Physician adherence to guidelines for tuberculosis and HIV care in Rio de Janeiro,Brazil

BackgroundTuberculosis is the most common opportunistic infection among HIV-infected patients in Brazil. Brazil's national policy for HIV care recommends screening for latent tuberculosis (TB) and implementing isoniazid preventive therapy (IPT).ObjectivesWe compared physician adherence to TB screening and other prevention and care policies among HIV primary care clinics in Rio de Janeiro City.MethodsData on performance of CD4 counts, viral load testing, tuberculin skin testing (TST) and IPT were abstracted from patient charts at 29 HIV clinics in Rio de Janeiro as part of the TB/HIV in Rio (THRio) study. Data on use of pneumocystis jiroveci pneumonia (PCP) prophylaxis were also abstracted from a convenience sample of 150 patient charts at 10 HIV clinics. Comparisons were made between rates of adherence to TB guidelines and other HIV care guidelines.ResultsAmong the subset of 150 patients with confirmed HIV infection in 2003, 96% had at least one reported CD4 counts result; 93% had at least one viral load result reported; and, PCP prophylaxis was prescribed for 97% of patients with CD4 counts < 200 cells/mm3 or when clinically indicated. In contrast, 67 patients (45%) had a TST performed (all eligible); and only 11% (17) of eligible patients started IPT. Among 12,027 THRio cohort participants between 2003 and 2005, the mean number of CD4 counts and viral load counts was 2.5 and 1.9, respectively, per patient per year. In contrast, 49% of 8,703 eligible patients in THRio had a TST ever performed and only 53% of eligible patients started IPT.ConclusionPhysicians are substantially more compliant with HIV monitoring and PCP prophylaxis than with TB prophylaxis guidelines. Efforts to improve TB control in HIV patients are badly needed.     

Scaling up antiretroviral therapy in South Africa: the impact of speed on survival

BACKGROUND: Only 33% of eligible human immunodeficiency virus (HIV)-infected patients in South Africa receive antiretroviral therapy (ART). We sought to estimate the impact of alternative ART scale-up scenarios on patient outcomes from 2007-2012. METHODS: Using a simulation model of HIV infection with South African data, we projected HIV-associated mortality with and without effective ART for an adult cohort in need of therapy (2007) and for adults who became eligible for treatment (2008-2012). We compared 5 scale-up scenarios: (1) zero growth, with a total of 100,000 new treatment slots; (2) constant growth, with 600,000; (3) moderate growth, with 2.1 million; (4) rapid growth, with 2.4 million); and (5) full capacity, with 3.2 million. RESULTS: Our projections showed that by 2011, the rapid growth scenario fully met the South African need for ART; by 2012, the moderate scenario met 97% of the need, but the zero and constant growth scenarios met only 28% and 52% of the need, respectively. The latter scenarios resulted in 364,000 and 831,000 people alive and on ART in 2012. From 2007 to 2012, cumulative deaths in South Africa ranged from 2.5 million under the zero growth scenario to 1.2 million under the rapid growth scenario. CONCLUSIONS: Alternative ART scale-up scenarios in South Africa will lead to differences in the death rate that amount to more than 1.2 million deaths by 2012. More rapid scale-up remains critically important.     

Acute inflammatory and immunologic responses against antigen in chronic bird-related hypersensitivity pneumonitis

BackgroundHypersensitivity pneumonitis (HP) is an immune-mediated lung disease induced by the inhalation of a wide variety of antigens and a persistent antigen exposure induces inevitably pulmonary fibrosis in chronic HP. Although neutrophils, Th1 and Th17 cells contribute to lung inflammation in acute phase of HP, there is no clear explanation as to how the immunological reaction occurs just after the inhalation of causative antigens in the chronic phase of HP.MethodsWe examined the inflammatory and immunologic profiles before and after the inhalation provocation test (IPT) in serum and bronchoalveolar lavage fluid (BALF) from patients with chronic bird-related HP (BRHP) and other interstitial lung diseases (ILDs). We analyzed BALF samples from 39 patients (19 BRHP and 20 other ILDs) and serum samples from 25 consecutive patients (20 BRHP and 5 other ILDs) who underwent the IPT.ResultsA significant increase of neutrophils was observed in the BALF from the BRHP patients following the IPT. Neutrophil chemoattractants, namely, granulocyte colony-stimulating factor, IL-6, IL-8, IL-17, and CXCL2 significantly increased in both the serum and BALF of the BRHP patients after the IPT. Serum IFN-γ and CXCL10, cytokines/chemokines that contributed to Th1 inflammation, were also significantly increased in BRHP following the IPT.ConclusionsThis study demonstrated the exposure to the causative antigen provoked acute neutrophilic and Th1 immunologic responses similar to acute HP even in the chronic phase of HP.     

