Issue 3-The occupational burden of respiratory diseases, an update.

INTRODUCTION AND AIMS: Workplace exposures are widely known to cause specific occupational diseases such as silicosis and asbestosis, but they also can contribute substantially to causation of common respiratory diseases. In 2019, the American Thoracic Society (ATS) and the European Respiratory Society (ERS) published a joint statement on the occupational burden of respiratory diseases. Our aim on this narrative review is to summarise the most recent evidence published after the ATS/ERS statement as well as to provide information on traditional occupational lung diseases that can be useful for clinicians and researchers. RESULTS: Newer publications confirm the findings of the ATS/ERS statement on the role of workplace exposure in contributing to the aetiology of the respiratory diseases considered in this review (asthma, COPD, chronic bronchitis, idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, infectious pneumonia). Except for COPD, chronic bronchitis and infectious pneumonia, the number of publications in the last 5 years for the other diseases is limited. For traditional occupational lung diseases such as silicosis and asbestosis, there are old as well as novel sources of exposure and their burden continues to be relevant, especially in developing countries. CONCLUSIONS: Occupational exposure remains an important risk factor for airways and interstitial lung diseases, causing occupational lung diseases and contributing substantially in the aetiology of common respiratory diseases. This information is critical for public health professionals formulating effective preventive strategies but also for clinicians in patient care. Effective action requires shared knowledge among clinicians, researchers, public health professionals, and policy makers.

Characterisation of Portuguese radiotherapy departments: Organisation, occupational exposure values and diagnostic reference levels for breast and prostate computed tomography planning.

INTRODUCTION: Portugal currently hosts 24 active radiotherapy departments, 8 public and 16 privates, presenting potential radiation exposure risks to multidisciplinary teams. Patients in these treatments also face ionising radiation during treatment planning and verification. METHODS: Authorisation and ethical approval were secured for a national online survey, disseminated to radiotherapy departments across Portugal. The survey encompassed three sections: equipment, staff, and radiographer role characterisation; occupational exposure values for one month; and exposure parameters, including computed tomography (CT) dose values [CT dose index (CTDIvol) and dose length product (DLP)] for breast and prostate cancer CT planning. Local Diagnostic Reference Levels (DRLs) derived were based on the 75th percentile of median dose values. RESULTS: The study garnered a 50% response rate from public institutions, 12,5% from private and 25% from all active radiotherapy institutions in Portugal. All departments employ Three-Dimensional Conformal Radiation Therapy (3D-CRT) and incorporate Intensity Modulated Radiation Therapy (IMRT) and/or Volumetric Modulated Arc Therapy (VMAT) irradiation techniques. Additionally, half of the departments also perform Brachytherapy (BT). Radiographers demonstrated an occupational dose of zero mSv. CT planning dose values were 13 mGy and 512 mGy cm for breast CT and 16 mGy and 689 mGy cm for prostate CT, pertaining to CTDIvol and DLP, respectively. CONCLUSION: Most aspects of national radiotherapy characterisation align with the established literature. Occupational exposure values exhibited consistency across radiotherapy modalities. An approach to national DRLs was formulated for breast and prostate CT planning, yielding values congruent with recent European studies. IMPLICATIONS FOR PRACTICE: This study offers vital insights for analysing occupational contexts and risk prevention, serving as the initial characterisation of the national radiotherapy landscape. It also pioneers the calculation of DRLs for CT planning in radiotherapy to optimise procedures.

The spatial distribution of microplastics in topsoils of an urban environment - Coimbra city case-study.

Due to their seemingly ubiquitous nature and links to environmental and human health problems, microplastics are quickly becoming a major concern worldwide. Artificial environments, such as those found in urban environments, represent some of the main sources of microplastic. However, very few studies have focused on the occurrence of microplastics in urban soils. The aim of the current research was to evaluate the microplastic contamination in urban soils from artificial and natural land uses throughout Coimbra city, Portugal. Sixty-seven spaces and ten land use areas were evaluated. The artificial land use areas were dumps, landfills, parking lots, industries and construction areas, and the natural land use areas were forests, urban parks, moors (wetlands), pastures and urban agricultural areas. Microplastic extraction was done by density separation. Quantification and size measurements of microplastics was carried out using a microscope. Polymer types were identified by µ-FTIR for 25% of the samples. The microplastic content ranged from 5 × 103 to 571 × 103 particles·kg-1, with a mean of 106 × 103 particle·kg-1. The green park was the land use with the highest concentration of microplastics (158 × 103 particle·kg-1) and the forest was the one with the lowest concentration (55 × 103 particle·kg-1). The landfill (150 × 103 particle·kg-1), industry (127 × 103 particle·kg-1) and dump (126 × 103 particle·kg-1) were the artificial spaces with the highest levels of microplastics. The main polymers detected were polypropylene and polyethylene, followed by polyvinyl chloride and rubber, and the main sizes measured between 50 and 250 µm. Our results indicate that natural spaces can contain higher amounts of microplastics as compared to artificial spaces in the urban environment. This suggests that microplastics are easily transported through the urban landscape and that urban green spaces can retain microplastics in their soils. Land use planning may present an opportunity to better control the levels of microplastics in urban environments.

