TB management in the European Union/European Economic Area: a multi-centre survey.

BACKGROUND: Essential TB care in the European Union/European Economic Area (EU/EEA) comprises 21 standards for the diagnosis, treatment and prevention of TB that constitute the European Union Standards for Tuberculosis Care (ESTC).METHODS: In 2017, we conducted an audit on TB management and infection control measures against the ESTC standards. TB reference centres in five EU/EEA countries were purposely selected to represent the heterogeneous European TB burden and examine geographic variability.RESULTS: Data from 122 patients, diagnosed between 2012 and 2015 with multidrug-resistant TB (n = 49), extensively drug-resistant TB (XDR-TB) (n = 11), pre-XDR-TB (n = 29) and drug-susceptible TB (n = 33), showed that TB diagnosis and treatment practices were in general in agreement with the ESTC.CONCLUSION: Overall, TB management and infection control practices were in agreement with the ESTC in the selected EU/EEA reference centres. Areas for improvement include strengthening of integrated care services and further implementation of patient-centred approaches.

Completeness of TB notification in Portugal, 2015: an inventory and capture-recapture study.

BACKGROUND: Despite the steady decline in the last few decades, Portugal remains the Western European country with the highest TB notification rates. The aim of this study was to estimate the completeness of notification to the National Tuberculosis Programme (NTP) Surveillance System (SVIG-TB) in 2015.METHODS: We implemented an inventory study and a three-source log-linear capture-recapture analysis using two additional data sources that were deterministic and probabilistically linked: the national notifiable diseases surveillance system (Sistema Nacional de Vigilância Epidemiológica SINAVE) and the national hospital discharge database (Grupos de Diagnósticos Homogéneos GDH).RESULTS: We identified 2328 unique probable/confirmed TB cases across the three data sources. We found a positive dependency between SVIG-TB and SINAVE (incidence rate ratio IRR 8.9, 95%CI 6.6-12.0) and between GDH and SINAVE (IRR 2.6, 95%CI 2.0-3.4). After adjusting for these dependencies, we estimated that 266 cases (95%CI 198-358) were not reported, indicating a notification (to SVIG-TB) completeness rate of 77.0%.CONCLUSION: True incidence rate of TB in Portugal in 2015 could have been as high as 26.1 per 100 000. This could be an overestimation because of false-positive cases recorded in both SINAVE and GDH or on a smaller scale, false non-matches. Studies aimed at validating potentially false-positive cases should be implemented to address these limitations.

Ecophysiological traits of highly mobile large marine predators inferred from nucleic acid derived indices.

Nucleic acid-derived indices such as RNA/DNA ratios have been successfully applied as ecophysiological indicators to assess growth, nutritional condition and health status in marine organisms given that they provide a measure of tissue protein reserves, which is known to vary depending on changes in the environment. Yet, the use of these biochemical indices on highly mobile large predators is scarce. In this study, we tested the applicability of using nucleic acids to provide insights on the ecophysiological traits of two marine mammal species (common bottlenose dolphins and short-finned pilot whales) and explored potential related factors (species, sex, season, and residency pattern), using skin tissue (obtained from biopsy darts) of apparently healthy and adult free-ranging animals. Significantly higher RNA/DNA ratios were obtained for bottlenose dolphins (p < 0.001), and for visitor pilot whales when compared with resident pilot whales (p = 0.001). No significant changes were found between the sexes. Based on the percentile approach, the samples contain individuals in a general good condition (as the 10th percentile is not closer to the mean than the 75th percentile), suggesting that the studied region of Macaronesia may be considered an adequate habitat. The combination of this effective tool with genetic sexing and photographic-identification provided an overall picture of ecosystem health, and although with some limitations and still being a first approach, it has the applicability to be used in other top predators and ecosystems.

Basil, tea tree and clove essential oils as analgesics and anaesthetics in Amphiprion clarkii (Bennett, 1830).

