Early detection of interstitial lung disease in rheumatic diseases: A joint statement from the Portuguese Pulmonology Society, the Portuguese Rheumatology Society, and the Portuguese Radiology and Nuclear Medicine Society.

INTRODUCTION: Interstitial lung disease (ILD) contributes significantly to morbidity and mortality in connective tissue disease (CTD). Early detection and accurate diagnosis are essential for informing treatment decisions and prognosis in this setting. Clear guidance on CTD-ILD screening, however, is lacking. OBJECTIVE: To establish recommendations for CTD-ILD screening based on the current evidence. METHOD: Following an extensive literature research and evaluation of articles selected for their recency and relevance to the characterization, screening, and management of CTD-ILD, an expert panel formed by six pulmonologists from the Portuguese Society of Pulmonology, six rheumatologists from the Portuguese Society of Rheumatology, and six radiologists from the Portuguese Society of Radiology and Nuclear Medicine participated in a multidisciplinary discussion to produce a joint statement on screening recommendations for ILD in CTD. RESULTS: The expert panel achieved consensus on when and how to screen for ILD in patients with systemic sclerosis, rheumatoid arthritis, mixed connective tissue disease, Sjögren syndrome, idiopathic inflammatory myopathies and systemic lupus erythematous. CONCLUSIONS: Despite the lack of data on screening for CTD-ILD, an expert panel of pulmonologists, rheumatologists and radiologists agreed on a series of screening recommendations to support decision-making and enable early diagnosis of ILD to ultimately improve outcomes and prognosis in patients with CTD.

Effects of respiratory muscle training on parasympathetic activity in diabetes mellitus.

This study verified the effects of respiratory muscle training (RMT) on hemodynamics, heart rate (HR) variability, and muscle morphology in rats with streptozotocin-induced diabetes mellitus (DM). Thirty-six male Wistar rats were randomized into 4 groups and 34 completed the study: i) sham-sedentary (Sham-ST; n=9); ii) sham-RMT (Sham-RMT; n=9); iii) DM-sedentary (DM-ST; n=8); and iv) DM-RMT (DM-RMT; n=8). Hemodynamics were assessed by central cannulation, and R-R intervals were measured by electrocardiogram. In addition, the effects of RMT on the cross-sectional area of the diaphragm, anterior tibial, and soleus muscles were analyzed. The induction of DM by streptozotocin resulted in weight loss, hyperglycemia, reduced blood pressure, and attenuated left ventricular contraction and relaxation (P<0.05). We also observed a decrease in root mean square of successive differences between adjacent RR intervals (RMSSD) index and in the cross-sectional area of the muscles assessed, specifically the diaphragm, soleus, and anterior tibial muscles in diabetic rats (P<0.05). Interestingly, RMT led to an increase in RMSSD in rats with DM (P<0.05). The induction of DM produced profound deleterious changes in the diaphragmatic and peripheral muscles, as well as impairments in cardiovascular hemodynamics and autonomic control. Nevertheless, RMT may beneficially attenuate autonomic changes and improve parasympathetic modulation.

The relationship between the phageome and human health: are bacteriophages beneficial or harmful microbes?

In the context of the global antibiotic resistance crisis, bacteriophages are increasingly becoming promising antimicrobial agents against multi-resistant bacteria. Indeed, a huge effort is being made to bring phage-derived products to the market, a process that will also require revising the current regulations in order to facilitate their approval. However, despite the evidence supporting the safety of phages for humans, the general public would still be reluctant to use 'viruses' for therapeutic purposes. In this scenario, we consider that it is important to discuss the role of these microorganisms in the equilibrium of the microbiota and how this relates to human health. To do that, this review starts by examining the role of phages as key players in bacterial communities (including those that naturally inhabit the human body), modulating the species composition and contributing to maintain a 'healthy' status quo. Additionally, in specific situations, e.g. an infectious disease, bacteriophages can be used as target-specific antimicrobials against pathogenic bacteria (phage therapy), while being harmless to the desirable microbiota. Apart from that, incipient research shows the potential application of these viruses to treat diseases caused by bacterial dysbiosis. This latter application would be comparable to the use of probiotics or prebiotics, since bacteriophages can indirectly improve the growth of beneficial bacteria in the gastrointestinal tract by removing undesirable competitors. On the other hand, possible adverse effects do not appear to be an impediment to promote phage therapy. Nonetheless, it is important to remember their potentially negative impact, mainly concerning their immunogenicity or their potential spread of virulence and antibiotic resistance genes, especially by temperate phages. Overall, we believe that phages should be largely considered beneficial microbes, although it is paramount not to overlook their potential risks.

