Meningeoma e glioblastoma concomitantes: registro de um caso

É relatado um caso com associação de glioblastoma heteromorfo e de meningioma meningotelial, cuja manifestação inicial foi crise convulsiva focal. Por ser infrequente a associação de neoplasias intracranianas, discute-se a forma de expressão clínica, as teorias referentes à presença concomitante de tais associações tumorais e, ainda, o valor do diagnóstico pré-operatório no estabelecimento da conduta cirúrgica e do prognóstico em tais ocasiões

The cost‐effectiveness of prophylaxis strategies for individuals with advanced HIV starting treatment in Africa

Introduction Many HIV‐positive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so have high risks of opportunistic infections and death. The REALITY trial found that an enhanced‐prophylaxis package including fluconazole reduced mortality by 27% in individuals starting ART with CD4 <100 cells/mm3. We investigated the cost‐effectiveness of this enhanced‐prophylaxis package versus other strategies, including using cryptococcal antigen (CrAg) testing, in individuals with CD4 <200 cells/mm3 or <100 cells/mm3 at ART initiation and all individuals regardless of CD4 count. Methods The REALITY trial enrolled from June 2013 to April 2015. A decision‐analytic model was developed to estimate the cost‐effectiveness of six management strategies in individuals initiating ART in the REALITY trial countries. Strategies included standard‐prophylaxis, enhanced‐prophylaxis, standard‐prophylaxis with fluconazole; and three CrAg testing strategies, the first stratifying individuals to enhanced‐prophylaxis (CrAg‐positive) or standard‐prophylaxis (CrAg‐negative), the second to enhanced‐prophylaxis (CrAg‐positive) or enhanced‐prophylaxis without fluconazole (CrAg‐negative) and the third to standard‐prophylaxis with fluconazole (CrAg‐positive) or without fluconazole (CrAg‐negative). The model estimated costs, life‐years and quality‐adjusted life‐years (QALY) over 48 weeks using three competing mortality risks: cryptococcal meningitis; tuberculosis, serious bacterial infection or other known cause; and unknown cause. Results Enhanced‐prophylaxis was cost‐effective at cost‐effectiveness thresholds of US$300 and US$500 per QALY with an incremental cost‐effectiveness ratio (ICER) of US$157 per QALY in the CD4 <200 cells/mm3 population providing enhanced‐prophylaxis components are sourced at lowest available prices. The ICER reduced in more severely immunosuppressed individuals (US$113 per QALY in the CD4 <100 cells/mm3 population) and increased in all individuals regardless of CD4 count (US$722 per QALY). Results were sensitive to prices of the enhanced‐prophylaxis components. Enhanced‐prophylaxis was more effective and less costly than all CrAg testing strategies as enhanced‐prophylaxis still conveyed health gains in CrAg‐negative patients and savings from targeting prophylaxis based on CrAg status did not compensate for costs of CrAg testing. CrAg testing strategies did not become cost‐effective unless the price of CrAg testing fell below US$2.30. Conclusions The REALITY enhanced‐prophylaxis package in individuals with advanced HIV starting ART reduces morbidity and mortality, is practical to administer and is cost‐effective. Efforts should continue to ensure that components are accessed at lowest available prices

Late presentation with HIV in Africa : phenotypes, risk, and risk stratification in the REALITY trial

