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Abstract Intravenous (i.v.) prostacyclin is the cornerstone treatment in high‐risk pulmonary arterial hypertension (PAH) patients. Selexipag is an orally available prostacyclin receptor agonist. Limited data are available regarding the feasibility of transitioning from i.v. epoprostenol to selexipag. A 50‐year‐old woman with idiopathic PAH was diagnosed in a World Health Organization (WHO) Functional Class (FC) IV. She improved with upfront triple combination therapy, including i.v. epoprostenol. Over 2 years of follow‐up, the patient remained at low risk and expressed strong preference towards oral therapies. After careful risk–benefit clinical consideration, she was transitioned from i.v. epoprostenol to selexipag. Selexipag was started at dosage of 200 μg twice daily (b.i.d.) and titrated up to 1600 μg b.i.d. over 8 weeks (up‐titration of 200 μg b.i.d. every week). Simultaneously, i.v. epoprostenol was down‐titrated 3.0 ng/kg/min every week from a dosage of 27.5 ng/kg/min. The transition occurred under strict medical surveillance and was well tolerated. One year after discontinuation of epoprostenol, the patient remains in WHO FC I and has no signs of clinical deterioration. Although not generalizable to most PAH patients, this case highlights that a carefully planned transition from epoprostenol to selexipag is feasible in selected low‐risk patients within a shared medical decision‐making framework.

Evaluations of the sustainability of the viticulture associated with wine production are still scarce in the literature. Usually, the ‘carbon footprint’ assumes the environmental dimension, while the economic pillar is focused on market orientation. In the present work, the integration of both was tested using a case study supported in a six-year series (2015–2021) of primary data from a farm in the Região Demarcada do Douro (Douro Demarcated Region, hereafter the RDD). Economic and environmental inputs and outputs were collected from ‘pruning to harvest’. Profitability was calculated based on the market prices and environmental impacts using the AgriBalyse database, which is available in OpenLCA 1.10.3. In the scope of the economic results, the following costs stand out: (1) ‘human labor’; (2) use of machinery; and (3) plant protection products. Concerning the environmental impacts, the greatest weight resulted from the use of fuels, and no relation was found between the grape production variation and environmental factor variation. The indicators studied were considered valuable for comparing production systems (conventional, organic, and biodynamic, among others) and might support stakeholders’ decision making. We highlight the importance of replication in further studies to better understand the complex world of viticulture’s sustainability.

The impact of exercise on the levels of endothelial progenitor cells (EPCs), a marker of endothelial repair and angiogenesis, and circulating endothelial cells (CECs), an indicator of endothelial damage, in heart failure patients is largely unknown. This study aims to evaluate the effects of a single exercise bout on the circulating levels of EPCs and CECs in heart failure patients. Thirteen patients with heart failure underwent a symptom-limited maximal cardiopulmonary exercise test to assess exercise capacity. Before and after exercise testing, blood samples were collected to quantify EPCs and CECs by flow cytometry. The circulating levels of both cells were also compared to the resting levels of 13 volunteers (age-matched group). The maximal exercise bout increased the levels of EPCs by 0.5% [95% Confidence Interval, 0.07 to 0.93%], from 4.2 × 10−3 ± 1.5 × 10−3% to 4.7 × 10−3 ± 1.8 × 10−3% (p = 0.02). No changes were observed in the levels of CECs. At baseline, HF patients presented reduced levels of EPCs compared to the age-matched group (p = 0.03), but the exercise bout enhanced circulating EPCs to a level comparable to the age-matched group (4.7 × 10−3 ± 1.8 × 10−3% vs. 5.4 × 10−3 ± 1.7 × 10−3%, respectively, p = 0.14). An acute bout of exercise improves the potential of endothelial repair and angiogenesis capacity by increasing the circulating levels of EPCs in patients with heart failure.

Abstract Background Cataracts are lens opacifications that are responsible for more than half of blindness cases worldwide, and the only treatment is surgical intervention. Phacoemulsification surgery, the most frequently performed cataract surgery in developed countries, has associated risks, some of which are related to excessive phacoemulsification energy levels and times. The protocol proposed in herein will be used to evaluate the feasibility of a new experimental medical device, the Eye Scan Ultrasound System (ESUS), for the automatic classification of cataract type and severity and quantitative estimation of the optimal phacoemulsification energy. Methods The pilot study protocol will be used to evaluate the feasibility and safety of the ESUS in clinical practice. The study will be conducted in subjects with age-related cataracts and on healthy subjects as controls. The procedures include data acquisition with the experimental ESUS, classification based on the Lens Opacity Classification System III (LOCS III, comparator) using a slit lamp, contrast sensitivity test, optical coherence tomography, specular microscopy and surgical parameters. ESUS works in A-scan pulse-echo mode, with a central frequency of 20 MHz. From the collected signals, acoustic parameters will be extracted and used for automatic cataract characterization and optimal phacoemulsification energy estimation. The study includes two phases. The data collected in the first phase (40 patients, 2 eyes per patient) will be used to train the ESUS algorithms, while the data collected in the second phase (10 patients, 2 eyes per patient) will be used to assess the classification performance. System safety will be monitored during the study. Discussion The present pilot study protocol will evaluate the feasibility and safety of the ESUS for use in clinical practice, and the results will support a larger clinical study for the efficacy assessment of the ESUS as a diagnostic tool. Ultimately, the ESUS is expected to represent a valuable tool for surgical planning by reducing complications associated with excessive levels of phacoemulsification energy and surgical times, which will have a positive impact on healthcare systems and society. The study is not yet recruiting. Trial registration ClinicalTrials.gov identifier NCT04461912 , registered on July 8, 2020.

In Europe, the Common Agricultural Policy (CAP) encouraged the specialisation of agriculture and forestry systems by supporting schemes that promoted productivity, despite the socio-ecological changes’ detrimental effects on ecosystem services and biodiversity. In the case of mountain viticulture of southern Europe, the adoption of intensive management techniques triggered noticeable changes in farming systems, namely the removal of traditional stonewalls and semi-natural vegetation, partially compensated by eco schemes and agri-environment-climate measures. By combining fieldwork information with spatio-temporal modelling techniques, a novel hybrid framework is explained and implemented to predict the population trends of a critically endangered bird species in Portugal, the Black Wheatear (Oenanthe leucura), to the individual and/or combined effects of the removal of traditional stonewall terraced vineyards and the implementation of cover crops. The results obtained demonstrate the relevance of stonewall terraced vineyards (and the negative effects of their removal) for the conservation of Black Wheatear, namely during the breeding season when holes and crevices are used for nesting. Conversely, and in accordance with our simulations, the increase in the area occupied by vineyards with cover crops seems particularly detrimental for the species, by decreasing the quality of the feeding grounds. As cover crops, and possibly other eco schemes and agri-environment-climate measures, might not be the panacea for halting biodiversity loss in mountain viticulture, adaptation of measures to species’ ecological requirements is urgent for a successful EU biodiversity strategy for 2030.