In this study were evaluated the anaesthesia and analgesic effects of clove Eugenia caryophyllata, tea tree Melaleuca alternifolia and basil Ocimum basilicum essential oils (EO) during handling of yellowtail clownfish Amphiprion clarkii. Juveniles (3.70 ± 0.75 cm and 1.03 ± 0.50 g; mean ± standard deviation) were submitted to concentrations of 40, 50, 60, 70 and 80 µl L-1 of clove, 150, 200, 250, 300 and 350 µl L-1 of basil and 200, 300, 400, 500 and 600 µl L-1 of tea tree oils (n=10/concentration), previously defined in pilot tests. Individually and only once, fish from each treatment were placed in a glass recipient containing 1 L of seawater at a temperature of 25 °C, salinity of 35 g L-1 and the specific concentration of diluted EO (stock solution). Control (only seawater) and blank (seawater and ethanol at the highest concentration used to dilute the oils) treatments were also conducted. After reaching the stage of surgical anaesthesia, fish were submitted to biometry and a sensibility test. After that, they were transferred to clean seawater for anaesthesia recovery. The times of induction needed to reach each anaesthesia stage and anaesthesia recovery were recorded. Animals were observed for 72 hours after the procedures. All the EO provoked anaesthesia and analgesic effects in A. clarkii, but basil oil is not recommended because it caused involuntary muscle contractions and mortality in 100% and 12% of fish, respectively. The lower concentrations that promote suitable induction and recovery times are 50 µl L-1 of clove oil and 500 µl L-1 of tea tree oil. However, due to its complementary high analgesic efficiency, clove oil is recommended as the ideal anaesthetic for A. clarkii.

Community-acquired pneumonia and influenza hospitalisations in northern Portugal, 2000-2005.

Hospital admissions for pneumonia, one of the most frequent complications of influenza, are more common in children and the elderly and in individuals with chronic disease. Portugal's Northern Health Region is one of the country's five health regions, and its 3.3 million inhabitants represent approximately one third of the country's population. We conducted a retrospective study to characterise the trend and the geographical distribution of hospitalisations due to pneumonia and influenza in public hospitals in northern Portugal. The distribution of the hospitalisations was investigated using exploratory techniques of spatial analysis based on data for pneumonia and influenza cases discharged from hospital between 2000 and 2005. There were 53,314 hospitalisations due to pneumonia and influenza during that period, representing an annual average hospitalisation rate of 274 per 100,000 inhabitants. The exploratory spatial analysis showed a moderate space dependence in the region (Moran's Index=0.51, p<0.05). The local indicator of space association for each area allowed the detection of a cluster of 11 municipalities in two north-eastern districts that had higher rates of hospitalisation than the remaining regions. The results showed that the spatial distribution of hospital admissions for pneumonia and influenza is not homogeneous in northern Portugal, indicating that it is not coincidental. The significant spatial dependence highlights the need to perform further studies to examine the underlying causes of such distribution.

Infectious diseases surveillance activities in the north of Portugal, during the EURO 2004 football tournament.

A European football tournament (EURO 2004) took place in Portugal, from the 12 June to the 4 July 2004. Portugal's Northern Regional Health Authority serves a population of 3.2 million people. This region hosted 12 matches, more than any other region. We describe the communicable disease surveillance activities in the region, during EURO 2004. Ten foodborne outbreaks, seven cases of meningococcal disease and one case of legionnaires disease, were detected. Visitors were not affected, furthermore, cases among residents seemed not to be influenced by the presence of thousands of visitors. A similar pattern has been observed at other mass gatherings where special surveillance activities were implemented. This does not reduce the importance of public health surveillance during such mass gatherings. Furthermore, evaluation of this special activities should be an opportunity to put, issues of communicable disease surveillance resources, priorities, organisation and training back on the agenda.

Outbreaks caused by parvovirus B19 in three Portuguese schools.

This paper reports the study of outbreaks of an acute exanthematous disease among children of three schools in the municipality of Braga (Portugal). Laboratory tests were performed for five cases, showing that the disease was not due to infection by measles or rubella virus, and infection with parvovirus B19 was confirmed. There were 41 cases in children: 12 in the kindergarten, 17 in the secondary school and 12 in the primary school. There was only one case in a staff member, who worked in the kindergarten. Eight cases were identified among household contacts; two of them were brothers, one from the kindergarten and another from the secondary school, where the outbreak occurred after the kindergarten outbreak. The estimated values of the basic reproduction number R0 were very low and it is very likely that asymptomatic infectious cases have occurred. The local health authority produced written documents and met with staff members and parents. Primary healthcare facilities and the obstetric department of the local hospital were also informed. As we are approaching the elimination of measles in Portugal and the rest of Europe, with very high vaccine coverage, it is very likely that a high proportion of infectious non-vesicular exanthemas will be due to B19 infections. This is to be taken into account in the design and conduct of surveillance activities, in the context of measles and rubella elimination programmes.

