Antenatal atazanavir: a retrospective analysis of pregnancies exposed to atazanavir.

INTRODUCTION: There are few data regarding the tolerability, safety, or efficacy of antenatal atazanavir. We report our clinical experience of atazanavir use in pregnancy. METHODS: A retrospective medical records review of atazanavir-exposed pregnancies in 12 London centres between 2004 and 2010. RESULTS: There were 145 pregnancies in 135 women: 89 conceived whilst taking atazanavir-based combination antiretroviral therapy (cART), "preconception" atazanavir exposure; 27 started atazanavir-based cART as "first-line" during the pregnancy; and 29 "switched" to an atazanavir-based regimen from another cART regimen during pregnancy. Gastrointestinal intolerance requiring atazanavir cessation occurred in five pregnancies. Self-limiting, new-onset transaminitis was most common in first-line use, occurring in 11.0%. Atazanavir was commenced in five switch pregnancies in the presence of transaminitis, two of which discontinued atazanavir with persistent transaminitis. HIV-VL < 50 copies/mL was achieved in 89.3% preconception, 56.5% first-line, and 72.0% switch exposures. Singleton preterm delivery (<37 weeks) occurred in 11.7% preconception, 9.1% first-line, and 7.7% switch exposures. Four infants required phototherapy. There was one mother-to-child transmission in a poorly adherent woman. CONCLUSIONS: These data suggest that atazanavir is well tolerated and can be safely prescribed as a component of combination antiretroviral therapy in pregnancy.

How likely is environmental or patient cross-contamination of Chlamydia trachomatis DNA to lead to false positive results in patients attending our clinic?

OBJECTIVES: Environmental contamination with DNA from Chlamydia trachomatis (CT) has previously been found in Genitourinary Medicine (GUM) clinics. There are no known cases of cross-contamination of clinical samples and no known nosocomial infections. We investigated whether diagnostic samples could become contaminated from the environment by running dummy sample and carrying out a patient-throughput analysis. A total of 29 748 patients attended clinics over a year. Of these, 2860 (9.6%) had a positive Chlamydia test result. METHOD: (1) A run of dummy samples (60 urine samples and 10 swabs) were processed as normal clinic specimens. (2) Patient-throughput analysis: Patient numbers attending the GUM clinic on a given day was categorised as low, moderate or high. χ(2) Tests were used to look for associations between categorical variables and Chlamydia test positivity. A Poisson regression model was fitted to look at the effect of the number of people in the clinic on the number of positive results in a given day. As some clinics were only run on certain days of the week, a sensitivity analysis was later performed with attendances at non-daily clinics removed. RESULTS: All dummy samples tested negative and we did not find evidence of an association between daily Chlamydia positivity and clinic attendance. CONCLUSIONS: It is unlikely that environmental or cross-contamination of CT has lead to significant numbers of false positive results. Laboratories check for possible cross-contamination routinely. The extension of this simple routine practice to all clinical areas could provide quality assurance, improving confidence in the results in clinics.

Delayed diagnosis of Kaposi's sarcoma in a HIV positive man with a high CD4 count and suppressed viral load.

A HIV positive man with a CD4 count of 777×10(6)/l and suppressed viral load on antiretroviral medication had a delayed diagnosis of Kaposi's sarcoma (KS) affecting his left leg. He was diabetic and on a controlled diet and had a previous deep vein thrombosis affecting the same leg. Factors that have been studied in HIV-related KS as well as classical KS, such as diabetes mellitus, not smoking and previous deep vein thrombosis, may have increased our patient's risk for the development of this disease. Clinicians should consider KS as a possible diagnosis even in patients with well-controlled HIV.

Twin pregnancy outcomes after increasing rate of vaginal twin delivery: retrospective cohort study in a Hong Kong regional obstetric unit.

OBJECTIVE: To determine any change in adverse neonatal/maternal outcomes after increasing the rate of vaginal twin delivery by comparing vaginal twin delivery and caesarean delivery with our previous cohort study. METHODS: In a retrospective cohort study, all twins booked at a Hong Kong regional obstetrics unit were evaluated during a 3-year period from 1 April 2009 to 31 March 2012. RESULTS: Out of the 269 sets of twins who eventually delivered in our unit, 68 (25.3%) of them were delivered vaginally, compared to 15.8% in our previous cohort study (p = 0.02). For those who were suitable for vaginal delivery, significantly more women attempted vaginal delivery: 93/133 (69.9%) versus 47/100 (47%) (p = 0.0005). The success rate for vaginal delivery and rate of requiring caesarean delivery for the 2nd twin were similar between these two periods. There were significantly more 2nd twins with cord blood pH < 7.2 when both twins were delivered by vaginal delivery. Otherwise, there was no significant difference between other neonatal/maternal morbidities. CONCLUSION: With proper counseling, significantly more women who were suitable for vaginal twin delivery would opt to do so. There was no significant increase in neonatal/maternal morbidities despite the increased rate of vaginal twin delivery.