Eleonora Paixão

Mortality in Portugal associated with the heat wave of August 2003: early estimation of effect, using a rapid method

During the first two weeks of August 2003, Portugal was affected by a severe heat wave. Following the identification in Portugal of the influence of heat waves on mortality in 1981 and 1991 (estimated excess of about 1900 and 1000 deaths respectively), the Observatório Nacional de Saúde (ONSA) - Instituto Nacional de Saúde Dr. Ricardo Jorge, together with the Vigilância Previsão e Informação - Instituto de Meteorologia, created a surveillance system called ÍCARO, which has been in operation since 1999. ÍCARO identifies heat waves with potential influence on mortality [1]. Before the end of the 2003 heat wave, ONSA had produced a preliminary estimate of its effect on mortality. The results based on daily number of deaths from 1 June to 12 August 2003 were presented within 4 working days. Data was gathered from 31 National Civil registrars, covering the district capitals of all 18 districts of mainland Portugal, and representing approximately 40% of the mainlands mortality. The number of deaths registered in the period 30 July to 12 August was compared with the ones registered during 3 comparison periods: (in July): 1-14 July, 1-28 July, and 15-28 July). 15-28 July, the period best resembling the heat wave in time and characteristics, produced an estimation of 37.7% higher mortality rate then the value expected under normal temperature conditions. From this value, an estimate of 1316 death excess was obtained for mainland Portugal. The main purpose of this article is to present the method used to identify and assess the occurrence of an effect (excess mortality) during the heat wave of summer 2003.

Pathogenic fungi: an unacknowledged risk at coastal resorts? New insights on microbiological sand quality in Portugal

Whilst the potential impact on beach users from microorganisms in water has received considerable attention, there has been relatively little investigation into microbial contaminants in sand. Thirty three beaches across Portugal were analyzed during a five year period (2006-2010) to determine the presence of yeasts, pathogenic fungi, dermatophytes, total coliforms, Escherichia coli and intestinal enterococci in sand. Our results showed that 60.4% of the samples were positive for fungi and that 25.2% were positive for the bacterial parameters. The most frequent fungal species found were Candida sp. and Aspergillus sp., whereas intestinal enterococci were the most frequently isolated bacteria. Positive associations were detected among analyzed parameters and country-regions but none among those parameters and sampling period. Regarding threshold values, we propose 15 cfu/g for yeasts, 17 cfu/g for potential pathogenic fungi, 8 cfu/g for dermatophytes. Twenty-five cfu/g for E. coli, and 10 [corrected] cfu/g for intestinal enterococci.

Epidemiology of candidemia in oncology patients: a 6-year survey in a Portuguese central hospital.

This study presents data on the incidence of candidemia in a Portuguese oncology hospital during a 6-year period. The species distribution and their antifungal susceptibility, as well as the clinical outcomes associated with candidemia were evaluated. A total of 119 episodes were reported, with the majority occurring among patients older than 56 years. The most common underlying medical conditions were solid tumors (64.5%) and hematological disease (28.2%). The most frequent species found was Candida albicans (48.7%), followed by C. parapsilosis (20.2%), C. tropicalis (8.4%), C. krusei (6.7%) and C. glabrata (5.0%), but Saccharomyces cerevisiae and Rhodotorula mucilaginosa were also isolated. Candida albicans was more frequently associated with solid tumors of the gastrointestinal and genitourinary tracts and breast (P=0.005), while non-C. albicans Candida species were most frequently recovered from hematological patients (P=0.007). The mortality rate associated with candidemia was 31.9% (P=0.016). All C....

