Cordon sanitaire, a necessary evil? Evaluation of non-pharmacological interventions against COVID-19 in Ovar, Portugal.

BACKGROUND AND AIM: From March 17 to April 17, 2020, the Portuguese municipality of Ovar was submitted to a cordon sanitaire due to a COVID-19 outbreak. During this period a whole Public Health structure had to be built up to respond to the healthcare needs of the population. The aim of this work is to contribute to the evidence on the efficacy of cordon sanitaire as an epidemic control strategy. METHODS: All the major institutions in Ovar, both health and socially related, were called from the first day to form a Crisis Cabinet. Case tracking was assured by the creation of an online database. A major telephone network oversaw contact tracing, isolation mandates and surveillance. A massive testing structure was built up, and clinical assistance was assured by the local hospital and the Primary Care units. Patient referral to testing and clinical visits were made through online forms that allowed an efficient response and data for epidemiologic research. RESULTS: A decline in the daily number of cases was seen after an incubation period (14 days), confirming lockdown was effective in blocking transmission chains. Besides, neighbouring municipalities were not significantly affected in relation to others. Lethality was bigger in Ovar than in whole Portugal. CONCLUSIONS: The decrease in the incidence, in the reproductive number and the non-affection of neighbouring municipalities appear to prove the cordon sanitaire as an effective Public Health measure to contain epidemics. However, an appropriate mitigation strategy must be adopted to conceal the challenge.

CHEST WALL RECONSTRUCTION USING CUSTOMIZED NEO-RIBS: CASE REPORT.

Chest wall tumours are challenging subjects. In the present article we describe a case of a 51 year old female who developed an angiosarcoma eight years after radiotherapy treatment due to left breast cancer at age 41. She had resection of the anterior segments of the 3rd to 5thribs followed by chest wall reconstruction, using MatrixRib fixation system®, Marlex® mesh and latissimus dorsi muscle flap. After two years the angiosarcoma relapsed. Considering the predicted extent of the chest wall resection, a reconstruction using titanium plates was not an option, so we opted to shape neo-ribs of Methyl Methacrylate using rubber drains as a mold. It affords very good anatomical contour of the chest wall and more physiological function than other options, although only long-term follow-up and future studies will determine the performance of this method.

Radiculopathy in a patient with chronic tophaceus gout: vertebral imaging.

INTRODUCTION: Spinal involvement is infrequent in chronic gout. However, some cases of back pain with radiculopathy secondary to this etiology have been reported. CASE REPORT: 56-year old male patient, with history of arterial hypertension, hypertriglyceridemia, obesity, glucose intolerance and alcohol abuse, diagnosed with gout in his fifth decade of life. The patient was started on urate lowering therapy, with poor compliance, and evolved with sustained hyperuricemia, recurrent episodes of arthritis, and growth of gouty tophi on the elbows, wrists, hands and knees. In 2011, the patient presented with radiculopathy. When pain recurred, a Computed Tomography was performed and it showed alterations compatible with spinal tophi formation and nerve root involvement. DISCUSSION/CONCLUSIONS: Our clinical case is another example of how gout can produce spinal inflammation and nerve damage and superimpose on previously damaged joints and how patients' compliance to therapeutics may have an important impact on prognosis.

The Portuguese Society of Rheumatology position paper on the use of biosimilars.

