Factors Associated with the Extent of Clinical Attachment Loss in Periodontitis: A Multicenter Cross-Sectional Study

Periodontitis has significant public health implications, affecting individuals' overall health, well-being, and quality of life. This study aimed to assess the risk factors associated with the extent of clinical attachment loss (CAL) in a population diagnosed with periodontitis. Six hundred and sixty-seven patients with different degrees of CAL (mild, n = 223; moderate, n = 256; and advanced, n = 188) were enrolled. Socio-demographics, lifestyle, microbiological profiles, specific immune response, obesity, and single-nucleotide polymorphism of the IL1 gene were determined. Unconditional logistic regression models were conducted to determine the factors associated with the extent of CAL. Aging, smoking, microbial factors, plaque index, and IgG2 antibodies against Aggregatibacter actinomycetemcomitans were associated with advanced CAL. IgG2 antibodies against A. actinomycetemcomitans (OR 1.50; CI 95% 1.23-1.81), plaque accumulation (OR 2.69; CI 95% 2.20-3.29), Porphyromonas gingivalis (OR 1.93; CI 95% 1.35-2.76), Tanerella forsythia (OR 1.88; CI 95%1.30-2.70), and current smoking (OR 1.94; CI 95% 1.31-2.87) were associated with advanced CAL. Gene IL polymorphisms, obesity, and stress were not associated with the extent of CAL. Aging, plaque accumulation, smoking, and having antibodies against A. actinomycetemcomitans were the most critical factors associated with advanced CAL. In contrast, obesity, stress, and gene polymorphisms were not associated with the extent of CAL.

Viral genetic clustering and transmission dynamics of the 2022 mpox outbreak in Portugal

Pathogen genome sequencing during epidemics enhances our ability to identify and understand suspected clusters and investigate their relationships. Here, we combine genomic and epidemiological data of the 2022 mpox outbreak to better understand early viral spread, diversification and transmission dynamics. By sequencing 52% of the confirmed cases in Portugal, we identified the mpox virus sublineages with the highest impact on case numbers and fitted them into a global context, finding evidence that several international sublineages probably emerged or spread early in Portugal. We estimated a 62% infection reporting rate and that 1.3% of the population of men who have sex with men in Portugal were infected. We infer the critical role played by sexual networks and superspreader gatherings, such as sauna attendance, in the dissemination of mpox virus. Overall, our findings highlight genomic epidemiology as a tool for the real-time monitoring and control of mpox epidemics, and can guide future vaccine policy in a highly susceptible population.

Development of an amplicon-based sequencing approach in response to the global emergence of mpox

The 2022 multicountry mpox outbreak concurrent with the ongoing Coronavirus Disease 2019 (COVID-19) pandemic further highlighted the need for genomic surveillance and rapid pathogen whole-genome sequencing. While metagenomic sequencing approaches have been used to sequence many of the early mpox infections, these methods are resource intensive and require samples with high viral DNA concentrations. Given the atypical clinical presentation of cases associated with the outbreak and uncertainty regarding viral load across both the course of infection and anatomical body sites, there was an urgent need for a more sensitive and broadly applicable sequencing approach. Highly multiplexed amplicon-based sequencing (PrimalSeq) was initially developed for sequencing of Zika virus, and later adapted as the main sequencing approach for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Here, we used PrimalScheme to develop a primer scheme for human monkeypox virus that can be used with many sequencing and bioinformatics pipelines implemented in public health laboratories during the COVID-19 pandemic. We sequenced clinical specimens that tested presumptively positive for human monkeypox virus with amplicon-based and metagenomic sequencing approaches. We found notably higher genome coverage across the virus genome, with minimal amplicon drop-outs, in using the amplicon-based sequencing approach, particularly in higher PCR cycle threshold (Ct) (lower DNA titer) samples. Further testing demonstrated that Ct value correlated with the number of sequencing reads and influenced the percent genome coverage. To maximize genome coverage when resources are limited, we recommend selecting samples with a PCR Ct below 31 Ct and generating 1 million sequencing reads per sample. To support national and international public health genomic surveillance efforts, we sent out primer pool aliquots to 10 laboratories across the United States, United Kingdom, Brazil, and Portugal. These public health laboratories successfully implemented the human monkeypox virus primer scheme in various amplicon sequencing workflows and with different sample types across a range of Ct values. Thus, we show that amplicon-based sequencing can provide a rapidly deployable, cost-effective, and flexible approach to pathogen whole-genome sequencing in response to newly emerging pathogens. Importantly, through the implementation of our primer scheme into existing SARS-CoV-2 workflows and across a range of sample types and sequencing platforms, we further demonstrate the potential of this approach for rapid outbreak response.

