Safety of nevirapine in pregnancy

BACKGROUND

Nevirapine has been widely used in pregnancy for its efficacy, low pill burden, bioavailability and rapid transplacental transfer. Concern about nevirapine toxicity during pregnancy has emerged over recent years.

OBJECTIVES

The aims of the study were to document the frequency of cutaneous and hepatic toxicity secondary to nevirapine use during pregnancy and to compare rates in women starting nevirapine during the current pregnancy with those in women who had commenced nevirapine prior to the current pregnancy.

DESIGN

This was a retrospective, comparative, five-centre study carried out in London, UK, in 1997-2003.

METHODS

All HIV-1-infected women who received nevirapine as part of combination antiretroviral therapy (ART) during pregnancy were included in the study. Data on demographics, HIV infection risk, Centers for Disease Control and Prevention (CDC) status, surrogate markers at initiation of therapy, other medications hepatitis B and C virus coinfection and clinical data relating to potential toxicity were collated and analysed.

RESULTS

Fifteen of 235 eligible women (6.4%) developed rash and eight (3.4%) developed hepatotoxicity, including four with coexistent rash, giving a combined incidence of 19 potential cases of nevirapine toxicity during pregnancy (8.1%). Alternative causes of rash/hepatotoxicity were suspected in seven cases and only 10 mothers (5.8%) discontinued nevirapine. Of the 170 women who commenced nevirapine during this pregnancy, 13 (7.6%) developed rash and eight (4.7%) hepatotoxicity, a combined incidence of 10%. Only two of 65 women with nevirapine exposure prior to this pregnancy developed rash (3.1%).

CONCLUSIONS

Nevirapine-containing ART was well tolerated in this cohort of pregnant women. Although pregnancy did not appear to increase the risk of nevirapine-associated toxicity compared to published adult data, CD(4) count may be less predictive of toxicity in pregnancy.

Should medical students be taught about rape? A survey of UK medical schools

Rape and other serious sexual assaults are common and result in long-term morbidity. Increasing numbers are reported but conviction rates are low. Victims of sexual assault present to a wide range of healthcare settings. Good immediate medical care and evidence collection are important in engaging victims with the criminal justice system, avoiding the loss of crucial evidence and minimising long-term morbidity. Of 21 UK medical schools surveyed, only eight provided teaching about sexual assault and ten provided other forensic teaching. Sixteen schools provided guidance about personal safety. As rape is so common and traumatic, medical schools should seriously consider providing teaching about this area.

Why are children still being infected with HIV? Experiences in the prevention of mother-to-child transmission of HIV in south London

OBJECTIVES

To evaluate the effectiveness of interventions to prevent mother-to-child transmission of HIV at a large teaching hospital in South East London, and to assess reasons for the small numbers of transmissions that continue to occur.

DESIGN

A database of all pregnant women diagnosed as HIV positive between 1993 and 2005 was reviewed, with detailed (retrospective) case-note review of all mother-infant pairs where HIV transmission occurred.

SETTING

King's College Hospital, London, UK, a teaching hospital serving an ethnically diverse and socially deprived population.

RESULTS

296 pregnancies to 274 women were recorded. 9 of 296 (3.0%) women were lost to follow-up before the end of the pregnancy. Of 287 pregnancies followed up until after delivery, 6 (2.1%) resulted in HIV infection in the infant. More recently, between 2000 and 2004, this transmission rate was even lower, at 3 in 231 (1.3%). Each of these six women had complications, including late presentation to services and defaulting follow-up appointments, which were likely to increase the risk of HIV transmission. Four of the six transmissions occurred in utero.

CONCLUSION

The overall transmission rate of 2% attests to the efforts of the multidisciplinary care team in managing this population which is often hard to reach. Clearly, good systems are needed to trace those women who default. Further data are needed regarding in utero transmissions.

The prognosis of occupational asthma due to detergent enzymes: clinical, immunological and employment outcomes

BACKGROUND

Little is known about the prognosis of occupational asthma induced by high molecular weight proteins.

OBJECTIVE

Our objective was to measure the clinical, immunological and employment outcomes of individuals with occupational asthma induced by detergent enzymes.