Genetic Diversity of Rift Valley Fever Strains Circulating in Namibia in 2010 and 2011

Outbreaks of Rift Valley fever (RVF) occurred in Namibia in 2010 and 2011. Complete genome characterization was obtained from virus isolates collected during disease outbreaks in southern Namibia in 2010 and from wildlife in Etosha National Park in 2011, close to the area where RVF outbreaks occurred in domestic livestock. The virus strains were sequenced using Sanger sequencing (Namibia_2010) or next generation sequencing (Namibia_2011). A sequence-independent, single-primer amplification (SISPA) protocol was used in combination with the Illumina Next 500 sequencer. Phylogenetic analysis of the sequences of the small (S), medium (M), and large (L) genome segments of RVF virus (RVFV) provided evidence that two distinct RVFV strains circulated in the country. The strain collected in Namibia in 2010 is genetically similar to RVFV strains circulating in South Africa in 2009 and 2010, confirming that the outbreaks reported in the southern part of Namibia in 2010 were caused by possible dissemination of the infection from South Africa. Isolates collected in 2011 were close to RVFV isolates from 2010 collected in humans in Sudan and which belong to the large lineage containing RVFV strains that caused an outbreak in 2006–2008 in eastern Africa. This investigation showed that the RVFV strains circulating in Namibia in 2010 and 2011 were from two different introductions and that RVFV has the ability to move across regions. This supports the need for risk-based surveillance and monitoring.     

Cost-effectiveness of including tuberculin skin testing in an IPT program for HIV-infected persons in Uganda.

SETTING: Tuberculosis (TB) is the most common opportunistic infection among persons with human immunodeficiency virus or the acquired immune-deficiency syndrome (HIV/AIDS). Isoniazid preventive therapy (IPT) effectively treats latent TB infection (LTBI) and prevents progression to active TB. OBJECTIVE: To analyse the costs and cost-effectiveness of tuberculin skin testing (TST) prior to offering IPT. DESIGN: We implemented a program for LTBI screening and IPT using TST for persons with HIV at a voluntary counseling and testing (VCT) center in Kampala, Uganda. Cost-effectiveness analyses using Markov methods were adopted to compare strategies of using and not using TST before offering IPT. RESULTS: The program enrolled 7073 persons with HIV. Based on the prevalence of LTBI in the population, 34/100 HIV-infected patients would benefit from IPT. The results showed that 28% of LTBI patients would be treated using the TST strategy, and 40% would be treated with a non-TST strategy. Compared to no intervention, the estimated incremental cost of identifying and providing IPT using TST was dollars 211 per patient; the incremental cost using a non-TST strategy was dollars 768 per patient. CONCLUSION: At a large VCT center in Uganda, the inclusion of TST to identify the HIV-infected persons who will most benefit from IPT is cost-effective.     

Tuberculosis case finding and preventive therapy in an HIV voluntary counseling and testing center in Uganda.