Would surgical Apgar score be useful to predict postoperative complications after proximal femoral fracture surgery? - A retrospective cohort study

BACKGROUND

The surgical Apgar score (SAS) is a perioperative risk evaluation score, which considers intraoperative minimum heart rate, minimum mean arterial pressure and estimated blood loss. Although validated in multiple surgical fields, SAS remains quite controversial in the orthopedic one. The main purpose of this study was to investigate if SAS relates with the occurrence of complications during the first 30-days after proximal femoral fracture surgery.

METHODS

Retrospective study including all consecutive patients submitted to proximal femoral fracture surgery between January and July 2019. Patients with no information about SAS were excluded. Patients were divided in two groups, based on the occurrence of complications during the first 30 post-operative days and their SAS calculated. Receiver operating characteristic (ROC) curves were used to assess SAS power as a predictive model of complications.

RESULTS

Forty-two percent (n = 76) of the 181 patients included in the study developed complications during the first 30 postoperative days. Eight patients (4,4%) died during that period. The patient's mean age was 79 years and 30,9% (n = 56) were men. Heart failure, pacemaker use, chronic kidney disease, chronic obstructive pulmonary disease and dementia were significantly associated with post-operative morbidity. There was no significant correlation between SAS and the occurrence of complications during the first 30 postoperative days. The AUC of SAS as a predictive model for postoperative complications after proximal femoral fracture surgery was 0,522, being insufficient to be considered an accepted model of prediction.

CONCLUSION

Based on this study, we conclude that SAS is not predictive of the development of complications in the first 30 post-operative days in patients submitted to proximal femoral fracture surgery. However, other clinical factors have been identified as associated with postoperative morbidity. In the future, prospective-based studies with higher samples may better clarify the role of SAS in this context.

Development of an amplicon-based sequencing approach in response to the global emergence of human monkeypox virus

The 2022 multi-country monkeypox (mpox) outbreak concurrent with the ongoing COVID-19 pandemic has further highlighted the need for genomic surveillance and rapid pathogen whole genome sequencing. While metagenomic sequencing approaches have been used to sequence many of the early mpox infections, these methods are resource intensive and require samples with high viral DNA concentrations. Given the atypical clinical presentation of cases associated with the outbreak and uncertainty regarding viral load across both the course of infection and anatomical body sites, there was an urgent need for a more sensitive and broadly applicable sequencing approach. Highly multiplexed amplicon-based sequencing (PrimalSeq) was initially developed for sequencing of Zika virus, and later adapted as the main sequencing approach for SARS-CoV-2. Here, we used PrimalScheme to develop a primer scheme for human monkeypox virus that can be used with many sequencing and bioinformatics pipelines implemented in public health laboratories during the COVID-19 pandemic. We sequenced clinical samples that tested presumptive positive for human monkeypox virus with amplicon-based and metagenomic sequencing approaches. We found notably higher genome coverage across the virus genome, with minimal amplicon drop-outs, in using the amplicon-based sequencing approach, particularly in higher PCR cycle threshold (lower DNA titer) samples. Further testing demonstrated that Ct value correlated with the number of sequencing reads and influenced the percent genome coverage. To maximize genome coverage when resources are limited, we recommend selecting samples with a PCR cycle threshold below 31 Ct and generating 1 million sequencing reads per sample. To support national and international public health genomic surveillance efforts, we sent out primer pool aliquots to 10 laboratories across the United States, United Kingdom, Brazil, and Portugal. These public health laboratories successfully implemented the human monkeypox virus primer scheme in various amplicon sequencing workflows and with different sample types across a range of Ct values. Thus, we show that amplicon based sequencing can provide a rapidly deployable, cost-effective, and flexible approach to pathogen whole genome sequencing in response to newly emerging pathogens. Importantly, through the implementation of our primer scheme into existing SARS-CoV-2 workflows and across a range of sample types and sequencing platforms, we further demonstrate the potential of this approach for rapid outbreak response.

