Hospital Pulido Valente

Clinical management of cystic echinococcosis (CE) has evolved over decades without adequate evaluation of important features such as efficacy, effectiveness, rate of adverse reactions, relapse rate, and cost. CE occurs in health care environments as different as Europe/North America and resource-poor countries of the South and the East. This creates setting-specific problems in the management of patients. Furthermore, studies carried out in either of the two fundamentally different environments lack external validity, i.e., results obtained in one setting may be different from those in the other and practices that can work in one may not be applicable to the other. In this paper, we review the current management procedures of CE with particular emphasis on the evidence base and setting-specific problems.

The lung is a complex ecosystem of host cells and microbes often disrupted in pathological conditions. Although bacteria have been hypothesized as agents of carcinogenesis, little is known about microbiota profile of the most prevalent cancer subtypes: adenocarcinoma (ADC) and squamous cell carcinoma (SCC). To characterize lung cancer (LC) microbiota a first a screening was performed through a pooled sequencing approach of 16S ribosomal RNA gene (V3-V6) using a total of 103 bronchoalveaolar lavage fluid samples. Then, identified taxa were used to inspect 1009 cases from The Cancer Genome Atlas and to annotate tumor unmapped RNAseq reads. Microbial diversity was analyzed per cancer subtype, history of cigarette smoking and airflow obstruction, among other clinical data. We show that LC microbiota is enriched in Proteobacteria and more diverse in SCC than ADC, particularly in males and heavier smokers. High frequencies of Proteobacteria were found to discriminate a major cluster, further subdivided into well-defined communities' associated with either ADC or SCC. Here, a SCC subcluster differing from other cases by a worse survival was correlated with several Enterobacteriaceae. Overall, this study provides first evidence for a correlation between lung microbiota and cancer subtype and for its influence on patient life expectancy.

Dyspepsia is defined as a persistent or recurrent pain or discomfort, localised in the upper abdomen, which may or may not be related to meals. Its prevalence in the general population is extraordinarily high (20-40%). Several pathological conditions can provoke dyspepsia, although non ulcer dyspepsia is the main cause. The relationships between Helicobacter pylori and non ulcer dyspepsia are discussed, namely the prevalence of Helicobacter pylori infection and the efficacy of its eradication in non ulcer dyspepsia. The management of dyspeptic patients in the community is analysed according to the Maastricht Consensus of 1996. Our opinion is that, in Helicobacter pylori-positive dyspeptic patients, after a careful investigation with exclusion of other organic diseases, the bacterium should be eradicated.

The superior vena cava syndrome (SVCS) comprises various symptoms due to occlusion of the SVC, which can be easily obstructed by pathological conditions (eg, lung cancer, due to the low internal venous pressure within rigid structures of the thorax [trachea, right bronchus, aorta]). The resulting increased venous pressure in the upper body may cause edema of the head, neck, and upper extremities, often associated with cyanosis, plethora, and distended subcutaneous vessels. Despite the often striking clinical presentation, SVCS itself is usually not a life-threatening condition. Currently, randomized controlled trials on many clinically important aspects of SVCS are lacking. This review gives an interdisciplinary overview of the pathophysiology, etiology, clinical manifestations, diagnosis, and treatment of malignant SVCS.

BACKGROUND: Current noninvasive tests to confirm the eradication of Helicobacter pylori must be performed 4 weeks or more after eradication therapy is completed. OBJECTIVE: To determine whether the stool antigen test, a relatively new noninvasive test for H. pylori, administered at various times after eradication therapy correctly identifies persons with persistent H. pylori infection. DESIGN: Prospective blinded study. SETTING: Six clinical centers in the United States and Europe. PATIENTS: 84 H. pylori --infected patients undergoing endoscopy for upper abdominal symptoms. MEASUREMENTS: At baseline and on day 35 after the completion of triple eradication therapy, all patients underwent endoscopy with histologic examination, rapid urease test and culture, urea breath test, and a stool antigen test. The stool antigen test was also performed on days 3, 7, 15, 21, 28, and 35 after completion of therapy. RESULTS: Compared with the gold-standard endoscopic tests on day 35 after antimicrobial therapy, the urea breath test had a sensitivity of 94% (95% CI, 71% to 100%) and a specificity of 100% (CI, 94% to 100%). The stool antigen test had a sensitivity of 94% (CI, 71% to 100%) and a specificity of 97% (CI, 89% to 100%). On day 7 after treatment, the stool antigen test was predictive of eradication (positive predictive value, 100% [CI, 69% to 100%]; negative predictive value, 91% [CI, 82% to 97%]). CONCLUSION: A positive result on the stool antigen test 7 days after completion of therapy identifies patients in whom eradication of H. pylori was unsuccessful.