METHODS

We undertook a workforce-based follow-up study in 35 (78%) of the 45 ex-employees from a single factory with occupational asthma. In each case the diagnosis was supported by evidence of specific sensitization and characteristic changes in peak flow or a positive response to specific bronchial provocation testing.

RESULTS

This group had left the factory on average 37 months before study. On review 25 (71%) reported chest symptoms during the last month. Compared with when working at the factory, most (86%) reported that their symptoms had improved. Twenty continued to attend their general practitioner for respiratory symptoms and 19 still used asthma medications. Since leaving the factory 16 (46%) and four (11%) had found full-time or part-time employment, respectively; of these 16 found they were paid less than when they worked at the factory. The remaining 15 subjects had not had any paid employment. All but two had positive skin prick tests to one or more three detergent enzymes. The estimated half-life of serum-specific IgE antibodies was 20 months for protease, and 21 months for cellulase and amylase.

CONCLUSIONS

Population-based follow-up studies of the prognosis of occupational asthma are rare but probably avoid the bias in clinic-derived surveys. This study demonstrates that 3 years after the avoidance of exposure with detergent enzymes most patients continue to be troubled by, albeit improved, symptoms and experience difficulty in re-employment.

Proton magnetic resonance spectroscopy in frontotemporal dementia

This study of frontotemporal dementia (FTD) was carried out to determine whether MR spectroscopy can provide an in vivo marker for the neuronal loss and gliosis that occur in this condition. We compared spectra in frontal and temporal regions known to be affected early in the course of the disease with spectra in the parietal lobe that is spared until late stages of FTD. We were interested in the relative concentrations of two compounds, NAA (a marker of neuronal integrity) and mI (a marker of gliosis), expressed as ratios to creatine (a relatively stable brain constituent). MR spectroscopy was performed on the temporal, parietal, and anterior cingulate cortices of five patients with the established semantic dementia form of FTD, two patients with the frontal form of FTD and 13 age matched controls. Structural MRI and neuropsychometry were also performed. Patients with FTD had reduced NAA/Cr in frontal and temporal, but not parietal lobes. The two patients with the frontal form of FTD had increased mI/Cr in their cingulate cortices. These data show for the first time that MR spectroscopy can reveal regionally selective abnormalities in patients with FTD. This opens up the possibility of using MR spectroscopy as a clinical tool to identify earlier presentations of the condition.

National review of maternity care for women with HIV infection

OBJECTIVE

To assess adherence to the British HIV Association (BHIVA) 2001 guidelines for the management of HIV-infected pregnant women.

METHODS

A survey and a case note review were carried out using structured questionnaires sent to providers of adult HIV care in the UK and Ireland. Participants were women with HIV infection who delivered a live or stillborn infant between October 2002 and September 2003. The main outcome measures were the appropriate use of antiretroviral therapy, the use and timing of elective Caesarean section, and support for the avoidance of breast-feeding.

RESULTS

Of 186 centres, 100 (54%) responded with data on 501 eligible pregnancies.

CONCLUSIONS

In general, practice was in accordance with the BHIVA 2001 guidelines. However, in a number of cases Caesarean sections were planned later than the recommended 38 weeks.

α- and β-FOX-7, Polymorphs of a High Energy Density Material, Studied by X-ray Single Crystal and Powder Investigations in the Temperature Range from 200 to 423 K