Equilibrium and symmetries of altitudinal magnetic rotors on a circle

Macroscopic magnets can easily be manipulated and positioned so that interactions between themselves and with external fields induce interesting dynamics and equilibrium configurations. In this work, we use rotating magnets positioned in a line or at the vertices of a regular polygon. The rotation planes of the magnets can be modified at will. The rich structure of stable and unstable configurations is dictated by symmetry and the side of the polygon. We show that both symmetric solutions and their symmetry-breaking bifurcations can be explained with group theory. Our results suggest that the predicted magnetic textures should emerge at any length scale as long as the interaction is polar, and the system is endowed with the same symmetries.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Phylogenomic characterization and signs of microevolution in the 2022 multi-country outbreak of monkeypox virus

The largest monkeypox virus (MPXV) outbreak described so far in non-endemic countries was identified in May 2022 (refs. 1-6). In this study, shotgun metagenomics allowed the rapid reconstruction and phylogenomic characterization of the first MPXV outbreak genome sequences, showing that this MPXV belongs to clade 3 and that the outbreak most likely has a single origin. Although 2022 MPXV (lineage B.1) clustered with 2018-2019 cases linked to an endemic country, it segregates in a divergent phylogenetic branch, likely reflecting continuous accelerated evolution. An in-depth mutational analysis suggests the action of host APOBEC3 in viral evolution as well as signs of potential MPXV human adaptation in ongoing microevolution. Our findings also indicate that genome sequencing may provide resolution to track the spread and transmission of this presumably slow-evolving double-stranded DNA virus.

Environmental DNA metabarcoding for benthic monitoring: A review of sediment sampling and DNA extraction methods

Environmental DNA (eDNA) metabarcoding (parallel sequencing of DNA/RNA for identification of whole communities within a targeted group) is revolutionizing the field of aquatic biomonitoring. To date, most metabarcoding studies aiming to assess the ecological status of aquatic ecosystems have focused on water eDNA and macroinvertebrate bulk samples. However, the eDNA metabarcoding has also been applied to soft sediment samples, mainly for assessing microbial or meiofaunal biota. Compared to classical methodologies based on manual sorting and morphological identification of benthic taxa, eDNA metabarcoding offers potentially important advantages for assessing the environmental quality of sediments. The methods and protocols utilized for sediment eDNA metabarcoding can vary considerably among studies, and standardization efforts are needed to improve their robustness, comparability and use within regulatory frameworks. Here, we review the available information on eDNA metabarcoding applied to sediment samples, with a focus on sampling, preservation, and DNA extraction steps. We discuss challenges specific to sediment eDNA analysis, including the variety of different sources and states of eDNA and its persistence in the sediment. This paper aims to identify good-practice strategies and facilitate method harmonization for routine use of sediment eDNA in future benthic monitoring.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Co-production of health: are communities being heard in local health planning in Portugal?

Background

Health planning is an essential tool to address communities' health needs. Although recommended by portuguese national guidelines, Local Health Plans (LHP) lack adequate community participation, which could improve their implementation and contribute to achieve the SDG agenda and universal health coverage. The aim of this study is to assess the degree of community participation in LHP in Portugal.

Methods

Data was collected from 52 (out of 54) publicly available LHP in April 2021. Each document was reviewed by two independent researchers and analysed considering time frame, participatory approach, stage of the health planning cycle in which the community was involved and methods used to promote community participation. A descriptive analysis was performed.

Results

Although 52 LHP were available, only 37 were valid for 2020. Although community participation was mentioned in all PLH, most did not include a comprehensive community participation approach (88%). Community representatives were particularly involved in the prioritizing health problems stage of the health planning cycle (81%); no LHP mentioned the involvement of the community in the monitoring and evaluation stage. Methods used to promote community participation were clearly stated in 48% of LHP.

Conclusions

Community participation is a key strategy for successful implementation of LHP in Portugal. Most LHP show a clear concern to include community representatives when it comes to prioritizing health problems and highlight the importance of co-production of health between health services and the community, but fail to integrate community participation throughout the health planning cycle. Specific community fora could improve community participation and therefore better implementation of LHP.

Key messages

Most Local Health Plans in Portugal lack a comprehensive community participation approach. A community-centred approach should be prioritized in order to improve LHP implementation.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

A silent “shipyard eye”: lessons from an epidemic keratoconjunctivitis outbreak in Portugal

Issue

Adenoviral conjunctivitis is the most common cause of conjunctivitis. Its most severe form is epidemic keratoconjunctivitis (EKC). This highly contagious disease is the only form to significantly involve the cornea and may cause visual impairing sequelae that persist for years.