Teleconsultation in respiratory medicine - A position paper of the Portuguese Pulmonology Society.

The COVID-19 pandemic crisis, among so many social, economic and health problems, also brought new opportunities. The potential of telemedicine to improve health outcomes had already been recognised in the last decades, but the pandemic crisis has accelerated the digital revolution. In 2020, a rapid increase in the use of remote consultations occurred due to the need to reduce attendance and overcrowding in outpatient clinics. However, the benefit of their use extends beyond the pandemic crisis, as an important tool to improve both the efficiency and capacity of future healthcare systems. This article reviews the literature regarding telemedicine and teleconsultation standards and recommendations, collects opinions of Portuguese experts in respiratory medicine and provides guidance in teleconsultation practices for Pulmonologists.

Issue 1 - "Update on adverse respiratory effects of outdoor air pollution" Part 2): Outdoor air pollution and respiratory diseases: Perspectives from Angola, Brazil, Canada, Iran, Mozambique and Portugal.

OBJECTIVE: To analyse the GARD perspective on the health effects of outdoor air pollution, and to synthesise the Portuguese epidemiological contribution to knowledge on its respiratory impact. RESULTS: Ambient air pollution has deleterious respiratory effects which are more apparent in larger, densely populated and industrialised countries, such as Canada, Iran, Brazil and Portugal, but it also affects people living in low-level exposure areas. While low- and middle-income countries (LMICs), are particularly affected, evidence based on epidemiological studies from LMICs is both limited and heterogeneous. While nationally, Portugal has a relatively low level of air pollution, many major cities face with substantial air pollution problems. Time series and cross-sectional epidemiological studies have suggested increased respiratory hospital admissions, and increased risk of respiratory diseases in people who live in urban areas and are exposed to even a relatively low level of air pollution. CONCLUSIONS: Adverse respiratory effects due to air pollution, even at low levels, have been confirmed by epidemiological studies. However, evidence from LMICs is heterogeneous and relatively limited. Furthermore, longitudinal cohort studies designed to study and quantify the link between exposure to air pollutants and respiratory diseases are needed. Worldwide, an integrated approach must involve multi-level stakeholders including governments (in Portugal, the Portuguese Ministry of Health, which hosts GARD-Portugal), academia, health professionals, scientific societies, patient associations and the community at large. Such an approach not only will garner a robust commitment, establish strong advocacy and clear objectives, and raise greater awareness, it will also support a strategy with adequate measures to be implemented to achieve better air quality and reduce the burden of chronic respiratory diseases (CRDs).

Pre- and post-COVID practice of interventional pulmonology in adults in Portugal.

