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- A point-of-care neutrophil elastase activity assay identifies bronchiectasis severity, airway infection and risk of exacerbation.Publication . Shoemark, A; Cant, E; Carreto, L; Smith, A; Oriano, M; Keir, HR, et al.Abstract INTRODUCTION: Neutrophil elastase activity in sputum can identify patients at high risk of airway infection and exacerbations in bronchiectasis. Application of this biomarker in clinical practice is limited, because no point-of-care test is available. We tested whether a novel semi-quantitative lateral flow device (neutrophil elastase airway test stick - NEATstik®) can stratify bronchiectasis patients according to severity, airway infection and exacerbation risk. METHODS: Sputum samples from 124 patients with stable bronchiectasis enrolled in the UK and Spain were tested using the NEATstik®, which scores neutrophil elastase concentration from 0 (<8 µg·mL-1 elastase activity) to 10 (maximum detectable neutrophil elastase activity). High neutrophil elastase activity was regarded as a NEATstik® grade >6. Severity of disease, airway infection from sputum culture and exacerbations over the 12 months were recorded. An independent validation was conducted in 50 patients from Milan, Italy. MEASUREMENTS AND MAIN RESULTS: Patients had a median age of 69 years and forced expiratory volume in 1 s (FEV1) 69%. High neutrophil elastase activity was associated with worse bronchiectasis severity using the bronchiectasis severity index (p=0.0007) and FEV1 (p=0.02). A high NEATstik® grade was associated with a significant increase in exacerbation frequency, incident rate ratio 2.75 (95% CI 1.63-4.64, p<0.001). The median time to next exacerbation for patients with a NEATstik® grade >6 was 103 days compared to 278 days. The hazard ratio was 2.59 (95% CI 1.71-3.94, p<0.001). Results were confirmed in the independent validation cohort. CONCLUSIONS: A novel lateral flow device provides assessment of neutrophil elastase activity from sputum in minutes and identifies patients at increasing risk of airway infection and future exacerbations
- Breathe, breathe in the air, don't be afraid to carePublication . Pamplona, P; Ravara, S; Boléo-Tomé, JP; Rosa, P; Morais, A
- Admission of Lung Cancer Patients to Intensive Care UnitsPublication . Carreto, L; Simão, C; Silveira, M; Almeida, MA
- O Médico, o Doente Fumador e o Desafio dos Cigarros EletrónicosPublication . Boléo-Tomé, JP; Pamplona, P; Rosa, P; Cordeiro, CApesar dos esforços e das medidas de prevenção e controlo que vêm sendo adotadas desde a década de 80 do século passado, o tabagismo continua a ser, em Portugal e no mundo, um dos mais importantes fatores evitáveis de doença crónica e de mortalidade prematura. 1 A carga da doença atribuível ao tabaco em Portugal foi estimada por Borges et al 2 há mais de uma década. Nesse estudo 11,7% das mortes em Portugal foram atribuídas ao consumo de tabaco. Medida a carga da doença atra- vés dos anos de vida ajustados por incapacidade (disabi- lity adjusted life years — DALY) gerados pela mortalidade, a proporção da carga da doença atribuível ao tabaco foi de 11,2%. Baseados em dados disponíveis para Portugal, em 2005, os autores evidenciaram grande disparidade na análise de género, sendo o tabaco no homem responsável por 15,4% da carga da doença e 17,7% das mortes, e na mulher responsável por 4,9% da carga da doença e 5,2% das mortes. O estudo apresentava ainda estimativas sobre a carga da doença redutível, ou seja, a redução de mortali- dade e DALY que ocorreriam se os fumadores abandonas- sem o tabagismo e passassem a apresentar o risco médio das populações de ex-fumadores, caso em que a carga da doença se reduziria em 5,8% (7,8% dos homens e 2,8% das mulheres) e as mortes em 5,8% (8,5% dos homens e 2,9% das mulheres). Nos anos seguintes, muito foi feito em Portugal para melhorar o controlo do tabagismo. No entan- to, e apesar destes esforços, o consumo de tabaco é ainda crescente na mulher portuguesa 1 . Em 2007, a Direção-Geral de Saúde emitiu o Progra- ma-Tipo de Actuação em Cessação Tabágica 3 e em 2008, a Convenção-Quadro para o Controlo do Tabagismo da Organização Mundial de Saúde (OMS) propôs um conjunto de estratégias concertadas para ajudar os países a contro- lar a epidemia do tabaco e a reduzir o seu rasto mortífero. 