Cadaverine and Spermine Elicit Ca2+ Uptake in Human CP Cells via a Trace Amine-Associated Receptor 1 Dependent Pathway.

The choroid plexus (CP) constitutes a barrier between the blood and the cerebrospinal fluid (CSF) which regulates the exchange of substances between these two fluids through mechanisms that are not completely understood. Polyamines as spermine, spermidine and putrescine are produced by all cells and are present in the CSF. Interestingly, their levels are altered in some neuronal disorders as Alzheimer's and Parkinson's diseases, thus increasing the interest in their signalling in the central nervous system (CNS). Cadaverine, on the other hand, is synthetized by the intestinal microbiome, suggesting that the presence of this bacterial metabolite in the CSF requires that it is up taken to the CNS across brain barriers. We knew that polyamines are detected by the olfactory signalling cascade operating at the CP, but the receptor involved had not been identified. The zebrafish TAAR13c was the only receptor known to bind a polyamine-cadaverine. Thus, we searched for a human receptor with homology to TAAR13c and found that some human TAARs including TAAR1 showed great homology. Then, we confirmed the expression of TAAR1 mRNA and protein in a human cell line of the CP, and in human CP samples. Calcium imaging assays after TAAR1 knockdown in these cells with a specific siRNA against TAAR1 showed a consistent reduction in the responses of these cells to cadaverine and spermidine, but not to spermine, suggesting that TAAR1 is activated by cadaverine and spermidine, but not spermine.

Effects of respiratory muscle training on parasympathetic activity in diabetes mellitus

This study verified the effects of respiratory muscle training (RMT) on hemodynamics, heart rate (HR) variability, and muscle morphology in rats with streptozotocin-induced diabetes mellitus (DM). Thirty-six male Wistar rats were randomized into 4 groups and 34 completed the study: i) sham-sedentary (Sham-ST; n=9); ii) sham-RMT (Sham-RMT; n=9); iii) DM-sedentary (DM-ST; n=8); and iv) DM-RMT (DM-RMT; n=8). Hemodynamics were assessed by central cannulation, and R-R intervals were measured by electrocardiogram. In addition, the effects of RMT on the cross-sectional area of the diaphragm, anterior tibial, and soleus muscles were analyzed. The induction of DM by streptozotocin resulted in weight loss, hyperglycemia, reduced blood pressure, and attenuated left ventricular contraction and relaxation (P<0.05). We also observed a decrease in root mean square of successive differences between adjacent RR intervals (RMSSD) index and in the cross-sectional area of the muscles assessed, specifically the diaphragm, soleus, and anterior tibial muscles in diabetic rats (P<0.05). Interestingly, RMT led to an increase in RMSSD in rats with DM (P<0.05). The induction of DM produced profound deleterious changes in the diaphragmatic and peripheral muscles, as well as impairments in cardiovascular hemodynamics and autonomic control. Nevertheless, RMT may beneficially attenuate autonomic changes and improve parasympathetic modulation.

The senses of the choroid plexus.

The composition of cerebrospinal and brain interstitial fluids is ensured by barriers between the blood and the brain parenchyma (the blood-brain barrier) and between the blood and the cerebrospinal fluid (the blood-cerebrospinal fluid barrier). Barrier function results from the combination of tight junctions between cells that impair solute flux via the paracellular pathway, cell membrane transporters that enable selective transcellular solute passage, and intracellular metabolizing enzymes that transform molecules in transit. Collectively, they comprise a chemical surveillance system, essential to protect the brain from toxicants, microorganisms, and other harmful compounds. Conversely, this chemical surveillance system compromises the brain delivery of many pharmacologic agents against brain cancer and brain metastasis, neurodegenerative diseases, and brain infections. Despite their importance, the mechanisms underlying the regulation of the components of this chemical surveillance system in response to alterations in the composition of blood and brain fluids are still poorly understood. We propose that odorant receptors, vomeronasal receptors and taste receptors, recently identified at brain barriers might be upstream components of this surveillance system. These chemosensory receptors are strategically placed to monitor the composition of blood, cerebrospinal and brain interstitial fluids. Upon ligand-binding, they may deploy the action of transporters and detoxifying enzymes or other unprecedented functions in brain barrier cells, to cope with alterations in the composition of blood and brain cerebrospinal and interstitial fluids, working as guardians of the central nervous system.