INTRODUCTION AND OBJECTIVES: There is a lack of information regarding bronchoscopy practice in adults in Portugal. Our objective was to obtain an overview of the characteristics, resources, techniques and behaviors in national interventional pulmonology (IP) units, before and after SARS-CoV-2 outbreak. MATERIALS AND METHODS: An online survey was developed by an expert panel with a total of 46 questions comprising the specifications of each unit, namely physical space, equipment, staff, procedure planning, monitoring, technical differentiation, and numbers pre- and post-COVID-19. Forty-one interventional pulmonology centers were invited to participate between April and May 2021. RESULTS: 37 units (90.2%) responded to the survey. The majority (64.9%) have a fully dedicated space with a weekly presence of ≥3 chest physicians (82.1%) and support of an anesthesiologist on specific days (48.6%). There is marked heterogeneity in the IP unit's equipment, and 56.8% acquired disposable bronchoscopes after COVID-19 pandemics. Pre-bronchoscopy hemogram, platelet count and coagulation tests are regularly asked by more than 90% of the units, even when deep sedation or biopsies are not planned. In 97.3% of cases, topical anesthesia and midazolam are utilized. Propofol (21.6%) and fentanyl (29.7%) are occasionally employed in some institutions. Most units use ancillary sampling techniques to diagnose central or peripheral lesions, with radial EBUS being used for guidance of distal procedures in 37.8% of centers, linear EBUS and EUS-B-FNA for mediastinal diagnosis and/or staging in 45.9% and 27.0% of units, respectively. Cryobiopsies are used by 21.6% of respondents to diagnose diffuse lung diseases. Rigid bronchoscopy is performed in 37.8% of centers. There was a decrease in the number of flexible (p < 0.001) and rigid (p = 0.005) bronchoscopies and an upscale of personal protective equipment (PPE) during the COVID-19 outbreak. CONCLUSIONS: IP units have variable bronchoscopic practices, but during the COVID-19 pandemic, they complied with most international recommendations, as elective procedures were postponed and PPE levels increased.

Emerging new avian reovirus variants from cases of enteric disorders and arthritis/tenosynovitis in Brazilian poultry flocks.

1. The objective of this study was to characterise circulating Brazilian avian reovirus (ARV) strains by genetic analysis of the σC protein encoded by segment 1 of the viral genome and compare these with those of viral strains used for immunising commercial poultry.2. The analysis detected the presence of ARV genomes by quantitative reverse transcriptase PCR (RT-qPCR) in the enteric samples and the joint tissues (JT) of birds with signs of viral arthritis/tenosynovitis. Nucleotide sequencing used 16 strains (three commercial vaccines, 10 from enteric tissues and three from JT). The results indicated high variability in the amino acid sequences of 13 wild strains, showing between 40% and 75% similarity compared with the vaccine strains (S1133 and 2177).3. The sequences were grouped into three well-defined clusters in a phylogenetic tree, two of these clusters together with previous Brazilian σC ARV sequences, and one cluster (VII) that was novel for Brazilian strains. Antigenic analysis showed that there were amino acids within putative epitopes located on the surface of the receptor-binding region of the σC protein with a high degree of variability.4. The study confirmed the presence of ARV genetic variants circulating in commercial birds in Brazil, and according to the antigenic prediction, the possibility of antigenic variants appears to be high.

Tibial tuberosity advancement technique in small breed dogs: study of 30 consecutive dogs (35 stifles).

OBJECTIVES: To assess the outcome and peri-operative complications of the tibial tuberosity advancement technique in small dogs with cranial cruciate ligament rupture. MATERIALS AND METHODS: Cranial cruciate ligament rupture was diagnosed by positive drawer sign or tibial thrust test and confirmed at surgery in 30 dogs (35 stifles) weighing less than 15 kg. Clinical and radiographic follow-up was obtained at 4 and 12 weeks or later. Thigh diameter and affected and non-affected stifle joint flexion and extension angles were also measured. RESULTS: At 4-week follow-up 26 of 35 (74%), eight of 35 (23%) and one of 35 (3%) showed no, mild and moderate lameness, respectively. Similarly, at 12 weeks or later the respective outcomes were 32 of 35 (91%), two of 35 (6%) and one of 35 (3%). The mean thigh diameter of affected limbs at 12 or more weeks was 96% of the mean of normal limbs and stifle range of motion reached 98% of normal extension and 97% of normal flexion. There were complications in two of 35 stifles: one screw partially inserted into the joint and postoperative wound dehiscence, both of which required surgical correction. CLINICAL SIGNIFICANCE: The tibial tuberosity advancement technique leads to acceptable outcomes in small dogs with cranial cruciate ligament rupture.

Assessing long-term changes in potential ecosystem services of a peri-urbanizing Mediterranean catchment.

