Publications by authors named "António Pires"

71 Publications

Percutaneous management of a ruptured sinus of Valsalva aneurysm in an infant.

Cardiol Young 2021 Mar 2:1-3. Epub 2021 Mar 2.

Department of Paediatric Cardiology, Referral Centre for Congenital Cardiac Defects, CHUC, Coimbra, Portugal.

Ruptured sinus of Valsalva aneurysm is a rare entity in children. To our knowledge, this is the youngest child reported in the literature with a sinus of Valsalva ruptured aneurysm being successfully treated percutaneously using an AmplatzerTM Duct Occluder II Additional Sizes device.
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http://dx.doi.org/10.1017/S1047951121000652DOI Listing
March 2021

Production of high-quality SARS-CoV-2 antigens: Impact of bioprocess and storage on glycosylation, biophysical attributes, and ELISA serologic tests performance.

Biotechnol Bioeng 2021 Feb 24. Epub 2021 Feb 24.

iBET, Instituto de Biologia Experimental e Tecnológica, Oeiras, Portugal.

Serological assays are valuable tools to study SARS-CoV-2 spread and, importantly, to identify individuals that were already infected and would be potentially immune to a virus reinfection. SARS-CoV-2 Spike protein and its receptor binding domain (RBD) are the antigens with higher potential to develop SARS-CoV-2 serological assays. Moreover, structural studies of these antigens are key to understand the molecular basis for Spike interaction with angiotensin converting enzyme 2 receptor, hopefully enabling the development of COVID-19 therapeutics. Thus, it is urgent that significant amounts of this protein became available at the highest quality. In this study, we produced Spike and RBD in two human derived cell hosts: HEK293-E6 and Expi293F™. We evaluated the impact of different and scalable bioprocessing approaches on Spike and RBD production yields and, more importantly, on these antigens' quality attributes. Using negative and positive sera collected from human donors, we show an excellent performance of the produced antigens, assessed in serologic enzyme-linked immunosorbent assay (ELISA) tests, as denoted by the high specificity and sensitivity of the test. We show robust Spike productions with final yields of approx. 2 mg/L of culture that were maintained independently of the production scale or cell culture strategy. To the best of our knowledge, the final yield of 90 mg/L of culture obtained for RBD production, was the highest reported to date. An in-depth characterization of SARS-CoV-2 Spike and RBD proteins was performed, namely the antigen's oligomeric state, glycosylation profiles, and thermal stability during storage. The correlation of these quality attributes with ELISA performance show equivalent reactivity to SARS-CoV-2 positive serum, for all Spike and RBD produced, and for all storage conditions tested. Overall, we provide straightforward protocols to produce high-quality SARS-CoV-2 Spike and RBD antigens, that can be easily adapted to both academic and industrial settings; and integrate, for the first time, studies on the impact of bioprocess with an in-depth characterization of these proteins, correlating antigen's glycosylation and biophysical attributes to performance of COVID-19 serologic tests.
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http://dx.doi.org/10.1002/bit.27725DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014509PMC
February 2021

Kawasaki Disease: Predictors of Resistance to Intravenous Immunoglobulin and Cardiac Complications.

Arq Bras Cardiol 2021 Jan 18. Epub 2021 Jan 18.

Centro Hospitalar e Universitário de Coimbra EPE - Cardiologia Pediátrica, Coimbra - Portugal.

Background: Kawasaki disease (KD) is the leading cause of acquired cardiac disease in children, in developed countries.

Objectives: To identify predictive factors for resistance to intravenous immunoglobulin (IVIG), calculate the effectiveness of Japanese predictive models and characterize cardiac complications.

Methods: Retrospective analysis of KD cases admitted in a Portuguese paediatric hospital between january 2006 and july 2018. ROC curves were used to determine predictive factors for resistance and the multivariate logistic regression analysis was used to develop the predictive model. A significance level of 5% was used.

Results: 48 patients with a median age of 36 months were included. The IVIG resistance was 21%. Echocardiographic anomalies were noted in 46%, with coronary involvement in 25% of the sample population. As predictive variable of resistance, the C-reactive protein (CRP) presented an AUC ROC = 0.789, optimal cut-off value 15.1 mg/dL, sensitivity (Sn) 77.8% and specificity (Sp) 78.9%. The erythrocyte sedimentation rate (ESR) presented an AUC ROC = 0.781, optimal cut-off value 90.5 mm/h, Sn 66.7% and Sp 85.7%. The model with the two variables showed p = 0.042 and AUC ROC = 0.790. Predictive strength of Japanese models were: Kobayashi (Sn 63.6%, Sp 77.3%), Egami (Sn 66.7%, Sp 73.1%), Sano (Sn 28.6%, Sp 94.1%).

Conclusion: CRP and ESR are independent variables that were related to IVIG resistance, with optimal cut-off points of 15.1 mg/dL and 90.5 mm/h, respectively. About half of the patients had some form of cardiac involvement. The Japanese models appeared to be inadequate in our population. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).
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http://dx.doi.org/10.36660/abc.20190758DOI Listing
January 2021

PATENT DUCTUS ARTERIOSUS CLOSURE: EXPERIENCE FROM A TERTIARY REFERRAL CENTER.