Implication of the RDRio Mycobacterium tuberculosis sublineage in multidrug resistant tuberculosis in Portugal

Multidrug and extensively drug resistant Mycobacterium tuberculosis are a threat to tuberculosis control programs. Genotyping methods, such as spoligotyping and MIRU-VNTR typing (Mycobacterial Interspersed Repetitive Units), are useful in monitoring potentially epidemic strains and estimating strain phylogenetic lineages and/or genotypic families. M. tuberculosis Latin American Mediterranean (LAM) family is a major worldwide contributor to tuberculosis (TB). LAM specific molecular markers, Ag85C(103) single nucleotide polymorphism (SNP) and RD(Rio) long-sequence polymorphism (LSP), were used to characterize spoligotype signatures from 859 patient isolates from Portugal. LAM strains were found responsible for 57.7% of all tuberculosis cases. Strains with the RD(Rio) deletion (referred to as RD(Rio)) were estimated to represent 1/3 of all the strains and over 60% of the multidrug resistant (MDR) strains. The major spoligotype signature SIT20 belonging to the LAM1 RD(Rio) sublineage, represented close to 1/5th of all the strains, over 20% of which were MDR. Analysis of published datasets according to stipulated 12loci MIRU-VNTR RD(Rio) signatures revealed that 96.3% (129/134) of MDR and extensively drug resistant (XDR) clusters were RD(Rio). This is the first report associating the LAM RD(Rio) sublineage with MDR. These results are an important contribution to the monitoring of these strains with heightened transmission for future endeavors to arrest MDR-TB and XDR-TB.

Air conditioning and intrahospital mortality during the 2003 heatwave in Portugal: evidence of a protective effect

Objectives The objective of the study was to analyse the association between the presence of air conditioning in hospital wards and the intrahospital mortality during the 2003 heatwave, in mainland Portugal. Methods Historical cohort study design including all patients aged 45 or more who were hospitalised in the 7 days before the heatwave. The outcome was survival during the 18 days the heatwave lasted and during the 2 days after the end of the heatwave. A comparison group was also selected in four analogous periods without any heatwave event during January to May 2003. Data were obtained from the 2003 hospital discharges database. Air conditioning presence in hospital wards was determined using a survey sent to hospital administrations. A Cox-regression model was used to estimate the confounder-adjusted HR of death, during the heatwave and the comparison period, in patients in wards with air conditioning (AC+) versus patients in wards without air conditioning (AC−). Results 41 hospitals of mainland Portugal (49% of all hospitals in mainland Portugal) participated, and 2093 patients were enrolled. The overall confounder-adjusted HR of death in AC+ patients versus AC− patients was 0.60 (95% CI 0.37 to 0.97) for the heatwave period and 1.05 (95% CI 0.84 to 1.32) for the comparison group. Conclusions The study found strong evidence that, during the August 2003 heatwave, the presence of air conditioning in hospital wards was associated with an increased survival of patients admitted before the beginning of the climate event. The reduction of the risk of dying is estimated to be 40% (95% CI 3% to 63%).

Crosstalk between inflammation, iron metabolism and endothelial function in Behçet’s disease

Behçets disease (BD) is a rare chronic vasculitis of unclear etiology. It has been suggested that inflammatory response has an important role in BD pathophysiology. Herein, we aimed to study the interplay between inflammation, iron metabolism and endothelial function in BD and search for its putative association with disease activity. Twenty five patients clinically diagnosed with BD were selected and twenty four healthy age-sex matched individuals participated as controls. Results showed an increase of total number of circulating white blood cells and neutrophils, serum transferrin, total iron binding capacity, mieloperoxidase (MPO), ceruloplasmin (Cp), C reactive protein, β2 microglobulin and Cp surface expression in peripheral blood monocytes in BD patients comparatively to healthy individuals (p < 0,05). Of notice, the alterations observed were associated to disease activity status. No significant differences between the two groups were found in serum nitric oxide concentration. The results obtained suggest an important contribution from innate immunity in the pathogenesis of this disease. In particular, surface expression of leukocyte-derived Cp may constitute a new and relevant biomarker to understand BD etiology.