SETTING: A large, urban human immunodeficiency virus (HIV) voluntary counseling and testing (VCT) center in Kampala, Uganda. OBJECTIVE: Tuberculosis (TB) is a leading cause of morbidity and mortality in persons with HIV infection in sub-Saharan Africa. Intensified TB case finding and use of isoniazid preventive therapy (IPT) for latent infection reduces the burden of TB, but few programs have been implemented due to concerns about feasibility. DESIGN: Retrospective evaluation of a TB case finding and IPT program. RESULTS: Over a 25-month period, 6305 patients newly diagnosed with HIV infection underwent evaluation: 293 (5%) had TB disease; 1955 (37%) patients were not eligible for preventive therapy because they lived > 20 km away, had advanced HIV disease, or had previously had TB. Of 3366 who had a tuberculin skin test (TST) placed, 2548 (76%) had the TST read; 894 (35%) of these were positive. Of 506 persons who started treatment, 335 (66%) completed it. CONCLUSION: This unique program was feasible, detected a high proportion of undiagnosed TB, and successfully treated persons with latent infection. Expanding access to HIV VCT as well as collaboration between HIV/ AIDS and TB programs can increase the proportion of HIV-infected persons who can benefit from these programs.     

Implementation of intermittent preventive treatment with sulphadoxine-pyrimethamine for control of malaria in pregnancy in Kisumu, western Kenya

OBJECTIVE: In 1998, the Kenyan Ministry of Health introduced intermittent preventive treatment (IPT) with sulphadoxine-pyrimethamine (SP), one treatment dose in the second trimester (16-27 weeks) and one treatment dose between 28 and 34 weeks of gestational age, for the control of malaria in pregnancy. We evaluated the coverage and determinants of receipt of IPT after its introduction in the Provincial Hospital in Kisumu, western Kenya. METHODS: Information on the use of IPT in pregnancy was collected from women who attended the antenatal clinic (ANC) and delivered in the same hospital. In exit interviews, we assessed patterns of IPT use in the ANC. RESULTS: Of 1498 women who delivered between June 1999 and June 2000, 23.7%, 43.4% and 32.9% received > or =2, 1 or no dose of SP, respectively. Late first ANC attendance was the most important factor contributing to incomplete IPT; 45% of the women started attending ANC in the third trimester. More women received at least one tetanus toxoid immunization than at least one dose of IPT (94%vs. 67%, P < 0.05). In exit interviews, 74% correctly associated IPT with treatment of malaria; however, knowledge on the need for the second dose was poor. Three per cent of the administrations were given despite contraindications. The agreement between gestational age by date of last menstrual period and by palpation was low (kappa = 0.1). CONCLUSIONS: Education of pregnant women and ANC staff to increase earlier attendance for ANC has the potential to substantially increase the proportion of women receiving two doses of IPT with SP.     

The impact of antiretroviral therapy and isoniazid preventive therapy on tuberculosis incidence in HIV-infected patients in Rio de Janeiro, Brazil

BACKGROUND: Tuberculosis is a common complication and leading cause of death in HIV infection. Antiretroviral therapy (ART) lowers the risk of tuberculosis, but may not be sufficient to control HIV-related tuberculosis. Isoniazid preventive therapy (IPT) reduces tuberculosis incidence significantly, but is not widely used. METHODS: We analysed tuberculosis incidence in 11 026 HIV-infected patients receiving medical care at 29 public clinics in Rio de Janeiro, Brazil, between 1 September 2003 and 1 September 2005. Data were collected through a retrospective medical record review. We determined rates of tuberculosis in patients who received neither ART nor IPT, only ART, only IPT, or both ART and IPT. RESULTS: The overall tuberculosis incidence was 2.28 cases/100 person-years (PY) [95% confidence interval (CI) 2.06-2.52]. Among patients who received neither ART nor IPT, incidence was 4.01/100 PY. Patients who received ART had an incidence of 1.90/100 PY (95% CI 1.66-2.17) and those treated with IPT had a rate of 1.27/100 PY (95% CI 0.41-2.95). The incidence among patients who received ART and IPT was 0.80/100 PY (95% CI 0.38-1.47). Multivariate Cox proportional hazards modeling revealed a 76% reduction in tuberculosis risk among patients receiving both ART and IPT (adjusted relative hazard 0.24; P < 0.001) after adjusting for age, previous tuberculosis diagnosis, and CD4 cell counts at baseline. CONCLUSION: The use of both IPT and ART in HIV-infected patients is associated with significantly reduced tuberculosis incidence. In conjunction with expanded access to ART, the wider use of IPT in patients with HIV will improve tuberculosis control in high burden areas.     

