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- Diaphragm ultrasound for muscle strength assessment: a systematic literature reviewPublication . Leote, João; Monteiro, Margarida; Rocha, Cláudia; Rodrigues, Carolina; Pereira, Marco; Antunes, Maria Luz; Dias, Maria Hermínia Monteiro BritesObjective: To assess if diaphragmatic ultrasound (DU) reflects diaphragmatic muscle strength when compared to respiratory tests and neurophysiological studies. Methods: A systematic literature review was conducted on adults undergoing DU, compared to any respiratory or neurophysiological technique. The search strategy was applied in PubMed, Scopus, and Web of Science, and the analysis was conducted using the PRISMA methodology. Three eligibility assessment stages were performed: title, abstract, and full-text reading. The risk of bias was evaluated using the RoB 2.0, ROBINS-I, and Newcastle-Ottawa Scale tools. Results: Out of 155 identified articles, 25 were selected for full-text review (14 non-randomised studies, 8 case-control studies, and 3 randomised studies). The overall risk of bias was moderate, with the main biases related to population selection and intervention assessment. Twenty-three articles used maximal inspiratory pressure measurement as a comparator, which showed a weak-to-moderate correlation, significant in 10 studies, with diaphragmatic excursion. Three studies reported a weak association between diaphragmatic thickening and sniff pressure. Five articles reported a concordant correlation between diaphragmatic thickening and compound muscle action potential amplitude, significant only in one study. Conclusion: The variability of results obtained across different pathologies does not support the use of DU alone to predict diaphragmatic muscle strength.
- School air quality and thermal comfort: a multi-pollutant seasonal assessmentPublication . Charres, Isabel; Furst, Leonardo; Vicente, Estela D.; Soares, Marlene; Viegas, Carla; Cervantes, Renata; Pena, Pedro; Cerqueira, Mário; Feliciano, Manuel; Alves, CéliaAs evidence of children's vulnerability to air pollution grows, research on school air quality has increased significantly in the 21st century. Given the complex factors influencing indoor and outdoor air quality in schools, each study offers valuable insights. This study contributes by assessing particulate matter, gaseous pollutants, thermal comfort, and microorganisms in a large school encompassing different education levels over two seasons. The assessment combined passive and continuous sampling using various techniques, including chromatography and estimations of air change and ventilation rates. Classroom ventilation was insufficient to ensure adequate air renewal. During class hours, CO2 concentrations ranged from 760 to 1,118 ppm in winter and from 807 to 1,022 ppm in spring, repeatedly exceeding 1,000 ppm. CO2 and PM10 concentrations were significantly higher during school hours than when the classrooms were empty, indicating the strong influence of school activities. In contrast, PM1 and PM2.5 concentrations were more influenced by external factors, especially outside of school hours. The lack of thermal comfort created an unhealthy environment. Carbonyl concentrations were higher in classrooms (average: 68.8 μg m−3) compared to the schoolyard (3.86 μg m−3), in both seasons. Microbial analysis revealed the presence of fungi with toxigenic potential, with the highest fungal diversity observed in spring. These findings highlight that while some pollutant levels may appear low, they can occasionally reach extremely high levels, even in newer buildings. The novelty of this research lies in demonstrating that, despite recent improvements and numerous studies, significant progress is still needed to ensure healthier school settings.
