To be or not to be hospitalised with tuberculosis in Portugal

SETTING: In Portugal, as in other countries, tuberculosis (TB) is considered a disease that should be managed on an ambulatory basis. However, hospitalisation remains important to manage some at-risk groups and complications.OBJECTIVE: To identify the possible risk factors associated with hospitalisations in TB patients in Portugal.DESIGN: Data extraction through two national databases (one for registration of TB cases and the other with hospitalisation information in public health facilities) between 2007 and 2013. Univariate and multivariate analysis of demographic and clinical variables was performed.RESULTS: We identified 4421 hospitalisations. Chronic diseases, cancer, substance abuse, a higher social/economic risk, extra-pulmonary TB, lung cavitary disease and previous uncompleted treatment were more frequent among hospitalised patients. Human immunodeficiency virus coinfection, cancer, alcohol abuse, extra-pulmonary TB and uncompleted previous TB treatment were the most important predictors of hospitalisation with TB. The hospitalisation rate among TB patients in Portugal was lower when compared with other countries with lower and higher incidences.CONCLUSION: Immune dysfunctions and progression of chronic diseases are associated with more severe forms of TB and frequent adverse effects which can be sufficiently severe to necessitate hospital admission. Despite having an intermediate TB incidence, the hospitalisation rate in Portugal is not higher than that of other countries.

Ex vivo interaction between blood components and hormone-dependent breast cancer cells induces alterations associated with epithelial-mesenchymal transition and thrombosis

The prevalence of breast cancer is steadily increasing with metastasis and thromboembolic complications identified as the most common causes of death. The acquisition of an aggressive phenotype by hormone-dependent breast cancers is mediated by Transforming Growth Factor Beta 1 (TGF-β₁) expression and is associated with epithelial-mesenchymal transition (EMT) and, potentially, increased propensity for thrombosis. We investigated this phenomenon by assessing the effect of platelet-rich plasma (PRP) and whole blood (WB) on parameters of EMT and hypercoagulation in vitro. MCF-7 breast cancer cells were cultured under standard conditions, followed by co-culture with PRP or WB. Cells were processed for real-time PCR (TGF-β₁ and vimentin), electron microscopy or immunocytochemistry (TGF-β₁). Micrographs were qualitatively assessed, and real-time PCR data analyzed with PAST Statistical Software. The addition of blood components heightened TGF-β₁ immunolocalization and significantly increased corresponding gene expression. Both PRP and WB significantly increased vimentin expression and induced a shape change from a typical epithelial phenotype to a spindle-shape morphology, indicative of EMT. Fibrin fiber, network and plaque formation indicated a hypercoagulatory environment. The results thus show that in preparation for hematogenous metastasis, hormone-dependent breast cancer cells assume an aggressive phenotype associated with EMT, simultaneously increasing the propensity for the formation of thrombo-emboli.

Application of multivariate analysis on naphthalene adsorption in aqueous solutions

Naphthalene (NAP) is found as a pollutant in water, soil, and air, and adsorption is the most prominent removal process of this compound, among the methods studied. A study concerning the types of adsorbents and the parameters with the greatest influence on the adsorption process is interesting to direct future works on new adsorbents. The use of multivariate data analysis tools becomes an appealing way to compile data obtained from bibliographic reviews and to establish a behavior in NAP adsorption. This work aims to evaluate the parameters with greater influence on NAP adsorption process regarding adsorption capacity (qe_exp) with the principal component analysis (PCA), and to group common NAP adsorbents by chemical characteristics through hierarchical cluster analysis (HCA). The variables qe_exp, S, [NAP]₀, T, CT, and [Ads] were used to perform PCA with correlation matrix. For the HCA, the variables S, [NAP]₀, T, CT, and [Ads] with average linkage method (UPGMA) and Euclidean distance were used. Through PCA, it is possible to infer that S and [NAP]₀ are the factors with greater influence in qe_exp of NAP, while T, CT, and [Ads] have little correlation. PCA also shows that activated charcoal is the adsorbent with higher qe_exp. HCA grouped the adsorbents into four groups by their chemical classes, except group A. Both PCA and HCA methods show themselves as potential tools to evaluate a data set of NAP adsorption processes.