The alpha-beta phase transition in the novel energetic material 1,1-diamino-2,2-dinitroethylene, C2H4N4O4 (FOX-7), has been studied by single-crystal X-ray investigations at five different temperatures over the 200-393 K range. In these investigations, the positions of the hydrogen atoms were experimentally determined without any geometric constraints. In addition, X-ray powder investigations using the Guinier technique have been performed to characterize the beta-phase up to 423 K. The alpha-beta phase transition at 389 K is first order, shows a discontinuous increase of the molar volume and entropy (DeltaV = 1.75 cm3/mol, X-ray investigation; DeltaS = 1.5 cal/K mol, DSC analysis), and can be classified as displacive. The hitherto unknown structure of beta-FOX-7 was solved at 393 K and showed simple structural relations to the alpha-polymorph. The characteristic bonding in wave-shaped layers is now found for beta-FOX-7 (P2(1)2(1)2(1), z = 4, a= 6.9738(7) A, b = 6.635(1) A, c = 11.648(2) A, 393 K), as well as for alpha-FOX-7 (P2(1)/n, z = 4, a = 6.9467(7) A, b = 6.6887(9) A, c = 11.350(1) A, beta = 90.143(13) degrees , 373 K). Interestingly, whereas the intramolecular C-C, C-N, N-O, and N-H bond distances remain nearly unchanged for both polymorphs over the whole temperature range from 200 to 393 K, the two nitro groups deviate strongly from the molecular plane formed by the two carbon and two amino nitrogen atoms. In alpha-FOX-7 at 373 K, the nitro groups are twisted -47 and +6 degrees with respect to the carbon-carbon bond, but in beta-FOX-7 at 393 K, these twist angles are changed to -36 and +20 degrees . Within the layers, the FOX-7 molecules show strong pi-conjugation and extensive intra- and intermolecular hydrogen bonding. In this investigation, we have been able to show that alpha- and beta-FOX-7 build up different nets of intermolecular hydrogen bonds. In alpha-FOX-7, each oxygen atom of the nitro groups is involved in two hydrogen bonds resulting in two intramolecular and six intermolecular hydrogen bonds. But in beta-FOX-7 this coordination changes, and half of the oxygen atoms build up two and the other half build up three hydrogen bonds leading to two intramolecular and eight intermolecular hydrogen bonds. The average intermolecular hydrogen bond distance increases slightly from 2.31 A in alpha-FOX-7 to 2.52 A in beta-FOX-7. The C-NO2 bonds are of particular interest because they are referred to as the detonation trigger. It has been suggested that these bonds could be strengthened by the extensive intermolecular hydrogen bonding within the layers in both polymorphs. Such bond strengthening via cooperative effects was proposed in earlier DFT calculations on FOX-7 and may be one key to understanding its low sensitivity and high activation energy to impact.

Supermarket baker's asthma: how accurate is routine health surveillance?

BACKGROUND

Regular health surveillance is commonly recommended for workers exposed to occupational antigens but little is known about how effective it is in identifying cases.

AIMS

To report one large company's surveillance and compare its findings with those of a standard cross-sectional survey in the same workforce.

METHODS

A supermarket company with 324 in-store bakeries producing bread from raw ingredients conducted a three-stage health surveillance programme in around 3000 bakery employees. The first stage involved the administration of a simple respiratory questionnaire. If chest symptoms were present a second questionnaire focusing on their work relationship was administered. If positive a blood sample was requested for the measurement of specific IgE to flour and fungal alpha-amylase. The results were compared to an independent cross-sectional survey of employees in 20 of the company's stores.

RESULTS

Two hundred and ninety nine (92%) of the company's bakeries took part in surveillance. The overall employee response for the first stage was 77%; a quarter of those with respiratory symptoms reported that they were work related. Seventy four (61%) of those with work related chest symptoms had a measurement of specific IgE to either flour or fungal alpha-amylase, of whom 30 (41%) had a positive result. Surveillance estimated that 1% of bakery employees (1% bakers, 2% managers, 0.6% confectioners) had work related symptoms with specific IgE. This compared with 4% (7.5% bakers, 3.3% managers, 0% confectioners) in the cross-sectional survey (n = 166, 93% response).

CONCLUSION

Comparison with a standard cross-sectional survey suggests that routine surveillance can underestimate the workplace burden of disease. The reasons may include technical or resource issues and uncertainties over confidentiality or the perceived consequences of participation. More research needs to be done looking into the design and efficacy of surveillance in occupational asthma.

The changing distribution of occupational asthma: a survey of supermarket bakery workers

In the UK, since the mid 1980s, supermarkets have accounted for an increasing volume of bread production. Occupational asthma among employees who produce bread from raw ingredients in supermarkets has not been previously investigated. A cross-sectional survey was undertaken involving 239 (71%) employees from 20 different supermarket bakeries. The work-related symptoms were investigated by using questionnaires and measuring the radioallergosorbent test serum-specific immunoglobulin (Ig)E to flour and fungal alpha-amylase. A total of 89 employees underwent whole-shift personal measurement of dust exposure. The geometric mean dust exposure for bakers was 1.2 mg x m(-3), which was higher than for other bakery employees. A total of 37 (15%) employees also reported work-related chest symptoms. Serum IgE to flour was present in 24 (11%) employees and to fungal alpha-amylase in nine (4%) employees. The combination of work-related chest symptoms and specific IgE was found in six (9%) bakers, one (4%) manager and two (3%) assistants. One-quarter of all employees, but half of bakers and managers, had previously worked for different, mainly small, bakeries. This population of bakery workers has important levels of sensitisation and work-related respiratory symptoms, despite low levels of dust exposure. Changes in the location and process of bread manufacture have led to a change in the distribution of bakers' asthma in the UK.