Air pollution is one of the main environmental risk factors for health and is linked to cardiovascular diseases, which are the leading cause of mortality worldwide.In this position paper, we discuss the main air pollutants and how they can promote the development of cardiovascular disease or cardiovascular events. We also summarise the main evidence supporting the association between air pollution and cardiovascular events, such as coronary events (acute coronary syndromes/myocardial infarction; chronic coronary syndromes), stroke, heart failure and mortality. Some recommendations are made based on these data and the European Society of Cardiology guidelines on cardiovascular disease prevention, acknowledging that it is important to increase awareness and literacy on this topic in Portugal. Resumo: A poluição do ar é um dos principais fatores de risco ambiental para a saúde e está associada à principal causa de morte em todo o mundo que são as doenças cardiovasculares. Neste position paper discutimos a forma como os principais poluentes atmosféricos podem promover o desenvolvimento de doenças ou eventos cardiovasculares. Também agregámos a melhor evidência que suporta a associação entre poluição do ar e eventos cardiovasculares, como eventos coronários (síndromes coronárias agudas/enfarte do miocárdio; síndromes coronárias crónicas), acidente vascular cerebral, insuficiência cardíaca e o risco de morte. Foram feitas recomendações de acordo com a evidência, os dados nacionais e as orientações da Sociedade Europeia de Cardiologia sobre prevenção de doenças cardiovasculares, reconhecendo que é importante aumentar a sensibilização e literacia sobre este tema em Portugal.

This work deals with the evaluation of adhesive single-lap joints using ultrasound guided waves; in particular, it is intended to characterize the signal propagation when defects are present in the adhesive joint by simulation and experimental approaches. The propagation of guided waves in the joint is developed from matrix formulations. The behavior of the guided wave modes that exist in the bonded region is characterized. It is found that its amplitudes can be estimated from the properties of the incoming wave that propagates in the non-bonded region. It is verified that the excitation of these modes is related to the degree to which the shapes of both modes match each other. A 3D simulation of two aluminum-bonded plates using 500 kHz ultrasonic transducers in a pitch-and-catch configuration was implemented using the Matlab k-Wave toolbox. Scattering effects, due to some defects located in the bond line of the joints, were simulated. The experimental setup with some artificial defects produced in the aluminum joints was used in order to compare it with the simulation. Qualitative agreement was observed between the two approaches. The observed deviation can be due to the different characteristics of the experimental and simulated defects.

Introduction: Menopause marks an extensive period of hormonal changes in women. Estrogen depletion, combined with the aging process, increases fat mass, particularly intra-abdominal fat, and generates a decrease in muscle and bone mass, affecting women's usual levels of physical activity (PA) and compromising their quality of life. Exposure to the natural environment confers numerous health benefits, however, much remains unknown about the differences in the nature visits according to a woman's reproductive stages, and often PA levels are measured through questionnaires. Purpose: This study analyzed the variation of adiposity levels, PA and nature visits according to the stages of reproductive aging in women. Methods In this cross-sectional study, women aged 18 to 75 were categorized in the reproductive age (G1, n=94), menopausal transition (G2, n=12) and postmenopause (G3, n=36), considering the reproductive aging stages described in STRAW +10. Fat mass (FM, %) and visceral fat area (VFA) were assessed by octopolar bioimpedance (InBody 720). Physical activity (moderate-vigorous and steps/day) was measured using ActiGraph accelerometers (wGT3X-BT) and nature visits were assessed through a questionnaire. Analyses of variance were used to analyze the data. Some transformations of the variables were conducted, to normalize their distribution (moderate-vigorous PA) or to improve their asymmetry (VFA and nature visits). The standard significance level was set a p ≤0.05. Results: A higher percentage of women with obesity (%FM and VFA) and non-recommended levels of moderate-vigorous PA were recorded in group 3 (77.8%, 83.3%, and 72.2% respectively). Half of the women in G2 had high levels of total and central adiposity and levels of MVPA 0.05) and nature visits (p =0.17). Conclusions: Our results suggest that postmenopausal women evidence increased levels of total and central adiposity and simultaneously, limited levels of physical activity compared to women in the reproductive phase. These findings underline the need to implement PA programs oriented to weight control and to encourage the regular practice of PA adjusted to the needs evidenced by these women, contributing to a better quality of life for them. Funding: This work is supported by National Funds by FCT-Portuguese Foundation for Science and Technology, under the projects UIDB/04033/2020, UID04045/2020 and UIDB/00073/2020. The investigation was also supported by European funding program Interreg Atlantic Area, under the project (EAPA_772/2018-Triple-C).

Abstract Limited data are available on physical activity (PhA) levels in chronic thromboembolic pulmonary hypertension (CTEPH) patients, as well as on the clinical utility of PhA measurements using questionnaires and accelerometers. We aimed to study PhA levels of CTEPH patients and their clinical correlates, and to compare PhA levels measured by the International Physical Activity Questionnaire (IPAQ) with measures from accelerometers. This is a cross‐sectional study (n = 50). PhA levels were measured using accelerometers and questionnaires (IPAQ). Clinical parameters evaluated were walked distance on the 6‐min‐walking test (6MWT), pulmonary vascular resistance, N‐terminal brain natriuretic peptide and quality of life (HRQoL) (Cambridge Pulmonary Hypertension Outcome Review questionnaire). Time spent in sedentary behavior was lower in self‐reported measurement (279 ± 165 min/day) compared with accelerometry (446 ± 117 min/day, p

Hiking is a natural exercise that has become one the most popular outdoor activities, promoting physical fitness and de-stress without large investments or special equipment. However, hiking has downsides, particularly in the areas in which it takes place. From soil compaction and erosion to disturbance and ecological impacts, mounting evidence shows that it is far from innocuous to ecosystems. Despite spanning several decades, research on the impacts of hiking on ecosystems and particularly on the pertinence of using ecological indicators is still scarce. This work reviews the published information conducted with invertebrates and, by doing so, offers insights to guide not only management actions but also further investigation in this scope. We address some of the current knowledge gaps and provide recommendations by focusing on ground beetles (Coleoptera: Carabidae) for their sensitivity to disturbance, representativeness but also due to their taxonomic and functional diversity. Due to the limited number of studies published so far, the classification of species based on their habitat preference, within the context of trail impacts, is non-consensual. Alternatively, such classification should derive from its respective study and avoid being generalized, or done with great caution. Additionally, sampling methods that distinguish mortality from behavioural changes were considered crucial to determine possible effects. Ultimately, the joint use of both vegetation and invertebrates, particularly ground beetles, was considered relevant to assess hiking trail ecological impacts.