Atherosclerotic vascular disease is more prevalent among black ESKD patients on long-term CAPD in South Africa

Background

Occurrence of cardiovascular disease (CVD) in the setting of chronic kidney disease (CKD) can be described as a “cruel alliance”, with CVD responsible for about half of all deaths among CKD patients. Chronic kidney disease patients are more likely to die from CVD than progress to end stage kidney disease (ESKD). Dyslipidaemia, a known traditional risk factor for CVD, is highly prevalent among CKD patients and with an even higher frequency among ESKD patients on dialytic therapies. Prolonged exposure of continuous ambulatory peritoneal dialysis (CAPD) patients to high glucose concentrations in CAPD fluid have been associated with increased risk of cardiovascular events. In this study, we investigated the relationship of atherosclerotic vascular disease (AsVD) to clinical and echocardiographic parameters among black South Africans with CKD (stage 3) and ESKD on CAPD and haemodialysis (HD).

Methods

This was a cross-sectional study of 40 adult (18–65 years) non-diabetic CKD patients (kidney disease outcome quality initiative [KDOQI] stage 3), 40 ESKD patients on CAPD, 40 ESKD patients on HD and 41 age and sex-matched healthy controls. An interviewer-administered questionnaire was used to obtain information on participants’ sociodemographic and cardiovascular risk factors. Anthropometric parameters were measured. Serum blood samples were analysed for creatinine, albumin and lipid profile; lipoprotein ratios, Framingham’s risk score and the 10-year risk of developing coronary heart disease (CHD) were calculated. Echocardiography was performed on all patients and carotid intima media thickness (CIMT) was measured in both right and left carotid arteries at 1 cm proximal to the carotid bulb. Spearman’s rank correlation and binary logistic regression were conducted to determine the relationship of AsVD to clinical and echocardiographic parameters.

Results

Atherosclerotic vascular disease was most prevalent among ESKD patients on CAPD (70%, n = 28/40). Chronic kidney disease and HD patients exhibited a similar prevalence (47.5%, n = 19/40), while the prevalence in controls was 17.1% (n = 7/41). Presence of AsVD was associated with significantly older age, higher waist hip ratio (WHR), left ventricular mass index (LVMI) and Framingham’s 10-year risk of developing CHD. Significant differences in clinical and echocardiographic parameters were observed when the study groups were compared. Age and LVH independently predicted AsVD.

Conclusion

Atherosclerotic vascular disease was more prevalent among CAPD patients compared to pre-dialysis CKD and HD patients. Among all lipoprotein ratios assessed, non-HDL-C showed the most consistent significant difference between the groups. Age (> 40 years) and presence of LVH were independent predictors of AsVD.

Pre-transplantation Risks and Transplant-Techniques in Haematopoietic Stem Cell Transplantation for Acute Leukaemia

BACKGROUND

The role of conditioning intensity and stem cell source on modifying pre-transplantation risk in allogeneic haematopoietic stem cell transplantation (HSCT) is a matter of debate, but crucial when benchmarking centres.

METHODS

This Retrospective, multicenter exploratory-validation analysis of 9103 patients, (55.5% male, median age 50 years; 1-75 years range) with an allogeneic HSCT between 2010 and 2016 from a matched sibling (N = 8641; 95%) or matched unrelated donor (N = 462; 5%) for acute myeloid (N = 6432; 71%) or acute lymphoblastic (N = 2671; 29%) leukaemia in first complete remission, and reported by 240 centres in 30 countries to the benchmark database of the European Society for Blood and Marrow Transplantation (EBMT) searched for factors associated with use of transplant techniques (standard N = 6375;70% or reduced intensity conditioning N = 2728;30%, respectively bone marrow N = 1945;21% or peripheral blood N = 7158;79% as stem cell source), and their impact on outcome.

FINDINGS

Treatment groups differed significantly from baseline population (p < 0.001), and within groups regarding patient-, disease-, donor-, and centre-related pre-transplantation risk factors (p < 0.001); choice of technique did depend on pre-transplantation risk factors and centre (p < 0.001). Probability of overall survival at 5 years decreased systematically and significantly with increasing pre-transplantation risk score (score 2 vs 0/1 HR: 1·2, 95% c.i. [1·1-1·.3], p = 0.002; score 3 vs 0/1 HR: 1·5, 95% c.i. [1·3-1·7], p < 0.001; score 4/5/6 vs 0/1 HR: 1·9, 95% c.i. [1·6-2·2], p < 0.001) with no significant differences between treatment groups (likelihood ratio test on interaction: p = 0.40). Overall survival was significantly associated with selection steps and completeness of information (p < 0.001).

INTERPRETATION

Patients' pre-transplantation risk factors determine survival, independent of transplant techniques. Transplant techniques should be regarded as centre policy, not stratification factor in benchmarking. Selection criteria and completeness of data bias outcome. Outcomes may be improved more effectively through better identifying pre-transplantation factors as opposed to refinement of transplant techniques.

FUNDING

The study was funded by EBMT.

