Agostinho Marques

Pneumococcal polysaccharide vaccination for adults: new perspectives for Europe

Vaccination is the only public-health measure likely to reduce the burden of pneumococcal diseases. In 2010, a group of European experts reviewed evidence on the burden of pneumococcal disease and the immunogenicity, clinical effectiveness and cost–effectiveness of vaccination with 23-valent pneumococcal polysaccharide vaccine (PPV23). They also considered issues affecting the future use of PPV23 and pneumococcal conjugate vaccines in the elderly and adults at high risk of pneumococcal disease. PPV23 covers 80–90% of the serotypes responsible for invasive pneumococcal disease in Europe. Primary vaccination and revaccination with PPV23 are well tolerated, induce robust, long-lasting immune responses in elderly adults and are cost effective. Ensuring protection against pneumococcal disease requires monitoring of the changing epidemiology of pneumococcal serotypes causing invasive pneumococcal disease and improving vaccine coverage. In the future, it will be critically important for pneumococcal vaccination recommendations for elderly adults to be based on comparative evaluations of PPV23 and newer pneumococcal conjugate vaccines with regard to their long-term immunogenicity, clinical effectiveness and cost–effectiveness.

Survival predictors in advanced non-small cell lung cancer

The authors studied the influence on survival of 21 clinical, anatomical, haematological and biochemical factors evaluated, at diagnosis, of 411 patients (pts) with advanced Non Small Cell Lung Cancer (NSCLC) followed in our department between 1984 and 1990. Most of the patients were male (347--84.4%) and only 64 (15.6%) were females. Median age was 62 years, but was slightly higher in females. Only 34 patients were aged under 45 years. Squamous cell carcinoma (215 pts--52%) and adenocarcinoma (152 pts--37%) were the most frequent histologic types. Performance status was poor--only 103 (25%) continued active; 120 (29%) spent at least half of the time in bed; 188 (46%) were severely limited. After staging, 179 (44%) presented locally advanced disease (stage IIIB) and 232 (56%) metastatic dissemination (stage IV). Therapy was defined by the oncologic group according to individual characteristics and based on clinical grounds. Anti-neoplastic therapy was performed in 225 (55%), chemotherapy alone in 121 (30%), radiation therapy alone in 67 (16%), and sequential combined treatment (chemotherapy and thoracic radiation) in 37 (9%). Until 1987, the main chemotherapy regimen was MACC (Metrotrexate + Adriamycine + Cyclophosphamide + Lomustin), afterwards VP(M) (Cisplatin + Vimblastin + Mitomycine). Radiation therapy was performed using Co60, 2 Gy/day, 5 days a week, for 4 weeks (approximately 45 Gy total). The response rate was poor--four complete responses (2%), 42 (19%) partial responses. The overall median survival was 4.3 months and only 5% of patients were alive after 18 months of follow up. Prognostic importance of each characteristic studied was initially done by unifactorial analysis, followed by multifactorial analysis according to two methods: Cox proportional hazards model and recursive partitioning amalgamation--RECPAM. Regardless of the method used, the main determinants of survival were found to be performance status (Zubrod), weight loss and serum albumin. Other factors such as the staging (presence or absence of metastasis), lymphocytes, lactic dehydrogenase, and hoarseness were also significant. It is noteworthy that age and histological type were irrelevant; sex and hoarseness only proved important when integrated within a multifactorial model. The overall prognostic evaluation and therapeutic decision of advanced NSCLC patients could be improved by combining the prognostic value of TNM with that of performance status, weight loss and serum albumin. These prognostic guidelines must be taken into account when designing new clinical trials.

Indoor air pollution on nurseries and primary schools: impact on childhood asthma - study protocol

BackgroundSeveral studies have demonstrated an association between the exposure to indoor air pollution (IAP) and childhood asthma. Evidence is suggesting that several air pollutants may contribute to both exacerbation and development of asthma, but some uncertainty remains concerning the specific causative role of IAP. This paper reports an epidemiologic study aiming to reduce the existing lacks on the association between long-term exposure to pollution mixtures and the development and exacerbation of childhood asthma.Methods/designBased on the implementation of the study in 8 nurseries and 8 primary schools, from which, 2 nurseries and 2 primary schools in sites influenced by traffic and other 2 nurseries and 2 primary schools in background sites at urban and rural areas, the study will analyse the exposure to both urban and rural pollution as well as to traffic emissions (some homes of the children will be included in the study). Furthermore, based on the answers to validated questionnaires (as those used in the International Study of Asthma and Allergies in Childhood - ISAAC) filled in by the parents and on medical exams, the study will assess the prevalence, incidence and exacerbation of asthma, thus considering both short and long-term effects. The approximate number of children in the study will never be less than 600, guaranteeing 80% of study power (significant at a 5% level).DiscussionThis study intends to contribute for the understanding of the role of environmental factors, namely indoor air pollution, on asthma considering a risk group of different ages, and for the development of preventive measures, which are considered priority issues by the European Commission, according to the European Environmental Agency and the World Health Organization.