Considering the present ecological crisis, land use-biodiversity relationships have become a major topic in landscape planning, ecosystem management and ecological restoration. In this scope, consistent patterns of outstanding biodiversity have been identified in agroforestry systems within diverse biogeographic regions and types of management. Empirical work has revealed that agroforestry higher structural complexity, when compared with current simplified agricultural systems, might be partially responsible for the observed patterns. The recently developed Habitat Amount Hypothesis predicts diversity for a local habitat patch, from the amount of the same habitat within the local landscape. We have expanded the previous hypothesis to the landscape level, computing the influence of the dominant land uses on the diversity of coexisting guilds. As a case study, we have considered archetypal landscapes dominated (or co-dominated) by crops or trees, which were compared using normalized diversities. The results obtained show that agroforestry systems substantially increase functional diversity and overall biodiversity within landscapes. We highlight that the normalized values should be parametrized to real conditions where the type of crop, tree and agroecological management will make a difference. Most importantly, our findings provide additional evidence that agroforestry has a critical role in enhancing biodiversity in agricultural landscapes and, in this way, should be regarded as a priority measure in European Agri-environmental funding schemes.

Despite cardiac rehabilitation (CR) being a recommended treatment for patients with heart failure with reduced ejection fraction (HFrEF), it is still underused. This study investigated the clinical determinants and barriers to enrollment in a CR program for HFrEF patients. We conducted a cohort study using the Cardiac Rehabilitation Barriers Scale (CRBS) to assess the reason for non-enrollment. Of 214 HFrEF patients, 65% had not been enrolled in CR. Patients not enrolled in CR programs were older (63 vs. 58 years; p < 0.01) and were more likely to have chronic obstructive pulmonary disease (COPD) (20% vs. 5%; p < 0.01). Patients enrolled in CR were more likely to be treated with sacubitril/valsartan (34% vs. 19%; p = 0.01), mineralocorticoid receptor antagonists (84% vs. 72%; p = 0.04), an implantable cardioverter defibrillator (ICD) (41% vs. 20%; p < 0.01), and cardiac resynchronization therapy (21% vs. 10%; p = 0.03). Multivariate analysis revealed that age (adjusted OR 1.04; 95% CI 1.01–1.07), higher education level (adjusted OR 3.31; 95% CI 1.63–6.70), stroke (adjusted OR 3.29; 95% CI 1.06–10.27), COPD (adjusted OR 4.82; 95% CI 1.53–15.16), and no ICD status (adjusted OR 2.68; 95% CI 1.36–5.26) were independently associated with CR non-enrollment. The main reasons for not being enrolled in CR were no medical referral (31%), concomitant medical problems (28%), patient refusal (11%), and geographical distance to the hospital (9%). Despite the relatively high proportion (35%) of HFrEF patients who underwent CR, the enrollment rate can be further improved. Innovative multi-level strategies addressing physicians’ awareness, patients’ comorbidities, and geographical issues should be pursued.

The evaluation of microflaws in carbon-fiber-reinforced composite laminate (CFRP) via ultrasound requires the knowledge of some important factors in addition to its structural composition. Since the laminates are heterogeneous, the high-frequency requirements to acquire high-resolution signals have limitations due to the great scattering that prevents good signal-to-noise ratios. Additionally, the ultrasonic probe’s spatial and lateral resolution characteristics are important parameters for determining the detectability level of microflaws. Modelling appears as a good approach to evaluating the abovementioned factors and the probability of detection of defects in the micron range because it makes it possible to reduce the time and cost associated with developments based on experimental tests. Concerning the subject of this work, simulation is the best way to evaluate the detectability level of the proposed defects since experimental samples are not available. In this work, the simulation was implemented using the Matlab k-Wave toolbox. A 2D matrix for mimicking a CFRP was constructed with 1 μm of resolution. Four different defect types in the micron range were created in the matrix. The simulated and experimental results presented good agreement. It was concluded that the highest frequency probe that could be used to detect the simulated defects without ambiguity was 25 MHz.

The effects of climate change are increasingly noticed worldwide, and crops are likely to be impacted in direct and indirect ways. Thus, it is urgent to adopt pliable strategies to reduce and/or mitigate possible adverse effects to meet the growing demand for sustainable and resilient food production. Monoculture cropping is globally the most common production system. However, adaptation to ongoing climate change, namely, to more extreme environmental conditions, has renewed the interest in other practices such as agroforestry, agroecology, and permaculture. This article provides an overview of ecological and physiological interactions between trees and crops in Mediterranean agroforestry systems and compares them with those from monocultures. The advantages and disadvantages of both systems are explored. The added value of modeling in understanding the complexity of interactions within agroforestry systems, supporting decision-making under current and future weather conditions, is also pinpointed. Several interactions between trees and crops might occur in agroforestry systems, leading to mutual positive and/or negative effects on growth, physiology, and yield. In this sense, selecting the most suitable combination of tree/crop species in mixtures may be best be indicated by complementary traits, which are crucial to maximizing trade-offs, improving productivity, ecosystem services, and environmental sustainability.

