Immigrants' access to health care: Problems identified in a high-risk tuberculosis population.

INTRODUCTION: Immigrants may utilize health care services differently than other residents and may also have a greater risk for tuberculosis (TB). OBJECTIVE: Identify barriers to healthcare access by immigrants, factors associated with these barriers, and discuss strategies that may reduce these barriers. MATERIAL AND METHODS: Anonymous questionnaires were given to immigrants at National Immigrant Support Centres between 2015 and 2016. Barriers to healthcare were identified using logistic regression. RESULTS: One-hundred and nineteen questionnaires were administered to immigrants, 9 of whom (8%) presented with TB while in Portugal. Twenty-one percent of immigrants reported barriers to healthcare access, and 69% had general practitioners (GPs). The presence of barriers to healthcare access was negatively associated with having a GP and with being married or in a de facto union. CONCLUSIONS: A considerable proportion of immigrants reported having difficulties accessing healthcare services in Portugal where legally these barriers are nonexistent. Certain factors were associated with these difficulties.

HIV screening of tuberculosis patients in Portugal: what are we missing?

BACKGROUND: Knowledge of human immunodeficiency virus (HIV) status is essential to effectively manage both tuberculosis (TB) and HIV infection. This is why the World Health Organization (WHO) recommends routine HIV testing in all TB patients. OBJECTIVE: To determine the number of TB patients with unknown HIV status in Portugal and to identify the factors associated with unknown HIV status. METHODS: A retrospective study of all TB notifications from 2008 to 2014 in Portugal was conducted. A multiple logistic regression model was used to evaluate the association of sociodemographic and clinical factors with unknown HIV status. RESULTS: We examined the records of 18 445 patients with TB notification, 2402 of whom (13%) had unknown HIV status. Unknown HIV status was positively associated with age 65 years (adjusted odds ratio [aOR] 1.208, 95%CI 1.037-1.408) and extra-pulmonary TB (aOR 1.381, 95%CI 1.252-1.523), but negatively associated with unemployment (aOR 0.755, 95%CI 0.637-0.895), alcohol dependence (aOR 0.809, 95%CI 0.682-0.959) and drug dependence (aOR 0.566, 95%CI 0.449-0.713). CONCLUSION: Risk perception is the most important barrier to complete knowledge of HIV status in TB patients in Portugal. Given the importance of HIV screening in TB patients, every effort should be made to ensure that all TB patients undergo HIV screening.

Tuberculosis in children from diagnosis to decision to treat.

SETTING: Confirmation of tuberculosis (TB) in children is difficult, so clinicians use different procedures when deciding to treat. OBJECTIVE: Identify criteria to initiate and maintain TB treatment in children younger than 5 years-old, without diagnosis confirmation. DESIGN: A web-based survey was distributed by email to the corresponding authors of journal articles on childhood TB. The observations were clustered into disjoint groups, and analyzed by Ward's method. RESULTS: We sent out 260 questionnaires and received 64 (24.6%) responses. Forty-six respondents (71.9%) said that microbiological confirmation was not important for initiation of anti-TB treatment, and that the epidemiological context and signs/symptoms suggestive of disease were most important. Sixty-one respondents (95.3%) said that the decision to continue therapy was mainly dependent on clinical improvement. A cluster of older respondents (median age: 52 years-old) who were active at a hospital or primary health care centre placed the most value on immunological test results and chest X-rays. A cluster of younger respondents (median age: 38 years-old) who were less experienced in management of TB placed more value on Interferon Gamma Release Assay (IGRA) results and chest computed tomography (CT) scans. A cluster of respondents with more experience in treating TB and working at specialized TB centres placed greater value on the clinical results and specific radiological alterations ("tree-in-bud" pattern and pleural effusion). CONCLUSION: TB management varied according to the age, work location and experience of the clinicians. It is necessary to establish standardized guidelines used for the diagnosis and decision to treat TB in children.

Tuberculosis among the homeless: should we change the strategy?