BTNL2 gene polymorphism associations with susceptibility and phenotype expression in sarcoidosis

A functional polymorphism within butyrophilin-like 2 (BTNL2) gene has been described as a potential risk factor for sarcoidosis. The association between chronicity and the rs2076530 SNP A allele has also been reported. This study evaluates the BTNL2 rs2076530 G/A allele associations with sarcoidosis susceptibility and disease evolution in a Portuguese cohort of patients. A case-control study of 151 patients and 150 controls was performed. Allele frequencies were compared with Chi-square test in a univariate analysis and with logistic regression in a multivariate analysis. BTNL2 rs206530 A allele frequencies were significantly higher in sarcoidosis with no linkage disequilibrium with HLA-DRB1 alleles, except in the subgroup of patients with Löfgren syndrome where the determinant allele was HLA-DRB1*03. The A allele was also increased in those with isolated thoracic disease, with no differences regarding radiological stages or disease evolution. HLA-DRB1*03, besides the association with Löfgren syndrome was significantly related with disease resolution. Our data confirms the association of BTNL2 rs2076530 A allele with sarcoidosis susceptibility in a Portuguese population. We found independent genetic risk factors in clinically distinct disease phenotypes: BTNL2 rs2076530 A allele in patients without Löfgren syndrome or with isolated thoracic disease, and HLA-DRB1*03 in Löfgren syndrome or disease resolution.

Bronchiectasis: A retrospective study of clinical and aetiological investigation in a general respiratory department

BACKGROUND Bronchiectasis can result from many diseases, which makes the aetiological investigation a complex process demanding special resources and experience. The aetiological diagnosis has been proven to be useful for the therapeutic approach. OBJECTIVE Evaluate how accurately and extensive the clinical and aetiological research was for adult bronchiectasis patients in pulmonology outpatient service which were not following a pre-existing protocol. METHODS We retrospectively reviewed the records of 202 adult patients with bronchiectasis, including the examinations performed to explain the aetiology. RESULTS The mean age of the patients was 54 ± 15 years, there was a predominance of female (63.9%) and non-smoker (70%) patients. Functional evaluation showed a mild airway obstruction. The sputum microbiological examination was available for 168 patients (43.1% had 3 or more sputum examinations during one year). Immunoglobulins and α1-antitrypsin were measured in around 50% of the patients. The sweat test and the CF genotyping test were performed in 18% and 17% of the patients, respectively. The most commonly identified cause was post-infectious (30.3%), mostly tuberculosis (27.2%). No definitive aetiological diagnosis was established in 57.4% of the patients. We achieved a lower aetiological diagnosis if we compare our series with studies in which a diagnostic algorithm was applied prospectively. CONCLUSIONS The general characteristics of our patients were similar with other series. Detailed investigation of bronchiectasis is not a standard practice in our outpatient service. These results suggest that the use of a predefined protocol, based on current guidelines, could improve the assessment of these patients and facilitate the achievement of a definitive aetiology.

Involving community partners in the management of tuberculosis among drug users

R. Duarte *, A. Santos , M. Mota , A. Carvalho , A. Marques , H. Barros d Centro de Diagnóstico Pneumológico de Vila Nova de Gaia, Rua Conselheiro Veloso da Cruz, 4400 037 Vila Nova de Gaia, Portugal Giru Gaia, Vila Nova de Gaia, Portugal Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal d Faculdade de Medicina, Universidade do Porto, Portugal Centro de Referência para TBMR na Região Norte, Portugal

Diagnosis of sputum smear-negative forms of pulmonary tuberculosis by transthoracic fine-needle aspiration.

We reviewed 25 patients submitted to transthoracic fine-needle aspiration (TFNA) who had a final diagnosis of pulmonary tuberculosis. In all cases, bacteriological stains and cultures of sputum and bronchial washing had been performed before admission and were negative. According to the material obtained from the procedure, the aspirates were divided in three groups: diagnostic (Ziehl-Neelsen and/or culture positive, n = 8, 32%), suggestive (granulomatous inflammatory changes, n = 10, 40%) and inconclusive (nonspecific inflammatory changes, isolated giant cells and/or blood, n = 7, 28%). On chest X-ray, 12 patients had opacities with the greatest diameter not exceeding 4 cm. All aspirates in the diagnostic group were from patients with this type of lesion, while all the inconclusive aspirates belonged to patients with larger lesions. As complications, 1 patient needed thoracic drainage for pneumothorax and 3 patients had haemoptyses. Thus TFNA has a place in the diagnosis of suspected pulmonary tuberculosis when more simple methods have failed, and its effectiveness seems to be increased when the lesions do not exceed 4 cm in diameter.