Resumo Fundamento A aptidão física é um importante determinante da qualidade de vida (QV) em pacientes com insuficiência cardíaca com fração de ejeção preservada (ICFEP). No entanto, ainda não se sabe como os diferentes componentes da aptidão física se relacionam com as dimensões específicas da QV em pacientes com ICFEP. Objetivo Avaliar a associação entre diferentes componentes da aptidão física e dimensões da QV em pacientes com ICFEP, e examinar quais componentes da aptidão física foram independentemente associados à QV. Métodos Os pacientes com ICFEP foram avaliados quanto à aptidão física [equilíbrio dinâmico e mobilidade (“teste 8-feet Up-and-go ”), força da parte superior do corpo (Teste de força de preensão manual), aptidão cardiorrespiratória (ACR) (teste de caminhada de 6 minutos) e composição corporal (índice de massa corporal)] e para QV ( Minnesota Living With Heart Failure Questionnaire ). Uma correlação parcial foi utilizada para verificar a associação entre os componentes da aptidão física e as dimensões da QV. A análise das dimensões dos preditores independentes de QV foi realizada através da análise de regressão linear multivariada stepwise . A significância estatística foi estabelecida em p

The therapeutic potential of exercise training in the mobilization of endothelial progenitor cells (EPCs) into the peripheral blood in patients with cardiovascular disease is not yet clear. A systematic review and meta-analysis was performed in order to assess the effectiveness of exercise training in increasing the number of circulating EPCs in patients with cardiovascular disease. A literature search was conducted across the PubMed, Scopus, Web of Science and EBSCO databases, including the reference lists of relevant papers. The quality of randomized clinical trials was evaluated using the PEDro scale. The primary outcome data were circulating EPC levels. Six studies (236 participants) – three on heart failure (n=111), one on peripheral arterial disease (n=40) and two on coronary artery disease (n=85) – were included. There was an increase in EPC levels in the exercise training groups (effect size [ES]=0.57; 95% CI: 0.01-1.12), with considerable heterogeneity (I2=75.6%; p

Neotropical caves located in pristine ecosystems harbor high biodiversity but face functional shifts and degradation interlinked with aboveground changes. Cave-roosting bats have been proposed as integrity indicators of karst landscapes considering their sensitive to both the underground and aboveground characteristics and resources. In the present study, the selection of caves by bats in karst areas across a landscape gradient in the Brazilian Amazon was investigated. We envisioned that taxonomic and guild diversity should respond dissimilarly to disturbance at different scales, namely by a selective offsetting of the bat community. To test our hypothesis, we accordingly selected caves spanning a gradient of disturbance, located in old growth forests, secondary forests, forest fragments, agricultural landscapes, and pastures. Species and traits showing responses to the gradient of caves and aboveground ecosystems were identified. On the basis of patterns of occurrence, we determined those communities unique to or primarily associated with undisturbed caves located in pristine ecosystems and landscapes. Disturbed caves, which are generally located in areas of agriculture and pastures, were found to have detrimental effects on specialized species and functional guilds diversity. Our preliminary results reveal that bat communities are particularly sensitive to gradients of cave and ecosystem disturbance, and consequently might add ecological information to the currently used indicators for assessing the ecological status of landscapes in the Neotropics.

Sustainable management of biodiversity in agricultural landscapes is a European Union objective supported on multifunctional agri-environment measures. The effectiveness of specific practices implemented to reverse declines in farmland biodiversity should be monitored using straightforward methodologies and indicators. This work outlines an innovative hybrid framework to predict the response of biodiversity indicators to farm management options. We exemplify the framework application, integrating monitoring, statistics and spatio-temporal modelling procedures with a case study using flying vertebrates’ patterns for indicating biodiversity trends. The indicators considered depict significant divergences within contrasting on-farm implemented environmental management options. In fact, while birds’ abundance was expected to increase within environmentally friendly options, bats passes showed fluctuating patterns. Overall, the framework and indicators selected were considered relevant for biodiversity assessments in vineyard landscapes. This approach also provides a promising baseline to support sustainable management practices and options for other agroecosystems, derived from ecological models with increased predictive power and intuitiveness to decision makers and environmental managers.

Cardiovascular disease (CVD) is the leading cause of death in developed countries and disproportionately affects older adults. Frailty is a complex clinical syndrome with multiple causes and contributing factors in which there is increased vulnerability when exposed to a minor stressor and increased risk for adverse outcomes, such as disability, hospitalization and mortality. Frailty is an important prognostic factor in patients with CVD, and so identifying this feature when assessing these patients may help to individually tailor cardiovascular treatment. The first step is to identify frailty. Several tools have been validated as screening methods for frailty. However, they diverge with regard to complexity, nature, feasibility and the outcome they can predict. The aim of this review is to describe the available screening tools for frailty and to examine their usefulness in patients with CVD. Resumo: As doenças cardiovasculares (DCV) constituem a principal causa de morte nos países desenvolvidos e afetam desproporcionalmente os indivíduos idosos. A fragilidade é definida como uma síndrome clínica complexa com múltiplos fatores predisponentes e caraterizada por um aumento da vulnerabilidade e maior risco de desfechos adversos, nomeadamente, incapacidade, institucionalização e/ou mortalidade. Parece ser um fator prognóstico importante em doentes com DCV, pelo que o reconhecimento dos doentes com fragilidade pode permitir identificar os doentes com maior risco e assim orientar a estratégia terapêutica cardiovascular mais segura e eficaz. Assim, primeiramente é fundamental identificar a fragilidade. Vários instrumentos foram validados como métodos de rastreio de fragilidade. No entanto, eles divergem quanto à complexidade, natureza, viabilidade e resultados que podem prever. O objetivo desta revisão é descrever as ferramentas disponíveis para rastreio de fragilidade e avaliar as suas diferenças e utilidade nos doentes com DCV. Keywords: Frailty, Cardiovascular disease, Assessment, Screening, Palavras-chave: Fragilidade, Doenças cardiovasculares, Avaliação, Rastreio