4 O acrónimo MPOWER resume as seis políticas com mais impacto: M — Monitorizar a epidemia e as políticas de con- trolo; P — Proteger do fumo ambiental; O — Oferecer ajuda na cessação tabágica; W — (Warn) avisar sobre os male- fícios do tabaco; E — (Enforce bans) Impor a proibição da publicidade, promoção e patrocínio do tabaco; R — (Raise taxes) Aumentar os impostos sobre os produtos do taba- co. Estes pilares viriam a servir de referência para o Plano Nacional para a Prevenção e Controlo do Tabagismo (PNPCT) em Portugal, lançado em 2012. 5 Oferecer ajuda na cessação tabágica é uma das principais estratégias no controlo do tabagismo, mas as restantes medidas preconi- zadas pela OMS necessitam de implementação e desen- volvimento, para que o seu efeito sinérgico se faça sentir. Um enorme desafio surgiu, nos últimos anos, com o aparecimento de novos produtos de tabaco, entre os quais os cigarros electrónicos (CE), que podem colocar em cau- sa os esforços desenvolvidos nas últimas duas décadas. Em Portugal, este fenómeno é ainda menos expressivo do que o observado em muitos países, mas obriga o médico a estar bem informado sobre estes novos produtos e os seus riscos (já conhecidos ou potenciais). Apesar da população portuguesa ter aumentado a per- cepção de risco relacionado com estes produtos, 6 cerca de um terço da população europeia (29,1%) não sabe se são ou não prejudiciais. 6 Consequentemente, tem-se verificado um aumento crescente da sua experimentação e consumo diário, não só em Portugal 6 como na Europa em geral. 7 Habitualmente o médico não aborda o consumo de CE com o seu doente. Uma investigação recente 8 conclui que apenas uma minoria dos médicos o faz de acordo com as recomendações para a melhor prática da cessação tabági- ca. Um dos maiores problemas da ‘discussão sobre cigar- ros eletrónicos’ é o da ambivalência gerada pela incerteza e contradição da informação científica disponível.
- Ventilator-Associated Pneumonia and PaO2/FIO2 Diagnostic Accuracy: Changing the Paradigm?Publication . Ferrer, M; Sequeira, T; Cilloniz, C, et al.BACKGROUND: Ventilator-associated pneumonia (VAP) is associated to longer stay and poor outcomes. Lacking definitive diagnostic criteria, worsening gas exchange assessed by PaO2/FIO2 ≤ 240 in mmHg has been proposed as one of the diagnostic criteria for VAP. We aim to assess the adequacy of PaO2/FIO2 ≤ 240 to diagnose VAP. METHODS: Prospective observational study in 255 consecutive patients with suspected VAP, clustered according to PaO2/FIO2 ≤ 240 vs. > 240 at pneumonia onset. The primary analysis was the association between PaO2/FIO2 ≤ 240 and quantitative microbiologic confirmation of pneumonia, the most reliable diagnostic gold-standard. RESULTS: Mean PaO2/FIO2 at VAP onset was 195 ± 82; 171 (67%) cases had PaO2/FIO2 ≤ 240. Patients with PaO2/FIO2 ≤ 240 had a lower APACHE-II score at ICU admission; however, at pneumonia onset they had higher CPIS, SOFA score, acute respiratory distress syndrome criteria and incidence of shock, and less microbiological confirmation of pneumonia (117, 69% vs. 71, 85%, p = 0.008), compared to patients with PaO2/FIO2 > 240. In multivariate logistic regression, PaO2/FIO2 ≤ 240 was independently associated with less microbiological confirmation (adjusted odds-ratio 0.37, 95% confidence interval 0.15-0.89, p = 0.027). The association between PaO2/FIO2 and microbiological confirmation of VAP was poor, with an area under the ROC curve 0.645. Initial non-response to treatment and length of stay were similar between both groups, while hospital mortality was higher in patients with PaO2/FIO2 ≤ 240. CONCLUSION: Adding PaO2/FIO2 ratio ≤ 240 to the clinical and radiographic criteria does not help in the diagnosis of VAP. PaO2/FIO2 ratio > 240 does not exclude this infection. Using this threshold may underestimate the incidence of VAP.