REALITY was funded by the Joint Global Health Trials Scheme (JGHTS) of the UK Department for International Development, the Wellcome Trust, and Medical Research Council (MRC) (grant number G1100693). Additional funding support was provided by the PENTA Foundation and core support to the MRC Clinical Trials Unit at University College London (grant numbers MC_UU_12023/23 and MC_UU_12023/26). Cipla Ltd, Gilead Sciences, ViiV Healthcare/GlaxoSmithKline, and Merck Sharp & Dohme donated drugs for REALITY, and ready-to-use supplementary food was purchased from Valid International. A. J. P. is funded by the Wellcome Trust (grant number 108065/Z/15/Z). J. A. B. is funded by the JGHTS (grant number MR/M007367/1). The Malawi-Liverpool–Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine (grant number 101113/Z/13/Z) and the Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Programme, Kilifi (grant number 203077/Z/16/Z) are supported by strategic awards from the Wellcome Trust, United Kingdom. Permission to publish was granted by the Director of KEMRI. This supplement was supported by funds from the Bill & Melinda Gates Foundation.Background. Severely immunocompromised human immunodefciency virus (HIV)-infected individuals have high mortality shortly afer starting antiretroviral therapy (ART). We investigated predictors of early mortality and "late presenter" phenotypes. Methods. Te Reduction of EArly MortaLITY (REALITY) trial enrolled ART-naive adults and children =5 years of age with CD4 counts .1). Results. Among 1711 included participants, 203 (12%) died. Mortality was independently higher with older age; lower CD4 count, albumin, hemoglobin, and grip strength; presence of World Health Organization stage 3/4 weight loss, fever, or vomiting; and problems with mobility or self-care at baseline (all P <.04). Receiving enhanced antimicrobial prophylaxis independently reduced mortality (P =.02). Of fve late-presenter phenotypes, Group 1 (n = 355) had highest mortality (25%; median CD4 count, 28 cells/μL), with high symptom burden, weight loss, poor mobility, and low albumin and hemoglobin. Group 2 (n = 394; 11% mortality; 43 cells/μL) also had weight loss, with high white cell, platelet, and neutrophil counts suggesting underlying inflammation/infection. Group 3 (n = 218; 10% mortality) had low CD4 counts (27 cells/μL), but low symptom burden and maintained fat mass. Te remaining groups had 4%-6% mortality. Conclusions. Clinical and laboratory features identifed groups with highest mortality following ART initiation. A screening tool could identify patients with low CD4 counts for prioritizing same-day ART initiation, enhanced prophylaxis, and intensive follow-up.Peer reviewe

Intra orbital Schwanoma of the supraorbital nerve

Background: The orbital region can be occupied by various lesions including both neoplastic or non-neoplastic. Schwannomas of the supraorbital nerve are very rare tumors. Case Report: A case of a 15 years-old female patient with a one year history of progressive proptosis and no visual symptoms is presented with. This patient underwent a combined surgery with total removal of the tumor. Discussion: Intraorbital schwannomas are usually associated with neurofibromatosis and different structures can originate these tumours, including peripheral and cranial nerves. The signs and symptoms usually follow a chronic process. Surgical treatment is necessary, with various reported surgical approaches. Conclusion: We report, to the best of our knowledge, the eleventh case of schwannoma of the supraorbital nerve, describing the main features of this pathology. </jats:p

Aneurisma micotico cerebral bilateral em criança: registro de um caso e revisão da literatura Bilateral cerebral mycotic aneurysm in a child: case report and review of the literature

Os autores relatam caso de paciente masculino, de 6 anos de idade, hospitalizado com diagnóstico de meningite purulenta. A pneumencefalografia mostrou processo expansivo fronto-temporal esquerdo. A arteriografia carotídea bilateral demonstrou presença de aneurisma da artéria frontal ascendente, com hematoma circundante, à esquerda e, aneurisma da artéria temporal posterior, à direita. Cirurgia para evacuação do hematoma e clipagem do aneurisma foi realizada. O paciente piorou no pós-operatório e faleceu. A autópsia demonstrou a presença de hemorragia subaracnóide, hematoma fronto-temporal esquerdo e para-capsular direito. No interior do hematoma, à direita, evidencia-se massa arredondada, cujo exame histopatológico demonstrou tratar-se de paredes arteriais dilatadas, com intenso processo inflamatório supurativo. Os autores tecem considerações a respeito da frequência de aneurismas micóticos na infância, a multiplicidade dos mesmos, a sua etiopatogenia, a localização dos mesmos na árvore arterial intracraniana, do valor diagnóstico da angiografia carotídea e da indicação cirúrgica.The case of a 6 year-old boy, who was hospitalized with the diagnosis of purulent meningitis is reported. The CSF examination disclosed pleocytosis and the antibioticotherapy was instituded. The bilateral carotid angiography demonstrated an arterial aneurysm of the frontal ascendent artery with hematoma in the left side, and another in the posterior temporal artery, in the right side. The patient was operated on because of the hematoma, in the left side. The condition of the patient in the post-operatory period deteriorated and the death ocurred. The post-mortem examination disclosed a sub-arachnoidal hemorrhage, fronto-temporal hematoma in the left side and a para-capsular hematoma in the right side. The histological examination of the central part of the hematoma revealed a dilated arterial walls with a supurative inflammatory process. The authors took in consideration the frequency of mycotic aneurysms in children, especially the multiplicity of them, the etiopathogeny and their localization in the intracranial arterial tree