BACKGROUND: Otilonium bromide (OB) is a spasmolytic agent that blocks L-Type Calcium channels in human colonic smooth muscle. AIM: To study the efficacy of OB in symptom control in irritable bowel syndrome (IBS). METHODS: A total of 356 patients (46.16±19years, 71% female) with IBS participated in a double-blind, randomised, parallel placebo-controlled phase IV study. OB (40mg t.d.s.) or placebo was administered for 15weeks, and follow-up was extended 10 additional weeks. RESULTS: Otilonium bromide (n=179) and placebo (n=177) groups had comparable demographics, symptom severity and IBS subtype. Both OB and placebo reduced abdominal pain and IBS symptoms. The effect of OB was significantly greater than placebo in the reduction of weekly frequency of episodes of abdominal pain at the end of treatment period (primary endpoint, -0.90±0.88 vs. -0.65±0.91, P=0.03), reduction of abdominal bloating (-1.2±1.2 vs. -0.9±1.1, P=0.02) and global efficacy by patient assessment (1.3±1.1 vs. 1.0±1.1, P=0.047). Intensity of abdominal pain, proportion of patient responders, safety and quality of life scores were similarly affected by OB and placebo. During follow-up, the therapeutic effect of OB remained greater than placebo in terms of withdrawal rate due to symptom relapse (10% vs. 27%, P=0.009), global efficacy of treatment and relapse-free probability (P=0.038). CONCLUSIONS: This placebo-controlled double-blind study shows that otilonium bromide is safe, well tolerated and superior to placebo in reducing the frequency of abdominal pain, severity of abdominal bloating and protecting from symptom relapse in IBS. These results further confirm that patients with IBS can improve during and following treatment with otilonium bromide.

Echinococcosis is among the most neglected parasitic diseases. Development of new drugs and other treatment modalities receives very little attention, if any. In most developed countries, Cystic Echinococcosis (CE) is an imported disease of very low incidence and prevalence and is found almost exclusively in migrants from endemic regions. In endemic regions, predominantly settings with limited resources, patient numbers are high. Whole communities do not have access to appropriate treatment. The choice of treatment modalities is limited because of poor infrastructure and shortage of equipment and drugs. In this context, CE meets the criteria for a neglected disease. Furthermore, the terminology related to the designations around the parasite, its evolution and some therapeutic procedures is not uniform and sometimes inappropriate terms and wrong designations are used based on incorrect concepts. Although all of us know the different aspects of the disease it is pertinent to remember some important points and, above all, to clarify some aspects concerning the hydatid cyst's nomenclature in order to understand better the therapeutic options in the liver locations, particularly the different surgical approaches.

BACKGROUND: Transthoracic ultrasound (US) is an important instrument to identify pleural effusions and safely conduct invasive procedures. It also allows systematic scanning of the pleural surface, though its value remains uncertain for differentiation between malignant (MPE) and nonmalignant pleural effusion (non-MPE) in routine clinical practice. OBJECTIVES: To evaluate the utility of US features to predict malignancy in undiagnosed pleural effusions in a real-life clinical setting. METHODS: The US features of 154 consecutive patients with a pleural effusion were prospectively assessed. Anonymous images were recorded by an operator blinded to the clinical and radiological results. The US findings were classified by independent reviewers and compared to the final diagnosis. RESULTS: A total of 133 patients were included (age 67 ± 16 years; BMI 25.1 ± 4.6; 54.1% females). The final diagnosis was MPE in 66 cases and non-MPE in 67 cases. US had an overall sensitivity of 80.3%, a specificity of 83.6%, and positive and negative predictive values of 82.8 and 81.2%, respectively, for the detection of malignancy. US accuracy was 81.9%. The presence of pleural/diaphragmatic nodules, pleural/diaphragmatic thickness >10 mm, and a swirling sign was significantly different between both groups (p < 0.001). Lung air bronchogram sign and a septated US pattern were more common in non-MPE patients (p < 0.01). The existence of nodularity and the absence of air bronchograms were more likely to indicate malignancy (OR 29.0, 95% CI 7.65-110.08 and OR 10.4, 95% CI 1.65-65.752, respectively). CONCLUSIONS: In the presence of an undiagnosed pleural effusion, US morphological characteristics can aid in differentiating MPE from non-MPE. Pleural/diaphragmatic nodularity was the most relevant feature although no finding was pathognomonic of MPE.