Rev Paul Pediatr 2020 27;39:e2020013. Epub 2020 Nov 27.

Universitário de Coimbra, Coimbra, Portugal.

Objective: To characterize the number and methods of closure of Persistent Ductus Arteriosus (PDA) over a span of 16 years in a third level maternity hospital.

Methods: Retrospective study of neonates born between January 2003 and Deccember 2018, who underwent ductus arteriosus closure by pharmacological, surgical and/or transcatheter methods. Gestational age, birth weight, number and methods of closures per year were evaluated. The success rate of the pharmacologic method was calculated, as well as the mortality rate. The association between mortality and birthweight, treatment used and treatment failure was explored.

Results: There were 47,198 births, 5,156 were preterm, 325 presented PDA and 106 were eligible for closure (median gestational age - 27 weeks, birthweight <1000 g - 61%). Frequency of PDA closure decreased during the study period, especially starting in 2010. Success rate with pharmacologic treatment was 62% after the first cycle and 74% after the second. After drug failure, 12 underwent surgical ligation and two underwent transcatheter closure. Exclusive surgical ligation was indicated in four infants. Ibuprofen replaced indomethacin in 2010, and acetaminophen was used in three infants. Among the 106 infants, hospital mortality was 12% and it was associated with birthweight <1000 g (13/65 <1000 vs. 0/41 >1000 g; p=0.002) and with failure in the first pharmacologic treatment cycle (13/27 with failure, vs. 0/75 without failure; p<0.001).

Conclusions: The national consensus published in 2010 for the diagnosis and treatment of PDA in preterm infants led to a decrease in the indication for closure. Pharmacological closure was the method of choice, followed by surgical ligation. Birthweight <1000 g and first cycle of pharmacologic treatment failure were associated with higher mortality.
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http://dx.doi.org/10.1590/1984-0462/2021/39/2020013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7695124PMC
November 2020

Atherosclerotic Process in Seroreverter Children and Adolescents Exposed to Fetal Antiretroviral Therapy.

Curr HIV Res 2020 Nov 18. Epub 2020 Nov 18.

Coimbra Institute for Clinical and Biomedical Researh (iCBR) - Faculty of Medicine - University of Coimbra, Coimbra. Portugal.

Background: Human immunodeficiency virus infection is a recognized risk factor for premature atherosclerosis in children and adolescents. However, the atherosclerotic process in uninfected children exposed in utero to the virus and antiretroviral therapy is less clear.

Objective: To determine the potential cardiovascular risk associated to this in utero milieu exposition.

Material And Methods: A total of 115 individuals were studied (77 in the sample group and 38 controls). Eighteen analytical mediators involved in the atherogenic pathways (metabolic dysregulation, inflammation and prothrombotic state) were analyzed. The carotid intima-media thickness, which is a subclinical marker of atherosclerosis, was also measured.

Results: No significant statistical differences were identified between the sample and control groups, either in the biochemical or the echographic markers.

Conclusion: In utero exposure to the HIV virus and antiretroviral therapy in uninfected children and adolescents is not correlated to accelerated atherosclerosis.
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http://dx.doi.org/10.2174/1570162X18999201118155026DOI Listing
November 2020

Pneumopericardium and pleural effusion: a rare complication of paediatric pericardiocentesis.

BMJ Case Rep 2020 Nov 3;13(11). Epub 2020 Nov 3.

Paediatric Cardiology, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal.

Pneumopericardium is a rare complication of pericardiocentesis (PC), occurring as a result of either a direct pleuropericardial communication or a leaky drainage system. Pneumopericardium is often self-limiting; however, physicians should be aware of this complication as it may progress to tension pneumopericardium, which requires immediate recognition and management. PC has been associated with pneumothorax, pneumomediastinum or subcutaneous emphysema, but the association with pleural effusion has been less reported. The authors present the case of a 14-year-old healthy boy who developed post-PC pneumopericardium and pleural effusion, a rare association reported in the literature. The diagnosis of this potential life-threatening event was made using readily available complementary diagnostic methods, such as transthoracic echocardiography and chest X-ray.
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http://dx.doi.org/10.1136/bcr-2020-236308DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7640467PMC
November 2020

A case of double-outlet left ventricle, malposition of the great arteries, and superior-inferior ventricular arrangement.

Cardiol Young 2020 Aug 27;30(8):1173-1174. Epub 2020 Jul 27.

Department of Paediatric Cardiology, Referral Centre for Congenital Cardiac Defects, CHUC, Coimbra, Portugal.

Superior-inferior ventricular arrangement with double-outlet left ventricle and malposition of the great arteries is an extremely rare congenital cardiac anomaly. The authors present the case of an infant who presented with cyanosis and respiratory distress. To the best of our knowledge, this is the first case reported.
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http://dx.doi.org/10.1017/S104795112000222XDOI Listing
August 2020

A rare case of isolated anomalous origin of the left pulmonar artery.

Rev Port Cardiol 2020 Jun 16;39(6):353-355. Epub 2020 Jun 16.

Hospital Pediatrico de Coimbra, Serviço de Cardiologia Pediátrica, Coimbra, Portugal.