Evaluation of a single extraction test to estimate the human oral bioaccessibility of potentially toxic elements in soils: Towards more robust risk assessment.

Intake of soil by children and adults is a major exposure pathway to contaminants including potentially toxic elements (PTEs). However, only the fraction of PTEs released in stomach and intestine are considered as bioaccessible and results from routine analyses of the total PTE content in soils, therefore, are not necessarily related to the degree of bioaccessibility. Experimental methods to determine bioaccessibility usually are time-consuming and relatively complicated in terms of analytical procedures which limits application in first tier assessments. In this study we evaluated the potential suitability of a recently developed single extract method (ISO-17586:2016) using dilute (0.43M) nitric acid (HNO3) to mimic the bioaccessible fraction of PTEs in soils. Results from 204 soils from Portugal, Brazil and the Netherlands including all major soil types and a wide range of PTEs' concentrations showed that the extraction efficiency using 0.43M HNO3 of Ba, Cd, Cu, Ni, Pb and Zn in soils is related to that of in vitro methods including the Simple Bioaccessibility Extraction Test (SBET) and Unified BARGE Method (UBM). Also, differences in the degree of bioaccessibility resulting from differences in parent material, geology and climate conditions did not affect the response of the 0.43M HNO3 extraction which is a prerequisite to be able to compare results from different soils. The use of 0.43M HNO3 as a first screening of bioaccessibility therefore offers a robust and representative way to be included in first tier standard soil tests to estimate the oral bioaccessibility. CAPSULE: The single dilute (0.43M) nitric acid extraction can be used in first tier soil risk assessment to assess both geochemical reactivity and oral bioaccessibility of PTEs.

Portuguese recommendations for the prevention, diagnosis and management of primary osteoporosis - 2018 update.

BACKGROUND: Advances in osteoporosis (OP)case definition, treatment options, optimal therapy duration and pharmacoeconomic evidence in the national context motivated the Portuguese Society of Rheumatology (SPR) to update the Portuguese recommendations for the diagnosis and management of osteoporosis published in 2007. METHODS: SPR bone diseases' working group organized meetings involving 55 participants (rheumatologists, rheumatology fellows and one OP specialist nurse) to debate and develop the document. First, the working group selected 11 pertinent clinical questions for the diagnosis and management of osteoporosis in standard clinical practice. Then, each question was investigated through literature review and draft recommendations were built through consensus. When insufficient evidence was available, recommendations were based on experts' opinion and on good clinical practice. At two national meetings, the recommendations were discussed and updated. A draft of the recommendations full text was submitted to critical review among the working group and suggestions were incorporated. A final version was circulated among all Portuguese rheumatologists before publication and the level of agreement was anonymously assessed using an online survey. RESULTS: The 2018 SPR recommendations provide comprehensive guidance on osteoporosis prevention, diagnosis, fracture risk assessment, pharmacological treatment initiation, therapy options and duration of treatment, based on the best available evidence. They attained desirable agreement among Portuguese rheumatologists. As more evidence becomes available, periodic revisions will be performed. Target audience and patient population: The target audience for these guidelines includes all clinicians. The target patient population includes adult Portuguese people. Intended use: These recommendations provide general guidance for typical cases. They may not be appropriate in all situations - clinicians are encouraged to consider this information together with updated evidence and their best clinical judgment in individual cases.

Addressing the impact of mercury estuarine contamination in the European eel (Anguilla anguilla L., 1758) - An early diagnosis in glass eel stage based on erythrocytic nuclear morphology.

The decline of the European eel (Anguilla anguilla L., 1758) population throughout Europe has been partially attributed to pollution. As glass eel estuarine migration may represent a considerable threat, the impact of mercury (Hg) contamination at this stage was evaluated through an in situ experiment (7days). Total Hg (tHg) bioaccumulation was evaluated concomitantly with erythrocytic nuclear morphology alterations: erythrocytic nuclear abnormalities assay (ENA), frequency of immature erythrocytes (IE) and the erythrocytic maturity index (EMI). The ENA results suggested a genotoxic pressure at the most contaminated sites, in line with the tHg increase. The EMI data, together with IE frequency, showed that fish exposed to high levels of Hg exhibited alterations of haematological dynamics, translated into an erythropoiesis increment. Despite the presence of these compensatory mechanisms, the present findings suggest a harmful impact of Hg on genome integrity at this early development stage, potentially affecting eels' condition and ultimately the population sustainability.

