A paired trial comparing mononuclear cell collection in two machines for further inactivation through an inline or offline extracorporeal photopheresis procedure

BACKGROUND

Extracorporeal photopheresis (ECP) is an effective treatment. However, protocols differ widely, and some questions, such as the number of cells to be collected or the number of ECP treatment days per treatment cycle, are still unsolved. The aim of this study was to compare a multistep (offline) (Spectra Optia and Macogenic G2) against an integrated (inline) ECP system (Therakos Cellex system) with respect to mononuclear cell (MNC) collection.

STUDY DESIGN AND METHODS

The number and quality parameters of the MNC products collected were evaluated together with some machine parameters, such as collection time. Comparisons were made through paired sample analysis with the t test.

RESULTS

Fourteen patients underwent 15 double-paired procedures using both ECP protocols. The average MNC collected in the multistep procedure was 77.4 × 10⁸ , four times more than in the integrated procedure (18.5 × 10⁸ ). MNC purity (84.4% vs. 63.8%) and enrichment (27.9 vs. 5.9) in the product collected were also higher in the multistep procedure. The whole ECP time was higher in the multistep than in the integrated procedure (272 vs. 106 min), but the calculated time to collect 25 × 10⁸ MNCs in the multistep was shorter compared with the one-step procedure (77.8 vs. 172 min). All these differences between the two protocols were statistically significant.

CONCLUSIONS

These two ECP protocols are different with respect to MNC collection and length of procedure. Some unresolved questions, such as the better MNC dose to inactivate or the number of consecutive days that ECP should be performed for optimal clinical efficacy, require further review.

Evaluation of resistance to HIV-1 infection ex vivo of PBMCs isolated from patients with chronic myeloid leukemia treated with different tyrosine kinase inhibitors

Current antiretroviral treatment (ART) may control HIV-1 replication but it cannot cure the infection due to the formation of a reservoir of latently infected cells. CD4+ T cell activation during HIV-1 infection eliminates the antiviral function of the restriction factor SAMHD1, allowing proviral integration and the reservoir establishment. The role of tyrosine kinases during T-cell activation is essential for these processes. Therefore, the inhibition of tyrosine kinases could control HIV-1 infection and restrict the formation of the reservoir. A family of tyrosine kinase inhibitors (TKIs) is successfully used in clinic for treating chronic myeloid leukemia (CML). The safety and efficacy against HIV-1 infection of five TKIs was assayed in PBMCs isolated from CML patients on prolonged treatment with these drugs that were infected ex vivo with HIV-1. We determined that the most potent and safe TKI against HIV-1 infection was dasatinib, which preserved SAMHD1 antiviral function and avoid T-cell activation through TCR engagement and homeostatic cytokines. Imatinib and nilotinib showed lower potency and bosutinib was quite toxic in vitro. Ponatinib presented similar profile to dasatinib but as it has been associated with higher incidence of arterial ischemic events, dasatinib would be the better choice of TKI to be used as adjuvant of ART in order to avoid the establishment and replenishment of HIV-1 reservoir and move forward towards an HIV cure.

Is the use of unrelated donor transplantation leveling off in Europe? The 2016 European Society for Blood and Marrow Transplant activity survey report

Hematopoietic cell transplantation (HCT) is an established procedure for acquired and congenital disorders of the hematopoietic system. In 2016, there was a tendency for continued activity in this field with 43,636 HCT in 39,313 patients [16,507 allogeneic (42%), 22,806 autologous (58%)] reported by 679 centers in 49 countries in 2016. The main indications were myeloid malignancies 9547 (24%; 96% allogeneic), lymphoid malignancies 25,618 (65%; 20% allogeneic), solid tumors 1516 (4%; 2% allogeneic), and non-malignant disorders 2459 (6%; 85% allogeneic). There was a remarkable leveling off in the use of unrelated donor HCT being replaced by haploidentical HCT. Continued growth in allogeneic HCT for marrow failure, AML, and MPN was seen, whereas MDS appears stable. Allogeneic HCT for lymphoid malignancies vary in trend with increases for NHL and decreases for Hodgkin lymphoma and myeloma. Trends in CLL are not clear, with recent increases after a decrease in activity. In autologous HCT, the use in myeloma continues to expand but is stable in Hodgkin lymphoma. There is a notable increase in autologous HCT for autoimmune disease. These data reflect the most recent advances in the field, in which some trends and changes are likely to be related to development of non-transplant technologies.