Objectives: This study aims to assess the long-term survival of pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) patients followed in a Portuguese pulmonary hypertension (PH) referral center. Methods: We studied PAH and CTEPH patients diagnosed between January 2005 and December 2016. Cumulative survival was estimated using the Kaplan-Meier method. Survival trends were compared over two periods (2005-2010 vs. 2011-2016). Results: Of the 142 studied PH patients (age 54±18 years; 31% male), 47 had CTEPH and 95 had group 1 PH. Most patients with CTEPH and idiopathic/heritable PAH (I/HPAH) were in NYHA III-IV at diagnosis (64% and 57%, respectively). At the time of death, 31% of patients with connective tissue disease (CTD)-associated PAH (CTD-PAH) and all I/HPAH patients were on double or triple combination therapy. No patient underwent lung transplantation. Pulmonary endarterectomy or angioplasty were performed in 36% of CTEPH patients. Age at diagnosis tended to increase over time in CTD-PAH (53±15 vs. 63±15 years; p=0.13) and I/HPAH (39±15 vs. 51±19 years; p=0.10). The five-year survival estimates for I/HPAH, CTD-PAH and CTEPH patients were 80%, 52%, and 81%, respectively. Over time, CTD-PAH and CTEPH showed better five-year survival (33 vs. 67% and 77 vs. 84%), but I/HPAH did not (84 vs. 75%). Conclusions: Our data indicate a trend toward improved survival over time of CTD-PAH and CTEPH patients treated at a Portuguese referral PH center. Earlier diagnosis, increasing use of parenteral prostanoids, and surgical treatment may further improve PH prognosis. Resumo: Introdução: Este estudo tem como objetivo avaliar a sobrevivência a longo prazo em doentes com hipertensão arterial pulmonar (PAH) e hipertensão pulmonar tromboembólica crónica (CTEPH) seguidos num centro de tratamento. Métodos: Doentes diagnosticados com PAH ou CTEPH entre janeiro 2005 e dezembro 2016 foram incluídos. A sobrevivência cumulativa foi estimada utilizando o método Kaplan-Meier. Compararam-se os padrões de sobrevivência de dois períodos (2005-2010 versus 2011-2016). Resultados: Foram estudados 142 doentes (54 ± 18 anos; 31% homens), 47 diagnosticados com CTEPH e 95 com PAH. A maioria dos doentes com CTEPH e etiologia idiopática/hereditária (I/HPAH) apresentava classe funcional NYHA III-IV ao diagnóstico (64% e 57%, respetivamente). Aquando da morte, 31% dos doentes com doença do tecido conjuntivo (CTD) e todos os doentes com H/IPAH recebiam terapia dupla ou tripla. Nenhum doente realizou transplante pulmonar. Endarterectomia pulmonar (PEA) ou angioplastia foram realizadas em 36% dos doentes com CTEPH. A idade de diagnóstico de H/IPAH (39 ± 15 versus 51 ± 19 anos; p = 0,10) e CTD (53 ± 15 versus 63 ± 15 anos; p = 0.13) tendeu a aumentar. A sobrevivência a cinco anos foi estimada em 80%, 52% e 81% para H/IPAH, CTD e CTEPH, respetivamente. No 2.° período, a sobrevivência a cinco anos melhorou nos doentes com CTD e CTEPH (33% versus 67% e 77% versus 84%), mas não nos I/HPAH (84% versus 75%). Conclusões: Existe uma tendência de melhoria na sobrevivência de doentes com CTD-PAH e CTEPH tratados num centro de referência português. O diagnóstico precoce, o uso de prostanoides parenterais e a disponibilização de tratamentos cirúrgicos poderão traduzir-se em ganhos adicionais de sobrevida. Keywords: Pulmonary hypertension, Pulmonary arterial hypertension, Survival, Chronic thromboembolic pulmonary hypertension, Palavras-chave: Hipertensão pulmonar, Hipertensão arterial pulmonar, Sobrevivência, Hipertensão pulmonar tromboembólica crónica

BackgroundHeart failure (HF) risk is highest in late life, and impaired pulmonary vascular function is a risk factor for HF development. However, data regarding the contributors to and prognostic importance of pulmonary vascular dysfunction among HF-free elders in the community are limited and largely restricted to pulmonary hypertension. Our objective was to define the prevalence and correlates of abnormal pulmonary pressure, resistance, and compliance and their association with incident HF and HF phenotype (left ventricular [LV] ejection fraction [LVEF] ≥ or < 50%) independent of LV structure and function.Methods and findingsWe performed cross-sectional and time-to-event analyses in a prospective epidemiologic cohort study, the Atherosclerosis Risk in Communities study. This is an ongoing, observational study that recruited 15,792 persons aged 45-64 years between 1987 and 1989 (visit 1) from four representative communities in the United States: Minneapolis, Minnesota; Jackson, Mississippi; Hagerstown, Maryland; and Forsyth County, North Carolina. The current analysis included 2,810 individuals aged 66-90 years, free of HF, who underwent echocardiography at the fifth study visit (June 8, 2011, to August 28, 2013) and had measurable tricuspid regurgitation by spectral Doppler. Echocardiography-derived pulmonary artery systolic pressure (PASP), pulmonary vascular resistance (PVR), and pulmonary arterial compliance (PAC) were measured. The main outcome was incident HF after visit 5, and key secondary end points were incident HF with preserved LVEF (HFpEF) and incident HF with reduced LVEF (HFrEF). The mean ± SD age was 76 ± 5 years, 66% were female, and 21% were black. Mean values of PASP, PVR, and PAC were 28 ± 5 mm Hg, 1.7 ± 0.4 Wood unit, and 3.4 ± 1.0 mL/mm Hg, respectively, and were abnormal in 18%, 12%, and 14%, respectively, using limits defined from the 10th and 90th percentile limits in 253 low-risk participants free of cardiovascular disease or risk factors. Left heart dysfunction was associated with abnormal PASP and PAC, whereas a restrictive ventilatory deficit was associated with abnormalities of PASP, PVR, and PAC. PASP, PVR, and PAC were each predictive of incident HF or death (hazard ratio per SD 1.3 [95% CI 1.1-1.4], p < 0.001; 1.1 [1.0-1.2], p = 0.04; 1.2 [1.1-1.4], p = 0.001, respectively) independent of LV measures. Elevated pulmonary pressure was predictive of incident HFpEF (HFpEF: 2.4 [1.4-4.0, p = 0.001]) but not HFrEF (1.4 [0.8-2.5, p = 0.31]). Abnormal PAC predicted HFrEF (HFpEF: 2.0 [1.0-4.0, p = 0.05], HFrEF: 2.8 [1.4-5.5, p = 0.003]), whereas abnormal PVR was not predictive of either (HFpEF: 0.9 [0.4-2.0, p = 0.85], HFrEF: 0.7 [0.3-1.4, p = 0.30],). A greater number of abnormal pulmonary vascular measures was associated with greater risk of incident HF. Major limitations include the use of echo Doppler to estimate pulmonary hemodynamic measures, which may lead to misclassification; inclusions bias related to detectable tricuspid regurgitation, which may limit generalizability of our findings; and survivor bias related to the cohort age, which may result in underestimation of the described associations.ConclusionsIn this study, we observed abnormalities of PASP, PVR, and PAC in 12%-18% of elders in the community. Higher PASP and lower PAC were independently predictive of incident HF. Abnormally high PASP predicted incident HFpEF but not HFrEF. These findings suggest that impairments in pulmonary vascular function may precede clinical HF and that a comprehensive pulmonary hemodynamic evaluation may identify pulmonary vascular phenotypes that differentially predict HF phenotypes.