Availability of polycyclic aromatic hydrocarbons to earthworms in urban soils and its implications for risk assessment.

Polycyclic aromatic hydrocarbons (PAHs) are a global problem, and in urban soils they can be found at potentially hazard levels. Nevertheless, the real risks that these contaminants pose to the environment are not well known, since the bioavailability of PAHs in urban soils has been poorly studied. Therefore, the bioavailability of PAHs in some selected urban soils from Lisbon (Portugal) was evaluated. Moreover, the applicability of a first screening phase based on total contents of PAHs was assessed. Results show that bioavailability of PAHs is reduced (low levels in earthworms, low accumulation percentages, and low biota-to-soil accumulation factors values), especially in more contaminated soils. The aging of these compounds explains this low availability, and confirms the generally accepted assumption that accumulation of PAHs in urban areas is mostly related with a long-term deposition of contaminated particles. The comparison of measured PAHs concentrations in earthworm tissues with the ones predicted based on theoretical models, reinforce that risks based on total levels are overestimated, but it can be a good initial approach for urban soils. This study also highlights the need of more reliable ecotoxicological data.

Removal and recovery of Critical Rare Elements from contaminated waters by living Gracilaria gracilis.

The experiments performed in this work proved the ability of Gracilaria gracilis to concentrate and recover Critical Rare Elements (CRE) from contaminated waters. The importance of recycling these elements is related to their very limited sources in Nature and progressive use in technologies. Moreover, their mining exploitation has negative environmental impact, and recent studies point them as new emerging pollutants. To the best of our knowledge, this is the first report on the application of living macroalgae for the removal and recovery of CRE. G. gracilis (2.5gL-1, fresh weight) was exposed to mono- and multi-element saline solutions of 500µgL-1 of Y, Ce, Nd, Eu and La. Removal was up to 70% in 48h, with bioaccumulation following Elovich kinetic model. In multi-element solutions, selectivity was not observed although removal of lanthanides improved comparatively to single-element solutions. No mortality or adverse effect on growth was registered. The subsequent macroalgae digestion allowed collecting virtually 100% of all elements in a 300-fold more concentrated solution. The overall results suggest the application of living macroalgae as a simple and effective alternative technology for removing and recovering CRE from wastewaters, contributing to an improvement of water quality and CRE recycling.

Salinity induced effects on the growth rates and mycelia composition of basidiomycete and zygomycete fungi.

Soil salinization, as the combination of primary and secondary events, can adversely affect organisms inhabiting this compartment. In the present study, the effects of increased salinity were assessed in four species of terrestrial fungi: Lentinus sajor caju, Phanerochaete chrysosporium, Rhizopus oryzae and Trametes versicolor. The mycelial growth and biochemical composition of the four fungi were determined under three exposure scenarios: 1) exposure to serial dilutions of natural seawater (SW), 2) exposure to serial concentrations of NaCl (potential surrogate of SW); and 3) exposure to serial concentrations of NaCl after a period of pre-exposure to low levels of NaCl. The toxicity of NaCl was slightly higher than that of SW, for all fungi species: the conductivities causing 50% of growth inhibition (EC50) were within 14.9 and 22.0 mScm-1 for NaCl and within 20.2 and 34.1 mScm-1 for SW. Phanerochaete chrysosporium showed to be the less sensitive species, both for NaCl and SW. Exposure to NaCl caused changes in the biochemical composition of fungi, mainly increasing the production of polysaccharides. When fungi were exposed to SW this pattern of biochemical response was not observed. Fungi pre-exposed to low levels of salinity presented higher EC50 than fungi non-pre-exposed, though 95% confidence limits overlapped, with the exception of P. chrysosporium. Pre-exposure to low levels of NaCl also induced changes in the biochemical composition of the mycelia of L. sajor caju and R. oryzae, relatively to the respective control. These results suggest that some terrestrial fungi may acquire an increased tolerance to NaCl after being pre-exposed to low levels of this salt, thus, suggesting their capacity to persist in environments that will undergo salinization. Furthermore, NaCl could be used as a protective surrogate of SW to derive safe salinity levels for soils, since it induced toxicity similar or higher than that of SW.