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http://dx.doi.org/10.1016/j.repc.2020.02.010DOI Listing
June 2020

Experience on statin therapy in paediatric age: retrospective study in a Portuguese referral centre.

Cardiol Young 2020 Jun 15;30(6):840-851. Epub 2020 May 15.

Faculty of Medicine, University of Coimbra, Coimbra, Portugal.

Background: The use of statins in children, although not frequent, is recommended in specific clinical contexts, namely, familial hypercholesterolaemia, conditions carrying a moderate-high cardiovascular risk and sub-optimal cholesterol levels after implementation of lifestyle modifications. The aim of this study is to characterise children with dyslipidaemia managed with statins, followed at a tertiary referral centre in central Portugal.

Methods And Results: The authors carried out a retrospective and descriptive study made up of 66 patients (50% males, mean age of therapy onset 11.9 years) followed up at the Cardiovascular Clinic of a tertiary referral centre between January, 2012, and May, 2018. Clinical, analytical, and echocardiographic parameters were analysed. About 60.6% had clinical and/or molecular diagnosis of familial hypercholesterolaemia. On average, each patient had three cardiovascular risk factors, obesity (31%) being most prevalent, followed by arterial hypertension (14%). Statin therapy showed a statistically significant reduction in the lipid profile, particularly in the total cholesterol (23%) and low-density lipoprotein cholesterol (30%) levels, as well as in the carotid intima-media thickness (p = 0.015). Hepatic and muscle integrity markers were within normal range.

Conclusions: Statins are safe and efficient in the management of children with hypercholesterolaemia. Our study showed that apart from its lipid-lowering properties, it also reduced significantly the carotid intima-media thickness and, implicitly, the cardiovascular risk of these patients.
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http://dx.doi.org/10.1017/S1047951120001158DOI Listing
June 2020

Transcatheter Versus Surgical Pulmonary Valve Replacement: A Systemic Review and Meta-Analysis.

Ann Thorac Surg 2020 11 5;110(5):1751-1761. Epub 2020 Apr 5.

Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal.

Background: Transcatheter pulmonary valve replacement (TPVR) has emerged as an alternative to surgery in patients with pulmonary valve dysfunction.

Methods: We searched the Medline and Cochrane databases since their inception to January 2019 as well as references from article, for all publications comparing TPVR with surgical PVR (SPVR). Studies were considered for inclusion if they reported comparative data regarding any of the study endpoints. The primary endpoint was early mortality after PVR. Secondary endpoints included procedure-related complications, length of hospital stay, mortality during follow-up, infective endocarditis, need for reintervention, post-PVR transpulmonary peak systolic gradient, and significant pulmonary regurgitation.

Results: There were no differences in perioperative mortality between groups (0.2% vs 1.2%; pooled odds ratio, 0.56; 95% confidence interval, 0.19-1.59; P = .27, I = 0%). However TPVR conferred a significant reduction in procedure-related complications and length of hospital stay compared with SPVR. Midterm mortality and the need for repeat intervention were similar with both techniques, but pooled infective endocarditis was significantly more frequent in the TPVR group (5.8 vs 2.7%; pooled odds ratio, 3.09; 95% confidence interval, 1.89-5.06; P < .001, I = 0%). TPVR was associated with less significant PR and a trend towards a lower transpulmonary systolic gradient during follow-up.

Conclusions: TPVR is a safe alternative to SPVR in selected patients and is associated with a shorter length of hospital stay and fewer procedure-related complications. At midterm follow-up TPVR was comparable with SPVR in terms of mortality and repeat intervention but was associated with an increased risk of infective endocarditis.
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http://dx.doi.org/10.1016/j.athoracsur.2020.03.007DOI Listing
November 2020

Myocardial peak systolic velocity-a tool for cardiac screening of HIV-exposed uninfected children.

Eur J Pediatr 2020 Mar 25;179(3):395-404. Epub 2019 Nov 25.

Coimbra Institute for Clinical and Biomedical Researh (iCBR) - Faculty of Medicine, University of Coimbra, Coimbra, Portugal.

HIV-uninfected children exposed prenatally to the virus and to prophylactic antiretroviral therapy are at an uncertain risk of long-term myocardial dysfunction. This study aimed to analyse the structure and function of their ventricles and to identify potential screening tools for this at-risk population. One hundred and fifteen children (77 exposed vs 38 controls) aged between 2.7 and 16.2 years were included. An echocardiographic study was performed where both ventricles' dimensions and systolic functions were evaluated. In the left ventricle, parameters related to diastolic function were also analysed. Tissue Doppler values were determined in the basal state and after passive leg raising. Serologic analysis of amino-terminal pro-B-type natriuretic peptide (NT-proBNP) was carried out. The two groups had identical ventricular sizes and left ventricular diastolic functions. However, contractility assessed by myocardial peak systolic velocity was significantly inferior in the exposed group. These systolic echocardiographic differences were present despite similar values of NT-proBNP in both groups.Conclusion: HIV-exposed uninfected children may be vulnerable to ventricular systolic dysfunction at long term. Cardiovascular surveillance and periodic monitoring of biventricular function are therefore recommended. Myocardial peak systolic velocity may be a useful screening tool for this purpose.What is Known:• Previous studies on HIV-exposed uninfected children subjected prenatally to antiretroviral therapy have alerted to potential long-term cardiovascular toxicity effects on the left ventricle.What is New:• The study gives new insights on ventricular function and morphology in HIV-exposed uninfected children.• Myocardial peak systolic velocities are significantly inferior in this paediatric sub-group, therefore long-term cardiac surveillance is recommended.
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http://dx.doi.org/10.1007/s00431-019-03477-7DOI Listing
March 2020

How to develop a sustainable telemedicine service? A Pediatric Telecardiology Service 20 years on - an exploratory study.