A bronquite crônica é uma doença de alta ocorrência em cães. Sua etiologia é associada a causas alérgicas e/ou infecciosas, levando a irritação das vias aéreas, acúmulo de muco e sinais clínicos como a tosse produtiva. O diagnóstico baseia-se nos achados clínicos e radiográficos. Para descartar processo infeccioso, é indicado lavado brônquio-alveolar, com realização de citologia e cultura microbiológica. O protocolo terapêutico já estabelecido na clínica de pequenos animais, associado ao manejo complementar se tronam ferramentas imprescindíveis para resolução de casos mais complicados. O presente trabalho teve como objetivo estabelecer uma revisão bibliográfica sobre a bronquite crônica canina, baseando-se nos achados clínicos e estudo epidemiológico para o correto diagnóstico, tratamento e manejo.

Spiders have been increasingly used as environmental and ecological indicators in conservation and ecosystem management. In the Neotropics, there is a shortage of information regarding spiders’ taxonomies and ecological responses to anthropogenic disturbances. To unravel these hitches, we tested the possibility of using high-level diversity and high-level functionality indicators to evaluate spider assemblages’ sensitivity to landscape changes. This approach, if proven informative, might overcome the relevant limitations of taxonomic derived indexes, which are considered time-consuming, cost-demanding and dependent on the (few) expert taxonomists’ availability. Our results highlight the pertinence of both indicators’ responses to the structural changes induced by increasing anthropogenic disturbance, and are associated with reductions in ecosystem complexity, microclimates, and microhabitats. Overall, both indicators were sensitive to structural changes induced by anthropogenic disturbance and should be considered a useful resource for assessing the extent of ecosystems’ disruptions in the Neotropics, and also to guide managers in landscapes’ restoration.

The clinical manifestations of non-Hodgkin's lymphomas (NHL) are unspecific and may vary with their location, growth rate or organs involved. Chylothorax consists of an accumulation of chyle in pleural space. Lymphoproliferative diseases represent the main non-traumatic aetiology. The authors report the case of an 81-year-old woman admitted with right pleural effusion and lower limbs oedema, initially interpreted as decompensated heart failure. The thoracocentesis revealed a chylothorax and the aetiological study exposed a mantle cell lymphoma. The authors aim to alert to a less frequent presentation of NHL and remind that a low suspicion may delay the diagnosis.

Stemphylium vesicarium (Wallr.) E. G. Simmons is the pathogen responsible of brown spot disease in pear and has become one of the main concerns for European pear producers. In Portugal, S. vesicarium is responsible for significant yield reduction and economic losses in “Rocha” pear (Pyrus communis L. cv Rocha) production. Considering the antimicrobial potential of propolis, the high incidence of brown spot in pears and the emergence of fungicides resistance in S. vesicarium, this study aimed to evaluate the potential of Portuguese propolis as an alternative strategy to control brown spot disease in “Rocha” pear. In vitro assays showed that propolis extracts were able to inhibit up to 90% the S. vesicarium mycelial growth. In vivo assays in artificially wounded and inoculated “Rocha” pears showed that, compared to the control, the disease incidence decreased up to 25% and the lesions diameter up to 57%, in fruits treated with propolis. Moreover, propolis seems to be more efficient in reducing the disease incidence when applied after pathogen inoculation (curative assay) than when applied before pathogen inoculation (prophylactic assay). Thus, the results suggest that propolis extracts have potential to be applied as part of an integrated approach for the control of brown spot of pear.

Canine oral mucosal melanomas (OMM) are the most common oral malignancy in dogs and few treatments are available. Thus, new treatment modalities are needed for this disease. Bacillus anthracis (anthrax) toxin has been reengineered to target tumor cells that express urokinase plasminogen activator (uPA) and metalloproteinases (MMP-2), and has shown antineoplastic effects both, in vitro and in vivo. This study aimed to evaluate the effects of a reengineered anthrax toxin on canine OMM. Five dogs bearing OMM without lung metastasis were included in the clinical study. Tumor tissue was analyzed by immunohistochemistry for expression of uPA, uPA receptor, MMP-2, MT1-MMP and TIMP-2. Animals received either three or six intratumoral injections of the reengineered anthrax toxin prior to surgical tumor excision. OMM samples from the five dogs were positive for all antibodies. After intratumoral treatment, all dogs showed stable disease according to the canine Response Evaluation Criteria in Solid Tumors (cRECIST), and tumors had decreased bleeding. Histopathology has shown necrosis of tumor cells and blood vessel walls after treatment. No significant systemic side effects were noted. In conclusion, the reengineered anthrax toxin exerted inhibitory effects when administered intratumorally, and systemic administration of this toxin is a promising therapy for canine OMM.

The burden of deciding the fate of the supernumerary human embryo created in vitro in the context of Assisted Reproductive Technologies rests on the beneficiary couples or individuals who conceived the parental project. The beneficiaries must also take on the responsibility of choosing whether to donate surplus embryos either to others or to scientific research, or to request their destruction. Vulnerable beings, weakened from the point of view of their identity (facing the social stigma still associated with some circumstances such as being infertile, lesbian or a single mother), are required to have skills such as reflexivity and autonomy in dramatic situations that concern their relationship with their own reproductive body. Given the urgency of this issue at the socio-anthropological level, we are conducting ethnographic research aimed at analysing how specialists and lay people objectivate, evaluate and circulate different conceptions of the human embryo in vitro. Based on our research experience within this ongoing project, we intend to discuss some ethical, practical and methodological concerns for the researcher in accessing the field and conducting fieldwork. We take into account the fact that this research is focused on sensitive topics and on individuals who can be considered people in vulnerable situations.