Description

On January 2020, staff members at a childcare facility (CCF) alerted the Public Health Unit of Loures-Odivelas to a suspected conjunctivitis outbreak. The CCF was responsible for 57 children, separated in different rooms: a nursery (4-12 months), a pre-school (1-3 years) and a kindergarten (4-5 years). At the initial assessment, 4 cases of active disease were identified, all of which were at home and under treatment. CCF staff had previously identified 33 cases. Symptom onset of the index case had occurred more than 5 weeks before the alert. Infection control and epidemiological investigation were initiated. CCF staff was instructed to implement preventive measures, including careful disinfection of surfaces and toys, as well as frequent handwashing. Information about the disease and recommendations were sent to the children's caretakers.

Results

A total of 87 cases distributed in 8 weeks were identified: 28 at the CCF (25 children and 3 workers) and 59 close contacts (50 adults and 9 children). Average duration of disease was 14.1 days. In total, 43.9% of the children attending the CFF were affected. The highest attack rate was observed at the pre-school (69.2%, against 38.9% and 17.6% at the nursery and the kindergarten, respectively). 88.0% of the CCF children's households were affected. The average number of affected close contacts per affected child attending the CCF was 2.63. Corneal involvement was observed in 17,4% of cases.

Lessons

EKC outbreaks may go unnoticed by public health services, despite its high contagiousness and impact. Improvement of communication with organizations in the community is essential to secure future early detection and intervention.

Key messages

Epidemic keratoconjunctivitis is a highly contagious disease with potential long-term consequences. Early detection and intervention by public health services are essential to mitigate the impact of outbreaks and depend on well-established communication lines with institutions in the community.

External causes in women assisted by the Mobile Emergency Service - SAMU, in Espírito Santo, Brazil

Background

External causes are events that lead to traumas, injuries and any health problems, whether deliberate or not, with sudden onset and with immediate consequence, which may or may not lead to death or incapacitating injuries. Studies show that the main causes of death of women in fertile period are external causes, and they associate this fact with the change in habits and lifestyle adopted by this group in modern times that make them more vulnerable to the risks of becoming ill or dying from such causes. The objective of this study is precisely to analyze the prevalence of the main external causes in women assisted by SAMU 192 in Espírito Santo, Brazil, and in this way, assist in the development of accident and violence prevention strategies and also contribute to the scientific society through the description of the profile epidemiological profile of these events.

Methods

This is a cross-sectional study of primary care provided by SAMU 192, in the state of Espírito Santo, in 2015, in which only women victims of traffic accidents, aggression or falls were selected.

Results

Among the women assisted by SAMU 192, 23.5% were victims of accidents and violence. Of this total, 48.6% received assistance for falls, 46.6% for traffic accidents and 4.9% for aggression. Adulthood was the most frequent, with an average age of 44.9 ± 22.7 years.

Conclusions

External causes involving women represent a major problem in Brazil and worldwide. In Espírito Santo, falling was the most common type of external cause and mainly affected the elderly woman, while the traffic accident mainly affected the adult woman. As for the aggressions, these occurred mainly at night with association with the use of alcoholic beverages. Thus, it is immensely necessary to develop actions to promote and prevent external causes of harm to women's health in the state of Espírito Santo.

Key messages

Knowing what affects the most women's health in an emerging country like Brazil, is essential for public policy actions aimed at reducing the femininity, sexism and the death of women in general. Violence against women is an underreported event because of several factors, leading to the concealment of violence, emphasizing once again the importance of public policies for this purpose.

HIV infection and AIDS reported cases in two municipalities near Lisbon between 2015 and 2019

Background

In the WHO European Region, in 2018, there were 16.2 newly diagnosed HIV infections per 100,000. In Portugal, there were 9.5 new cases per 100,000 population. The aim of this study is to analyse HIV/AIDS's notifications in the group of primary healthcare centres of Loures-Odivelas (ACES LO), with 340,000 inhabitants, between 2015 and 2019.

Methods

An observational, descriptive, retrospective, quantitative study was performed. Data was collected in March 2020, from the National System of Epidemiological Surveillance Database. Variables included were age, sex, HIV's presentation, country of probable origin of infection, probable form of transmission, partner characteristics, pregnancy at diagnosis, reason for testing/consultation, anti-retroviral therapy (ART) before diagnostic of AIDS. Descriptive analysis was performed for all variables.