Supervised preventive therapy for latent tuberculosis infection in illegal immigrants in Italy

In a multicenter, prospective, randomized, open-label study of isoniazid-preventive therapy (IPT) for latent tuberculosis infection, illegal immigrants from countries where tuberculosis is highly endemic were enrolled at two clinical sites in Northern Italy. Of 208 eligible subjects, 82 received supervised IPT at a dose of 900 mg twice weekly for 6 mo (Regimen A), 73 received unsupervised IPT 900 mg twice weekly for 6 mo (Regimen B), and 53 received unsupervised IPT 300 mg daily for 6 mo (Regimen C). Supervised IPT was delivered at either one tuberculosis clinic or one migrant clinic. The probability of completing a 26-wk regimen was 7, 26, and 41% in Regimens A, B, and C, respectively (p < 0.005, Log- rank test calculated using Kaplan-Meier plots). The mean time to dropout was 3. 8, 6, and 6.2 wk in Regimens A, B, and C, respectively (p = 0.003 for regimen A versus either Regimens B or C). Treatment was stopped in five subjects (2.4%) because of adverse events. The rate of completion of preventive therapy for latent tuberculosis infection among illegal immigrants was low. Supervised, clinic-based administration of IPT significantly reduced adherence. Alternative strategies to implement preventive therapy in illegal immigrants are clearly required.     

The effect of partner HIV status on motivation to take antiretroviral and isoniazid preventive therapies: a conjoint analysis

Antiretroviral therapy (ART) and isoniazid preventive therapy (IPT) are important to reduce morbidity and mortality among people newly diagnosed of HIV. The successful uptake of ART and IPT requires a comprehensive understanding of patients’ motivation to take such therapies. Partners also play an important role in the decision to be initiated and retained in care. We quantified patients’ motivation to take preventive therapies (ART and IPT) and compared by partner HIV status among people newly diagnosed of HIV. We enrolled and surveyed adults (≥18 years) with a recent HIV diagnosis (<6 months) from 14 public primary care clinics in Matlosana, South Africa. Participants received eight forced-choice tasks comparing two mutually exclusive sub-sets of seven possible benefits related to preventive therapies. A linear probability model was fitted to estimate the probability of prioritizing each benefit. Tests of concordance were conducted across partner HIV status (no partner, HIV- or unknown, or HIV+). A total of 424 people completed surveys. At the time of interview, 272 (64%) were on ART and 334 (79%) had a partner or spouse. Keeping themselves healthy for their family was the most important motivator to take preventive therapies (p?p?p?=?0.72). Keeping themselves healthy was less prioritized. We demonstrate that social responsibility such as supporting family and preventing HIV transmission to partners may pose greater motivation for ART and IPT initiation and adherence compared to individual health benefits. These messages should be emphasized to provide effective patient-centered care and counseling.     

Isoniazid preventive therapy in correctional facilities: a systematic review

Tuberculosis (TB) remains a major cause of morbidity and mortality worldwide and the main cause of death in correctional facilities in middle- and low-income countries. Due to the closed environment and the concentration of individuals with TB-related risk factors, effective measures are required to control TB in such settings. Isoniazid preventive therapy (IPT) represents an effective and cost-effective measure. Despite international recommendations that IPT be integral to TB control, it is seldom deployed. A systematic review of interventions used to assess IPT initiation and completion in correctional facilities was conducted using published studies from two biomedical databases and relevant keywords. Additional references were reviewed, resulting in 18 eligible studies. Most (72%) studies were conducted in the United States and in jail settings (60%), with the main objective of improving completion rates inside the facility or after release. Studies that provided data about initiation and completion rates showed poor success in correctional facilities. Adverse consequences and treatment interruption ranged from 1% to 55% (median 5%) in reported studies; hepatotoxicity was the most prevalent adverse reaction. Despite its accelerating effect on the development of active TB, information on human immunodeficiency virus (HIV) status was provided in only half of the studies. Among the four studies where IPT effectiveness was assessed, the results mirror those described in community settings. Future studies require thorough assessments of IPT initiation and completion rates and adverse effects, particularly in low- and middle-income countries and where comorbid viral hepatitis may contribute significantly to outcomes, and in settings where TB and HIV are more endemic.     