New drugs and perspectives for new anti-tuberculosis regimens

Tuberculosis (TB) is the ninth cause of global death, more than any other infectious disease. With growing drug resistance the epidemic remains and will require significant attention and investment for the elimination of this disease to occur. With susceptible TB treatment not changing over the last four decades and the advent of drug resistance, new drugs and regimens are required. Recently, through greater collaboration and research networks some progress with significant advances has taken place, not withstanding the comparatively low amount of resources invested. Of late the availability of the new drugs bedaquiline, delamanid and repurposed drugs linezolid, clofazimine and carbapenems are being used more frequently in drug-resistant TB regimens. The WHO shorter multidrug-resistant tuberculosis regimen promises to reach more patients and treat them more quickly and more cheaply. With this new enthusiasm and hope we this review gives an update on the new drugs and perspectives for the treatment of drug-susceptible and drug-resistant tuberculosis.

Mycobacterium avium infection in Portugal

BACKGROUND

Although the incidence rates of non-tuberculous mycobacteria (NTM) have been increasing in many countries, the basic epidemiology of NTM remains to be fully understood.

OBJECTIVE

To assess the incidence, clinical relevance and geographical distribution of NTM disease in Portugal and to identify demographic and clinical characteristics associated with Mycobacterium avium complex (MAC) disease.

METHODS

Information stored in an electronic database of all NTM cases reported over an 11-year period was retrospectively reviewed. Significant demographic and clinical characteristics of MAC disease (vs. having any other NTM disease) were determined using multiple logistic regression models.

RESULTS

We identified 632 patients, mostly male, native Portuguese, with pulmonary disease, predominantly from Lisbon and Porto. The annual incidence of NTM disease was 0.54 per 100 000 population. The annual number of NTM cases increased throughout the study period. MAC was most frequently isolated. MAC disease was positively (and significantly) associated with being female, age >45 years and human immunodeficiency virus infection.

CONCLUSIONS

The increasing incidence of NTM over the study period emphasises the importance of NTM as a public health issue. This study provides important information for health care professionals and a basis for further study of NTM in Portugal.

Tuberculosis among the homeless: should we change the strategy?

BACKGROUND

Tuberculosis (TB) is a major concern among high-risk populations such as the homeless.

OBJECTIVES

To evaluate TB incidence and treatment outcomes among homeless patients in Portugal and to identify predictors of unsuccessful TB treatment outcomes among the homeless.

DESIGN

This was a retrospective cohort study of all TB patients notified in Portugal from 2008 to 2014. Characteristics of homeless TB patients were assessed and predictors of unsuccessful TB treatment were determined using logistic regression.

RESULTS

TB incidence among the homeless was 122/100,000 homeless persons and was positively correlated with TB incidence among non-homeless persons. Homeless TB patients had a higher prevalence of alcohol and/or drug use, human immunodeficiency virus (HIV) co-infection, cavitary TB and smear positivity. The rate of unsuccessful treatment outcomes among the homeless was 28.6%, and was significantly associated with increased age, injection drug use (IDU) and HIV co-infection.

CONCLUSION

TB incidence among homeless persons was five times that among the non-homeless, and higher in regions with greater TB incidence among non-homeless persons. The successful treatment outcome rate was lower. Predictors of unsuccessful treatment were age, IDU and HIV co-infection. Integrated TB programmes targeting homeless and non-homeless patients, with measures targeting specific characteristics, may contribute to TB elimination in Portugal.

Longitudinal clustering of tuberculosis incidence and predictors for the time profiles: the impact of HIV

BACKGROUND

Portugal remains the country with the highest tuberculosis (TB) incidence in Western Europe.

OBJECTIVES

To identify longitudinal trends in TB incidence in Portugal from 2002 to 2012 and investigate the longitudinal effect of sociodemographic and health-related predictors among the resident population on the TB incidence rate.

