Diagnostic Delay in HPV-Related Oropharyngeal Squamous Cell Carcinoma

Abstract Introduction Human papillomavirus-related (HPV +) oropharyngeal squamous cell carcinoma (OPSCC) is increasing in incidence and presents diagnostic challenges given its unique clinical presentation. Objective The purpose of the present study is to characterize the impact of the unique clinical presentation of HPV-related OPSCC on delays in diagnosis. Methods Retrospective review of presenting symptoms and clinical characteristics of 284 patients with OPSCC treated from 2002-2014. Delay in diagnosis was defined as the presence of any of the following: multiple non-diagnostic fine needle aspirate (FNA) biopsies; two or more courses of antibiotic therapy; surgery with incorrect preoperative diagnosis; evaluation by an otolaryngologist without further workup; or surgery without definitive postoperative diagnosis. Results p16+ tumors demonstrated a distinct clinical presentation that more commonly involved a neck mass (85.1% versus 57.3% of p16-; p < 0.001) and less frequently included odynophagia (24.6% versus 51.7% of p16-; p < 0.001). Patients who experienced diagnostic delay were more likely to have p16+ tumors (77.7% delayed versus 62.8% not delayed; p = 0.006). p16+ primary tumors were more likely to be undetectable by physical examination of the head and neck including flexible laryngoscopy (19.0% versus 6.7% of p16-; p = 0.007) and more frequently associated with nondiagnostic FNA biopsies of a cervical nodal mass (11.8% versus 3.4% of p16-, p = 0.03). Conclusions Compared with non-HPV related OPSCC, the unique clinical presentation and characteristics of HPV+ OPSCC are associated with an increased incidence of diagnostic delay. Targeted education of appropriate care providers may improve time to diagnosis and treatment.

The Economics; Financing and Implementation of HIV Treatment as Prevention: What will it Take to Get there?

"The 2013 Lancet Commission Report; Global Health 2035; rightly pointed out that we are at a unique place in history where a ""grand convergence"" of health initiatives to reduce both infectious diseases; and child and maternal mortality - diseases that still plague low income countries - would yield good returns in terms of development and health outcomes. This would also be a good economic investment. Such investments would support achieving health goals of reducing under-five (U5) mortality to 16 per 1 000 live births; reducing deaths due to HIV/AIDS to 8 per 100 000 population; and reducing annual TB deaths to 4 per 100 000 population. Treatment as prevention (TasP) holds enormous potential in reducing HIV transmission; and morbidity and mortality associated with HIV/AIDS - and therefore contributing to Global Health 2035 goals. However; TasP requires large financial investments and poses significant implementation challenges. In this review; we discuss the potential effectiveness; financing and implementation of TasP. Overall; we conclude that TasP shows great promise as a cost-effective intervention to address the dual aims of reducing new HIV infections and reducing the global burden of HIV-related disease. Successful implementation will be no easy feat; though. The dramatic increases in the numbers of persons who need antiretroviral therapy (ART) under a TasP approach will pose enormous challenges at all stages of the HIV treatment cascade: HIV diagnosis; antiretroviral (ARV) initiation; ARV adherence and retention; and increased drug resistance with long-term enrolment on ART. Overcoming these implementation challenges will require targeted implementation; not focusing exclusively on TasP; most-at-risk population (MARP)-friendly services for key populations; integrating services; task shifting; more efficient programme management; balancing supply and demand; integration into universal health coverage efforts; demand creation; improved ART retention and adherence strategies; the use of incentives to improve HIV treatment outcomes and reduce unit costs; continued operational research and tapping into technological innovations."

Severe hypertriglyceridemia in an infant with red cell pyruvate kinase deficiency.

Severe hypertriglyceridemia has been observed in infants with beta-thalassemia major, an association termed hypertriglyceridemia-thalassemia syndrome. The pathophysiological basis for this association has remained unclear. We describe 6-month-old American girl with red cell pyruvate kinase (PK) deficiency, failure to thrive, and marked hypertriglyceridemia (=1500 mg/dL). The hyperlipidemia resolved with hypertransfusion therapy. At age 18 months she underwent a splenectomy and has remained transfusion-independent with normal serum triglyceride levels. We suggest that severe hemolysis and chronic wasting are probably responsible for the hypertriglyceridemia seen in infants with thalassemia or PK deficiency.

Anestesia em gestante com hipertensão intracraniana por meningite tuberculosa: relato de caso / Anesthesia in pregnant patient with intracranial hypertension due to tuberculous meningitis: case report

JUSTIFICATIVA E OBJETIVOS: Está bem estabelecido que a técnica anestésica de escolha para cesariana eletiva é a anestesia regional. Porém, em gestantes com hipertensão intracraniana e infecção do sistema nervoso central esta técnica deve ser evitada. O objetivo deste artigo é relatar o manejo anestésico de uma gestante, com hipertensão intracraniana secundária à meningite tuberculosa, que foi submetida à cesariana eletiva. RELATO DO CASO: Paciente branca, 32 anos, 60 kg, 1,62 m de estatura, na 36ªsemana de idade gestacional, agendada para interrupção cirúrgica da gestação por apresentar-se tetraparética, com hidrocefalia decorrente de meningite tuberculosa. Escolheu-se a anestesia geral para a cesariana com indução em seqüência rápida e manobra de Sellick para a intubação traqueal. As drogas utilizadas foram tiopental (250 mg), rocurônio (50 mg), fentanil (100 æg) e lidocaína (60 mg) por via venosa. A indução anestésica foi suave e mantida com isoflurano até o início do fechamento da pele da paciente, com mínimas alterações de seus sinais vitais e do recém-nascido, que recebeu índice de Apgar 8 e 9, no 1° e 5° minutos, respectivamente. A paciente despertou precocemente, sem deficits neurológicos adicionais. CONCLUSÕES: A anestesia geral ainda é a técnica anestésica preferida para cesariana em gestantes com hipertensão intracraniana, utilizando-se drogas de meia-vida curta e que tenham mínima interferência na pressão intracraniana e no recém-nascido.