Cost-effectiveness of tuberculosis prophylaxis after release from short-term correctional facilities

BACKGROUND: There is poor adherence with tuberculosis preventive therapy among patients released from short-term correctional facilities, leading to recommendations against screening for latent tuberculosis infection (LTBI) in this setting. OBJECTIVES: To assess adherence to isoniazid preventive therapy (IPT) following release from short-term correctional facilities, and to estimate the cost-effectiveness of this practice. METHODS: Records of individuals referred for IPT from the Connecticut Department of Corrections to the City of Hartford Chest Clinic between January 1993 and June 1997 were reviewed. The data abstracted included demographics, adherence to IPT, and the duration of IPT completed before release from prison. An analysis was performed to determine the cost-effectiveness of this program. RESULTS: A total of 168 records were reviewed. The mean duration of IPT completed before release from prison was 8 weeks. Eighty-six subjects (57%) never came to clinic after release. Of the 64 subjects (43%) who attended clinic at least once, 35 subjects (55%) completed IPT and 29 subjects (45%) were unavailable for follow-up before completing therapy. Thirty-three of the 64 subjects (52%) who attended the clinic had to be restarted on IPT due to a prolonged lapse in therapy prior to the first visit. We estimate that $32,866 was spent on this program, but $42,093 in future costs associated with reactivation tuberculosis was prevented. CONCLUSIONS: Adherence with IPT is poor in patients released from short-term correctional facilities. Nonetheless, this program was cost-effective. An alternative strategy may be to screen for LTBI among inmates of short-term correctional facilities but withhold IPT in inmates expected to be released before therapy would be completed. Instead, these inmates could be referred to an appropriate clinic after release. Prophylaxis may be started in subjects who keep an initial clinic appointment after release.     

Use of intermittent preventive treatment for malaria by pregnant women in Buea, Cameroon

We identified individual factors associated with IPT use, by comparing characteristics of pregnant women who use IPT to those who do not.A cross-sectional study was conducted in antenatal clinics in Buea, Cameroon, from December 2006 to December 2007. Information on factors: age, parity, gravidity, gestational age, level of education, use of insecticide treated nets (ITN), socioeconomic status and IPT use was collected through interview and filled in a questionnaire. Data was entered using EPIDATA version 3 and analysis done using STATA version 8.2.A total of 527 pregnant women were interviewed with a mean (±SD) age of 26.45 ± 5.37 years. 69.71% of the pregnant women used at least two doses of IPT. Logistic regression revealed women with higher educational status were more likely to use IPT compared to those with lower educational status (OR = 3.14, 95% CI = 1.20–8.25, p = 0.02). Meanwhile, multigravid women tend to use IPT less than their primigravid counterparts (OR = 0.47, 95% CI = 0.26–0.84, p = 0.01). There was no evidence that maternal age, parity, marital status, gestational age, use of ITN and socioeconomic status were each associated to IPT use.In antenatal clinics in Buea, South Western Cameroon, educational status and gravidity are the key determinants of IPT use.     

Inflammatory pseudotumor following hematopoietic stem cell transplantation: a new case and review of the literature

Inflammatory pseudotumor (IPT) is a rare tumor that occurs in various organs and tissues. The clinical picture varies from the more frequent benign lesions to the rare malignant tumors with distant metastases. IPT associated with hematopoietic stem cell transplantation (HSCT) is rarely reported. In this article, we review the reports of IPT after HSCT and describe the first case of bladder IPT. We also review the possible factors involved in the pathogenesis. IPT might be rare but it is a potentially serious complication of HSCT. It should be considered in patients with otherwise unexplained inflammatory symptoms or signs or with any mass lesion in the post-HSCT period. A knowledge of this entity and insistence on a definitive biopsy of mass lesions in the post-HSCT period can avoid unnecessary treatment such as radical surgery, chemotherapy or radiotherapy.     