Aneurisma micotico cerebral bilateral em criança: registro de um caso e revisão da literatura

Os autores relatam caso de paciente masculino, de 6 anos de idade, hospitalizado com diagnóstico de meningite purulenta. A pneumencefalografia mostrou processo expansivo fronto-temporal esquerdo. A arteriografia carotídea bilateral demonstrou presença de aneurisma da artéria frontal ascendente, com hematoma circundante, à esquerda e, aneurisma da artéria temporal posterior, à direita. Cirurgia para evacuação do hematoma e clipagem do aneurisma foi realizada. O paciente piorou no pós-operatório e faleceu. A autópsia demonstrou a presença de hemorragia subaracnóide, hematoma fronto-temporal esquerdo e para-capsular direito. No interior do hematoma, à direita, evidencia-se massa arredondada, cujo exame histopatológico demonstrou tratar-se de paredes arteriais dilatadas, com intenso processo inflamatório supurativo. Os autores tecem considerações a respeito da frequência de aneurismas micóticos na infância, a multiplicidade dos mesmos, a sua etiopatogenia, a localização dos mesmos na árvore arterial intracraniana, do valor diagnóstico da angiografia carotídea e da indicação cirúrgica

The needs, challenges, and burden experienced by informal caregivers in Uganda: a scoping review

Abstract Background The impact of informal caregiving is increasingly recognised as an important but often particularly neglected area of research in low and middle income countries. It is important to understand not only the effect of care on patient outcomes, but also the impact of caring on caregivers’ health and wellbeing. Methods Guided by the Arksey and O’Malley (Res Methodol 8:19–32, 2005) framework, this scoping review sought to collate and chart existing research on the needs, burdens and challenges experienced by caregivers in Uganda. Results The results of this review indicate that research focusing on the needs of caregivers for individuals with communicable disease, particularly HIV, has been well developed in Uganda, however, there is a lack of research on caregiving related to non-communicable diseases. Research has been dominated by small qualitative studies that are informative for understanding roles, burdens and contextually-specific aspects of care, but there is a need for larger studies that develop and test interventions designed to support the needs of caregivers. Conclusions Recurrent themes identified within this review, such as challenges in providing physical support and accessing treatment services, financial costs of care, psychological and mental health impacts and the experience of stigma, should help to inform well targeted and contextually-appropriate future research and interventions. </jats:sec

Knowledge and practices related to plague in an endemic area of Uganda

Background: Plague is a virulent zoonosis reported most commonly from Sub-Saharan Africa. Early treatment with antibiotics is important to prevent mortality. Understanding knowledge gaps and common behaviors informs the development of educational efforts to reduce plague mortality. Methods: A multi-stage cluster-sampled survey of 420 households was conducted in the plague-endemic West Nile region of Uganda to assess knowledge of symptoms and causes of plague and health care-seeking practices. Results: Most (84%) respondents were able to correctly describe plague symptoms; approximately 75% linked plague with fleas and dead rats. Most respondents indicated that they would seek health care at a clinic for possible plague; however plague-like symptoms were reportedly common, and in practice, persons sought care for those symptoms at a health clinic infrequently. Conclusions: Persons in the plague-endemic region of Uganda have a high level of understanding of plague, yet topics for targeted educational messages are apparent. Keywords: Plague, Yersinia pestis, Knowledge, Practices, Behaviors, Afric