Reply to Letter: Outbreaks caused by parvovirus B19.

We are grateful for the comments provided by Kelly and Leydon, and Bernard J Cohen. They seem to share our previously expressed opinion that 'in the context of measles and rubella elimination programs, study protocols should include data collection procedures and laboratory tests able to confirm or discard the diagnosis of B19 infections.' [1]. They have provided a useful commentary with relevant information and references.

Outbreaks caused by parvovirus B19 in three Portuguese schools.

This paper reports the study of outbreaks of an acute exanthematous disease among children of three schools in the municipality of Braga (Portugal). Laboratory tests were performed for five cases, showing that the disease was not due to infection by measles or rubella virus, and infection with parvovirus B19 was confirmed. There were 41 cases in children: 12 in the kindergarten, 17 in the secondary school and 12 in the primary school. There was only one case in a staff member, who worked in the kindergarten. Eight cases were identified among household contacts; two of them were brothers, one from the kindergarten and another from the secondary school, where the outbreak occurred after the kindergarten outbreak. The estimated values of the basic reproduction number R0 were very low and it is very likely that asymptomatic infectious cases have occurred. The local health authority produced written documents and met with staff members and parents. Primary healthcare facilities and the obstetric department of the local hospital were also informed. As we are approaching the elimination of measles in Portugal and the rest of Europe, with very high vaccine coverage, it is very likely that a high proportion of infectious non-vesicular exanthemas will be due to B19 infections. This is to be taken into account in the design and conduct of surveillance activities, in the context of measles and rubella elimination programmes.

Long-term effect of lovastatin on lipoprotein profile in patients with primary nephrotic syndrome.

Eight patients with biopsy-proven primary nephrotic syndrome were included in an open, prospective, two-year study of lovastatin. One patients was withdrawn after 6 months due to an asymptomatic rise in creatinine phosphokinase, which was rapidly reversed after interruption of lovastatin. In the remaining patients, treatment was well-tolerated and produced no side effects. After 2 years of treatment, these 7 patients had decreases in total cholesterol from 446 +/- 165 to 250 +/- 57 mg/dl (p < 0.001), LDL cholesterol from 343 +/- 121 to 174 +/- 49 mg/dl (p < 0.001), Apo B lipoprotein from 162 +/- 60 to 108 +/- 42 mg/dl (p < 0.05), triglycerides from 336 +/- 273 to 182 +/- 71 mg/dl (p < 0.04). There was no change in HDL cholesterol. The LDL/HDL cholesterol and the total/HDL cholesterol ratios fell from 15.0 +/- 12.1 and 19.1 +/- 17.2 mg/dl before the study to 4.4 +/- 1.2 and 6.3 +/- 1.6 mg/dl, respectively, at 2 years. A decrease in proteinuria from 8.6 +/- 4.6 to 5.0 +/- 3.7 g/24 h (p < 0.02) was noted in 4 patients on concomitant ACE inhibitor therapy. Renal function remained stable in all patients throughout the study, except for one whose moderate impairment progressed to end-stage renal failure requiring dialysis 3 months poststudy. We conclude that long-term lovastatin in patients with primary nephrotic syndrome is an effective and generally safe treatment for accompanying dyslipidemia.

Foodborne outbreaks in northern Portugal, 2002.

In October 2001, foodborne outbreaks (FBO) were included in the Portuguese alert and response surveillance system. Accordingly, the northern regional health authority (Delegado Regional de Saude do Norte--DRSN) began a surveillance programme of foodborne outbreaks. This report is a brief description of data generated from this programme in 2002. For each foodborne outbreak the local health authority (Delegado de Saude Concelhio--DSC) produced a written report. Fifty-nine percent of the 27 FBOs studied by DSCs during 2002 were reported within 72 hours after the date of onset. Five hundred and seventy seven people became ill, 9.6% of the patients were admitted to hospital, and no deaths were reported. The aetiological agent was identified from patients in 63% of FBOs, and in food items in 18.5% of the situations. Salmonella enterica was responsible for 73.7% of the outbreaks in which the agent was laboratory confirmed. Meals implicated in the outbreak were mainly prepared in restaurants and private homes (75.0% of FBO). Inadequate processing, preparing or handling of foods were the contributing factors more often reported by the DSC. We believe that epidemiological surveillance and control of FBO must be reinforced in Portugal as part of a wider strategy to promote food safety.