BMC Health Serv Res 2019 Sep 23;19(1):681. Epub 2019 Sep 23.

Global Health and Tropical Medicine, GHTM, Instituto de Higiene e Medicina Tropical, IHMT, Universidade Nova de Lisboa, UNL, Rua da Junqueira 100, 1349-008, Lisboa, Portugal.

Background: Telemedicine services are promoting more access to healthcare. Portugal was an early adopter of telemedicine to overcome both its geological barriers and the shortage of healthcare professionals. The Pediatric Cardiology Service (PCS) at Coimbra University Hospital Centre (CHUC) has been using telemedicine to increase access and coverage since 1998. Their Pediatric Telecardiology Service has been daily connecting CHUC with 13 other Portuguese national hospitals, and regularly connecting with Portuguese-speaking African countries, through a teleconsultation platform.

Methods: This study aims at exploring the Pediatric Telecardiology Service's evolution, through a comprehensive assessment of the PCS's development, evolution and impact in public health, to better understand the critical factors for implementation and sustainability of telemedicine, in the context of healthcare services digitalization. A case study was performed, with cost-benefit, critical factors and organizational culture assessment. Finally, the Kingdon's framework helped to understand the implementation and scale-up process and the role of policy-making.

Results: With the total of 32,685 out-patient teleconsultations, growing steadily from 1998 to 2016, the Pediatric Telecardiology Service has reached national and international recognition, being a pioneer and an active promotor of telemedicine. This telemedicine service has saved significant resources, about 1.1 million euros for the health system (e.g. in administrative and logistic costs) and approximately 419 euros per patient (considering an average of 1777 patients per year). PCS presents a dominant "Clan" culture. The Momentum's critical factors for telemedicine service implementation enabled us to understand how barriers were overcome (e.g. political forces). Willingness, perseverance and teamwork, allied with partnership with key stakeholders, were the foundation for professionals' engagement and service networking development. Its positive results, new regulations and the increasing support from the hospital board, set up a window of opportunity to establish a sustainable telemedicine service.

Conclusion: The Pediatric Telecardiology Service enables real-time communication and the sharing of clinical information, overcoming many barriers (from geographical ones to shortage of healthcare professionals), improving access to specialized care both in Portugal and Africa. Motivation and teamwork, and perseverance, were key for the Pediatric Telecardiology Service to tackle the window of opportunity which created conditions for sustainability.
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http://dx.doi.org/10.1186/s12913-019-4511-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6757431PMC
September 2019

Management of Asymptomatic Wolff-Parkinson-White Pattern in Young Patients: Has Anything Changed?

Pediatr Cardiol 2019 Jun 8;40(5):892-900. Epub 2019 May 8.

Faculty of Medicine, University of Coimbra, Coimbra, Portugal.

The approach to pediatric asymptomatic Wolff-Parkinson-White (WPW) patients is controversial. The objective of this review is to update the last consensus of specialists of the Pediatric and Congenital Electrophysiology Society/Heart Rhythm Society on this subject in order to summarize the most recent evidence on the management of young patients with asymptomatic WPW pattern. A systematic review of the literature published between 2008 and 2018 was performed taking into account the protocol of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) in PubMed (including Cochrane), Embase, and Web of Science. Observational, experimental, and multicentric studies were included. Out of a total of 37 articles selected, 4 were considered eligible. Most studies considered a cutoff age of 8 or greater as recommended in the 2012 consensus. The identification of a shortest pre-excitatory RR interval (SPERRI) ≤ 250 ms seems to be the best predictor for risk stratification. The importance of routine isoprenaline use to improve the sensitivity of the electrophysiological study to identify patients at high risk of sudden death was consensual. Prophylactic ablative therapy has been indicated in asymptomatic children with an accessory pathway (AP) who have a low SPERRI and/or a low effective anterograde period of the AP and/or multiple APs. Despite the evidence found in the most recent studies, more studies are warranted in this setting.
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http://dx.doi.org/10.1007/s00246-019-02110-6DOI Listing
June 2019

Rare cause of cardiac failure in an infant.

Cardiol Young 2019 May 2;29(5):711-713. Epub 2019 May 2.

Paediatric Cardiology Department, Paediatric Hospital, Coimbra,Portugal.

Congenital stenosis of the pulmonary veins is a rare condition whose outcome is guarded despite the available treatment options. We report a case of a 6-month-old infant with significant stenosis of all four pulmonary veins.
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http://dx.doi.org/10.1017/S1047951119000428DOI Listing
May 2019

Importance of ambulatory blood pressure monitoring in the diagnosis and prognosis of pediatric hypertension.