Risk of undiagnosed infection in men attending a sexual assault referral centre

OBJECTIVES

To investigate men undergoing forensic examination at the Haven, a specialist centre for the management of sexual assault in south London.

METHODS

Forensic notes of 92 men attending the Haven from May 2000 to August 2003 were identified and a detailed review performed.

RESULTS

Males ranged in age from 12 to 51 years, with 83% within the range 12-35 years. 78% were white. Of those who were sexually active (n=82) 30% were heterosexual, 34% were homosexual, and the remainder provided no information regarding sexual orientation. Most clients were referred by the police (n=79) and attended within 3 days of the alleged assault (n=73). Many of the victims had increased vulnerability to assault-for example, through alcohol or drug consumption or mental health difficulties. One assailant was reported in 61 cases but two or more assailants in 26. Women were reported as assailants in four cases. The sexual assault was frequently accompanied by other physical assault (n=45). Use/threat of a weapon was reported in 18 cases. Rape or attempted rape was reported in 59 cases and was the most common assault. Non-genital injuries were documented in 37 men (40%). Anal injuries were seen in 31 (34%). The non-attendance rate at follow up was 41%. Post-exposure prophylaxis (PEP) against HIV was commenced in 31 men (34%). 23 of the 54 men (43%) reporting rape and 14 of the 31 (45%) with anal injuries initiated PEP.

CONCLUSIONS

The number of men presenting after sexual assault is likely to increase but despite significant risk many do not engage with medical care. This carries an unknown risk of HIV and other STI transmission.

Occupational asthma caused by cellulase and lipase in the detergent industry

Three employees from two different detergent companies were investigated for occupational asthma, using skin prick tests, serum specific IgE, and specific bronchial challenge. Two were challenged with lipase and one with cellulase. All three cases had immunological evidence of sensitisation to the detergent enzymes with which they worked. Bronchial challenge in each provoked a reproducible dual asthmatic response, which reproduced their work related symptoms. These are the first reported cases of occupational asthma attributable to cellulase and lipase in the detergent industry. Four of the most common enzymes used in this industry have now been reported to cause occupational asthma; continued vigilance and caution are needed when working with these or other enzymes.

Association of HLA-DQ5 and HLA-DR1 with sensitization to organic acid anhydrides

BACKGROUND

Organic acid anhydrides are low molecular weight industrial chemicals, able to cause rhinoconjunctivitis and asthma associated with specific IgE against hapten-carrier protein conjugate. Only a proportion of exposed workers develop IgE-associated allergy to acid anhydrides.

OBJECTIVE

We determined whether genetic susceptibility, in particular, HLA Class II alleles may be a risk factor.

METHODS

We undertook HLA typing in 52 cases who had confirmed specific IgE and in 73 referents matched on site, age and duration of acid anhydride exposure identified in cross-sectional studies of workers exposed to hexahydrophthalic (HHPA), methylhexahydrophthalic (MHHPA) and methyltetrahydrophthalic (MTHPA) anhydrides.

RESULTS

The linked alleles DQ5 (odds ratio [OR]=4.3; 95% confidence interval [95% CI]=1.7, 11) and DR1 (OR 3.0; 95% CI 1.2, 11) were more prevalent in cases than in referents. Within DQ5, DQB1(*)0501 was particularly frequent (OR 3.0; 95% CI 1.2, 7.4).

CONCLUSION

DQB1(*)05 gene confers susceptibility to develop specific IgE antibodies against HHPA, MHHPA and a non-significant trend with MTHPA. DQB1(*)0501 is protective for other low molecular chemical sensitizers (isocyanates and plicatic acid) which may indicate varying affinities for the corresponding specific class II molecules.