PURPOSE: Lower respiratory tract infections (LRTI) are the most frequent infectious complication in patients admitted to the intensive care unit (ICU). We aim to report the clinical characteristics of ICU-admitted patients due to nosocomial LRTI and to describe their microbiology and clinical outcomes. METHODS: A prospective observational study was conducted in 13 countries over two continents from 9th May 2016 until 16th August 2019. Characteristics and outcomes of ventilator-associated pneumonia (VAP), ventilator-associated tracheobronchitis (VAT), ICU hospital-acquired pneumonia (ICU-HAP), HAP that required invasive ventilation (VHAP), and HAP in patients transferred to the ICU without invasive mechanical ventilation were collected. The clinical diagnosis and treatments were per clinical practice and not per protocol. Descriptive statistics were used to compare the study groups. RESULTS: 1060 patients with LRTI (72.5% male sex, median age 64 [50-74] years) were included in the study; 160 (15.1%) developed VAT, 556 (52.5%) VAP, 98 (9.2%) ICU-HAP, 152 (14.3%) HAP, and 94 (8.9%) VHAP. Patients with VHAP had higher serum procalcitonin (PCT) and Sequential Organ Failure Assessment (SOFA) scores. Patients with VAP or VHAP developed acute kidney injury, acute respiratory distress syndrome, multiple organ failure, or septic shock more often. One thousand eight patients had microbiological samples, and 711 (70.5%) had etiological microbiology identified. The most common microorganisms were Pseudomonas aeruginosa (18.4%) and Klebsiella spp (14.4%). In 382 patients (36%), the causative pathogen shows some antimicrobial resistance pattern. ICU, hospital and 28-day mortality were 30.8%, 37.5% and 27.5%, respectively. Patients with VHAP had the highest ICU, in-hospital and 28-day mortality rates. CONCLUSION: VHAP patients presented the highest mortality among those admitted to the ICU. Multidrug-resistant pathogens frequently cause nosocomial LRTI in this multinational cohort study.

A prevalência da doença pulmonar obstrutiva crónica (DPOC) apresenta valores muito heterogéneos em todo o mundo. A iniciativa Burden of Obstructive Lung Disease (BOLD) foi desenvolvida para que a prevalência da DPOC possa ser avaliada com metodologia uniformizada. O objetivo deste estudo foi estimar a prevalência da DPOC em adultos com 40 ou mais anos numa população alvo de 2 700 000 habitantes na região de Lisboa, de acordo com o protocolo BOLD. A amostra foi estratificada de forma aleatória multifaseada selecionando-se 12 freguesias. O inquérito compreendia um questionário com informação sobre fatores de risco para a DPOC e doença respiratória autoreportada; adicionalmente, foi efetuada espirometria com prova de broncodilatação. Foram incluídos 710 participantes com questionário e espirometria aceitáveis. A prevalência estimada da DPOC na população no estadio GOLD I+ foi de 14,2% (IC 95%: 11,1; 18,1) e de 7,3% no estadio ii+ (IC 95%: 4,7; 11,3). A prevalência não ajustada foi de 20,2% (IC 95%: 17,4; 23,3) no estadio i+ e de 9,5% (IC 95%: 7,6; 11,9) no estadio ii+. A prevalência da DPOC no estadio GOLD II+ aumentou com a idade, sendo mais elevada no sexo masculino. A prevalência estimada da DPOC no estadio GOLD I+ foi de 9,2% (IC 95%: 5,9; 14,0) nos não fumadores versus 27,4% (IC 95%: 18,5; 38,5) nos fumadores com carga tabágica de ≥ 20 Unidades Maço Ano. Detetou-se uma fraca concordância entre a referência a diagnóstico médico prévio e o diagnóstico espirométrico, com 86,8% de subdiagnósticos. O achado de uma prevalência estimada da DPOC de 14,2% sugere que esta é uma doença comum na região de Lisboa, contudo com uma elevada proporção de subdiagnósticos. Estes dados apontam para a necessidade de aumentar o grau de conhecimento dos profissionais de saúde sobre a DPOC, bem como a necessidade de maior utilização da espirometria nos cuidados de saúde primários. There is a great heterogeneity in the prevalence of Chronic Obstructive Pulmonary Disease (COPD) demonstrates a great heterogeneity across the world. The Burden of Obstructive Lung Disease (BOLD) initiative was started to measure the prevalence of COPD in a standardized way. We aimed to estimate the prevalence of COPD in Portuguese adults aged 40 years or older of a target population of 2,700 000 in the Lisbon region, in accordance with BOLD protocol. A stratified, multi-stage random sampling procedure was used which included 12 districts. The survey included a questionnaire with information on risk factors for COPD and reported respiratory disease and a post-bronchodilator spirometry performed at survey centres. For the 710 participants with questionnaires and acceptable spirometry, the overall weighted prevalence of GOLD stage I+ COPD was 14.2% (95% C.I. 11.1, 18.1), and stage II+ was 7.3% (95% C.I. 4.7, 11.3). Unweighted prevalence was 20.2% (95% C.I.17.4, 23.3) for stage I+ and 9.5% (95% C.I. 7.6, 11.9) for stage II+. Prevalence of COPD in GOLD stage II+ increased with age and was higher in men. The prevalence of GOLD stage I+ COPD was 9.2% (95% C.I. 5.9, 14.0) in never smokers versus 27.4% (95% C.I. 18.5, 38.5) in those who had smoked >20 pack-years. The agreement between previous doctor diagnosis and spirometric diagnosis was low, with 86.8% of underdiagnosed individuals. The 14.2% of COPD estimated prevalence indicates that COPD is a common disease in the Lisbon region. In addition, a large proportion of underdiagnosed disease was detected. The high prevalence of COPD with a high level of underdiagnosis, points to the need of raising awareness of COPD among health professionals, and requires more use of spirometry in the primary care setting.