Society depends on goods and services provided by ecosystems, not only for survival but also for general wellbeing. Over the last decades, peri-urban areas have been subject to the pressure of urbanization and, thus, land-use changes. These changes modify the natural ecosystems and their ability to support human security and safety, but the extent of these impacts is not well-known. This study investigates the impact of five decades of land-use changes in potential ecosystem services (ESs) supply, in the peri-urban Ribeira dos Covões catchment, located in the periphery of Coimbra one of the largest cities in central Portugal. Based on eight land-use maps from 1958 to 2012, the ESs were estimated through a quantification matrix developed by local stakeholders. The expansion of urban and forest areas from 7% to 40% and from 43% to 55%, respectively, mostly through the occupation of agriculture fields (reduced from 48% to 4%), together with changes in the type of forest area (from mixed to commercial broad-leaved), led to a 73% reduction in the ESs potential supply. This reduction was driven by major losses in regulation but also provisioning services. Catchment management and urban planning should be supported by ESs assessment in order to mitigate the negative impacts on regulation, provisioning and cultural services provided by the ecosystems, and thus maximize the benefits for society.

Pharmacological treatment of COPD - New evidence.

Chronic Obstructive Pulmonary Disease (COPD) is currently the 4th leading cause of death worldwide but is projected to be the 3rd leading cause of death by 2020. In Portugal, the estimated prevalence of COPD in the Lisbon region is 14.2%, and a large proportion of underdiagnosed disease has been detected. In 2016, a Portuguese panel of experts proposed pharmacological treatment approaches to COPD based on the evidence available at the time. However, given that the GOLD 2017 report introduced considerable changes to the 2016 version, and that new evidence has emerged regarding treatment options, these proposals need to be updated. Also, and based on several studies, the concept of Pre-GOLD patients, which has diagnostic, prognostic and therapeutic implications, is introduced, along with a proposed algorithm for the identification and treatment of these patients.

New records of Helminths in Reptiles from five states of Brazil / Novos registros de helmintos em répteis de cinco estados do Brasil

Abstract Forty five specimens representing nine species of reptile (Salvator merianae, Enyalius bilineatus, Amphisbaena alba, Xenopholis undulatus, Chironius fuscus, Helicops angulatus, Chironius flavolineatus, Erythrolamprus viridis and Crotalus durissus) collected in five Brazilian states were examined for helminths. Twelve helminth species were found as follow: nine Nematoda (Physaloptera tupinambae, Strongyluris oscari, Paracapillaria sp., Dracunculus brasiliensis, Physaloptera liophis, Serpentirhabias sp. 1, Serpentirhabias sp. 2, Serpentirhabias sp. 3 and Aplectana sp.), one Cestoda (Semenoviella amphisbaenia), one Trematoda (Paracotyletrema sp.), and one Acantocephala (Centrorhynchus sp.). Ten new host records and seven new locality records were reported.

Resumo Quarenta e cinco espécimes que representa nove espécies de répteis (Salvator merianae, Enyalius bilineatus, Amphisbaena alba, Xenopholis undulatus, Chironius fuscus, Helicops angulatus, Chironius flavolineatus, Erythrolamprus viridis e Crotalus durissus) coletados em cinco estados brasileiros foram examinados para helmintos. Foram encontrados doze espécies de helmintos sendo: nove Nematoda (Physaloptera tupinambae, Strongyluris oscari, Paracapillaria sp., Dracunculus brasiliensis, Physaloptera liophis, Serpentirhabias sp. 1, Serpentirhabias sp. 2, Serpentirhabias sp. 3 e Aplectana sp.), um Cestoda (Semenoviella amphisbaenia), um Trematoda (Paracotyletrema sp.) e um Acantocephala (Centrorhynchus sp.). Dez novos registros de hospedeiros e sete novos registros de localidade foram relatados.

New records of Helminths in Reptiles from five states of Brazil.

Forty five specimens representing nine species of reptile (Salvator merianae, Enyalius bilineatus, Amphisbaena alba, Xenopholis undulatus, Chironius fuscus, Helicops angulatus, Chironius flavolineatus, Erythrolamprus viridis and Crotalus durissus) collected in five Brazilian states were examined for helminths. Twelve helminth species were found as follow: nine Nematoda (Physaloptera tupinambae, Strongyluris oscari, Paracapillaria sp., Dracunculus brasiliensis, Physaloptera liophis, Serpentirhabias sp. 1, Serpentirhabias sp. 2, Serpentirhabias sp. 3 and Aplectana sp.), one Cestoda (Semenoviella amphisbaenia), one Trematoda (Paracotyletrema sp.), and one Acantocephala (Centrorhynchus sp.). Ten new host records and seven new locality records were reported.

COPD: A stepwise or a hit hard approach?