BACKGROUND: Tuberculosis (TB) is a major concern among high-risk populations such as the homeless. OBJECTIVES: To evaluate TB incidence and treatment outcomes among homeless patients in Portugal and to identify predictors of unsuccessful TB treatment outcomes among the homeless. DESIGN: This was a retrospective cohort study of all TB patients notified in Portugal from 2008 to 2014. Characteristics of homeless TB patients were assessed and predictors of unsuccessful TB treatment were determined using logistic regression. RESULTS: TB incidence among the homeless was 122/100,000 homeless persons and was positively correlated with TB incidence among non-homeless persons. Homeless TB patients had a higher prevalence of alcohol and/or drug use, human immunodeficiency virus (HIV) co-infection, cavitary TB and smear positivity. The rate of unsuccessful treatment outcomes among the homeless was 28.6%, and was significantly associated with increased age, injection drug use (IDU) and HIV co-infection. CONCLUSION: TB incidence among homeless persons was five times that among the non-homeless, and higher in regions with greater TB incidence among non-homeless persons. The successful treatment outcome rate was lower. Predictors of unsuccessful treatment were age, IDU and HIV co-infection. Integrated TB programmes targeting homeless and non-homeless patients, with measures targeting specific characteristics, may contribute to TB elimination in Portugal.

Confirming the diagnosis of tuberculosis in children in Northern Portugal.

Childhood tuberculosis (TB) is difficult to diagnose and there are no standardised case definitions. TB records of patients aged >5 years reported in Northern Portugal between 2000 and 2009 were reviewed. Of the 116 children diagnosed with TB, 72 (62.1%) were male; the mean age was 2.2 ± 1.2 years. Of the 32 children (27.6%) with confirmed TB, only 46.7% had provided samples for culture, showing that little effort is made to obtain specimens for confirmation. We could not identify independent factors associated with the low rate of sample collection or anti-tuberculosis treatment without confirmation; chest radiography lesions were less frequent in children who began treatment without confirmation (adjusted OR 0.23, 95%CI 0.05-0.98).

Internal iliac and uterine arteries Doppler ultrasound in the assessment of normotensive and chronic hypertensive pregnant women.

The objective of this work was to compare Doppler flows pulsatility index (PI) and resistance indexes (RI) of uterine and internal iliac arteries during pregnancy in low risk women and in those with stage-1 essential hypertension. From January 2010 and December 2012, a longitudinal and prospective study was carried out in 103 singleton uneventful pregnancies (72 low-risk pregnancies and 31 with stage 1 essential hypertension)at the 1(st), 2(nd) and 3(rd) trimesters. Multiple linear regression models, fitted using generalized least squares and whose errors were allowed to be correlated and/or have unequal variances, were employed; a model for the relative differences of both arteries impedance was utilized. In both groups, uterine artery PI and RI exhibited a gestational age related decreasing trend whereas internal iliac artery PI and RI increased. The model testing the hemodynamic adaptation in women with and without hypertension showed similar trend. Irrespective of blood pressure conditions, the internal iliac artery resistance pattern contrasts with the capacitance pattern of its immediate pelvic division, suggesting a pregnancy-related regulatory mechanism in the pelvic circulation.

B-type natriuretic peptide measured in serum--calibration using plasma samples for research purposes.

BACKGROUND: We aimed to establish an equation for the estimation of the BNP concentration in plasma when only serum is available. METHODS: We enrolled 27 subjects aged at least 45 years, participating in a Portuguese cohort study. Blood samples were collected in plastic whole blood tubes, containing either ethylenediaminetetraacetic acid to obtain plasma or clot activator to obtain serum. The natural logarithm of serum BNP was calibrated with the natural logarithm of plasma BNP using a linear equation. RESULTS: The estimated regression parameters were 0.58 (95 % CI: 0.23 - 0.93) for beta0 and 1.01 (95 % CI: 0.90 - 1.11) for beta1. The absolute agreement between plasma BNP and that predicted by the equation according to the cut-off points 30 and 100 pg/mL were 96.3% (kappa = 0.92) and 96.3% (kappa = 0.91), respectively. CONCLUSIONS: Serum samples cannot be used to estimate absolute plasma concentrations, but serum BNP values and the calibration equation can be used to classify correctly the individuals with the usual cut-offs.