The impact of intermittent preventive treatment with sulfadoxine-pyrimethamine on the prevalence of malaria parasitaemia in pregnancy

The Roll Back Malaria initiatives were introduced to ensure that 60% of pregnant women receive intermittent preventive anti-malarial treatment by the end of 2005 in an attempt to halve the mortality from malaria by 2010. Our aim was to determine the prevalence of asymptomatic malaria parasitaemia in pregnant women on intermittent preventive treatment (IPT) with sulfadoxine-pyrimethamine (SP) compared with a control group. This comparative study involved testing the peripheral blood of pregnant women on IPT with SP and a control group that did not receive SP for the malaria parasite upon registration and at 34 weeks gestational age. The levels of parasitaemia in the intervention group upon registration (4.9%) and at 34 weeks (63.9%) were not significantly different (P > 0.05) from that of the control group (10%) and at 34 weeks gestation (68.3%). IPT with SP during pregnancy did not significantly reduce the prevalence of the malaria parasitaemia among the pregnant women in our environment.     

Spontaneous regression of an inflammatory pseudotumor of the liver

Inflammatory pseudotumors (IPT) have been described for virtually every site in the body but is rare in the liver. The clinical presentation of hepatic IPT is unspecific, patients complain of fever, malaise, weight loss and often of symptoms related to a mass effect. Routine imaging procedures are not sufficient to make the diagnosis and a biopsy is necessary to differentiate IPT from neoplasms. The course of the disease is unpredictable and in most of the reported cases the patients underwent resection or were medically treated. We report a patient with a histologically proven IPT of the liver that regressed spontaneously over several months without any specific treatment.     

A mixed methods study on the prioritisation of cancer and access to cancer drugs: the Cancer Drugs Fund in England

BackgroundBy April, 2016, the Cancer Drugs Fund (CDF) will have provided £1·27 billion. The CDF funds high-cost cancer drugs that have not been recommended or appraised by the National Institute for Health and Care Excellence. We aimed to combine the viewpoints of patients and clinicians about fair access to cancer drugs with measured equity of access to cancer drugs in the National Health Service.MethodsWe conducted semi-structured interviews with consultants in oncology and palliative care (n=16) and patients with terminal prostate and colorectal cancer (22) recruited from hospitals in South West England to explore values underpinning decisions about prioritisation. Researchers were independent of the clinical team and CDF. Qualitative thematic analysis was done with principles of constant comparison and facilitated by NVivo (version 10). Equity and timeliness of access to cancer drugs was assessed in cross-sectional (n=3193) and cohort (899) studies of South West CDF (2011–13) patients, respectively. We assessed equity by comparing access to the CDF in a reference eligible population of advanced type-matched patients from the South West Cancer Registry by age, sex, deprivation, and cancer network using χ² tests. Performance status was absent and not controlled for. Timeliness of treatment was assessed with Cox regression to calculate time from CDF authorisation to start of treatment by the same characteristics.FindingsAll but one interviewed clinician agreed that having a ring-fenced fund for cancer drugs was not the best use of National Health Service resource. Almost all patients and professionals felt that prioritising cancer over other diseases was unjustified. Prioritising life extension at the end of life raised concerns for many professionals, but for fewer patients. Older people (≥80 years) and women were less likely to have been referred to the CDF: in colorectal cancer, 45 (6·9%) of 648 older patients accessed the CDF (30·1% eligible [483/1606]; difference 23·2%, 95% CI 20·2–26·2). In malignant melanoma, 46 (36·8%) of 125 women accessed the CDF (48·7% eligible [1680/3453]; difference 11·9%, 3·1–20·7). There was regional variation in prescribing by cancer network, which was inconsistent across cancer types. Differences in treatment timeliness were negligible.InterpretationThe CDF lacks legitimacy for this population of users, and is unequal in its delivery. We recommend that a fundamental re-evaluation of the CDF is undertaken to ensure appropriate resource allocation according to population values.FundingCC is a National Institute for Health Research Doctoral Fellow.     