METHODS

We used data from the National Tuberculosis Surveillance System and other national institutions. K-means longitudinal clustering algorithm was performed on TB incidence time profiles from districts of Portugal.

RESULTS

Three longitudinal profiles for the TB incidence rate of Portugal were identified. In all of them, TB incidence decreased over time. Among all studied sociodemographic and health-related predictors, human immunodeficiency virus (HIV) notification rate and unemployment were shown to have (positive) significant effects on TB incidence. In particular, the greatest effects were found for the HIV notification rate.

CONCLUSIONS

Our study supports the view that combined TB-HIV strategies and the improvement of social determinants can contribute to decreases in TB incidence.

Diagnosis delay of tuberculosis in the Huambo province, Angola

INTRODUCTION

Early diagnosis is necessary for the success of the tuberculosis (TB) program.

GOAL

To identify factors associated with diagnosis delay of TB in Huambo, Angola.

MATERIAL AND METHODS

Cross-sectional study carried out in patients diagnosed with TB at the Huambo Anti-Tuberculosis Dispensary (ATD) in the period between October 2015 and January 2016.

RESULTS

The 247 patients included in the analysis had a median age of 27 years and a median diagnosis delay of 64 days. In the univariate analysis, age, consumption of alcoholic beverages, living in a residence further than 10km from a healthcare unit, and looking for any other health unit than the emergency unit were associated with longer diagnosis delay. In the multivariate analysis model, to be between 30 and 44 years of age (p=0.018), to live in a residence more than 10km from a healthcare unit (p=0.006) and to turn to traditional medicine as the first healthcare option (p<0.001) were factors that led to greater time delay before diagnosis.

CONCLUSIONS

In the Huambo province, age, distance to healthcare facility and the first healthcare service consulted were associated with diagnosis delay of TB.

Thyroid storm and myxoedema: two reversible causes of acute heart failure

Cardiovascular signs and symptoms can prevail in both hypothyroidism and hyperthyroidism. Case 1: 30-year-old female with acute right heart failure as first manifestation of Graves' disease. It illustrates some of its cardiovascular complications, particularly pulmonary hypertension, tricuspid regurgitation, atrial fibrillation, mitral valve prolapse and mitral regurgitation. Case 2: 83-year-old-man with a severe primary hypothyroidism/myxoedema crisis presented to emergency department with extreme bradyarrhythmia with hemodynamic impact and heart failure signs, which led to implantation of definitive pacemaker. Thyroid disorders are treatable entities and most cardiovascular changes are reversible. Early diagnosis is mandatory and can avoid severe complications and, eventually, invasive therapeutics interventions. Pulmonary hypertension and acute heart failure, especially in young adults, should be screened for underlying hyperthyroidism.

Tuberculosis, social determinants and co-morbidities (including HIV)

The risk of exposure, progression to active tuberculosis (TB) and then to cure is a process affected by several risk factors. Along with well known risk factors such as human immunodeficiency virus (HIV), use of immunosuppressive drugs and being of young age, emerging risk factors such socio-economic and behavioral aspects play a significant role in increasing the susceptibility to infection, and unsuccessful treatment outcomes. This paper summarizes the effects of these socio-economic determinants and co-morbidities (including HIV) on TB infection and disease.

Team approach to manage difficult-to-treat TB cases: Experiences in Europe and beyond

As recommended by the World Health Organization (WHO), optimal management of MDR-TB cases can be ensured by a multi-speciality consultation body known as 'TB Consilium'. This body usually includes different medical specialities, competences and perspectives (e.g., clinical expertise both for adults and children; surgical, radiological and public health expertise; psychological background and nursing experience, among others), thus lowering the risk of making mistakes - or managing the patients inappropriately, in order to improve their clinical outcomes. At present, several high MDR-TB burden countries in the different WHO regions (and beyond) have introduced TB Consilium-like bodies at the national or subnational level to reach consensus on the best treatment approach for their patients affected by TB. In addition, in countries/settings where a formal system of consultation does not exist, specialized staff from MDR-TB reference centres or international organizations usually spend a considerable amount of their working time responding to phone or e-mail clinical queries on how to manage M/XDR-TB cases. The aim of this manuscript is to describe the different experiences with the TB Consilia both at the international level (European Respiratory Society - ERS/WHO TB Consilium) and in some of the countries where this experience operates successfully in Europe and beyond. The Consilium experiences are described around the following topics: (1) history, aims and focus; (2) management and funding; (3) technical functioning and structure; (4) results achieved. In addition a comparative analysis of the TB Consilia in the different countries has been performed.