- Methaemoglobinemia Induced by Poppers and Bupropion Intoxication in the Emergency Department.Publication . Batista, F; Alves, C; Trindade, M; Duarte, JA; Marques, RA 40-year-old man presented to the emergency department with dyspnoea and fatigue after bupropion and popper consumption. Clinical examination was remarkable for central cyanosis not responding to supplementary oxygen. Arterial blood gas analysis showed a methaemoglobin value of 30.3%. Methaemoglobinemia was diagnosed and the patient was treated with methylene blue. However, during methylene blue administration, the patient developed a generalized tonic-clonic seizure that was successfully managed with diazepam. Combined intoxications can be a critical problem in the emergency department. Early recognition and treatment of poisoning are key for good patient outcome. LEARNING POINTS: Distinguishing toxidromes is critical for adequate treatment of patients with drug intoxication; the most common side effect of bupropion consumption is dose-dependent seizures.The diagnosis of methaemoglobinemia requires a high index of suspicion, particularly in a patient presenting with central cyanosis not responding to supplementary oxygen.Treatment with methylene blue is recommended when the percentage of methaemoglobin is above 30% or when the patient has symptoms related to methaemoglobinemia.
- Anaphylaxis to clavulanic acid: seven-year surveyPublication . Silveira, AM; Gaspar, A; Benito-Garcia, F, et al.
- Lung Adenocarcinoma Presenting as a Multiple Cavitary DiseasePublication . Carreto, L; Alves, C; Eurico, J; Cavinho, P
- Kounis Syndrome Associated With Selective Anaphylaxis to Cefazolin.Publication . Sequeira, T; Gaspar, A; Mota, I; Correia, M; Chambel, M; Morais-Almeida, M
- The Portuguese Severe Asthma Registry: Development, Features, and Data Sharing PoliciesPublication . Sá-Sousa A1, A; Fonseca, JA; Pereira, AM; Ferreira, A; Arrobas, A; Mendes, A; Drummond, M; Videira, W; Costa, T; Farinha, P; Soares, J; Rocha, P; Todo-Bom, A; Sokolova, A; Costa, A; Fernandes, B; Loureiro, C; Longo, C; Pardal, C; Costa, C, et al.The Portuguese Severe Asthma Registry (Registo de Asma Grave Portugal, RAG) was developed by an open collaborative network of asthma specialists. RAG collects data from adults and pediatric severe asthma patients that despite treatment optimization and adequate management of comorbidities require step 4/5 treatment according to GINA recommendations. In this paper, we describe the development and implementation of RAG, its features, and data sharing policies. The contents and structure of RAG were defined in a multistep consensus process. A pilot version was pretested and iteratively improved. The selection of data elements for RAG considered other severe asthma registries, aiming at characterizing the patient's clinical status whilst avoiding overloading the standard workflow of the clinical appointment. Features of RAG include automatic assessment of eligibility, easy data input, and exportable data in natural language that can be pasted directly in patients' electronic health record and security features to enable data sharing (among researchers and with other international databases) without compromising patients' confidentiality. RAG is a national web-based disease registry of severe asthma patients, available at asmagrave.pt. It allows prospective clinical data collection, promotes standardized care and collaborative clinical research, and may contribute to inform evidence-based healthcare policies for severe asthma.
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