OBJECTIVE: To determine the incidence of infection-erosion associated with the implantation of artificial urinary sphincters (AMS 800) in a high-risk group of patients (post-major pelvic surgery/radiotherapy), and to emphasize the commonly neglected risk factors associated with this complication. PATIENTS AND METHODS: One-hundred-and forty-five male patients aged 55-79 years (mean 71) who had had an AMS 800 artificial sphincter implanted between January 1987 and November 1993 were reviewed. All patients had undergone meticulous surgical technique, intra-operative shave and rigorous scrub, and were given peri-operative antibiotics. The mean follow-up was 34.3 months (range 1-83). RESULTS: Infection-erosion occurred in 13 patients (9%), of whom 10 are currently available for follow-up. One patient died of his underlying disease (bladder cancer) and two were lost to follow-up. All 13 patients had undergone radical pelvic surgery (radical retropubic prostatectomy, radical cystectomy and abdominoperineal resection); seven patients had also received radiation therapy. Cultures of the infected AMS 800 devices revealed a pleomorphic group of organisms, specifically enteric, Gram-positive and anaerobic organisms. The risk of infection-erosion was found to be increased in the presence of two main factors, improper urethral catheterization and urethral endoscopic manipulation with an activated AMS 800 artificial sphincter in place and exposure to radiation. At the time of revision, nine of the 13 patients were found to have positive urine cultures. CONCLUSION: Despite all the precautions taken, there remains a group of patients who are still at a higher risk of infection-erosion due to adverse circumstances that distort the anatomy of the perineal area, impair the host defence mechanisms, and ultimately enable the establishment of the infection-erosion complex. Radiotherapy is known to increase the likelihood of non-mechanical complications, specifically infection-erosion. Extreme care must be taken so that avoidable iatrogenic factors such as improper urethral catheterization and endoscopic manipulation with an activated AMS 800 device in situ are not the cause of 'failure'.