Rev Port Cardiol 2018 09 2;37(9):783-789. Epub 2018 Jun 2.

Serviço de Cardiologia Pediátrica, Hospital Pediátrico de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

The prevalence of high blood pressure (BP) at pediatric age has increased progressively, one of the causes of which is obesity. However, the dominant etiology in this age group is renal and/or cardiovascular pathology. Ambulatory blood pressure monitoring (ABPM) is the method of choice for the diagnosis of hypertension, especially in children at high cardiovascular risk. Its use is limited to children from five years of age. Choosing appropriate cuff size is key to obtaining correct blood pressure. The main indication for ABPM is to confirm the diagnosis of hypertension. It also allows the diagnosis of white coat hypertension (which may represent an intermediate stage between the normotensive phase and hypertension), or masked hypertension, associated with progression to sustained hypertension and left ventricular hypertrophy (LVH). Children with isolated nocturnal hypertension should be considered as having masked hypertension. BP load is defined as the percentage of valid measurements above the 95th percentile for age, gender, and height. Values above 25-30% are pathological and those above 50% are predictive of LVH. ABPM correlates with target organ damage, particularly LVH and renal damage. It is useful in the differentiation of secondary hypertension, since these children show higher BP load and less nocturnal dipping, and confirmation of response to therapy. Thus ABPM allows the diagnosis and classification of hypertension, provides cardiovascular prognostic information and identifies patients with intermediate phenotypes of hypertension.
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http://dx.doi.org/10.1016/j.repc.2017.09.026DOI Listing
September 2018

Unusual cause of left ventricular dysfunction in a child.

Rev Port Cardiol 2019 02 21;38(2):159.e1-159.e5. Epub 2018 May 21.

Centro de Cirurgia Cardiotorácica, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery is a rare congenital heart disease and a cause of myocardial ischemia during childhood. Most undiagnosed cases die in the first year of life as an extensive collateral network is essential for survival. The diagnosis requires a high index of clinical suspicion. The authors present the case of an 8-year-old black asymptomatic child referred from Cape Verde Island in order to clarify left ventricular dilatation and dysfunction with systo-diastolic turbulent flows observed at the interventricular septum. At the age of 3 months, she was diagnosed with heart failure, in the context of showing dilated cardiomyopathy. She was managed and clinically improved with anticongestive therapy, which she was still taking at the time of admission to our Center. The echocardiogram findings suggested Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery and the diagnosis was confirmed by computerized angiotomography and cardiac catheterization. The patient was successfully submitted to direct implantation of the left coronary artery into the aorta, allowing the creation of a double coronary perfusion system. This case illustrates an unusual presentation of a rare pathology that survived without a diagnosis after the first year of life. It also reinforces the importance of multimodality image screening in these cases.
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http://dx.doi.org/10.1016/j.repc.2017.07.017DOI Listing
February 2019

Stylus/tablet user input device for MRI heart wall segmentation: efficiency and ease of use.

Eur Radiol 2018 Nov 2;28(11):4586-4597. Epub 2018 May 2.

Department of Radiology, NYU Langone Medical Center, New York, NY, 10016, USA.

Objectives: To determine whether use of a stylus user input device (UID) would be superior to a mouse for CMR segmentation.

Methods: Twenty-five consecutive clinical cardiac magnetic resonance (CMR) examinations were selected. Image analysis was independently performed by four observers. Manual tracing of left (LV) and right (RV) ventricular endocardial contours was performed twice in 10 randomly assigned sessions, each session using only one UID. Segmentation time and the ventricular function variables were recorded. The mean segmentation time and time reduction were calculated for each method. Intraclass correlation coefficients (ICC) and Bland-Altman plots of function variables were used to assess intra- and interobserver variability and agreement between methods. Observers completed a Likert-type questionnaire.

Results: The mean segmentation time (in seconds) was significantly less with the stylus compared to the mouse, averaging 206±108 versus 308±125 (p<0.001) and 225±140 versus 353±162 (p<0.001) for LV and RV segmentation, respectively. The intra- and interobserver agreement rates were excellent (ICC≥0.75) regardless of the UID. There was an excellent agreement between measurements derived from manual segmentation using different UIDs (ICC≥0.75), with few exceptions. Observers preferred the stylus.

Conclusion: The study shows a significant reduction in segmentation time using the stylus, a subjective preference, and excellent agreement between the methods.

Key Points: • Using a stylus for MRI ventricular segmentation is faster compared to mouse • A stylus is easier to use and results in less fatigue • There is excellent agreement between stylus and mouse UIDs.
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http://dx.doi.org/10.1007/s00330-018-5435-xDOI Listing
November 2018

Abdominal pain of cardiovascular origin.

Rev Port Cardiol 2018 May 26;37(5):449.e1-449.e4. Epub 2018 Apr 26.

Hospital Pediátrico de Coimbra, Serviço de Cardiologia Pediátrica, Coimbra, Portugal.