A macroalgae-based biotechnology for water remediation: Simultaneous removal of Cd, Pb and Hg by living Ulva lactuca.

Metal uptake from contaminated waters by living Ulva lactuca was studied during 6 days, under different relevant contamination scenarios. In mono-metallic solutions, with concentrations ranging from 10 to 100 µg L-1 for Hg, 10-200 µg L-1 for Cd, and 50-1000 µg L-1 for Pb, macroalgae (500 mg L-1, d.w.) were able to remove, in most cases 93-99% of metal, allowing to achieve water quality criteria regarding both surface and drinking waters. In multi-metallic solutions, comprising simultaneously the three metals, living macroalgae still performed well, with Hg removal (c.a. 99%) not being significantly affected by the presence of Cd and Pb, even when those metals were in higher concentrations. Removal efficiencies for Cd and Pb varied between 57 and 96%, and 34-97%, respectively, revealing an affinity of U. lactuca toward metals: Hg > Cd > Pb. Chemical quantification in macroalgae, after bioaccumulation assays demonstrated that all Cd and Hg removed from solution was really bound in macroalgae biomass, while only half of Pb showed to be sorbed on the biomass. Overall, U. lactuca accumulated up to 209 µg g-1 of Hg, up to 347 µg g-1 of Cd and up to 1641 µg g-1 of Pb, which correspond to bioconcentration factors ranging from 500 to 2200, in a dose-dependent accumulation. Pseudo-first order, pseudo-second order and Elovich models showed a good performance in describing the kinetics of bioaccumulation, in the whole period of time. In the range of experimental conditions used, no mortality was observed and U. lactuca relative growth rate was not significantly affected by the presence of metals. Results represent an important contribution for developing a macroalgae-based biotechnology, applied for contaminated saline water remediation, more "green" and cost-effective than conventional treatment methods.

Histopathological and molecular effects of microplastics in Eisenia andrei Bouché.

The ocean has been assumed as the main sink of microplastics (MPs), however, soils may also receive MPs from different sources and through different pathways, which may affect the biota and their role in soil functions. To the best of our knowledge, only one study, until now, reported the effects of MPs on the survival and fitness of soil organisms (Lumbricus terrestris). In our study, epigeic earthworms, of the species E. andrei, were exposed to different concentrations of MPs (0, 62.5, 125, 250, 500 and 1000 mg/kg soildw) in an OECD artificial soil and tested for reproduction, survival and growth of adults, following a standard protocol. The size of the polyethylene MPs to which earthworms were exposed ranged between 250 and 1000 µm. No significant effects were recorded on survival, number of juveniles and, in the final weight of adult earthworms after 28d of exposure, to the different concentrations of MPs. Nevertheless, FTIR-ATR of earthworms and histopathological analysis of the gut provided evidences of damages and immune system responses to MPs.

Lead and PAHs contamination of an old shooting range: A case study with a holistic approach.

Soil pollution at firing ranges is an issue of growing importance, due to the accumulation in soils of contaminants derived from ammunition and clay targets. The concentration of Pb and PAHs was determined in five soils of an abandoned shooting range in Galicia (northwest Spain), and an ecotoxicological characterization was performed in order to obtain an assessment of risks. Therefore, the retention capacity of soils was assessed using test organisms of different trophic levels, and the role of soils as habitat for soil invertebrates was assessed by reproduction tests and bioaccumulation assays with earthworms. The sum of 15 PAHs ranged between 38 and 360mgkg-1, which exceed, together with Pb (160-720mgkg-1), the Galician generic reference value for urban and sporting field soils. Bioaccumulation in E. andrei showed contents up to 104,000µgPbkg-1dw, and up to 645µgPAHskg-1fw. High contents of Pb and PAHs in soil samples and in Eisenia andrei whole body, caused a reduction in the number of juveniles produced, whereas, Vibrio fischeri, Raphidocelis subcapitata and Daphnia magna displayed a slight toxic response to the soil elutriates tested. Therefore, the function of these soils to retain contaminants seemed not compromised, probably due to the high organic matter content and pH values, which are weakly acidic. The habitat function was affected, indicating that soil solution is not the only route of exposure to contaminants to E. andrei. The integration of chemical and ecotoxicological lines of evidence give rise to high risks values, restricting the use of these areas, and pointing for risks to surrounding ecosystems due to possible trophic transferences. The calculation of risks using the chemical and ecotoxicological data, required by Spanish legislation, could be a good approach to communicate with those responsible and/or involved in the management of contaminated sites.