BACKGROUND: Refractory benign esophageal strictures (RBESs) have been treated with the temporary placement of different self-expanding stents with conflicting results. We compared the clinical effectiveness of 3 types of stents: self-expanding plastic stents (SEPSs), biodegradable stents, and fully covered self-expanding metal stents (FCSEMSs), for the treatment of RBES. METHODS: This study prospectively evaluated 3 groups of 30 consecutive patients with RBESs who underwent temporary placement of either SEPSs (12 weeks, n = 10), biodegradable stents (n = 10) or FCSEMSs (12 weeks, n = 10). Data were collected to analyze the technical success and clinical outcome of the stents as evaluated by recurrent dysphagia, complications and reinterventions. RESULTS: Stent implantation was technically successful in all patients. Migration occurred in 11 patients: 6 (60%) in the SEPS group, 2 (20%) in the biodegradable group and 3 (30%) in the FCSEMS group (P = 0.16). A total of 8/30 patients (26.6%) were dysphagia-free after the end of follow-up: 1 (10%) in the SEPS group, 3 (30%) in the biodegradable group and 4 (40%) in the FCSEMS group (P = 0.27). More reinterventions were required in the SEPS group (n = 24) than in the biodegradable group (n = 13) or the FCSEMS group (n = 13) (P = 0.24). Multivariate analysis showed that stricture length was significantly associated with higher recurrence rates after temporary stent placement (HR = 1.37; 95% CI = 1.08-1.75; P = 0.011). CONCLUSIONS: Temporary placement of a biodegradable stent or of a FCSEMS in patients with RBES may lead to long-term relief of dysphagia in 30 and 40% of patients, respectively. The use of SEPSs seems least preferable, as they are associated with frequent stent migration, more reinterventions and few cases of long-term improvement. Additionally, longer strictures were associated with a higher risk of recurrence.

OBJECTIVES: To assess the efficacy of desmopressin nasal spray compared with diclofenac given intramuscularly in patients with acute renal colic caused by urolithiasis. PATIENTS AND METHODS: The study included 61 patients randomized into three different groups; group A received desmopressin (40 microg, nasal spray), group B diclofenac (75 mg) intramuscularly and group C, both desmopressin and diclofenac. Pain was assessed using a visual analogue scale (a 10-cm horizontal scale ranging from 'no pain' to 'unbearable pain') at baseline, 10, 20 and 30 min after administering the treatments. RESULTS: On admission, the pain level was the same in all three groups. At 10 min the pain decreased in all groups to a level that was not significantly different. At 20 min groups B and C had similar mean pain levels (3.7), whereas in group A it was 5.0. At 30 min, groups B and C scored 2-3, and group A 5.6. All three treatments were equally effective at 10 and 20 min but at 30 min there was a stabilization/slight increase in pain level in group A. CONCLUSIONS: Desmopressin has several advantages, e.g. ease of administration, simplicity of delivery and apparent lack of side-effects, which makes it suitable for ambulatory use. Desmopressin acts rapidly and seems to be effective in both single and combined therapy with diclofenac; it decreases the need for a second treatment and increases the analgesic effect of diclofenac. Some patients responded well to desmopressin, with rapid and complete pain relief. These results indicate that desmopressin may be used to treat renal colic either alone or combined, increasing the analgesic effect of other drugs. More studies are needed to validate and confirm the results; it would also be useful to determine factors that may identify the subgroup of patients who respond quickly and with almost complete pain relief.

OBJECTIVES: This study aimed to estimate the prevalence of diabetes mellitus (DM) in hospitalized patients with community-acquired pneumonia (CAP) and its impact on hospital length of stay and in-hospital mortality. RESEARCH DESIGN AND METHODS: We carried out a retrospective, nationwide register analysis of CAP in adult patients admitted to Portuguese hospitals between 2009 and 2012. Anonymous data from 157 291 adult patients with CAP were extracted from the National Hospital Discharge Database and we performed a DM-conditioned analysis stratified by age, sex and year of hospitalization. RESULTS: The 74 175 CAP episodes that matched the inclusion criteria showed a high burden of DM that tended to increase over time, from 23.7% in 2009 to 28.1% in 2012. Interestingly, patients with CAP had high DM prevalence in the context of the national DM prevalence. Episodes of CAP in patients with DM had on average 0.8 days longer hospital stay as compared to patients without DM (p<0.0001), totaling a surplus of 15 370 days of stay attributable to DM in 19 212 admissions. In-hospital mortality was also significantly higher in patients with CAP who have DM (15.2%) versus those who have DM (13.5%) (p=0.002). CONCLUSIONS: Our analysis revealed that DM prevalence was significantly increased within CAP hospital admissions, reinforcing other studies' findings that suggest that DM is a risk factor for CAP. Since patients with CAP who have DM have longer hospitalization time and higher mortality rates, these results hold informative value for patient guidance and healthcare strategies.