Effectiveness of intermittent preventive treatment with sulphadoxine-pyrimethamine for control of malaria in pregnancy in western Kenya: a hospital-based study

OBJECTIVE: To monitor the effectiveness of intermittent preventive treatment (IPT) with sulphadoxine-pyrimethamine (SP) for the control of malaria in pregnancy at delivery in the Provincial Hospital in Kisumu, Kenya, and to assess the effect of IPT in participants in a cohort study. METHODS: Between June 1999 and June 2000, information on IPT and birth outcome was collected in 2302 consecutive deliveries. A group of 889 women, who were enrolled in a cohort to assess the interaction between malaria and HIV, were analysed separately because of the enrollment criteria and different access to health care. RESULTS: The prevalence of placental malaria was 13.8% and of low birthweight (LBW) was 12.2%. In multivariable analysis, IPT (> or =1 dose of SP) was associated with a reduction in placental malaria and LBW [adjusted odds ratio (OR) 0.56, 95% confidence interval (CI) 0.39-0.83 and OR 0.65, 95% CI 0.45-0.95, respectively]. An adjusted mean increase in birthweight of 61 g was seen (95% CI 22-101 g) for each increment in number of SP doses (> or =2 doses grouped together). IPT was associated with a reduction in placental malaria in HIV-seronegative women (OR 0.49, 95% CI 0.28-0.86) but this was not significant among HIV-seropositive women (OR 0.45, 95% CI 0.20-1.05). A significant effect on birthweight could not be detected among participants in the HIV-cohort. CONCLUSIONS: This evaluation confirms that IPT with SP is effective in reducing placental malaria and LBW. It will be important to increase coverage of IPT and to extend IPT to antenatal clinics in peri-urban and rural areas.     

Role of MR in the differentiation of IgG4-re-lated from non-IgG4-related hepatic inflamma-tory pseudotumor

BACKGROUND:Hepatic inflammatory pseudotumor (IPT) is classified into 2 types based on IgG4 stain: IgG4-related and non-IgG4-related; the two types differ not only in their patho-logical characteristics, but also in the clinical features. This study aimed to investigate the MR character of hepatic IPT, and differentiate the IgG4-related IPT from the non-IgG4-re-lated IPT. METHODS: Twenty-five patients with 27 histologically proven hepatic IPTs were retrospectively analyzed. Ten lesions were diagnosed as IgG4-related IPT, and the other 17 as non-IgG4-related IPT. The MR signal features on T1, T2-weighted, dynamic-enhanced, and diffusion-weighted im-aging were evaluated and compared. RESULTS: The dominant lesions were subcapsularly distrib-uted (n=17, 63.0%) with clear boundary (n=20, 74.1%), and showed progressive enhancement pattern (n=21, 77.8%) with diffuse homogeneous (n=12, 44.4%) or heterogeneous (n=8, 29.6%) hyperintensity, accompanied by delayed capsule-like enhancement (n=17, 63.0%) and central nonenhanced areas (n=18, 66.7%). Morphological features (P>0.05) were not suf-ficient to differentiate IgG4-related IPT from non-IgG4-relat-ed IPT; the wash-out pattern was only found in 2 IgG4-related IPT, while the progressive enhancement pattern was more common in the non-IgG4-related lesions (n=16) (P=0.022). During portal and delayed phases, iso-/hypoenhanced lesions were only seen in 3 IgG4-related IPT, and circular-enhanced lesions (n=5) existed exceptionally in the non-IgG4-related group with significant differences (P=0.029 and 0.027). Most IgG4-related IPTs had lower apparent diffusion coefficient compared with the liver parenchyma (n=6), while most non-IgG4-related IPTs had higher apparent diffusion coeffi-cient value (n=13) (P=0.046). CONCLUSIONS: Although MR images of hepatic IPT have certain characteristics, they are not enough to differentiate IgG4-related IPT from non-IgG4-related IPT. The enhance-ment pattern, signal features on portal and delayed phases, and the apparent diffusion coefficient value of the lesion may be helpful for the diagnosis.