Non-Tuberculous Mycobacteria: Seven-Year Experience of a Tertiary Hospital

Introduction: Non-tuberculous mycobacteria are ubiquitous organisms. Precise determination of infection numbers is difficult, since reporting them to public health departments is frequently not mandatory; furthermore, isolating a non-tuberculous mycobacteria does not necessarily translate into disease. The aims of this study were to ascertain non-tuberculous mycobacteria data of a tertiary hospital, determine the incidence and approach to colonization versus disease, and the incidence of predisposing comorbidities. Material and Methods: Retrospective study in a tertiary hospital, involving patients with positive cultural exam for non-tuberculous mycobacteria in any biological sample, from 2010 to 2017. Results: A total of 125 non-tuberculous mycobacteria isolates was identified, corresponding to 96 patients. Of these, 57.4% were male (n = 54); median age was 65 years (interquartile range = [50 - 82]). From these, 60.7% (n = 57) had some degree of immunosuppression, most frequently due to malignant tumour (49.0%) or HIV infection (39.2%). It was found that 29 patients (31.0%) had structural respiratory tract changes. Colonization was defined in 65.6% of patients (n = 63). While 71.0% of non-tuberculous mycobacteria infections were pulmonary, the remaining 29.0% presented as disseminated. According to available clinical records, 60.6% (n = 20) of the presumably infected patients fulfilled American Thoracic Society diagnostic criteria for non-tuberculous mycobacteria disease. Discussion: Several cases of non-tuberculous mycobacteria infection in this study presented as life-threatening, multi-systemic disease, highlighting the importance of accurate diagnosis and timely treatment. Other cases of presumed infection might instead have corresponded to colonization, possibly resulting in futile therapy. Conclusion: While there are diagnostic criteria for treatment of non-tuberculous mycobacteria infections, no such guidelines exist to assess colonization. One of the most challenging aspects remains the correct differentiation between colonization and early-stage infection

Elevada Incidência de Infecções Sexualmente Transmissíveis em Doentes com Infecção por VIH

Introduction: Sexual transmitted infections (STI) are an important health problem and increase the risk for acquisition and transmission of HIV. We aimed to identify STIs diagnosed in patients with known human immunodeficiency virus (HIV) infection and in newly diagnosed ones.Methods: Retrospective analysis of medical charts of individuals attending a specialized STI Clinic from 2009 to 2013.Results: A total of 680 patients were included, accounting for 8% of the patients observed during the study period. The majority (638, 92%) were male and men who have sex with men (MSM) (489, 72%). Almost half (304, 45%) were migrants. Overall, 270 (40%) patients were diagnosed with at least one STI, syphilis was the most common (123, 18%), followed by Chlamydia trachomatis (46, 7%), Neisseria gonorrhoeae infection (42, 6%) and genital warts (32, 5%). Concerning HIV status, 329 (48%) patients had known infection and 351 (52%) were newly diagnosed during the study period. The newly diagnosed patients were significantly younger (37.3±9.7 vs 32.4± 9.5 years) and more frequently sought attention for screening. Past history of STIs, partner referral, symptoms and being diagnosed with at least one concomitant STI were significantly more common in previously known HIV patients.Conclusion: At least one new STI (other than HIV) was diagnosed in 40% of the patients. This represents an important problem not only because concomitant STIs increase the risk of HIV acquisition (for the new diagnosed cases) but also because patient with known HIV infection maintain a high-risk behaviour pattern.Introdução: As infecções sexualmente transmissíveis (IST) são um importante problema de saúde e aumentam o risco de adquirir o vírus da imunodeficiência humana (VIH). O objectivo foi identificar as ISTs diagnosticadas em doentes com infecção VIH conhecida e nos com diagnóstico de novo.Métodos: Análise retrospectiva dos processos clínicos dos utentes que recorreram a uma clínica especializada em IST de 2009 a 2013.Resultados: Foram incluídos 680 doentes, correspondendo a 8% dos observados no período de estudo. A maioria (638, 92%) era do sexo masculino e homens que têm sexo com homens (489, 72%). Quase metade (304, 45%) eram migrantes. Do total, 270 (40%) dos doentes tiveram diagnóstico de pelo menos uma IST, sendo sífilis a mais comum (123, 18%), seguida por infecção por Chlamydia trachomatis (46, 7%), Neisseria gonorrhoeae (42, 6%) e condilomas genitais (32, 5%). Relativamente à infecção VIH, 329 (48%) doentes tinham infecção conhecida e 351 (52%) foram diagnosticados de novo. Estes eram significativamente mais jovens e recorreram mais frequentemente para rastreio. Nos doentes com infecção VIH conhecida encontrou-se maior frequência de antecedentes pessoais de IST, referenciação por parceiros, sintomatologia e diagnóstico de novas ISTs.Conclusões: Foi diagnosticada pelo menos uma IST (excepto VIH) em 40% dos indivíduos observados. Tal facto representa um problema importante não só porque uma IST concomitante aumenta o risco de aquisição de VIH (para os indivíduos diagnosticados de novo), mas também porque demonstra que os indivíduos com infecção VIH conhecida mantêm um padrão comportamental de elevado risco