The INNO-LiPA Rif.TB assay for the identification of Mycobacterium tuberculosis complex strains and the detection of rifampin (RIF) resistance has been evaluated with 360 smear-positive respiratory specimens from an area of high incidence of multidrug-resistant tuberculosis (MDR-TB). The sensitivity when compared to conventional identification/culture methods was 82.2%, and the specificity was 66.7%; the sensitivity and specificity were 100.0% and 96.9%, respectively, for the detection of RIF resistance. This assay has the potential to provide rapid information that is essential for the effective management of MDR-TB.

BACKGROUND: DNA methylation and DNA cytometric parameters were evaluated in the rectal mucosa from patients with extensive and long-standing ulcerative colitis. METHODS: Twenty-six patients with extensive disease for more than 7 years and 11 healthy controls were included. Global DNA methylation was assessed as the capacity of the DNA test to incorporate [3H]methyl groups from [3H]-S-adenosyl-methionine in the presence of Sss1 methylase. A higher incorporation reflects a lower state of intrinsic methylation. DNA ploidy, S-phase fraction, and proliferative index (PI = S + G2M) of the cell cycle were analyzed by flow cytometry. RESULTS: Incorporation of the [3H]methyl groups into DNA was 10-fold higher in patients compared with controls (P < 0.001) and was significantly higher in patients with histologically active disease (P = 0.02). With regard to flow cytometry, all samples showed a diploid pattern, but S-phase fraction and the proliferative index values were significantly increased in patients compared with controls (P = 0.0007 and P = 0.003, respectively). A positive correlation was found between S-phase fraction and proliferative index and the number of exacerbations of the disease (P < 0.005), and there was a trend among those patients who had disease for longer than 20 years to present with increased cellular proliferation compared with those with a shorter evolution of disease (P > 0.05). CONCLUSIONS: DNA hypomethylation and proliferative activity are increased in this group of patients, supporting the concept that their colonic mucosa undergoes epigenetic and kinetic changes that might predispose these individuals to develop colorectal neoplasms. However, it cannot be ruled out that these markers solely reflect hyperproliferation associated with active inflammation.

OBJECTIVE: Microsatellite instability (MSI) detected in non-neoplastic mucosa of patients with ulcerative colitis has been ascribed to an excess of DNA damage associated with chronic inflammation. Folate deficiency, commonly found in patients with long-standing disease, could further contribute to this defect because folate is essential for DNA replication and repair. We evaluated MSI in the colonic mucosa of 26 patients with ulcerative colitis for >10 yr and 10 patients with Crohn's colitis and correlated MSI with folate status. METHODS: DNA was amplified using primers directed at nine different loci. Folate concentrations in serum, whole blood, and colonic mucosa were determined using the Lactobacillus casei assay. RESULTS: MSI was found in 3/23 patients (13%) with ulcerative colitis and in none of the patients with Crohn's colitis. All three patients with MSI had inactive histological disease, whereas all patients with active disease were negative for MSI (p = 0.08). Serum, whole blood, and colonic concentrations of folate were 30-50% lower in patients with MSI (p > 0.05), and folate supplements had been administered less frequently during the past 5-yr (p = 0.06). One of the patients with MSI was randomized to receive folate 5 mg/d for 6 months, and a clear change in MSI pattern was observed in three of six markers. CONCLUSIONS: A defect in DNA repair associated with a low folate status may be one additional cause for patients with ulcerative colitis exhibiting MSI in non-neoplastic mucosa.