Nosocomial tuberculosis prevention in Portuguese hospitals: a cross-sectional evaluation

SETTING

Measures to control tuberculous infection are crucial to prevent nosocomial transmission and protect health care workers (HCWs). In Portugal, the extent of implementation of tuberculosis (TB) control measures in hospitals is not known.

OBJECTIVE

To determine the current implementation of preventive measures for tuberculous infection at administrative, environmental and personal levels in Portuguese hospitals.

DESIGN

A cross-sectional evaluation was performed using two anonymous questionnaires: one sent to all the hospital infection control (IC) committees and the other sent to all pulmonologists and physicians specialising in infectious disease.

RESULTS

Fourteen IC committees and 72 physicians responded. According to the IC committees, 92% of hospitals had a written TB control plan, but only 37% of the physicians said there was always/almost always a fast track for diagnosing suspected pulmonary TB cases. The majority of the hospitals had an isolation policy (85%) and these patients were always/almost always admitted in separate rooms, according to 70% of physicians. Both HCWs and TB patients used respiratory protection equipment (92%).

CONCLUSION

These findings indicate that the most basic TB IC measures had been undertaken, but some TB IC measures were not fully implemented at all hospitals. An institutional effort should be made to solve this problem and strengthen TB prevention activities.

Tuberculosis in children from diagnosis to decision to treat

SETTING

Confirmation of tuberculosis (TB) in children is difficult, so clinicians use different procedures when deciding to treat.

OBJECTIVE

Identify criteria to initiate and maintain TB treatment in children younger than 5 years-old, without diagnosis confirmation.

DESIGN

A web-based survey was distributed by email to the corresponding authors of journal articles on childhood TB. The observations were clustered into disjoint groups, and analyzed by Ward's method.

RESULTS

We sent out 260 questionnaires and received 64 (24.6%) responses. Forty-six respondents (71.9%) said that microbiological confirmation was not important for initiation of anti-TB treatment, and that the epidemiological context and signs/symptoms suggestive of disease were most important. Sixty-one respondents (95.3%) said that the decision to continue therapy was mainly dependent on clinical improvement. A cluster of older respondents (median age: 52 years-old) who were active at a hospital or primary health care centre placed the most value on immunological test results and chest X-rays. A cluster of younger respondents (median age: 38 years-old) who were less experienced in management of TB placed more value on Interferon Gamma Release Assay (IGRA) results and chest computed tomography (CT) scans. A cluster of respondents with more experience in treating TB and working at specialized TB centres placed greater value on the clinical results and specific radiological alterations ("tree-in-bud" pattern and pleural effusion).

CONCLUSION

TB management varied according to the age, work location and experience of the clinicians. It is necessary to establish standardized guidelines used for the diagnosis and decision to treat TB in children.

Tuberculosis in native- and foreign-born populations in Portugal

BACKGROUND

Tuberculosis (TB) is a major global health problem, and during the last 20 years, industrialised countries have shown similar patterns in TB notifications: decreasing TB incidence in native populations and increasing incidence in foreign-born populations.

OBJECTIVES

To characterise risk factors associated with TB among native- and foreign-born TB patients in Portugal and identify barriers to the management of foreign cases.

METHODS

Analysis of the data from the national tuberculosis surveillance system and data from an online survey of physicians managing TB cases in the country.

RESULTS

Risk factors in the two populations differed. Foreign-born patients were younger, less likely to use drugs or alcohol and had fewer comorbidities. They were also more likely to be human immunodeficiency virus positive, to be employed and to be homeless/living in shelters. The outcome of the disease and the time to diagnosis were not significantly different between the two populations. The most important barriers to the management of foreign-born TB cases were language and fear of deportation.

CONCLUSIONS

As there are significant differences between the two populations, different TB control strategies should be implemented in the two populations.