Biotechnological drugs have become a fundamental resource for the treatment of rheumatic patients. Patent expiry of some of these drugs created the opportunity for biopharmaceutical manufacturers to develop biosimilar drugs intended to be as efficacious as the originator product but with a lower cost to healthcare systems. Due to the complex manufacturing process and highly intricate structure of biologicals, a biosimilar can never be an exact copy of its reference product. Consequently, regulatory authorities issued strict preclinical and clinical guidelines to ensure safety and efficacy equivalence and, in September 2013, the biosimilar of infliximab was the first biosimilar monoclonal antibody to be authorized for use in the European Union. The current document is a position statement of the "Sociedade Portuguesa de Reumatologia" (Portuguese Society of Rheumatology) on the use of biosimilar drugs in rheumatic diseases. Two systematic literature reviews were performed, one concerning clinical trials and the other one concerning international position papers on biosimilars. The results were presented and discussed in a national meeting and a final position document was discussed, written and approved by Portuguese rheumatologists. Briefly, this position statement is contrary to automatic substitution of the originator by the biosimilar, defends either a different INN or the prescription by brand name, supports that switching between biosimilars and the originator molecule should be done after at least 6 months of treatment and based on the attending physician decision and after adequate patient information, recommends the registration of all biosimilar treated patients in Reuma.pt for efficacy, safety and immunogenicity surveillance, following the strategy already ongoing for originators, and opposes to extrapolation of indications approved to the originator to completely different diseases and/or age groups without adequate pre-clinical, safety or efficacy data.

Metallo-beta-lactamase VIM-2 in Pseudomonas aeruginosa isolates from a cystic fibrosis patient.

The increased incidence of Pseudomonas aeruginosa isolated from patients with cystic fibrosis (CF) along with an increase in its multidrug resistance makes therapeutic management very problematic. Careful identification and accurate studies of susceptibility to antibiotics are critical for improving therapeutic measures and for facilitating our understanding of the epidemiology of this pathogen. Fifteen P. aeruginosa isolates obtained from five CF children in the Paediatric Hospital of Coimbra were studied. Isolates from a female patient were resistant to all agents tested except colistin. A VIM-2 enzyme inserted in integron In58 was detected, and this isolate presented a unique random amplified polymorphic DNA (RAPD) type. Others isolates were susceptible to beta-lactams, and each isolate had a different RAPD type. VIM-2 confers resistance to the majority of beta-lactams and is associated with other gene cassettes coding for enzymes that inactivate aminoglycosides. Person-to-person transmission of these isolates is not well understood, therefore it is important to design infection control policies to avoid acquisition and dissemination of multiresistant strains.

Molecular characterization of bla(IMP-5), a new integron-borne metallo-beta-lactamase gene from an Acinetobacter baumannii nosocomial isolate in Portugal.

Acinetobacter baumannii 65FFC, an imipenem-resistant clinical strain, isolated from the urine of a patient at the Coimbra University Hospital, Portugal, in 1998, produced a metallo-beta-lactamase with a calculated pI 9.3. The isolate was highly resistant to penicillins, broad-spectrum cephalosporins, including ceftazidime, ceftriaxone, cefepime, cefpirome, and to aztreonam, but it remained susceptible to ampicillin/sulbactam, aminoglycosides and quinolones. Nucleotide sequence revealed a new allelic variant of other bla(IMP) genes, named bla(IMP-5). IMP-5 beta-lactamase showed a greater homology with IMP-1, IMP-3 and IMP-4 (identified in Southeast Asia), than with IMP-2, found in Italy (93%, 92%, 91% and 87% of amino acid identity, respectively). bla(IMP-5) was the only gene cassette inserted into a class 1 integron, named In76. This is the first IMP-enzyme reported in Portugal and the second in Europe, indicating a wider dissemination in the environment of bla(IMP) alleles.

Metallo-beta-lactamase VIM-2 in clinical isolates of Pseudomonas aeruginosa from Portugal.

Resistance to carbapenems is emerging, and it is a great problem to therapeutics. Three isolates of Pseudomonas aeruginosa from a Portuguese hospital identified in urine and sputum, in 1995, presented a high-level resistance to imipenem (> 32 mg/L). Afterward, one isolate of P. aeruginosa recovered from urine of an ambulatory patient in 1998 showed high resistance to imipenem and meropenem. The resistance to carbapenems in these strains was associated with the production of a class B beta-lactamase, as was demonstrated by imipenem hydrolysis and inhibition by EDTA. Using primers described for bla(IMP) and bla(VIM), the amplification of the latter was observed in all isolates and a VIM-2 metallo-enzyme was identified. The pulsed-field gel electrophoresis (PFGE) patterns of these isolates were indistinguishable, suggesting dissemination to the community of this VIM-2 producer.