Reactivação do vírus da hepatite B em doente com Doença de Crohn sob terapêutica com infliximab : caso clínico

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2016A reactivação do VHB tem sido descrita em doentes sob terapêutica imunossupressora ou quimioterapia. Uma doente do sexo feminino, 48 anos, com doença de Crohn e com história prévia de hepatite aguda por VHB, a realizar terapêutica imunossupressora com Azatioprina e Infliximab surge com um quadro de icterícia. Foram realizadas serologias que demonstraram “reverse seroconversion”, i.e., reaparecimento do AgHBs, com elevação das transaminases e carga viral do VHB de 122000000 UI/ml. Previamente à introdução do Infliximab, a doente fez o anti-TNF Adalimumab e enquanto fazia este fármaco assistiu-se ao desaparecimento do anticorpo anti-HBs e ao surgimento de carga viral detectável. Este caso reflecte a importância da monitorização de doentes com história prévia de infecção pelo VHB a fazerem terapêutica com anti-TNF, em que o diagnóstico precoce de perda de imunidade para o VHB deve levar à adopção de medidas terapêuticas (anti-virais) que evitem episódios de hepatite aguda, que podem em alguns casos ser graves.HBV reactivation has been described in patients under imunossupression or during chemotherapy. This is the case of a 48 year old female, with Crohn’s disease and history of acute hepatitis B. While taking Azathioprine and Infliximab she appeared with jaundice. She showed reverse seroconversion, with conversion to HBsAg-positive status, elevation of ALT and AST and an HBV DNA level of 122000000 IU/ml. Before starting therapy with Infliximab, the patient was already taking Adalimumab, another anti-TNF. While she was taking Adalimumab, she turned anti-HBs negative and her serum HBV DNA became detectable. This case reinforces the role of HBV screening in patients under anti-TNF therapies with previous history of HBV infection, since in such cases the early diagnosis of HBV reactivation should prompt therapeutic measures (antiviral therapy) to prevene episodes of acute hepatitis, that can have a poor outcome in some patients

Grávida Sem Útero: Um Caso de Pseudociese a Preceder Psicose

Pseudocyesis is an uncommon syndrome in which a woman firmly believes to be pregnant, and manifests signs and symptoms of pregnancy, in the absence of true gestation. A woman of 37 years of age, hysterectomized at 34 and was currently divorcing an 85-year-old vasectomized man, after engaging in an extra-conjugal relationship. Soon after, she developed signs and symptoms of pregnancy and the belief of being pregnant. After being exposed to additional stressors such as sleep deprivation, she presented for psychiatric evaluation with a psychotic episode, centered around a delusional pregnancy. She was admitted and treated with antipsychotics, which enabled full remission, matching a diagnosis of brief psychotic disorder. When the belief in pregnancy takes the form of a delusion, it is arguably easier to treat than as an overvalued idea, or pseudocyesis vera. Although little is known about prognosis, psychotherapy may play an important role in relapse prevention.A pseudociese é uma síndrome psicopatológica incomum em que uma mulher acredita firmemente estar grávida, e manifesta sinais e sintomas de gravidez, na ausência de verdadeira gestação. Descrevemos aqui o caso de uma mulher de 37 anos, histerectomizada aos 34 que se encontrava a divorciar-se de um homem de 85 anos, vasectomizado, e que após ter-se envolvido num relacionamento extraconjugal desenvolveu sinais e sintomas de gravidez e a crença de estar grávida. Após exposição a factores de stress adicionais, como privação de sono, desenvolveu um episódio psicótico, centrado num delírio de gravidez. Foi internada e tratada com antipsicóticos, com remissão total, compatível com um diagnóstico de perturbação psicótica breve. Quando a crença errónea de gravidez toma a forma de uma ideia delirante, é possivelmente mais fácil de tratar do que como uma ideia sobrevalorizada, ou pseudociese vera. Apesar de se saber pouco sobre factores prognósticos, a psicoterapia pode ter um papel fundamental na prevenção de recidiva

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research