LGBTQI+: conceitos e definições aplicados no contexto da saúde

Introdução: A Organização Mundial de Saúde e a comunidade médica têm vindo a reconhecer a necessidade de intervir nos grupos considerados como minorias sexuais e de género, nomeadamente na comunidade de lésbicas, gays, bissexuais, “trans” (transgéneros e transsexuais), queer e intersexuais (LGBTQI). Objetivos: O presente artigo pretende rever a terminologia utilizada na distinção dos vários grupos de orientação sexual, identidade de género, outros conceitos relevantes e o seu impacto clínico. Materiais e métodos: Revisão da literatura com recurso à base de dados científica Pubmed utilizando as palavras-chave gender identity, gender variance, transgender, sexual orientation, transsexualism. Foi realizada pesquisa da terminologia e conceitos LGBTQI em websites e jornais de associações de apoio à comunidade LGBTQI. Resultados: A identidade de género é a forma como uma pessoa se identifica internamente e que determina a expressão de género, a qual resulta da combinação do comportamento, linguagem, apresentação estética e contexto cultural. A orientação sexual corresponde à atração sexual e/ou emocional que pode contribuir para o estabelecimento de relações sexuais e/ou emocionais e é determinada por três dimensões: a atração, o comportamento e a identidade sexual. Discussão: Alguns estudos mostram que utentes LGBTQI podem ter uma menor procura de cuidados de saúde, em particular devido ao receio de discriminação. Estes apresentam também necessidades específicas em cuidados de saúde, conforme os fatores de risco de exposição sexual ou inerentes à redesignação sexual cirúrgica/médica. Conclusão: O género e a sexualidade são determinantes sociais para a saúde que devem ser distinguidos e aferidos na prestação de cuidados de saúde. O clínico deve estar sensibilizado para reconhecer esses problemas e intervir

COVID-19 and Seasonal Flu During the Autumn-Winter of 2020/2021 and the Challenges Lying Ahead for Hospitals

The possibility of a second wave of the COVID-19 pandemic coexisting with a simultaneous epidemic of influenza and the co-circulation of other seasonal respiratory viruses sets the stage for a perfect storm. Preparing for the Autumn-Winter of 2020/2021 is complex, requiring centralized guidance but local and regional solutions, with strong leadership and a high level of coordination. It is essential to act upstream of hospitals in order to reduce demand on emergency departments, minimizing the risk of transmission that occurs there and the team overload, as well as downstream to ensure capacity for hospitalization and in the hospital itself to optimize resources and organization. The failure of this plan will create unbearable pressure on hospital care. The authors describe the challenges lying ahead for hospitals and the most important measures that should be included in this plan to prepare the Autumn-Winter of 2020/2021 in Portugal.publishersversionpublishe