BACKGROUND: Lung cancer diagnosis is usually achieved through a set of bronchoscopic techniques or computed tomography guided-transthoracic needle aspiration (CT-TTNA). However these procedures have a variable diagnostic yield and some patients remain without a definite diagnosis despite being submitted to an extensive workup. The aim of this study was to evaluate the efficacy and cost of linear endobronchial (EBUS) and endoscopic ultrasound (EUS) guided fine needle aspiration (FNA), performed with one echoendoscope, for the diagnosis of suspicious lung cancer lesions after failure of conventional procedures. METHODS: One hundred and twenty three patients with an undiagnosed but suspected malignant lung lesion (paratracheal, parabronchial, paraesophageal) or with a peripheral lesion and positron emission tomography positive mediastinal lymph nodes who had undergone at least one diagnostic flexible bronchoscopy or CT-TTNA attempt were submitted to EBUS and EUS-FNA. Patients with endobronchial lesions were excluded. RESULTS: Of the 123 patients, 88 had a pulmonary nodule/mass and 35 were selected based on mediastinal PET positive lymph nodes. Two patients were excluded because an endobronchial mass was detected at the time of the procedure. The target lesion could be visualized in 121 cases and FNA was performed in 118 cases. A definitive diagnosis was obtained in 106 cases (87.6%). Eighty-eight patients (72.7%) had non-small cell lung cancer, 15 (12.4%) had small cell lung cancer and metastatic disease was found in 3 patients (2.5%). The remaining 15 negative cases were subsequently diagnosed by surgical procedures. Twelve patients (9.9%) had a malignant tumor and in 3 (2.5%) a benign lesion was found. The overall sensitivity, specificity, positive and negative predictive values of EBUS and EUS-FNA to diagnose malignancy were 89.8%, 100%, 100% and 20.0% respectively. The diagnostic accuracy was 90.1% in a population with 97.5% prevalence of cancer. The ultrasonographic approach avoided expensive surgical procedures and significantly reduced costs (p < 0.001). CONCLUSIONS: Linear EBUS and EUS-FNA are able to improve the diagnostic yield of suspicious lung cancer lesions after non-diagnostic conventional techniques. These techniques, performed with one scope, can be offered to patients with accessible lesions as an intermediate step for diagnosis since they may avoid more invasive procedures and hence reduce costs.

BACKGROUND: Limited information is available on pneumococcal colonization among adults. We studied pneumococcal carriage dynamics in healthy adults using high-sensitivity approaches. METHODS: Eighty-seven adults (25-50 years old) were followed for 6 months in Portugal. Nasopharyngeal, oropharyngeal, and saliva samples were obtained monthly; pneumococcal carriers were also sampled weekly. Carriage was investigated by quantitative polymerase chain reaction (targeting lytA and piaB) and culture. Positive samples were serotyped. RESULTS: Approximately 20% of the adults were intermittent carriers; 10% were persistent carriers (>4 months). Pneumococcal acquisition and clearance rates were 16.5 (95% confidence interval [CI], 11.2-24.2) and 95.9 (95% CI, 62.3-145.0) cases/1000 person-weeks, respectively. Living with children increased pneumococcal acquisition (hazard ratio, 9.7 [95% CI, 2.6-20.5]; P < .001). Median duration of carriage was 7 weeks and did not depend on regular contact with children. CONCLUSIONS: The pneumococcal carrier state in healthy adults is more dynamic than generally assumed: Acquisition is frequent and duration of carriage is often long. This suggests that some adults may act as reservoirs of pneumococci and hence, depending on the social structure of a community, the magnitude of herd effects potentially attainable through children vaccination may vary. These findings are important when designing strategies to prevent pneumococcal disease in adults.

BACKGROUND: There is a common assumption that a normal ECG or a normal heart size on chest X-ray virtually rules out a diagnosis of heart failure. AIMS: To assess the value of the electrocardiogram and chest X-ray in identifying patients with chronic heart failure in the community. METHODS AND RESULTS: This study was a secondary analysis of data prospectively collected at the time of patient's enrollment in the EPICA study, an epidemiological study of the prevalence of heart failure in Portugal. A total of 6300 subjects were clinically evaluated. Patients who presented with symptoms or signs of heart failure, and/or were receiving diuretics for chronic heart failure (CHF) had a chest X-ray, ECG, and echocardiogram. The diagnosis of heart failure was confirmed in 551 cases. Patients with right atrial enlargement, atrial flutter, atrial fibrillation, 2nd degree-Mobitz I atrioventricular block, 1st degree atrioventricular block, left bundle branch block, lung interstitial oedema, and bilateral pleural effusion were more likely to be diagnosed with heart failure. For the diagnosis of heart failure, in the Portuguese population aged over 25 years, an abnormal electrocardiogram had an estimated sensitivity of 81%, and negative predictive value of 75%; an abnormal chest X-ray had an estimated sensitivity of 57%, and negative predictive value of 83%. Twenty five percent of patients with CHF had a normal ECG or chest X-ray. CONCLUSION: Our results show that electrocardiographic and roentgenographic features are not sufficient to allow heart failure to be reliably predicted in the community and support the recommendation that all patients with suspected heart failure should undergo echocardiography.