An outbreak of legionnaires' disease in a municipality in northern Portugal.

Eleven cases of legionnaires' disease, all patients living in the same municipality, were admitted to a district hospital in northern Portugal. Preliminary investigations suggested an association with the events of the annual festivities in that municipality. Legionella pneumophila was not isolated from any of the suspected sources, but evidence from a case control study suggested that an aerosol produced by a decorative fountain in the main square during the night of a rock concert was the likely vehicle of infection. The prevalence of smoking was higher among cases than controls.

An outbreak of legionnaires disease in a municipality in northern Portugal.

Eleven cases of legionnaires disease, all patients living in the same municipality, were admitted to a district hospital in northern Portugal. Preliminary investigations suggested an association with the events of the annual festivities in that municipality. Legionella pneumophila was not isolated from any of the suspected sources, but evidence from a case control study suggested that an aerosol produced by a decorative fountain in the main square during the night of a rock concert was the likely vehicle of infection. The prevalence of smoking was higher among cases than controls.

[Acute renal insufficiency as presentation form of multiple myeloma]. / Insuficiência renal aguda como forma de apresentação do mieloma múltiplo.

Multiple Myeloma (MM) causes a wide range of serious clinical, alterations, including acute renal failure (ARF) often present and contributing to the global mortality of this neoplasm. ARF usually occurs well after MM is diagnosed. We describe a case of ARF in a 42 years old male patient requiring urgent hemodialysis that subsequently proved to have MM. The singularity of this case lead us to review cases of ARF admitted to the Nephrology Department between 1978 and 1990. We describe 7 patients (4 male) with ARF as presenting form of MM. Their mean +/- SD age was 60.0 +/- 10.6 (range 42-73). ARF with conserved diuresis was the presenting form in 6, 5 has systemic infection, and none was hypertensive. Replacement therapy with hemodialysis was needed in 6 patients and plasmapheresis was performed in 3. 4 patients died while admitted, 2 were discharged on chronic hemodialysis and there was recovery of renal function in 1 patient.

[Kidney disease and pregnancy. Experience at the nephrology unit of Saint Mary's Hospital]. / Doença renal e gravidez. Experiência da Consulta de Nefrologia do H.S.M.

29 pregnancies in 27 renal patients were reviewed. The etiology of renal disease was mainly glomerular (14 patients). At the beginning of pregnancy 11 patients had renal failure and 14 patients had a high blood pressure. Only two patients had pregnancy related worsening of the renal function (the two patients had a normal renal function before pregnancy). Maternal morbidity was infrequent with no mortality. Fetal loss was 21.5% related to prematurity. There were no congenital anomalies. Renal failure at the beginning of pregnancy caused an obstetric risk factor. (greater fetal prematurity and mortality).

[Cytomegalovirus infection in kidney transplantation]. / Infecção por citomegalovírus no transplante renal.

150 patients, subjected to kidney graft transplantation between January 1988 and December 1989, were studied. Mean +/- 95% CL age was 37.5 +/- 2.03 (range 12-69) years. IgG and IgM antibodies levels (ELISA) cytomegalovirus (CMV) were investigated in the donor before organ harvesting and in the kidney recipients on 1st and 21th days and then on the 3rd, 6th and 9th months after transplantation. Patients lacking either donor or 1st day studies were excluded. 133 donor (D) receptor (R) pairs were classified as group 1) D+/R+, 2) D+/R-, 3) D-/R+ e 4) D-/R-. Prevalence, severity of CMV disease and date of diagnosis were studied. Mean time +/- 95% CI of diagnosis after transplantation was 78.4 +/- 15.1 days. Seronegative receptors had a statistically significant higher prevalence of the disease as to seropositive receptors, but not a higher incidence of disease severity. One out of five patients had a serious form of disease. Hiperimmune globulin was used in 15 patients (all serious forms and 3 moderate forms of of disease). No patient died as a result of CMV infection.

Confirming the diagnosis of tuberculosis in children in Northern Portugal.