BackgroundThis study aimed to compare the independent and incremental prognostic value of peak oxygen consumption (VO2) and minute ventilation/carbon dioxide production (VE/VCO2) in heart failure (HF) with preserved (HFpEF), midrange (HFmEF), and reduced (HFrEF) ejection fraction (LVEF). Methods and ResultsIn 195 HFpEF (LVEF ≥50%), 144 HFmEF (LVEF 40–49%), and 630 HFrEF (LVEF

Background: Matrix metalloproteinases (MMPs) are a family of enzymes important for the resorption of extracellular matrices, control of vascular remodeling and repair. Increased activity of MMP2 has been demonstrated in heart failure, and in acutely decompensated heart failure (ADHF) a decrease in circulating MMPs has been demonstrated along with successful treatment. Objective: Our aim was to test the influence of spironolactone in MMP2 levels. Methods: Secondary analysis of a prospective, interventional study including 100 patients with ADHF. Fifty patients were non-randomly assigned to spironolactone (100 mg/day) plus standard ADHF therapy (spironolactone group) or standard ADHF therapy alone (control group). Results: Spironolactone group patients were younger and had lower creatinine and urea levels (all p < 0.05). Baseline MMP2, NT-pro BNP and weight did not differ between spironolactone and control groups. A trend towards a more pronounced decrease in MMP2 from baseline to day 3 was observed in the spironolactone group (-21 [-50 to 19] vs 1.5 [-26 to 38] ng/mL, p = 0.06). NT-pro BNP and weight also had a greater decrease in the spironolactone group. The proportion of patients with a decrease in MMP2 levels from baseline to day 3 was also likely to be greater in the spironolactone group (50% vs 66.7%), but without statistical significance. Correlations between MMP2, NT-pro BNP and weight variation were not statistically significant. Conclusion: MMP2 levels are increased in ADHF. Patients treated with spironolactone may have a greater reduction in MMP2 levels.

Heart failure (HF) and atrial fibrillation (AF) are two growing epidemics associated with significant morbidity and mortality. They often coexist due to common risk factors and shared pathophysiological mechanisms. Patients presenting with both HF and AF have a worse prognosis and present a particular therapeutic challenge to clinicians. This review aims to appraise the common pathophysiological background, as well as the prognostic and therapeutic implications of coexistent HF and AF.

Resumo: Introdução e objetivos: O benefício da trombectomia aspirativa manual (TbA) na reperfusão do enfarte de miocárdio com elevação de ST (EAMST) tem sido muito debatida. Na maioria das séries, a ineficácia da TbA tem sido pouco evidenciada. Os nossos objetivos visaram conhecer a taxa, os preditores e o impacto na mortalidade cumulativa da TbA ineficaz (TbANE) numa série de doentes submetidos a intervenção coronária percutânea primária (ICPP). Métodos: Estudo retrospetivo, unicêntrico, consecutivo, de doentes com EAMST submetidos a ICPP com TbA. Considerou‐se TbANE se após a TbA e antes de prosseguir a angioplastia se se obtivesse fluxo coronário TIMI

Introdução: Nos últimos anos, o contexto global da formação médica, e em particular do Internato Médico em Portugal, sofreu profundas alterações. O presente estudo teve como objetivo avaliar e caracterizar a satisfação dos médicos internos com a realização do Internato Médico em Portugal e identificar aspetos passíveis de melhoria. Material e Métodos: Foi utilizado como modelo de inquérito o questionário Postgraduate Hospital Educational Environment Measure desenvolvido no Reino Unido e dirigido a médicos internos, o qual foi traduzido e adaptado à realidade portuguesa. O questionário esteve disponível online durante os meses de abril e maio de 2016. Resultados: Foram obtidas 3456 respostas, correspondendo a uma taxa de resposta de 35%. Endocrinologia/Nutrição, Cardiologia, Anestesiologia, Medicina Geral e Familiar e Gastrenterologia foram as especialidades nas quais o grau de satisfação foi mais elevado, enquanto que Medicina Legal, Oncologia Médica, Medicina Interna, Cirurgia Geral e Pneumologia apresentaram o grau de satisfação mais baixo. Discussão: O presente estudo apresenta uma elevada taxa de resposta comparativamente com estudos prévios. A nível nacional, no global, os médicos internos apresentaram níveis elevados de satisfação, destacando-se marcadas assimetrias de acordo com o ano de especialidade, região, tipologia de instituição e de especialidade. Conclusão: Os resultados deste inquérito poderão constituir uma ferramenta de apoio à implementação de medidas de âmbito local e nacional relacionadas com o Internato Médico, sendo desejável a realização regular de inquéritos de satisfação aos médico internos.

Resumo: Introdução e objetivos: A doença coronária representa a principal causa de morte das mulheres no mundo e diversos estudos documentam uma sub‐representação destas na terapêutica de reabilitação cardíaca. Os objetivos deste estudo foram descrever a prevalência das mulheres num programa de reabilitação cardíaca e avaliar a resposta deste subgrupo a esta intervenção. Métodos: Estudo retrospetivo constituído por doentes que frequentaram um programa de reabilitação cardíaca baseado no exercício, após síndrome coronária aguda ou intervenção coronária percutânea eletiva, entre janeiro de 2008 e dezembro de 2012. Os 858 doentes foram divididos pelo género e estudou‐se o impacto desta terapêutica sobre os fatores de risco cardiovascular e NT‐proBNP, e numa subpopulação de 386 doentes sobre a capacidade funcional, frequência cardíaca em repouso, índice cronotrópico e recuperação cronotrópica. Resultados: Dos 858 doentes que frequentaram o programa apenas 24% eram mulheres. Verificou‐se de forma estatisticamente significativa que após o programa as mulheres apresentaram uma melhoria de todos os fatores de risco cardiovascular, NT‐proBNP, capacidade funcional e recuperação cronotrópica (p

Coronary artery stent thrombosis is an uncommon but potentially catastrophic complication. The risk of very late stent thrombosis (VLST) raises important safety issues regarding the first generation of drug-eluting stents (DES). Although several complex mechanisms for VLST have been suggested and various predictors have been described, its pathophysiology is not completely understood and it is not known whether longer-term dual antiplatelet therapy reduces the risk. We present a rare case of simultaneous very late DES thrombosis in the three vascular territories, following discontinuation of antiplatelet therapy seven years after stent placement, presenting as cardiogenic shock. Resumo: A trombose de stent coronário é uma complicação rara mas potencialmente catastrófica. O risco de trombose muito tardia de stent (TMTS) tem levantado questões importantes sobre a segurança do uso de stents revestidos com fármacos (SRF) de primeira geração. Embora sejam vários e complexos os mecanismos da TMTS e vários os preditores que têm sido descritos, a sua fisiopatologia ainda não está totalmente esclarecida e desconhece-se se o prolongar da terapêutica antiagregante dupla reduz esse risco. Descrevemos um caso raro de trombose muito tardia de SRF ocorrendo em simultâneo nos três territórios vasculares, após interrupção da terapêutica antiagregante, sete anos após implantação dos stents, apresentando-se como choque cardiogénico. Keywords: Very late stent thrombosis, Drug-eluting stents, Palavras-chave: Trombose muito tardia de stent, Stents revestidos