Results

In ACES LO, there were 83 notified cases of HIV infection/AIDS between 2015 and 2019, with 36.1% of cases notified in 2019. The male to female ratio was 1.4. The average age was 41.7 years old. At time of notification, 56.6% of cases were asymptomatic and 25.3% had clinical criteria for AIDS. Guinea-Bissau was the probable origin of infection in 43.0% of cases (n = 23). Men having sex with men (MSM) was the probable form of transmission in 19.3% of cases. In 19.6% of cases of heterosexual contact, the partner was known to have HIV infection. Six women were pregnant at time of diagnosis. Testing was done on a routine basis in 22.2% of cases (n = 54). Among those with clinical criteria for AIDS (n = 21), 5 cases had previously taken ART.

Conclusions

There was an increase in notified cases of HIV infection/AIDS from 2015 to 2019 in ACES LO. The male to female ratio was lower than for Portugal in 2018.The proportion of cases with AIDS at time of notification was higher than for Portugal in 2018. Preventive strategies should be reinforced for people with partners diagnosed with HIV infection and perhaps for people.

Key messages

More than one third of cases were notified in 2019. Preventive strategies should be reinforced for people with partners diagnosed with HIV infection.

Notification of sexually transmitted infections: the tip of the iceberg?

Background

Sexually transmitted infections (STIs) are a major public health problem in Europe and in Portugal, their incidence has been increasing since the 90s. Although STIs are among the most frequently reported infections globally, they still go often underdiagnosed. Their under notification is also a problem in Portugal. The aim of this study is to describe STIs' notifications in the area of the groups of primary healthcare centers of Loures-Odivelas (ACES LO), between 2015-2019.

Methods

An observational, descriptive, quantitative study was performed. Data was collected in January 2020, from the National System of Epidemiological Surveillance Database. Variables included for each STIs notification were age and sex. Univariate descriptive analysis and evolution trends were performed for each variable.

Results

A total of 638 cases of STIs were reported from 2015 to 2019. The number of reported cases increased from 87 to 197 cases (126.4%). The annual mean incidence of HBV and HCV notifications were 8 and 4, respectively. There was an increase in reported cases of syphilis (33 to 57), HIV (13 to 29), chlamydia (13 to 46) and gonorrhea (18 to 51). In 2019, 30.9% of the notified cases were syphilis infections, 23.5% gonorrhea infections, 22.1% chlamydia infections and 13.2% HIV infections.Males comprised 460 cases (72.1%), and, in patients aged between 15 and 44 years old, 484 cases (75.9%) were reported. From 2015 to 2019, the co-infections of gonorrhea and chlamydia increased from 2 to 10 cases (25.0%). In 2019, 17.5% of the notified cases of gonorrhea were co-infections.

Conclusions

The modification of risk behaviors and the appropriate treatment of infected people, including infected partners, are determinant to prevent recurrent infections and to interrupt the transmission cycle. Increasing notification should facilitate the monitoring of STIs' trends, contributing to the implementation of appropriate interventions and for better decision-making in public health.

Key messages

Campaigns about sexual health promotion are important to increase safer sexual health practices. More notifications contribute to better data quality and more robust decision-making.

A retrospective study of an International Vaccination Centre in the Lisbon Metropolitan Area

Background

Vaccination is one of the most cost-effective disease prevention strategies. Trips from Portugal to other countries have increased in the past 5 years. Depending on the destination, certain vaccines are advised to travellers in order to reduce travel-related risk. We analyzed the data of an International Vaccination Centre (IVC) in the Public Health Unit of the Primary Care Centres Group (ACES) of Loures-Odivelas.

Methods

A retrospective observational study comprising data from an IVC database between 2014 and 2018. Variables included were sex, age, destination, purpose, referral, and prescriptions. Descriptive analyses were performed for all variables.

Results

Between 2014 and 2018, there was a total of 4,873 users. Regarding individual characteristics, 51% were female, 80% had between 15 and 64 years of age, and 51% were referred by general practitioners of the ACES. Africa was the leading destination (66% average for all years) with a downward trend (from 82% in 2014 to 47% in 2018) followed by South America (12%) with an upward trend (from 4% to 16% in the same period). The primary purpose of travelling was tourism (74%) followed by work (15%). A total of 7,323 vaccines were administered, with an annual increase from 1,250 administrations in 2014 to 1,862 in 2018. The yellow fever vaccine accounted for 36,9% of all administrations, followed by typhoid fever vaccine (32,3%) and hepatitis A vaccine (10,2%).

