RESUMO
Cryptococcal meningitis (CM) remains a significant global health burden, especially for persons living with HIV. Despite effective antiretroviral and antifungal therapy, mortality rates are still approximately 70% in low- and middle-income countries and 20-30% in high-income countries. Central nervous system symptoms range from mild to severe, depending on burden of disease, and prompt and appropriate therapy is critical to reducing mortality. Treatment consists of three phases: induction, consolidation, and maintenance. Although treatment regimens have largely remained unchanged for decades, recent clinical trials have led the World Health Organization to update guidelines to reflect best practices in resource-limited settings. We review the clinical presentation, diagnosis, and standard therapy for CM, present a case with a challenging diagnostic and treatment course complicated by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, and discuss the benefits of a new treatment dosing strategy highlighting potential advantages of adopting this novel dosing option in high-income countries.
RESUMO
Hepatitis C (HCV) care cascades have been described in diverse clinical settings, patient populations and countries, highlighting the steps in HCV care where improvements can be made and resources allocated. However, more research is needed to examine barriers to HCV treatment in rural, underserved populations and in Federally Qualified Health Centers (FQHCs). As part of a quality improvement (QI) project, this study aimed to describe and evaluate the HCV treatment cascade in an FQHC serving a large rural patient population in the Western United States. Standardized chart abstraction was utilized to aggregate data regarding patient demographics, the percentage of patients achieving each step in the treatment cascade, and relevant patient (i.e., viral load) and service variables (i.e., whether and when patients received treatment or medication). 389 patients were identified as having HCV and 86% were aware of their diagnosis. Fifty-five percent had their infection confirmed via viral load, 21% were staged for liver disease, 24% received a prescription for treatment, and 19% achieved cure. Compared to national data, the current regional sample had greater rates of diagnosis awareness and access to care, as well as sustained virologic response (SVR), but lower rates of viral load confirmation. Current findings suggest that rural patients living with HCV who receive care at FQHCs struggle to navigate the treatment cascade and achieve a cure, particularly with regard to infection confirmation, liver staging, and prescription. However, compared to national estimates, patients had greater rates of diagnosis awareness/treatment access and SVR.
Assuntos
Hepatite C/terapia , Serviços de Saúde Rural/organização & administração , Provedores de Redes de Segurança/organização & administração , Antivirais/uso terapêutico , Conhecimentos, Atitudes e Prática em Saúde , Acessibilidade aos Serviços de Saúde/organização & administração , Hepatite C/diagnóstico , Humanos , Área Carente de Assistência Médica , Serviços de Saúde Rural/normas , Provedores de Redes de Segurança/normas , Resposta Viral Sustentada , Estados Unidos , Carga Viral , Populações VulneráveisAssuntos
Infecções por HIV/epidemiologia , HIV-1/isolamento & purificação , Adolescente , Adulto , Bissexualidade , Análise por Conglomerados , Feminino , Infecções por HIV/transmissão , Infecções por HIV/virologia , Homossexualidade Masculina , Humanos , Idaho/epidemiologia , Masculino , Abuso de Substâncias por Via Intravenosa , Adulto JovemRESUMO
An increasing number of patients are developing chronic kidney disease (CKD). Appropriate care for patients with CKD must occur in the earliest stages, preferably before CKD progresses to more severe stages. Therefore, recognition and treatment of CKD and its associated complications must occur in primary care settings. Patients with CKD often have comorbid conditions such as diabetes mellitus, hypertension, and dyslipidemia, creating specific considerations when treating these diseases. Also, these patients have CKD-related conditions, including anemia and renal osteodystrophy, that are not traditionally evaluated and monitored by the primary care practitioner. Collectively, many opportunities exist for pharmacists who practice in the primary care setting to improve the care of patients with CKD.