- Overview of systematic reviews on treatments for pulmonary arterial hypertension: assessing methodological quality and mapping evidence gapsPublication . Vilela, Ana Paula Oliveira; Deffert, Flávia; Tonin, Fernanda; Pontarolo, RobertoBackground: Higher quality scaled-up evidence on pulmonary arterial hypertension (PAH), a rare and life-threatening disease, is needed to support informed decision-making. We aimed to map the current knowledge of PAH treatments and evaluate the methodological quality of published systematic reviews. Methods: An overview with literature searches in PubMed and Embase (May 2025) was performed (CRD42023414469). The methodological and reporting quality of the eligible records was assessed using the Measurement Tool to Assess Systematic Reviews (AMSTAR 2) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist, respectively. Association analyses between tools' scores with key variables (article publication date, journal impact factor, country/region) were performed (SPSS v.28). An evidence map summarizing the most reported treatments and outcomes was also built. Results: Overall, 57 systematic reviews (n = 52; 91.2% with meta-analysis) published between 1997 and 2025 (median year 2017), authored mostly by countries from Asia (n = 35; 61.4%) and North America (n = 12; 21.1%), were included. The classes of phosphodiesterase type-5 inhibitors, endothelin receptor antagonists, prostanoids, and combination therapies were each assessed in one-third of the studies. Over 20 different outcomes were reported, with the most common surrogate endpoints being 6-minute walking distance (n = 42; 73.7%) and mean pulmonary arterial pressure (n = 33; 57.9%). Most studies were classified as having critically low methodological quality (n = 48; 84.2%), with only three presenting high-quality methodology according to AMSTAR 2. The mean PRISMA score was 21.3 ± 2.9, indicating an adherence rate of 78.9% to the checklist among authors. Although there was an improvement over time in the quality of the reviews (p = 0.016 for AMSTAR; p = 0.002 for PRISMA), no correlations were found based on country or journal impact factor. Conclusions: Methodological weaknesses remain common in systematic reviews of PAH; therefore, enforcing compliance with guidelines and standardizing outcome measurements through a core outcome set is crucial for improving data comparability and clinical application. Registration: PROSPERO identifier no. CRD42023414469.
- Exercise prescription for frail older adults: impact on handgrip strength and gait speed (a systematic review)Publication . Carvalho, Andreia; Palma, Vânia Cerqueira; Tomás, Maria TeresaIntroduction: Frailty necessitates effective exercise interventions, yet optimal prescriptions remain unclear. This study aimed to determine such a prescription to improve gait speed and/or handgrip strength in frail older adults. Methods: A systematic review following PRISMA, using PEDro, MEDLINE, Scopus, and Web of Science databases, was performed. The evidence certainty was assessed with GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Results: Six studies (628 frail older adults) were included. Combined exercise program, with a frequency between two-three times a week, an intensity of moderate to intense, and a duration of each session of 45–60 minutes, yielded the most significant improvements in gait speed (good evidence with very low certainty) and handgrip strength (good evidence with low certainty). Discussion: Handgrip strength and gait speed are likely to improve or be maintained after a combined exercise program of moderate or high intensity performed two to three times a week for at least 45 minutes, in frail older adults.
- The comet assay as a tool in human biomonitoring of exposure to heavy metals: a systematic review and meta-analysisPublication . Møller, Peter; Bankoglu, Ezgi Eyluel; Stopper, Helga; Gajski, Goran; Gerić, Marko; Haveric, Anja; Azqueta, Amaya; Giovannelli, Lisa; Collins, Andrew; Ladeira, CarinaExposure to heavy metals such as lead, arsenic, and chromium is associated with genotoxicity and increased risk of cancer. In this systematic review and meta-analysis, we have assessed the effects of heavy metal exposure on levels of DNA strand breaks in leukocytes, measured by the comet assay, in human biomonitoring studies. We distinguish between traditional toxic metals (lead), semi-metals/metalloids (arsenic), transition metals (chromium), and other heavy metals. The literature search led to 66 studies, which were assessed by meta-analysis. Using standardized mean difference and 95 % confidence interval (CI), the meta-analyses show increased levels of DNA strand breaks in subjects exposed to lead (1.99, 95 % CI: 1.47, 2.51), arsenic (1.36, 95 % CI: 0.94, 1.77), chromium/welding fume (2.03, 95 % CI: 1.48, 2.57), and other heavy metals (0.81, 95 % CI: 0.45, 1.18). Subgroup analysis indicates that all studies combined from middle-income countries have a higher effect size (1.99, 95 % CI: 1.63, 2.35) than studies from high-income countries (0.81, 95 % CI: 0.37, 1.26). The lower effect size in high-income countries may be due to differences in exposure levels, related to stricter regulation of emissions or more awareness/use of personal protective equipment in the working environment. Sensitivity analysis does not unequivocally link effect size to comet assay measurement bias, inferred by insufficient information on comet assay procedures, missing assay controls, non-blinded analysis of samples, or exposure misclassification. In conclusion, this systematic review and meta-analysis shows that exposure to heavy metals - lead, arsenic, and chromium - is associated with increased levels of DNA strand breaks in human leukocytes.