Cytotoxicity and oxidative stress responses of silica-coated iron oxide nanoparticles in CHSE-214 cells.

The present study aimed at investigating cytotoxicity and oxidative stress induced by silica-coated iron oxide nanoparticles functionalized with dithiocarbamate (Fe3O4 NPs) in Chinook salmon cells (CHSE-214) derived from Oncorhynchus tshawytscha embryos. A significant reduction in cell viability was evident in response to Fe3O4 NPs as revealed by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) assay after 24 h of exposure. Out of the tested concentrations (10, 20, and 30 µg/ml), the highest concentration has shown significant decrease in the viability of cells after 24 h of exposure. Alterations in the morphology of CHSE-214 cells was also evident at 10 µg/ml concentration of Fe3O4 NPs after 24 h. Fe3O4 NPs elicited a significant dose-dependent reduction in total glutathione content (TGSH), catalase (CAT), glutathione reductase (GR) with a concomitant increase in lipid peroxidation (LPO), and protein carbonyl (PC) at highest concentration (30 µg/ml) after 24 h of exposure. In conclusion, our data demonstrated that Fe3O4 NPs have potential to induce cytotoxicity in CHSE-214 cells, which is likely to be mediated through reactive oxygen species generation and oxidative stress.

Sex Hormone Decline and Amyloid ß Synthesis, Transport and Clearance in the Brain.

Sex hormones (SH) are essential regulators of the central nervous system. The decline in SH levels along with ageing may contribute to compromised neuroprotection and set the grounds for neurodegeneration and cognitive impairments. In Alzheimer's disease, besides other pathological features, there is an imbalance between amyloid ß (Aß) production and clearance, leading to its accumulation in the brain of older subjects. Aß accumulation is a primary cause for brain inflammation and degeneration, as well as concomitant cognitive decline. There is mounting evidence that SH modulate Aß production, transport and clearance. Importantly, SH regulate most of the molecules involved in the amyloidogenic pathway, their transport across brain barriers for elimination, and their degradation in the brain interstitial fluid. This review brings together data on the regulation of Aß production, metabolism, degradation and clearance by SH.

Recommendations for Vaccination in Adult Patients with Systemic Inflammatory Rheumatic Diseases from the Portuguese Society of Rheumatology.

BACKGROUND: Serious infections are a major cause of morbidity and mortality in systemic inflammatory rheumatic disease (SIRD) patients. Although vaccination may prevent numerous infections, vaccination uptake rates are low in this group of patients. OBJECTIVES: To develop evidence-based recommendations for vaccination in SIRD patients. METHODS: We searched MEDLINE (until 31 October 2014) and EMBASE (until 14 December 2014) databases, as well as the ACR and EULAR congress abstracts (2011-2014). Patients with any systemic inflammatory rheumatic disease were included and all vaccines were considered. Any safety and efficacy outcomes were admitted. Search results were submitted to title and abstract selection, followed by detailed review of suitable studies. Data were subsequently pooled according to the type of vaccine and the SIRD considered. Results were presented and discussed by a multidisciplinary panel and systematic literature review (SLR)-derived recommendations were voted according to the Delphi method. The level of agreement among rheumatologists was assessed using an online survey. RESULTS: Eight general and seven vaccine-specific recommendations were formulated. Briefly, immunization status should routinely be assessed in all SIRD patients. The National Vaccination Program should be followed and some additional vaccines are recommended. To maximize the efficacy of vaccination, vaccines should preferably be administered 4 weeks before starting immunosuppression or, if possible when disease activity is controlled. Non-live vaccines are safe in SIRD, including immunosuppressed patients. The safety of live attenuated vaccines in immunosuppressed patients deserves further ascertainment, but might be considered in particular situations. DISCUSSION: The present recommendations combine scientific evidence with the multidisciplinary expertise of our taskforce panel and attained desirable agreement among Portuguese rheumatologists. Vaccination recommendations need to be updated on a regular basis, as more scientific data regarding vaccination efficacy and safety, emergent infectious threats, new vaccines as well as new immunomodulatory therapies become available.