The incidence of multidrug and full class resistance in HIV-1 infected patients is decreasing over time (2001–2006) in Portugal

Despite improvements in HIV treatment, the prevalence of multidrug resistance and full class resistance is still reported to be increasing. However, to investigate whether current treatment strategies are still selecting for multidrug and full class resistance, the incidence, instead of the prevalence, is more informative. Temporal trends in multidrug resistance (MDR defined as at most 1 drug fully susceptible) and full class resistance (FCR defined as no drug in this class fully susceptible) in Portugal based on 3394 viral isolates genotyped from 2000 to 2006 were examined using the Rega 6.4.1 interpretation system. From July 2001 to July 2006 there was a significant decreasing trend of MDR with 5.7%, 5.2%, 3.8%, 3.4% and 2.7% for the consecutive years (P = 0.003). Multivariate analysis showed that for every consecutive year the odds of having a new MDR case decreased with 20% (P = 0.003). Furthermore, a decline was observed for NRTI- and PI-FCR (both P < 0.001), whereas for NNRTI-FCR a parabolic trend over time was seen (P < 0.001), with a maximum incidence in 2003–'04. Similar trends were obtained when scoring resistance for only one drug within a class or by using another interpretation system. In conclusion, the incidence of multidrug and full class resistance is decreasing over time in Portugal, with the exception of NNRTI full class resistance which showed an initial rise, but subsequently also a decline. This is most probably reflecting the changing drug prescription, the increasing efficiency of HAART and the improved management of HIV drug resistance. This work was presented in part at the Eighth International Congress on Drug Therapy in HIV Infection, Glasgow (UK), 12-16 November 2006 (PL5.5); and at the Fifth European HIV Drug Resistance Workshop, Cascais (Portugal), 28-30 March 2007 (Abstract 1)

Antibody response against selected epitopes in the HIV-1 envelope gp41 ectodomain contributes to reduce viral burden in HIV-1 infected patients

The ectodomain of gp41 is the target of potent binding and neutralizing antibodies (NAbs) and is being explored in new strategies for antibody-based HIV vaccines. Previous studies have suggested that the W164A-3S (3S) and EC26-2A4 (EC26) peptides located in the gp41 ectodomain may be potential HIV vaccine candidates. We assessed 3S- and EC26-specific binding antibody responses and related neutralizing activity in a large panel of chronic HIV-1-infected Portuguese individuals on ART. A similar proportion of participants had antibodies binding to 3S (9.6%) and EC26 (9.9%) peptides but the level of reactivity against 3S was significantly higher compared to EC26, except in the rare patients with double peptide reactivity. The higher antigenicity of 3S was unrelated with disease stage, as assessed by CD4+ T cell counts, but it was directly related with plasma viral load. Most patients that were tested (89.9%, N = 268) showed tier 1 neutralizing activity, the potency being inversely associated with plasma viral load. In the subset of patients that were tested for neutralization of tier 2 isolates, neutralization breadth was inversely correlated with plasma viral load and directly correlated with CD4+ T cell counts. These results are consistent with a role for neutralizing antibodies in controlling viral replication and preventing the decline of CD4+ T lymphocytes. Importantly, in patients with 3S-specific antibodies, neutralizing titers were inversely correlated with viral RNA levels and proviral DNA levels. Moreover, patients with 3S and/or EC26-specific antibodies showed a 1.9-fold higher tier 2 neutralization score than patients without antibodies suggesting that 3S and/or EC26-specific antibodies contribute to neutralization breadth and potency in HIV-1 infected patients. Overall, these results suggest that antibodies targeting the S3 and EC26 epitopes may contribute to reduce viral burden and provide further support for the inclusion of 3S and EC26 epitopes in HIV-1 vaccine candidates.publishersversionpublishe

Characterization of NS5A and NS5B Resistance-Associated Substitutions from Genotype 1 Hepatitis C Virus Infected Patients in a Portuguese Cohort