Childhood tuberculosis (TB) is difficult to diagnose and there are no standardised case definitions. TB records of patients aged >5 years reported in Northern Portugal between 2000 and 2009 were reviewed. Of the 116 children diagnosed with TB, 72 (62.1%) were male; the mean age was 2.2 ± 1.2 years. Of the 32 children (27.6%) with confirmed TB, only 46.7% had provided samples for culture, showing that little effort is made to obtain specimens for confirmation. We could not identify independent factors associated with the low rate of sample collection or anti-tuberculosis treatment without confirmation; chest radiography lesions were less frequent in children who began treatment without confirmation (adjusted OR 0.23, 95%CI 0.05-0.98).

Basil, tea tree and clove essential oils as analgesics and anaesthetics in Amphiprion clarkii (Bennett, 1830) / Óleos essenciais de manjericão, melaleuca e cravo como anestésicos e analgésicos em Amphiprion clarkii (Bennett, 1830)

Abstract In this study were evaluated the anaesthesia and analgesic effects of clove Eugenia caryophyllata, tea tree Melaleuca alternifolia and basil Ocimum basilicum essential oils (EO) during handling of yellowtail clownfish Amphiprion clarkii. Juveniles (3.70 ± 0.75 cm and 1.03 ± 0.50 g; mean ± standard deviation) were submitted to concentrations of 40, 50, 60, 70 and 80 µl L-1 of clove, 150, 200, 250, 300 and 350 µl L-1 of basil and 200, 300, 400, 500 and 600 µl L-1 of tea tree oils (n=10/concentration), previously defined in pilot tests. Individually and only once, fish from each treatment were placed in a glass recipient containing 1 L of seawater at a temperature of 25 °C, salinity of 35 g L-1 and the specific concentration of diluted EO (stock solution). Control (only seawater) and blank (seawater and ethanol at the highest concentration used to dilute the oils) treatments were also conducted. After reaching the stage of surgical anaesthesia, fish were submitted to biometry and a sensibility test. After that, they were transferred to clean seawater for anaesthesia recovery. The times of induction needed to reach each anaesthesia stage and anaesthesia recovery were recorded. Animals were observed for 72 hours after the procedures. All the EO provoked anaesthesia and analgesic effects in A. clarkii, but basil oil is not recommended because it caused involuntary muscle contractions and mortality in 100% and 12% of fish, respectively. The lower concentrations that promote suitable induction and recovery times are 50 µl L-1 of clove oil and 500 µl L-1 of tea tree oil. However, due to its complementary high analgesic efficiency, clove oil is recommended as the ideal anaesthetic for A. clarkii.

Resumo Neste estudo foram avaliados os efeitos anestésicos e analgésicos dos óleos essenciais (OE) de cravo Eugenia caryophyllata, melaleuca Melaleuca alternifolia e manjericão Ocimum basilicum durante manejo de peixes-palhaços Amphiprion clarkii. Juvenis (3.70 ± 0.75 cm e 1.03 ± 0.50 g; média ± desvio padrão) foram submetidos às concentrações de 40, 50, 60, 70 e 80 µl L-1 de cravo, 150, 200, 250, 300 e 350 µl L-1 de manjericão e 200, 300, 400, 500 e 600 µl L-1 de melaleuca (n=10/concentração), previamente definidas em testes pilotos. Individualmente e somente uma vez, os peixes de cada tratamento foram colocados em recipiente de vidro contendo 1 L de água salgada, em temperatura de 25 °C, salinidade de 35 g L-1 e a concentração específica de OE diluída (solução estoque). Tratamentos controle (apenas água marinha) e branco (água marinha e a maior concentração de etanol utilizada para diluição dos óleos) também foram conduzidos. Após atingirem o estágio de anestesia cirúrgica, os peixes foram submetidos à biometria e teste de sensibilidade. Em seguida, foram transferidos para água marinha limpa. Os tempos necessários para atingir cada estágio anestésico e recuperação foram registrados. Os animais foram observados por 72 horas após os procedimentos. Todos os OE provocaram anestesia e analgesia em A. clarkii, porém o óleo de manjericão não é recomendado, pois causou contrações musculares involuntárias e mortalidade em 100% e 12% dos animais, respectivamente. As menores concentrações que promovem indução anestésica e recuperação em tempos adequados são 50 µl L-1 de óleo de cravo e 500 µl L-1 de óleo de melaleuca. Entretanto, devido à sua alta eficiência analgésica complementar, o óleo de cravo é recomendado como o anestésico ideal para A. clarkii.