- The comet assay as a tool in human biomonitoring studies: effects of confounding factorsPublication . Møller, Peter; Gajski, Goran; Gerić, Marko; Giovannelli, Lisa; Azqueta, Amaya; Haveric, Anja; Stopper, Helga; Bankoglu, Ezgi Eyluel; Collins, Andrew; Ladeira, CarinaThe comet assay is widely used in human biomonitoring studies of environmental and occupational exposures. However, it is clear from multiple studies that various types of confounding factors might affect the direct relationship between exposure and DNA damage in the comet assay. In addition to common confounders such as age, sex, and smoking, other factors considered to be important determinants for background levels of DNA damage in the comet assay include exhaustive physical exercise, chronic diseases, medical treatment, and diet. These are typically controlled in biomonitoring studies by restriction or matching of subjects. Period effects (or seasonal variation) have been observed in a relatively large number of studies. There are various putative factors, which may cause period effects, including temporal variation in solar radiation, temperature, and air pollution. The present review describes the effects of these confounding factors in measurements of DNA strand breaks by the comet assay. In general, the literature does not indicate that any confounding factor is consistently associated with an increased level of DNA damage, measured by the comet assay. In this respect, it is important to balance the need to control for confounding with the risk of introducing in the statistical analysis a variable, which is influenced by exposure and outcome (i.e. collider bias). In addition, it is important that investigators describe procedures for controlling the effect of confounding factors in the selection of subjects and statistical analysis. Care should be taken in study design and statistical analysis to avoid unwanted effects of confounding factors.
- Predictors of father-infant attachment security in a Portuguese samplePublication . Almeida, Rita; Barros, Luísa; Santos, Margarida; Beeghly, Marjorie; Fuertes, MarinaA growing literature shows that fathers play a critical role in their children's development and mental health. However, few studies have evaluated fathers as caregivers and attachment figures, particularly across cultures. We address this gap by investigating specific predictors of infant-father attachment patterns during the first year postpartum and their links to infant-father attachment at 12 months. The sample included Portuguese father-infant dyads who were recruited at the infant's birth and followed longitudinally to 12 months. At 3 and 9 months, dyads were observed during free play and the Face-to-Face Still-Face paradigm (FFSF). Fathers also reported on their involvement in daily caregiving activities. At 12 months, father-infant dyads were observed in Ainsworth's Strange Situation paradigm (SSP), and fathers reported on their parenting stress. Results showed that multiple infant and paternal variables were associated with secure attachment at 12 months, including a social-positive regulatory pattern exhibited in the FFSF at 9 months, greater paternal sensitivity and less control, and more infant cooperation, during free play at 3 and 9 months, and greater paternal involvement in specific caregiving activities at 9 months. Fathers of infants with a disorganized attachment were less involved in play interactions at 3 and 9 months, and their infants exhibited less cooperative behavior and were more likely to display an inconsolable regulatory pattern during the FFSF. Results of binary logistic regression indicate that 9-month paternal sensitivity and control predicted secure attachment. This study confirms the uniqueness of father-infant relationships.
- Thickness profile of the ganglion cell complex and choroid in patients with persistent diabetic macular edemaPublication . Condelipes, Ana; Correia, Daniela; Fernandes, Inês; Silva, Tiago; Correia, Eduardo; Pereira, Bruno; Camacho, PedroPurpose: Approximately 40% of patients with diabetic macular edema (DME) do not respond optimally to first-line treatment with intravitreal injections of anti-vascular endothelial growth factor (VEGF). Evidence suggests that additional vascular and neurodegenerative mechanisms may be involved. This study aimed to characterise the thickness of the Ganglion Cell Complex (GCC) and investigate the Choroidal Vascularity Index (CVI) in patients with different patterns of therapeutic response to AVEGF DME. Methods: This cross-sectional study included 27 diabetic patients divided into three groups based on their response to AVEGF therapy: a control group, a responder DME group, and a persistent DME group. The study's approach to vascular and neurodegenerative imaging biomarkers involved three steps: (1) Automatic quantification of GCC thickness, with manual correction when necessary; (2) Semi-automatic measurement of choroidal thickness; and (3) Analysis of choroidal area and choroidal luminal area using ImageJ software to calculate the CVI. Results: In the overall characterization of the sample, a significant difference was observed only in the Best Corrected Visual Acuity (BCVA). There was a significant difference in Average Retinal Thickness (1 mm, 3 mm, and 6 mm) between the 3 groups and in GCC thickness at 1 mm. BCVA was negatively correlated with mean retinal thickness, while CVI showed a potential positive correlation with BCVA. Conclusions: While demographic and general clinical characteristics showed minimal differences across the groups, important differences in GCC and choroidal characteristics were observed. GCC (1 mm) may be interesting to explore in predicting visual outcomes after treatment, and CVI may impact visual gain.