Multidrug-resistant tuberculosis in Lisbon: unfavourable treatment and associated factors, 2000-2014

SETTING: The incidence of tuberculosis (TB) has been decreasing in Portugal. Lisbon concentrates the largest number of cases of multidrug-resistant (MDR) TB in the country. This study aims at identifying clinical and demographic factors associated with unfavourable treatment results of patients with MDR-TB in the city.METHOD: The data on 265 MDR-TB cases, notified from 2000 to 2014 in the District of Lisbon, were collected from the Tuberculosis Surveillance System. Unfavourable cases were classified as failure, loss to follow-up (LTFU) and death. Bivariate and multivariate logistic regressions were undertaken to estimate the factors associated with unfavourable outcomes, LTFU and death.RESULTS: The proportion of unfavourable outcomes was 30.5%. These were associated mostly with being male, foreign-born and resistant to kanamycin. Death was associated with being human immunodeficiency virus-positive and resistant to kanamycin. Being foreign-born had a 4.46-fold higher odds of a LTFU outcome than did being Portuguese-born. The foreign-born patients were mostly African immigrants.CONCLUSION: The main finding in this study is that foreign-born patients are associated with a higher probability of unfavourable outcomes than Portuguese-born patients. Therefore, foreign-born patients need more careful monitoring in the control of MDR-TB.

HIV screening of tuberculosis patients in Portugal: what are we missing?

BACKGROUND

Knowledge of human immunodeficiency virus (HIV) status is essential to effectively manage both tuberculosis (TB) and HIV infection. This is why the World Health Organization (WHO) recommends routine HIV testing in all TB patients.

OBJECTIVE

To determine the number of TB patients with unknown HIV status in Portugal and to identify the factors associated with unknown HIV status.

METHODS

A retrospective study of all TB notifications from 2008 to 2014 in Portugal was conducted. A multiple logistic regression model was used to evaluate the association of sociodemographic and clinical factors with unknown HIV status.

RESULTS

We examined the records of 18 445 patients with TB notification, 2402 of whom (13%) had unknown HIV status. Unknown HIV status was positively associated with age 65 years (adjusted odds ratio [aOR] 1.208, 95%CI 1.037-1.408) and extra-pulmonary TB (aOR 1.381, 95%CI 1.252-1.523), but negatively associated with unemployment (aOR 0.755, 95%CI 0.637-0.895), alcohol dependence (aOR 0.809, 95%CI 0.682-0.959) and drug dependence (aOR 0.566, 95%CI 0.449-0.713).

CONCLUSION

Risk perception is the most important barrier to complete knowledge of HIV status in TB patients in Portugal. Given the importance of HIV screening in TB patients, every effort should be made to ensure that all TB patients undergo HIV screening.

La Jument lighthouse: a real-scale laboratory for the study of giant waves and their loading on marine structures

This paper presents results from an experiment designed to improve the understanding of the relationship between extreme breaking waves and their mechanical loading on heritage offshore lighthouses. The experiment, conducted at La Jument, an iconic French offshore lighthouse, featured several records of wave, current and structure accelerations acquired during severe storm conditions, with individual waves as high as 24 m. Data analysis focuses on a storm event marked by a strong peak in the horizontal accelerations measured inside La Jument. Thanks to stereo-video wave measurements synchronized to the acceleration record we were able to identify and describe the breaking wave responsible for this intense loading. Our observations suggest that this giant wave (19 m high) had a crest elevation high enough to directly hit the lighthouse tower, above the substructure. This paper reveals the potential for conducting ambitious field experiments from offshore lighthouses in order to collect valuable storm waves and wave loading observations. This offers a possible second service life for these heritage structures as in situ laboratories dedicated to the study of the coastal hydrodynamics and its interaction with marine structures. This article is part of the theme issue 'Environmental loading of heritage structures'.

Death after hematopoietic stem cell transplantation: changes over calendar year time, infections and associated factors

Information on incidence, and factors associated with mortality is a prerequisite to improve outcome after hematopoietic stem cell transplantation (HSCT). Therefore, 55'668 deaths in 114'491 patients with HSCT (83.7% allogeneic) for leukemia were investigated in a landmark analysis for causes of death at day 30 (very early), day 100 (early), at 1 year (intermediate) and at 5 years (late). Mortality from all causes decreased from cohort 1 (1980-2001) to cohort 2 (2002-2015) in all post-transplant phases after autologous HSCT. After allogeneic HSCT, mortality from infections, GVHD, and toxicity decreased up to 1 year, increased at 5 years; deaths from relapse increased in all post-transplant phases. Infections of unknown origin were the main cause of infectious deaths. Lethal bacterial and fungal infections decreased from cohort 1 to cohort 2, not unknown or mixed infections. Infectious deaths were associated with patient-, disease-, donor type, stem cell source, center, and country- related factors. Their impact varied over the post-transplant phases. Transplant centres have successfully managed to reduce death after HSCT in the early and intermediate post-transplant phases, and have identified risk factors. Late post-transplant care could be improved by focus on groups at risk and better identification of infections of "unknown origin".