Conclusions

African countries are still the most common destination for Portuguese travellers, but changing trends might influence the vaccination strategies in the IVC. Information provided in the IVC can be optimized to suit individual profiles better.

Key messages

As travelling increases, the International Vaccination Centre has an essential role in the prevention of disease. Africa remains the most common destination, requiring pre-travel health counselling and vaccine prophylaxis.

A retrospective study of a pre-travel consultation in the Lisbon Metropolitan Area, Portugal

Background

Travel from Portugal to other countries has increased in the past 5 years. A pre-travel health consultation is advised to all travellers to raise awareness and reduce travel-related risk. We describe the experience of a pre-travel consultation centre in the public health service.

Methods

A retrospective observational study about consultations in an international vaccination centre between 2014-2018. Variables included were: sex, age, destination, purpose, referral, and prescriptions. Descriptive analyses were performed for all variables.

Results

Between 2014 and 2018, there were 1,546 consultations. Regarding individual characteristics, 54% were female, and 80% had between 15 and 64 years of age. There was no referral in 66% of the consultations, followed by 16% from general practitioners in the Primary Care Centres Group. The leading destination was Africa (54%), in a downward trend (74% in 2015 and 32% in 2018) followed by Asia (18%) with an upward trend (12% to 28% in the same period). The primary purpose was tourism (83%), followed by work (9%). In total, 3,287 vaccines were prescribed with typhoid fever vaccine accounting for 26%, hepatitis A vaccine 22%, and yellow fever vaccine 15%. Mefloquine was the primary therapeutic drug prescribed for destinations with risk for malaria (41%). Regarding destinations with low risk for malaria, in 42% of the consultations, personal protective measures were the only recommendation.

Conclusions

Our data show that pre-travel consultations seem to be valued and actively asked for by travellers, but medical referral is still insufficient. Regarding health promotion and prevention of diseases, tracking trends in the most common destinations allows to optimize the information provided in the consultation, effectively capacitating the traveller to recognize and act on the most common travel-related health risks. In further studies, a post-travel follow-up should be carried out to determine the impact of the consultation.

Key messages

Pre-travel consultation is an actively sought-after service by the community, but awareness should be promoted in the medical community. Pre-travel consultation can have an important role in the health literacy of travellers.

Tuberculosis’ surveillance in a group of primary healthcare centres of Lisbon district

Background

Tuberculosis (TB), a communicable disease, is the leading cause of death from a single infectious agent and one of the top 10 causes of death worldwide. Its burden varies among different countries. In the 31 European Economic Area member states, in 2017, the TB notification rate was 10.7/100,000 population; in Portugal, this rate was 17.5/100,000 population and the majority of the notified cases occurred in two districts: Lisbon and Oporto. The aim of this study is to analyse TB's notifications in a group of primary healthcare centres of Loures-Odivelas (ACES LO), between 2015 and 2019.

Methods

An observational, descriptive, retrospective, quantitative study was performed. Data was collected in January 2020, from the National System of Epidemiological Surveillance Database. Variables included were: age, sex, TB's presentation, antimicrobial susceptibility testing, HIV testing. Descriptive analysis was performed for all variables.

Results

In ACES LO, notified cases of TB dropped 18.0% between 2015 and 2017, having since increased by 54.8% (n = 113), a notification rate of 32.3/100,000 population in 2019. The male to female ratio was 1.7 and the most affected age group was the 30-40 year old group (n = 25). Notified cases in children &lt;10 years old have increased from 0 in 2016 to 7 in 2019. Pulmonary TB was reported in 73.5% (n = 83) of the notified cases; in 56.6% (n = 64), antimicrobial susceptibility testing revealed that first-line treatment would be effective; HIV testing was positive in 10.6% (n = 12).

Conclusions

Surveillance is the first step towards taking action to control and eliminate TB. ACES LO has a high notification rate of TB, therefore effort should be made in order to reduce TB's incidence. More investigation should be performed in order to evaluate the possibility of reintroduction of Bacille Calmette-Guérin (BCG) vaccine to the general population, instead of only risk groups, as it happens in ACES LO since 2016.

Key messages

Surveillance is one of the ten essential Public Health operations, allowing us to measure and analyse health problems in a certain population. Tuberculosis’ incidence is still high in some populations; it is a critical issue to raise awareness about.