We discuss the case of a 49-year-old patient with left ventricular systolic dysfunction and a large, mobile and protruding apical thrombus. In spite of anticoagulation treatment, extensive and clearly defined systemic embolization occurred.We discuss the current evidence on the treatment of intracardiac thrombus with high risk of systemic embolization and propose a tailored approach to avoid potential catastrophic consequences. Resumo: Apresentamos o caso de um doente de 49 anos com disfunção sistólica ventricular esquerda e um trombo apical de grandes dimensões, móvel e com protrusão para a cavidade ventricular. Apesar do tratamento anticoagulante, ocorreram vários fenómenos de embolização sistémica, extensos e muito ilustrativos.Discutimos a evidência atual sobre o tratamento de trombos intracardíacos com alto risco de embolização sistémica e propomos uma reflexão sobre uma abordagem personalizada para evitar potenciais consequências catastróficas. Keywords: Left ventricular thrombus, Embolization, Anticoagulation, Thrombectomy, Palavras-chave: Trombo do ventrículo esquerdo, Embolização, Anticoagulação, Trombectomia

Takotsubo cardiomyopathy is an acute cardiac entity with clinical manifestations similar to myocardial infarction, accounting for 1-2% of acute coronary syndrome admissions. Its underlying pathophysiology is not yet well established. It is usually associated with acute physical or emotional stress, but the list of potential triggers has grown as the condition attracts the attention of the medical community. In order to diagnose the condition correctly and to gain new insights into it, we need to know its potential triggers as well as its clinical presentation and diagnostic criteria. We report a case of takotsubo cardiomyopathy triggered by hyponatremia. Resumo: A cardiomiopatia de Takotsubo é uma entidade nosológica que se caracteriza por manifestações clínicas similares às do enfarte agudo do miocárdio, representando cerca de 1-2% de todos os doentes admitidos por síndrome coronária aguda. A sua etiopatogenia ainda não está totalmente esclarecida. Geralmente, está associada a vigorosos estímulos físicos ou emocionais. Com o crescente reconhecimento desta entidade, a lista de potenciais estímulos despoletadores tem crescido nos últimos anos. O conhecimento destes novos estímulos permitirá não só um diagnóstico correcto mas também o aprofundamento dos seus mecanismos fisiopatológicos. Os autores descrevem um caso de cardiomiopatia de Takotsubo induzida por hiponatremia. Keywords: Stress cardiomyopathy, Takotsubo cardiomyopathy, Hyponatremia, Palavras-chave: Cardiomiopatia de stress, Cardiomiopatia de Takotsubo, Hyponatremia

We describe the case of a 47-year-old man with new-onset heart failure who was found to have severe biventricular wall thickening. We present comprehensive data from invasive and non-invasive multimodality imaging, genetic and histologic tests, and briefly describe their importance in the final diagnosis.To our knowledge, this is the first case of the Portuguese variant of familial amyloid polyneuropathy presenting with heart failure in the fifth decade of life.This is an unusual case report, but also an illustration of how to approach any patient with suspected infiltrative cardiomyopathy. Resumo: Descrevemos o caso de um doente do sexo masculino de 47 anos, com insuficiência cardíaca de novo, que apresentava marcado aumento da espessura da parede de ambos os ventrículos. Apresentamos dados dos exames de imagem, estudo genético e análise histológica que nos guiaram no diagnóstico, explicando o nosso precurso pelos diagnósticos diferenciais e a interpretação dos diferentes testes.Tanto quanto sabemos, é o primeiro caso descrito de um doente com a variante portuguesa da polineuropatia amiloidótica familiar que se apresenta com insuficiência cardíaca na quinta década de vida.Este é um caso clínico invulgar, mas também um exemplo ilustrativo da abordagem de um doente com suspeita de cardiomiopatia infiltrativa. Keywords: Heart failure, Ventricular wall thickening, Infiltrative cardiomyopathy, Familial amyloid polyneuropathy, Echocardiography, Palavras-chave: Insuficiência cardíaca, Hipertrofia ventricular, Cardiomiopatia infiltrativa, Polineuropatia amiloidótica familiar, Ecocardiografia

Background. Patients presenting with acutely decompensated heart failure (ADHF) and positive circulating cardiac troponins were found to be a high-risk cohort. The advent of high-sensitive troponins resulted in a detection of positive troponins in a great proportion of heart failure patients. However, the pathophysiological significance of this phenomenon is not completely clear. Objectives. The aim of this study is to determine the early evolution and clinical significance of high-sensitivity troponin T (hsTnT) in ADHF. Methods. Retrospective, secondary analysis of a prospective study including 100 patients with ADHF. Results. Globally, high-sensitivity troponin T decreased from day 1 to day 3 (P=0,039). However, in the subgroup of patients who remained decompensated no significant differences in hsTnT from day 1 to day 3 were observed (P=0,955), whereas in successfully compensated patients a significant reduction in hsTnT levels was observed (P=0,025). High-sensitivity troponin T decrease was correlated with NTproBNP reduction (P=0,007). Patients with hsTnT increase had longer length of stay (P=0,033). Conclusions. Episodes of ADHF are associated with transient increases in the blood levels of hsTnT that are reduced with effective acute episode treatment. The decrease in hsTnT can translate less myocardial damage along with favourable ADHF treatment.

O autor apresenta uma proposta de organização da consulta de cessação tabágica, resultado da experiência dos últimos quatro anos, como responsável pelo programa de tabagismo da UCS - Cuidados Integrados de Saúde (Serviços de Saúde do Grupo TAP), onde se combina a intervenção motivacional ao apoio comportamental e farmacológico, numa consulta estruturada em três encontros clínicos directos e cinco contactos telefónicos. Neste contexto, onde a intervenção do profissional de saúde é particularmente «não directiva», sublinha-se a importância da motivação na adesão do indivíduo dependente ao tratamento e caracteriza-se os aspectos essenciais de cada uma das etapas diferenciadas do processo de mudança, com realce para suporte comportamental e para as questões que provocam «falas de mudança», que permitem a expressão verbal e encorajam a pessoa a tomar a decisão de parar de fumar.