This study is focused on the prevalent NS5 coding region resistance-associated substitutions (RASs) in DAA-naive genotype (GT)1 HCV-infected patients and their potential impact on success rates. Plasma RNA from 81 GT1 HCV-infected patients was extracted prior to an in-house nested RT-PCR of the NS5 coding region, which is followed by Sanger population sequencing. NS5A RASs were present in 28.4% (23/81) of all GT1-infected patients with 9.9% (8/81) having the Y93C/H mutation. NS5B RASs showed a prevalence of 14.8% (12/81) and were only detected in GT1b. Overall 38.3% (31/81) of all GT1 HCV-infected patients presented baseline RASs. The obtained data supports the usefulness of resistance testing prior to treatment since a statistically significant association was found between treatment failure and the baseline presence of specific NS5 RASs known as Y93C/H (p = 0.04).publishersversionpublishe

Protecting healthcare workers against SARS-CoV-2

A COVID-19 é uma séria ameaça à capacidade de resposta dos serviços de saúde. Neste contexto espera-se que os trabalhadores de saúde (TdS) laborem longas horas, sob grande pressão profissional, familiar e emocional, com recursos muitas vezes inadequados, enquanto aceitam os perigos inerentes à atividade, à proximidade com pessoas infeciosas, aos perigos inseparáveis dos ambientes de trabalho. O impacto na pandemia reflete-se nos TdS enquanto indivíduos, mas também afeta as suas famílias, quer relativamente ao menor tempo disponível quer ao nível da saúde mental. Fatores como a quantidade, o custo, a disponibilidade bem como a falta de hábito no uso de equipamentos de proteção individual (EPI) condicionam a sua utilização pelos TdS. A utilização de EPI não é proteção suficiente se não for acompanhada da adoção de outras medidas de controlo de infeção, como a higienização das mãos e distanciamento físico entre funcionários em todas as situações. Deve também ser dada prioridade à testagem de TdS. A pandemia desafia os sistemas de saúde a uma adaptação dinâmica na gestão dos recursos existentes, com um especial enfoque nos sistemas de informação. Os serviços digitalizados ou de telemedicina podem potencialmente reduzir o contato com o paciente e, portanto, os riscos de infeção por SARS-CoV-2. Na perspetiva de uma vacina contra o SARS-CoV-2 para breve, os TdS deverão estar entre os grupos prioritários para a receber. Os TdS são dos recursos mais importantes de um país, pelo que há que cuidar destes profissionais em todos os aspetos nas organizações de saúde, para que os TdS estejam em melhores condições de responder às exigências desta pandemia e outras que eventualmente irão ocorrer no futuro. A pandemia não reconhece fronteiras. Devendo ser abordada de forma a fortalecer uma colaboração internacional que possibilite a solidariedade e a partilha equitativa de recursos. COVID-19 is a serious threat to the responsiveness of health services. In this context, health workers (HW) are expected to work long hours, under great professional, family and emotional pressure, with resources often inadequate, while accepting the dangers inherent in the activity, the proximity to infectious people, inseparable dangers of work environments.The impact of the pandemic is reflected in HW as individuals, but it also affects their families, both in terms of less time available and in terms of mental health. Factors such as quantity, cost, availability as well as the lack of habit of use of personal protective equipment (PPE) affects its use by HW. The use of PPE is not sufficient protection if not accompanied by the adoption of other infection control measures, such as hand hygiene and physical distance. Priority should also be given to testing H W. The pandemic challenges health systems to a dynamic adaptation in the management of existing resources, with a special focus on information systems. Telemedicine services can potentially reduce direct contact with the patients and, therefore, the risk of SARS-CoV-2 infection. In the perspective of a SARS-CoV-2 vaccine soon, HW should be among the priority groups to receive it .HW are one of the most important resources in a country, so it is necessary to take care of these professionals in all aspects in health organizations, so that HW are able to respond to the demands of this pandemic and others that will eventually occur in the future. The pandemic does not recognize borders. It must be addressed in a way that strengthens international collaboration that enables solidarity and equitable resource sharing.publishersversionpublishe