Thrombopoietin Receptor Agonists for Severe Thrombocytopenia after Allogeneic Stem Cell Transplantation: Experience of the Spanish Group of Hematopoietic Stem Cell Transplant

Persistent thrombocytopenia is a common complication after allogeneic hematopoietic stem cell transplantation (allo-SCT). Romiplostim and eltrombopag are the currently available thrombopoietin receptor agonists (TPO-RAs), and some studies with very small numbers of cases have reported their potential efficacy in the allo-SCT setting. The present retrospective study evaluated the safety and efficacy of TPO-RAs in 86 patients with persistent thrombocytopenia after allo-HSCT. Sixteen patients (19%) had isolated thrombocytopenia (PT), and 71 (82%) had secondary failure of platelet recovery (SFPR). TPO-RA therapy was started at a median of 127 days (range, 27 to 1177 days) after allo-SCT. The median initial and maximum administered doses were 50 mg/day (range, 25 to 150 mg/day) and 75 mg/day (range, 25 to 150 mg/day), respectively, for eltrombopag and 1 µg/kg (range, 1 to 7 µg/kg) and 5 µg/kg (range, 1 to 10 µg/kg), respectively, for romiplostin. The median platelet count before initiation of TPO-RA therapy was 14,000/µL (range, 1000 to 57,000/µL). Platelet recovery to ≥50,000/µL without transfusion support was achieved in 72% of patients at a median time of 66 days (range, 2 to 247 days). Eighty-one percent of the patients had a decreased number of megakaryocytes before treatment, showing a slower response to therapy (P = .011). The median duration of treatment was 62 days (range, 7 to 700 days). Grade 3-4 adverse events (hepatic and asthenia) were observed in only 2% of the patients. At last follow-up, 81% of patients had discontinued TPO-RAs and maintained response, and 71% were alive. To our knowledge, this is the largest series analyzing the use of TPO-RAs after allo-SCT reported to date. Our results support the efficacy and safety in this new setting. Further prospective trials are needed to increase the level of evidence and to identify predictors of response.

Gonadal Function after Busulfan Compared with Treosulfan in Children and Adolescents Undergoing Allogeneic Hematopoietic Stem Cell Transplant

Gonadal impairment is an important late effect with a significant impact on quality of life of transplanted patients. The aim of this study was to compare gonadal function after busulfan (Bu) or treosulfan (Treo) conditioning regimens in pre- and postpubertal children. This retrospective, multicenter study included children transplanted in pediatric European Society for Blood and Marrow Transplantation (EBMT) centers between 1992 and 2012 who did not receive gonadotoxic chemoradiotherapy before the transplant. We evaluated 137 patients transplanted in 25 pediatric EBMT centers. Median age at transplant was 11.04 years (range, 5 to 18); 89 patients were boys and 48 girls. Eighty-nine patients were prepubertal at transplant and 48 postpubertal. One hundred eighteen children received Bu and 19 Treo. A higher proportion of girls treated with Treo in the prepubertal stage reached spontaneous puberty compared with those treated with Bu (P = .02). Spontaneous menarche was more frequent after Treo than after Bu (P < .001). Postpubertal boys and girls treated with Treo had significantly lower luteinizing hormone levels (P = .03 and P = .04, respectively) compared with the Bu group. Frequency of gonadal damage associated with Treo was significantly lower than that observed after Bu. These results need to be confirmed in a larger population.

Why does it take so long? The reasons behind tuberculosis treatment delay in Portugal

INTRODUCTION

Delayed diagnosis and treatment of tuberculosis contributes to the spread of the disease. In this study, we aimed to determine the patient and healthcare system delay among tuberculosis patients in Portugal and identify associated factors at individual and contextual level.

METHODS

We analysed all TB cases notified in Portugal between 2010 and 2014 using data from the national surveillance system. Patient and healthcare system delay were computed, log-transformed, and used as outcomes. Adjusted generalized linear models were fitted to identify sociodemographic, contextual and clinical determinants.