Bridging the gap between PCR detection of Mycobacterium tuberculosis complex and tuberculosis diagnosis

The growing demand for rapid diagnosis of tuberculosis (TB) has led to the incorporation of nucleic acid amplification (NAA) tests in case definitions. The objective of this study was to evaluate the contribution of a real-time polymerase chain reaction (PCR) assay in providing a result predictive of a confirmed TB case. Respiratory and extra-pulmonary specimens (n = 308) were subjected to NAA, culture and smear microscopy. Qualitative PCR assessment, translated by an increase in NAA cycles, disregarding template copy number, resulted in an increase in confirmed cases, helping to bridge the gap between the tests analytical performance and its actual performance in TB diagnosis.

An epidemiological approach to characterise the human exposure pathways in a contaminated estuarine environment

This studys aim was to develop and implement an integrative epidemiologic cross-sectional study that allows identifying and characterising exposure pathways of populations living and working on the shores of a contaminated estuarine environment. Population residing in Carrasqueira, located on the Sado estuary with known contaminated areas was compared to another population on a noncontaminated estuary (Vila Nova de Mil Fontes - VNMF), considered a nonexposed population. Simple random samples of individuals were selected in each study population from the National Health Service Lists: 140 individuals were selected in Carrasqueira and 219 in VNMF. Participation rates were higher in the exposed group (62.5%, n=102 in Carrasqueira and 48.3%, n=100 individuals in VNMF). The same structured questionnaire was used in both populations, including questions on occupational activities, leisure activities, consumption of food (including fish and mollusks from the estuary) and use of water for human intake and agriculture. Results showed that a significantly higher proportion of Carrasqueira participants reported doing tasks in their job that promote direct (48.8% vs 1.2% in VNMF, p-value<0.001) or indirect (30% vs 11.9% in VNMF, p-value=0.004) contact with water from the estuary. Regarding seafood consumption, the exposed population of Carrasqueira had a higher frequency of consumption of cuttlefish (23.5% vs 9% in VNMF, p-value=0.007), sole (22.5% vs 4% in VNMF, p-value<0.001) and clams (18.6% vs 5.0 in VNMF, p-value=0.004). The comparative study design, with exposed and nonexposed populations living on the shores of two different estuaries allowed us to confirm the hypothesis of a higher risk of contamination from the contaminated estuarine environment. The study design and the selection of both populations were adequate for this type of epidemiologic study of potential routes of human contamination in a mixture of contaminated estuarine environment and can be used in other estuarine areas with similar environmental risk.

Tuberculosis diagnosis after bleach processing for early stage tuberculosis laboratory capacity building.

The diagnosis of tuberculosis is seriously hampered in the absence of standard biosafety laboratory facilities for specimen concentration and Mycobacterium tuberculosis culture. Within a laboratory twinning arrangement, heat-fixed direct smear and sediment from 74 bleach-processed and 20 non-processed specimens from Cumura Hospital, Guinea-Bissau, were sent to Lisbon for molecular evaluation of rifampicin resistance. Sequence analysis of a 369 base-pair rpoB locus detected 3.2% (3/94) resistant specimens. To our knowledge, this represents the first report on the molecular analysis of M. tuberculosis from bleach-processed sputum, an alternative to current diagnostic practice in low-resource settings.The diagnosis of tuberculosis is seriously hampered in the absence of standard biosafety laboratory facilities for specimen concentration and Mycobacterium tuberculosis culture. Within a laboratory twinning arrangement, heat-fixed direct smear and sediment from 74 bleach-processed and 20 non-processed specimens from Cumura Hospital, Guinea-Bissau, were sent to Lisbon for molecular evaluation of rifampicin resistance. Sequence analysis of a 369 base-pair rpoB locus detected 3.2% (3/94) resistant specimens. To our knowledge, this represents the first report on the molecular analysis of M. tuberculosis from bleach-processed sputum, an alternative to current diagnostic practice in low-resource settings.