- Exploring athlete perceptions and nutritional supplement marketing: preliminary insights from the IRIS ProjectPublication . Tavares, Ana Sofia; Borrego, Rute; Barkoukis, Vassilis; Despoina, Ourda; Kostelo, Jukka; Lemattila, Mikko; Todorova, Teodorina; Nikolova, Eva; Liivsalu, Kadri; Jukk, Marit; Bingham, Kevin; Lazuras, LambrosNutritional supplement use has become ubiquitous among athletes at all levels of competition, driven by aggressive marketing campaigns and the promise of enhanced performance. The present research, integrated on the project “Improving athletes' risk appraisal and informed decision-making towards nutritional supplement use in recreational and competitive sport – IRIS”, funded by the European Union through ERASMUS+ Call on Sport Programme, investigates the widespread use of nutritional supplements among athletes across six European countries, highlighting consumption patterns, risk awareness, and regulatory effectiveness amid rising doping violations and health concerns. A mixed-methods approach was used, including surveys of 468 athletes and interviews with 22 competitors. Findings revealed significant national differences in supplement use, with over 60% of athletes in Finland and Portugal using supplements regularly, while only 45% did so in Greece. The study found a gender disparity, with male athletes showing 23% higher usage rates. Despite high usage, awareness of contamination risks was variable, with only 28% of athletes consistently verifying supplement quality. Misleading marketing was prevalent, with 73% of athletes encountering exaggerated claims. Regulatory challenges were evident, as only 12% of athletes could identify relevant regulatory bodies, and 68% of national markets lacked standardized contamination testing. The study emphasizes the need for enhanced regulation, including mandatory testing, standardized risk disclosures, and clear labelling. It also advocates for consumer protection measures and educational initiatives to raise awareness about supplement risks. The conclusions call for coordinated action among regulators, sports organizations, and public health authorities to safeguard athletes' health and uphold competitive integrity.
- Cardiotoxicidade: avaliação do strain da aurícula esquerda por ETTPublication . Sousa, Rui; Silva, Joana; Henriques, Madalena; Cavaco, Sofia; Clérigo, Anália Matos; Fonseca, VirgíniaIntrodução: O cancro da mama é uma das neoplasias malignas mais prevalentes, sendo a cardiotoxicidade induzida pelo tratamento com antraciclinas e trastuzumab uma complicação importante, associada à disfunção miocárdica e à insuficiência cardíaca. O ecocardiograma transtorácico (ETT) é considerado o método gold standard na avaliação da função cardíaca, sendo a fração de ejeção do ventrículo esquerdo (FEVE) e o strain longitudinal global (GLS) os principais parâmetros utilizados para a deteção precoce de cardiotoxicidade. O strain da aurícula esquerda (AE) representa a deformação miocárdica desta estrutura e a sua avaliação é realizada com base em três parâmetros principais, entre os quais se destaca o peak atrial longitudinal strain (PALS) por melhor refletir a função global da AE. O strain da AE surge, deste modo, como um potencial marcador precoce de cardiotoxicidade induzida pela quimioterapia. Objetivo: Avaliar o strain da aurícula esquerda, por ETT, como preditor de cardiotoxicidade, em diferentes fases do tratamento com antraciclinas e trastuzumab, em mulheres com neoplasia da mama.