Current guidelines differ slightly on the recommendations for treatment of Chronic Obstructive Pulmonary Disease (COPD) patients, and although there are some undisputed recommendations, there is still debate regarding the management of COPD. One of the hindrances to deciding which therapeutic approach to choose is late diagnosis or misdiagnosis of COPD. After a proper diagnosis is achieved and severity assessed, the choice between a stepwise or "hit hard" approach has to be made. For GOLD A patients the stepwise approach is recommended, whilst for B, C and D patients this remains debatable. Moreover, in patients for whom inhaled corticosteroids (ICS) are recommended, a step-up or "hit hard" approach with triple therapy will depend on the patient's characteristics and, for patients who are being over-treated with ICS, ICS withdrawal should be performed, in order to optimize therapy and reduce excessive medications. This paper discusses and proposes stepwise, "hit hard", step-up and ICS withdrawal therapeutic approaches for COPD patients based on their GOLD group. We conclude that all approaches have benefits, and only a careful patient selection will determine which approach is better, and which patients will benefit the most from each approach.

Detection and molecular characterization of chicken astrovirus associated with chicks that have an unusual condition known as "white chicks" in Brazil.

Chicken astrovirus (CAstV) is one of many viruses related to enteric diseases in poultry that are associated with Runting-Stunting Syndrome (RSS), which affects young chickens. CAstV was also recently associated with an unusual condition in chicks called "white chicks." Some hatcheries in certain states of Brazil have reported several incubation problems, mortality, and the presence of chicks with white plumages over the past several months. These chicks were termed locally as "white chicks." The present work investigated 30 chicks with this unusual condition using a multidisciplinary approach. Postmortem examination of each chick showed enlarged livers and intestines that were full of liquid and gas (30/30). The pancreas, kidneys, and spleen were pale (30/30). The other organs did not show any macroscopic alterations. CAstV, chicken parvovirus (ChPV), avian nephritis virus (ANV), avian rotavirus (ARtV), avian reovirus (AReoV), infectious bronchitis virus (IBV), and fowl adenovirus group I (FAdV-1) were tested in the intestines, pancreas, proventriculus, gizzard, liver, spleen, bursa, kidneys, thymus, lung, heart, brain, and yolk sac in each chick. All organs and yolk sacs were positive for CAstV in different titres and negative for the other tested viruses. The partial molecular characterization of the ORF 1b gene of CAstV using 28 sequences revealed a high similarity of the nucleotides and amino acids with sequences of CAstV from North America, Europe, and Asia, and our CAstV sequences clustered into a unique group that was separate from the other sequences. These results demonstrated that CAstV was associated with the white chick condition in Brazil. The virus was distributed in most organs, including the brain and yolk sac. These results suggest that the virus could be transmitted vertically. The molecular characterization also revealed that the CAstV associated with white chick condition was molecularly related to other CAstV sequences found worldwide.

Molecular detection of chicken parvovirus in broilers with enteric disorders presenting curving of duodenal loop, pancreatic atrophy, and mesenteritis.

Enteric disorders are an important cause of economic losses in broiler chickens worldwide. Several agents have been associated with enteric problems, such as viruses, bacteria, and parasites. In this study, broiler chickens showing signs of enteric disorders were subjected to molecular diagnosis for several viral agents and also for pathological examination for elucidating this problem. Thus, the chickens were screened for avian nephritis virus (ANV), chicken astrovirus (CAstV), avian rotavirus (ArtV), avian reovirus (AReoV), infectious bronchitis virus (IBV), fowl adenovirus group I (FAdV-1), and chicken parvovirus (ChPV). Postmortem examinations revealed a curving of the duodenal loop (J-like appearance) and intestines filled with liquid and gaseous content. Histopathological analysis of the duodenal loop showed pancreatic atrophy, acute mesenteritis, and enteritis. PCR results showed that ChPV was the sole viral agent detected in samples with lesions such as the curved duodenal loop and pancreatic atrophy. Molecular characterization of the nucleotide and deduced amino acid sequences revealed a high similarity with other strains of ChPV from Brazil, Canada, United States, Europe, and Asia. These findings suggest an association between ChPV and the development of enteritis, pancreatitis, and pancreatic atrophy, which may lead to curling of the duodenal loop. Together, these alterations may disrupt the normal functioning of the digestive system, diminishing digestion and the absorption of dietary nutrients and consequently leading to reduced weight gain, flock impairment, dwarfism, and an elevated feed conversion rate.