The number of cancers attributable to tobacco by sex, in mainland Portugal, in 2008

Background

In Portugal, cancer incidence increases annually about 3%. In 2016, cancer was the first cause of premature death, corresponding to 5 296.8 DALYs/100,000 inhabitants. The aim of this study is to estimate the number of cancers attributable to tobacco in mainland's Portugal by sex.

Methods

An observational, ecological, analytic study was performed. Data was collected by sex: tobacco consumption (current or past) in mainland Portugal resident population older than 20 years, in 1998; incidence of 12 types of cancer, by location: Esophagus (C15), Stomach (C16), Colon (C18), Rectum (C20), Liver (C22), Pancreas (C25), Larynx (C32), Lung (C34), Kidney (C64) and Bladder (C67), according to the ICD-10 classification, in 2008. The population attributable fraction (PAF), for each type of cancer, was calculated with Levin's formula. The confidence intervals (CI) were estimated by Monte Carlo simulation.

Results

The prevalence of tobacco consumption in population between 20-79 years old was 33.41% (CI 95% 32.44-34.38) and 9.88% (CI 95% 9.29-10.54) for men and women, respectively. Higher values of PAF were estimated to lung cancer (76.32% in men, 46.99% in women) followed by larynx cancer (69.55% in men, 39.13% in women).The largest number of attributed cases was estimated for lung cancer (1211 in men, 368 in women) and bladder cancer (827 in men, 114 in women). Total cancers attributable to tobacco were superior in men (3776 vs. 677).

Conclusions

In 2008, 4453 of the total common cancers in both sexes could have been avoided if there was no tobacco consumption (current and past). More cancers would have been prevented in men because they smoked more, but also because in most cancers' RR is higher in men. Actually, tobacco consumption has been increasing in women, thus, it is expected that its number of avoided cancers will approximate the one in men. Campaigns with well-defined target populations are important to increase its health level.

Key messages

Tobacco is a modifiable risk factor which can be prevented; thus it is important to promote campaigns in order to prevent early consumption. Secondary data must be used to provide evidence that will help Public Health in taking better decisions regarding interventions.

Do long-term care services meet the minimal requirements for the elderly?

Background

As the percentage of elderly people (aged over 65) is expected to rise, from 16.0% of the population in 2010 to 29.3% in 2060 in Europe, a quality long-term care system is of increasing priority for governments. The aim of this study is to analyse long-term care services (LTCS) in the geographical area of the group of primary healthcare centres of Loures-Odivelas.

Methods

A retrospective, observational, descriptive study comprising data from public health inspections to LTCS between 2015 and 2019. Variables included were the number of residents, nurses, orderly, cooks, kitchen helpers and medical doctors; licensing status, public health inspection results and the presence of air conditioning. Descriptive analysis was performed for all variables.

Results

Between 2015 and 2019, a total of 200 public health inspections were carried out in 106 LTCS. Only 41 (38.7%) LTCS were licensed. The total number of residents was 2,803, 168 (6.0%) of which were bedridden. Concerning the staff ratio, 79 (74.5%) LTCS fulfilled the ratio of nurse to resident of 1:40 and 67 (63.2%) the ratio of orderly to resident of 1:8. On the first inspection, 11 LTCS (10.4%) complied with the minimal requirements for health care, hygiene, food preparation and facilities conditions. After the implementation of corrective measures proposed by the Public Health Unit, the number of LTCS which had complied for the same criteria was 64 (60.4%).

Conclusions

Society needs to adapt to a growing ageing population. LCTS, while part of the solution, still have deficiencies. In this sample, the majority were illegal and lacked the appropriate conditions. Public Health interventions can contribute to improving these services.

Key messages

In an ageing society, long-term care services are essential but the majority lack the appropriate conditions. Public Health intervention is crucial in implementing corrective measures that will result in better conditions for the elderly.

Asymptotic theory for maximum likelihood estimates in reduced-rank multivariate generalized linear models

Reduced-rank regression is a dimensionality reduction method with many applications. The asymptotic theory for reduced rank estimators of parameter matrices in multivariate linear models has been studied extensively. In contrast, few theoretical results are available for reduced-rank multivariate generalized linear models. We develop M-estimation theory for concave criterion functions that are maximized over parameter spaces that are neither convex nor closed. These results are used to derive the consistency and asymptotic distribution of maximum likelihood estimators in reduced-rank multivariate generalized linear models, when the response and predictor vectors have a joint distribution. We illustrate our results in a real data classification problem with binary covariates.