Infective endocarditis is a microbial infection of the endocardium and it is rare in the pediatric population. In children, congenital heart disease is one of the most important risk factors for developing infective endocarditis and can involve other structures in addition to cardiac valves. The prognosis is generally better than in other forms of endocarditis, although the average mortality rate in the pediatric population is 15-25%. Clinical manifestations can mimic other diseases such as meningitis and collagen-vascular disease or vasculitis. Therefore, a high degree of suspicion is required to make an early diagnosis. Gram-positive bacteria, specifically alpha-hemolytic streptococci, Staphylococcus aureus and coagulase-negative staphylococci, are the most commonly involved bacteria. Diagnosis is based on the modified Duke criteria, which rely mostly on clinical assessment, echocardiography and blood cultures. Antibacterial treatment should ideally be targeted. However, if no specific bacteria have been identified, patients should promptly be treated empirically with multiple drug regimens based on local resistance and the most common etiologies. The authors describe a case of a seven-year-old girl with classic clinical signs of endocarditis, with a clinical twist.
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http://dx.doi.org/10.1016/j.repc.2017.06.023DOI Listing
May 2018

Rare forms of pediatric congenital right ventricular fistulae.

Rev Port Cardiol 2018 May 21;37(5):453-454. Epub 2018 Apr 21.

Serviço de Cardiologia Pediátrica, Hospital Pediátrico de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

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http://dx.doi.org/10.1016/j.repc.2017.01.015DOI Listing
May 2018

Online Interactive Case-Based Instruction in Prostate Magnetic Resonance Imaging Interpretation Using Prostate Imaging and Reporting Data System Version 2: Effect for Novice Readers.

Curr Probl Diagn Radiol 2019 Mar - Apr;48(2):132-141. Epub 2018 Jan 10.

Department of Radiology, NYU Langone Health, New York, NY.

Purpose: To assess the effect on reader performance of an interactive case-based online tutorial for prostate magnetic resonance imaging (MRI) interpretation using Prostate Imaging and Reporting Data System (PI-RADS).

Methods: An educational website was developed incorporating scrollable multiparametric prostate MRI examinations with annotated solutions based on PI-RADS version 2. Three second-year radiology residents evaluated a separate set of 60 prostate MRI examinations both before and after review of the online case material, identifying and scoring dominant lesions. These 60 examinations included 30 benign cases and 30 cases with a dominant lesion demonstrating Gleason score ≥3 + 4 tumor on fusion-targeted biopsy. The readers' pooled performance was compared between the 2 sessions using logistic regression and Wilcoxon signed rank tests.

Results: All readers completed the online material within four-hours. Review of the online material significantly improved sensitivity (from 57.8%-73.3%, P = 0.003) and negative predictive value (from 69.2%-78.2%, P = 0.049), but not specificity (from 70.0%-67.8%, P = 0.692) or positive predictive value (from 59.6%-64.7%, P = 0.389). Reader confidence (1-10 scale; 10 = maximal confidence) also improved significantly (from 5.6 ± 2.7 to 6.3 ± 2.6, P = 0.026). However, accuracy of assigned PI-RADS scores did not improve significantly (from 45.5%-53.3%, P = 0.149).

Conclusion: An online interactive case-based website in prostate MRI interpretation improved novice readers' sensitivity and negative predictive value for tumor detection, as well as readers' confidence. This online material may serve as a resource complementing existing traditional methods of instruction by providing a more flexible educational experience among a larger volume of learners. However, further more targeted educational initiatives regarding the proper application of PI-RADS remain warranted.
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http://dx.doi.org/10.1067/j.cpradiol.2018.01.003DOI Listing
March 2019

Infant heart tumour.

Rev Port Cardiol 2018 Jan 26;37(1):93-94. Epub 2017 Dec 26.

Hospital Pediátrico de Coimbra, Serviço de Cardiologia Pediátrica, Coimbra, Portugal.

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http://dx.doi.org/10.1016/j.repc.2017.02.019DOI Listing
January 2018

Barriers to insulin initiation in elderly patients with type 2 diabetes mellitus in Brazil.

Diabetes Metab Syndr 2018 Jan - Mar;12(1):39-44. Epub 2017 Aug 25.

Sociedade Brasileira de Diabetes, Rua Afonso Braz, 579, São Paulo, São Paulo, 04511-011, Brazil. Electronic address:

Aims: We aimed to explore insulin initiation barriers in the Brazilian Type 2 Diabetes Mellitus (T2DM) elderly population, according to the physician's perspective, and suggest strategies to overcome them.

Methods: A 45-questions survey addressing issues as clinical characteristics, barriers to insulinization, and treatment strategies in elderly patients with T2DM, was sent to six endocrinologists from different Brazilian locations. Thereafter, all the respondents participated in a panel discussion to validate their responses and collect additional relevant data.

Results: Endocrinologists had at least 15 years of experience, with a mean of 63 elderly patients per month. Nearly 25% of the elderly patients were treated in the Brazilian public healthcare system (SUS, Unified Health System); only a quarter presented proper glycemic control. In contrast, 55% of the patients from private healthcare system presented adequate glycemic control. The main barriers for insulin initiation for patients, according to physicians' perspective, are side effects and negative perception over treatment (100%). For endocrinologists, main barriers were lack of time to guide patients and concern over side effects (83%). Therefore, specialists considered education for both healthcare professionals and patients as one of the most important strategies to circumvent the current scenario related insulin therapy among elderly patients in the country.