Prevalência da asma e da rinite em adolescentes de 13 anos do Porto, Portugal

Background: The prevalence of asthma and rhinitis has been increasing over the past few decades, but the last few years have seen these rates stabilise or even decrease. Aim: The aim of our study was to describe the prevalence of rhinitis, asthma or asthma-like symptoms in 13 year-old urban adolescents. Methods: Eligible participants were all students at state and private schools in Porto born in 1990. 2161 (77.5%) agreed to participate. Information was obtained using self-administered questionnaires inquiring into social, demographic, behavioural and clinical history including asthma and allergic diseases in the adolescent and the family. We used the Portuguese version of the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire and we also performed spirometry tests. Results: In this sample of 13 year old urban adolescents the prevalence of asthma ever was 12.9%, 84.4% with physician diagnosis. Lifetime wheezing was reported by 18.3% and current wheezing by 9.3% of the adolescents. Rhinitis was referred to by 10.1%, but the prevalence of adolescents with sneezing ever, or a runny/blocked nose, was 32.0% and the prevalence in the last 12 months was 27.4%. Conclusion: We concluded that there was stabilisation or even decrease in the prevalence of asthma and rhinitis symptoms and diagnosis in adolescents reported in Porto, compared with the 2002 ISAAC study, as observed in other surveys in Europe. Asthma and rhinitis is frequently present in the same patient and nocturnal cough is an important symptom concomitant with nasal symptoms. Measures of lung function permitted the discrimination of adolescents with respiratory complaints. Rev Port Pneumol 2008; XIV (6): 747-768

Prevalence of asthma and rhinitis in 13 year old adolescents in Porto, Portugal

BACKGROUND The prevalence of asthma and rhinitis has been increasing over the past few decades, but the last few years have seen these rates stabilise or even decrease. AIM The aim of our study was to describe the prevalence of rhinitis, asthma or asthma-like symptoms in 13 year-old urban adolescents. METHODS Eligible participants were all students at state and private schools in Porto born in 1990. 2161 (77.5%) agreed to participate. Information was obtained using self-administered questionnaires inquiring into social, demographic, behavioural and clinical history including asthma and allergic diseases in the adolescent and the family. We used the Portuguese version of the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire and we also performed spirometry tests. RESULTS In this sample of 13 year old urban adolescents the prevalence of asthma ever was 12.9%, 84.4% with physician diagnosis. Lifetime wheezing was reported by 18.3% and current wheezing by 9.3% of the adolescents. Rhinitis was referred to by 10.1%, but the prevalence of adolescents with sneezing ever, or a runny/blocked nose, was 32.0% and the prevalence in the last 12 months was 27.4%. CONCLUSION We concluded that there was stabilisation or even decrease in the prevalence of asthma and rhinitis symptoms and diagnosis in adolescents reported in Porto, compared with the 2002 ISAAC study, as observed in other surveys in Europe. Asthma and rhinitis is frequently present in the same patient and nocturnal cough is an important symptom concomitant with nasal symptoms. Measures of lung function permitted the discrimination of adolescents with respiratory complaints.

Idiopathic pulmonary fibrosis in the era of antifibrotic therapy: Searching for new opportunities grounded in evidence

Idiopathic pulmonary fibrosis (IPF) is a progressive and fatal lung disease that up to now has been associated with a poor prognosis. However, the results of the INPULSIS and ASCEND trials and the approval of nintedanib and pirfenidone have marked the beginning of a new era for IPF patients. Questions remain, however. Should these drugs be used earlier? What effect will they have on more severe disease? Will their effects last beyond the trial period? This manuscript is the outcome of a multidisciplinary meeting between pulmonology, radiology, and pathology clinicians on the use of antifibrotic agents in IPF. In our opinion, the existing data show that pirfenidone and nintedanib slow functional decline in early stages of disease. These drugs also appear to result in therapeutic benefits when administered to patients with advanced disease at diagnosis and maintain effective over time. The data also suggest that continuing antifibrotic therapy after disease progression may confer benefits, but more evidence is needed. Early diagnosis and treatment are crucial for reducing functional decline, slowing disease progression, and improving quality of life.