BF remains an indispensable technique in the evaluation of airway complications in LT. However, due to his high specificity, CT can be useful in diagnosing significant stenosis.

Mediastinal germ cell tumours (M-GCT) are rare forms of neoplasms compared with other tumours of the same location. They are classified in seminomas, malignant non-seminomatous GCT and teratomas. The malignant transformation of the somatic component of the teratoma, with sarcomatous or carcinomatous degeneration, is even more uncommon. We report the clinical case of a 32 year old man who presented with severe chest pain on the right hemithorax. The image exams revealed the existence of a large heterogeneous lesion with a diameter of 7.7 cm, with areas of lipomatous density and a calcic image with the appearance of a tooth, in the right projection of the anterior mediastinum, in the vicinity of the large vessels, compatible with teratoma. The transthoracic biopsy (CT guided) showed morphologic aspects of sarcoma. The patient was operated on with the en bloc resection of the mediastinal mass, right lung, a segment of the pericardium and the thymus. The pathological studies showed a teratoma with malignant transformation of the mesenquimatous component, with muscular differentiation into leiomiosarcoma and rabdomiosarcoma. After surgery, the patient was treated with a scheme of doxorubicin and ifosfamide. The most prominent concepts related to this clinical entity, as well as its treatment, are debated in this article, based on the most recent publications dedicated to the subject.