Conclusion: Insulin therapy remains underused due to several barriers, such as concern over side effects and negative perception. Educational measures for patients and HCPs could improve the current scenario.
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http://dx.doi.org/10.1016/j.dsx.2017.08.011DOI Listing
September 2018

Brazilian guidelines on prevention of cardiovascular disease in patients with diabetes: a position statement from the Brazilian Diabetes Society (SBD), the Brazilian Cardiology Society (SBC) and the Brazilian Endocrinology and Metabolism Society (SBEM).

Diabetol Metab Syndr 2017 14;9:53. Epub 2017 Jul 14.

Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil.

Background: Since the first position statement on diabetes and cardiovascular prevention published in 2014 by the Brazilian Diabetes Society, the current view on primary and secondary prevention in diabetes has evolved as a result of new approaches on cardiovascular risk stratification, new cholesterol lowering drugs, and new anti-hyperglycemic drugs. Importantly, a pattern of risk heterogeneity has emerged, showing that not all diabetic patients are at high or very high risk. In fact, most younger patients who have no overt cardiovascular risk factors may be more adequately classified as being at intermediate or even low cardiovascular risk. Thus, there is a need for cardiovascular risk stratification in patients with diabetes. The present panel reviews the best current evidence and proposes a practical risk-based approach on treatment for patients with diabetes.

Main Body: The Brazilian Diabetes Society, the Brazilian Society of Cardiology, and the Brazilian Endocrinology and Metabolism Society gathered to form an expert panel including 28 cardiologists and endocrinologists to review the best available evidence and to draft up-to-date an evidence-based guideline with practical recommendations for risk stratification and prevention of cardiovascular disease in diabetes. The guideline includes 59 recommendations covering: (1) the impact of new anti-hyperglycemic drugs and new lipid lowering drugs on cardiovascular risk; (2) a guide to statin use, including new definitions of LDL-cholesterol and in non-HDL-cholesterol targets; (3) evaluation of silent myocardial ischemia and subclinical atherosclerosis in patients with diabetes; (4) hypertension treatment; and (5) the use of antiplatelet therapy.

Conclusions: Diabetes is a heterogeneous disease. Although cardiovascular risk is increased in most patients, those without risk factors or evidence of sub-clinical atherosclerosis are at a lower risk. Optimal management must rely on an approach that will cover both cardiovascular disease prevention in individuals in the highest risk as well as protection from overtreatment in those at lower risk. Thus, cardiovascular prevention strategies should be individualized according to cardiovascular risk while intensification of treatment should focus on those at higher risk.
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http://dx.doi.org/10.1186/s13098-017-0251-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5512820PMC
July 2017

Impaired flow-mediated dilation response and carotid intima-media thickness in patients with type 1 diabetes mellitus with a mean disease duration of 4.1 years.

Arch Endocrinol Metab 2017 Dec 13;61(6):542-549. Epub 2017 Jul 13.

Endocor - Instituto de Cardiologia e Endocrinologia de São José do Rio Preto, São Paulo, SP, Brasil.

Objective: This study aimed at assessing the endothelial function in patients with Type 1 diabetes (T1DM) using flow-mediated dilation (FMD) response and carotid artery intima-media thickness (CIMT).

Materials And Methods: This study enrolled 32 T1DM patients (mean disease duration 4.1 years) and 28 age-matched controls (CTL Group). Endothelial function and CIMT were assessed with high-resolution ultrasound using standardized offline measurements.

Results: FMD was significantly lower in patients in the T1DM Group (8.9 ± 3.2%) compared with those in the CTL Group (13.3 ± 4.3%; P-value < 0.0001). Similarly, CIMT differed significantly between T1DM patients (0.525 ± 0.03 mm) and controls (0.508 ± 0.03 mm; P-value = 0.041). Even though, the values are within the normal range for age.

Conclusions: Patients with T1DM have impaired endothelial function characterized by reduced FMD when compared to controls. However, vascular remodeling as seen by increases in CIMT was not found in this study.
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http://dx.doi.org/10.1590/2359-3997000000281DOI Listing
December 2017

Incidental finding in a newborn with respiratory distress.

Einstein (Sao Paulo) 2017 Jul-Sep;15(3):378-379. Epub 2017 Jun 12.

Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

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http://dx.doi.org/10.1590/S1679-45082017AI4001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5823058PMC
May 2018

Molecular analysis reveals hidden diversity in Zungaro (Siluriformes: Pimelodidade): a genus of giant South American catfish.

Genetica 2017 Jun 13;145(3):335-340. Epub 2017 May 13.

Laboratório de Biodiversidade Molecular e Conservação, Departamento de Genética e Evolução, Universidade Federal de São Carlos, Rodovia Washington Luis km 235, 13565-905, São Carlos, SP, Brazil.

The genus Zungaro contains some of the largest catfish in South America. Two valid species are currently recognized: Zungaro jahu, inhabiting the Paraná and Paraguay basins, and Zungaro zungaro, occurring in the Amazonas and Orinoco basins. Analysing Zungaro specimens from the Amazonas, Orinoco, Paraguay and Paraná basins, based on the sequencing of COI and D-loop, we found at least three MOTUs, indicating the existence of hidden diversity within this fish group. Considering the ecological and economic values of this fish, our results are surely welcomed for its conservation, disclosing new findings on its diversity and pointing out the necessity for a detailed taxonomic revision.
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http://dx.doi.org/10.1007/s10709-017-9968-8DOI Listing
June 2017

Clinical factors predicting the therapeutic response to ustekinumab in patients with moderate to severe chronic plaque psoriasis.