RESULTS

The study included 6838 patients. The median of patient and healthcare system were 33 and 17 days, respectively. Adjusted regression models revealed that higher patient delay occurred in foreign patients (exponentiated beta: 1.177, 95%CI 1.091-1.270) and those addicted to alcohol (1.169, 1.072-1.276) and drugs (1.153, 1.027-1.295). Higher healthcare system delay was observed among patients with extra-pulmonary TB (2.067, 1.885-2.268) and pulmonary comorbidities - lung cancer (2.391, 1.656-3.452), sarcoidosis (3.316, 1.370-8.022) and COPD (1.295, 1.059-1.584) - and in patients residing further from a healthcare service (1.040, 1.018-1.062).

CONCLUSION

We found that various individual and contextual factors affect the time delay in tuberculosis treatment. Our findings indicate that some strategies, such as facilitating the access to healthcare services among foreign patients and patients with addictions and increasing the awareness towards TB among healthcare professionals, may result in better TB control.

Breast cancer cell-induced platelet activation is compounded by tamoxifen and anastrozole in vitro

Platelet-tumour cell interaction is implicated in the initiation of breast cancer-associated thrombosis, with hormone-therapy (Tamoxifen/Anastrozole), increasing this risk. However, recent in vitro research indicates that Tamoxifen inhibits platelet activation, while the effects of Anastrozole on platelet activation are not well characterised. This study investigated platelet activation caused by Tamoxifen or Anastrozole-treated breast cancer cells in vitro. MCF7 and T47D cells were pre-treated with Tamoxifen or Anastrozole to mimic the effects of the drugs in vivo, and co-cultured with whole blood. Platelet activation was determined using flow cytometry. Platelet (CD41a⁺CD62P⁺) was determined using an interval gating strategy. Platelet morphology was visualised using scanning electron microscopy. Our results support clinical findings, showing that hormone-therapy is associated with platelet activation. Tamoxifen-treated MCF7 cells increased P-selectin expression, with ultrastructural analysis showing fully spread platelets. Conversely, Tamoxifen-treated T47D cells decreased P-selectin expression with platelets showing signs of early aggregation. Anastrozole pre-treatment decreased P-selectin expression, with treated MCF7 cells inducing platelet membrane folds and lamellipodia extension, and treated T47D cells inducing platelet aggregation and fibrin network formation indicating hypercoagulation. The findings support clinical studies. Hormone-therapy augments tumour cell-induced platelet activation, which may be linked to cell phenotype. This may have clinical implications for treatment strategies.

Non-Graft-versus-Host Disease Ocular Complications after Hematopoietic Cell Transplantation: Expert Review from the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society for Blood and Marrow Transplantation

Non-graft-versus-host disease (GVHD) ocular complications are generally uncommon after hematopoietic cell transplantation (HCT) but can cause prolonged morbidity affecting activities of daily living and quality of life. Here we provide an expert review of non-GVHD ocular complications in a collaboration between transplantation physicians and ophthalmologists through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. Complications discussed in this review include cataracts, glaucoma, ocular infections, ocular involvement with malignancy, ischemic microvascular retinopathy, central retinal vein occlusion, retinal hemorrhage, retinal detachment and ocular toxicities associated with medications. We summarize the incidence, risk factors, screening, prevention, and treatment of individual complications and generate evidence-based recommendations. Baseline ocular evaluation before HCT should be considered in all patients who undergo HCT. Follow-up evaluations should be considered according to clinical signs and symptoms and risk factors. Better preventive strategies and treatments remain to be investigated for individual ocular complications after HCT. Both transplantation physicians and ophthalmologists should be knowledgeable about non-GVHD ocular complications and provide comprehensive collaborative team care.

Ocular Graft-versus-Host Disease after Hematopoietic Cell Transplantation: Expert Review from the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation

Ocular graft-versus-host disease (GVHD) occurs in more than one-half of patients who develop chronic GVHD after allogeneic hematopoietic cell transplantation (HCT), causing prolonged morbidity that affects activities of daily living and quality of life. Here we provide an expert review of ocular GVHD in a collaboration between transplantation physicians and ophthalmologists through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. Recent updates in ocular GVHD regarding pathophysiology, preclinical models, risk factors, prevention, screening, diagnosis, response criteria, evaluation measures, and treatment are discussed. Ocular GVHD involves at least 3 biological processes: lacrimal gland dysfunction, meibomian gland dysfunction, and corneoconjunctival inflammation. Preclinical models have identified several novel pathogenic mechanisms, including the renin angiotensin system and endoplasmic reticulum stress signaling, which can be targeted by therapeutic agents. Numerous studies have identified reliable tests for establishing diagnosis and response assessment of ocular GVHD. The efficacy of systemic and topical treatment for ocular GVHD is summarized. It is important that all health professionals caring for HCT recipients have adequate knowledge of ocular GVHD to provide optimal care.