Artemether-lumefantrine treatment failure of uncomplicated Plasmodium falciparum malaria in travellers coming from Angola and Mozambique

Funding Information: We are grateful to the two patients who participated in the study. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. This work was supported by Funda??o para a Ci?ncia e Tecnologia (FCT) through GHTM (UID/04413/2020); Medical Research Council UK (Grant no. MR/M01360X/1, MR/N010469/1, MR/R025576/1, and MR/R020973/1); BBSRC (Grant no. BB/R013063/1). Study sponsors had no involvement in the study design; in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication. Both patients signed a written informed consent for the analysis of parasite genes, under the IHMT Ethics Committee Approval n?11.18 and CHLO Ethics Committee Approval RNEC:20170700050. Funding Information: This work was supported by Fundação para a Ciência e Tecnologia (FCT) through GHTM (UID/04413/2020); Medical Research Council UK (Grant no. MR/M01360X/1, MR/N010469/1, MR/R025576/1, and MR/R020973/1); BBSRC (Grant no. BB/R013063/1). Study sponsors had no involvement in the study design; in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication. Publisher Copyright: © 2021 The AuthorsThe failure of artemisinin combination therapy (ACT) in malaria patients returning from endemic regions may be driven by parasite resistance to this treatment. ACT is used globally as the first-line treatment for Plasmodium falciparum malaria. However, artemisinin-resistant strains of P. falciparum have emerged and spread across Southeast Asia, with the risk of reaching high malaria burden regions in Africa and elsewhere. Here, we report on two malaria imported cases from Africa with possible parasite resistance to the ACT artemether-lumefantrine (AL). Case presentation: Two middle-aged males returning from Angola and Mozambique developed malaria symptoms in Portugal, where they were diagnosed and received treatment with AL as hospital inpatients. After apparent cure and discharge from hospital, these individuals returned to hospital showing signs of late clinical failure. Molecular analysis was performed across a number of drug resistance associated genes. No evidence of pfk13-mediated artemisinin resistance was found. Both subjects had complete parasite clearance after treatment with a non-ACT antimalarials. Conclusion: Our case-studies highlight the need for close monitoring of signs of unsatisfactory antimalarial efficacy among AL treated patients and the possible implication of other genes or mutations in the parasite response to ACTs.publishersversionpublishe

Routine HIV Screening in Portugal: Clinical Impact and Cost-Effectiveness

Objective: To compare the clinical outcomes and cost-effectiveness of routine HIV screening in Portugal to the current practice of targeted and on-demand screening. Design: We used Portuguese national clinical and economic data to conduct a model-based assessment. Methods: We compared current HIV detection practices to strategies of increasingly frequent routine HIV screening in Portuguese adults aged 18-69. We considered several subpopulations and geographic regions with varying levels of undetected HIV prevalence and incidence. Baseline inputs for the national case included undiagnosed HIV prevalence 0.16%, annual incidence 0.03%, mean population age 43 years, mean CD4 count at care initiation 292 cells/μL, 63% HIV test acceptance, 78% linkage to care, and HIV rapid test cost €6 under the proposed routine screening program. Outcomes included quality-adjusted survival, secondary HIV transmission, cost, and incremental cost-effectiveness. Results: One-time national HIV screening increased HIV-infected survival from 164.09 quality-adjusted life months (QALMs) to 166.83 QALMs compared to current practice and had an incremental cost-effectiveness ratio (ICER) of €28,000 per quality-adjusted life year (QALY). Screening more frequently in higher-risk groups was cost-effective: for example screening annually in men who have sex with men or screening every three years in regions with higher incidence and prevalence produced ICERs of €21,000/QALY and €34,000/QALY, respectively. Conclusions: One-time HIV screening in the Portuguese national population will increase survival and is cost-effective by international standards. More frequent screening in higher-risk regions and subpopulations is also justified. Given Portugal’s challenging economic priorities, we recommend prioritizing screening in higher-risk populations and geographic settings