J Dermatol 2017 May 18;44(5):560-566. Epub 2016 Nov 18.

Department of Dermatology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.

While ustekinumab has been widely used as an effective biologic for the treatment of chronic plaque psoriasis, no prospective studies have specifically investigated the clinical factors that may influence treatment outcomes with ustekinumab. This post-hoc analysis aimed to identify specific clinical factors that may influence treatment outcomes with ustekinumab in psoriasis patients. In the MARCOPOLO study, 102 Korean patients with moderate to severe psoriasis were analyzed to assess the influence of baseline characteristics as clinical factors on clinical response (improvement in Psoriasis Area and Severity Index by ≥75%/90% [PASI75/PASI90]) to ustekinumab. In addition, differences in PASI75 and PASI90 responses between the responder group and non-responders were evaluated at weeks 28 and 52. Multiple logistic regression analysis was used to determine adjusted clinical factors predicting treatment outcomes among patient characteristics. At week 28, there was a significant difference in PASI75/PASI90 response based on prior biologic experience, although the difference did not persist at week 52. In addition, after adjusting for the effects of relevant clinical factors, biologic experience was significantly associated with less PASI75 (odds ratio [OR] = 0.14, P = 0.001) and PASI90 (OR = 0.22, P = 0.036) responses at week 28. The presence of comorbidities was higher among non-responders than among PASI75/PASI90 responders at both weeks 28 and 52, but was not statistically significant. Previous biologic use was the only clinical factor predicting less response at week 28, although it did not influence the clinical response after week 52. Further studies are warranted to investigate the association between presence of comorbidities and clinical response.
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http://dx.doi.org/10.1111/1346-8138.13681DOI Listing
May 2017

The MARCOPOLO Study of Ustekinumab Utilization and Efficacy in a Real-World Setting: Treatment of Patients with Plaque Psoriasis in Asia-Pacific Countries.

Ann Dermatol 2016 Apr 31;28(2):222-31. Epub 2016 Mar 31.

Department of Dermatology and Cutaneous Biology Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.

Background: Ustekinumab is a fully human monoclonal antibody approved for the treatment of chronic moderate-to-severe plaque psoriasis in adults. However, factors including efficacy, tolerability, ease of use, and cost burden may affect ustekinumab utilization. Noncompliance may, in turn, affect treatment response.

Objective: To evaluate ustekinumab utilization in the real-world setting in Asia-Pacific countries.

Methods: In this phase 4 observational study conducted in Indonesia, Malaysia, Singapore, Korea, and Taiwan, adults with plaque psoriasis receiving ustekinumab were followed for up to 52 weeks. Study endpoints were the proportion of all patients using ustekinumab according to label-recommended intervals and the proportion of Korean patients who achieved a psoriasis area severity index 75 response at week 16. Safety was assessed by monitoring adverse events.

Results: Overall, 169 patients received ustekinumab (Korea, n=102; other countries, n=67). Just over half (56.2%) of patients used ustekinumab with the label-recommended interval from baseline to week 40; the proportion was higher in Korea (73.5%) than in other countries (29.9%), probably because ustekinumab was provided without charge for Korean patients up to week 40. Noncompliance increased after week 40 in Korea and from week 28 in other Asia-Pacific countries, with cost cited as the most common reason. At week 16, 56.9% of Korean patients achieved a Psoriasis Area Severity Index 75 response. Safety results were in line with those seen in previous studies.

Conclusion: More than half of all patients in Asia-Pacific countries used ustekinumab as per the label-recommended dose interval, but reimbursement variations between countries may have confounded overall results.
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http://dx.doi.org/10.5021/ad.2016.28.2.222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4828387PMC
April 2016

Assessment of Change in Psychoanalysis: Another Way of Using the Change After Psychotherapy Scales.

J Am Psychoanal Assoc 2016 04 12;64(2):285-305. Epub 2016 Apr 12.

A systematic method is presented whereby material from a full course of psychoanalytic treatment is analyzed to assess changes and identify patterns of change. Through an analysis of session notes, changes were assessed using the CHange After Psychotherapy scales (CHAP; Sandell 1987a), which evaluate changes in five rating variables (symptoms, adaptive capacity, insight, basic conflicts, and extratherapeutic factors). Change incidents were identified in nearly every session. Early in the analysis, relatively more change incidents related to insight were found than were found for the other types of change. By contrast, in the third year and part of the fourth year, relatively more change incidents related to basic conflicts and adaptive capacity were found. While changes related to symptoms occurred throughout the course of treatment, such changes were never more frequent than other types of change. A content analysis of the change incidents allowed a determination of when in the treatment the patient's main conflicts (identified clinically) were overcome. A crossing of quantitative data with clinical and qualitative data allowed a better understanding of the patterns of change.
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http://dx.doi.org/10.1177/0003065116644743DOI Listing
April 2016