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Jao J, Kacanek D, Williams PL, Geffner ME, Livingston EG, Sperling RS, Patel K, Bardeguez AD, Burchett SK, Chakhtoura N, Scott GB, Van Dyke RB, Abrams EJ. Birth Weight and Preterm Delivery Outcomes of Perinatally vs Nonperinatally Human Immunodeficiency Virus-Infected Pregnant Women in the United States: Results From the PHACS SMARTT Study and IMPAACT P1025 Protocol. Clin Infect Dis 2018; 65:982-989. [PMID: 28575201 DOI: 10.1093/cid/cix488] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 05/23/2017] [Indexed: 12/16/2022] Open
Abstract
Background Pregnancy outcomes of perinatally human immunodeficiency virus-infected women (PHIV) are poorly defined. Methods We compared preterm delivery and birth weight (BW) outcomes (low BW [LBW], <2500 g), small-for-gestational-age [SGA], and BW z scores [BWZ]) in HIV-exposed uninfected infants of PHIV vs nonperinatally HIV-infected (NPHIV) pregnant women in the Pediatric HIV/AIDS Cohort Study Surveillance Monitoring of ART Toxicities or International Maternal Pediatric Adolescent AIDS Clinical Trials P1025 studies. Mixed effects models and log binomial models were used to assess the association of maternal PHIV status with infant outcomes. Age-stratified analyses were performed. Results From 1998 to 2013, 2270 HIV-infected pregnant women delivered 2692 newborns (270 born to PHIV and 2422 to NPHIV women). PHIV women were younger, (mean age 21 vs 25 years, P < .01) and more likely to have a pregnancy CD4 count <200 cells/mm3 (19% vs 11%, P = .01). No associations between maternal PHIV status and preterm delivery, SGA, or LBW were observed. After adjustment, BWZ was 0.12 lower in infants of PHIV vs NPHIV women (adjusted mean, -0.45 vs -0.33; P = .04). Among women aged 23-30 years (n = 1770), maternal PHIV was associated with LBW (aRR = 1.74; 95% confidence interval, 1.18, 2.58; P < .01). Conclusion The overall lack of association between maternal PHIV status and preterm delivery or infant BW outcomes is reassuring. The higher rates of LBW observed in PHIV women aged 23-30 years warrants further mechanism-based investigations as this is a rapidly growing and aging population worldwide. Clinical Trials Registration PHACS SMARTT study, NCT01310023. Clinical Trials Registration IMPAACT 1025, NCT00028145.
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Porter KA, Turpin J, Begg L, Brown G, Chakhtoura N, Church E, Grossman C, Wira C, Veronese F. Understanding the Intersection of Young Age, Mucosal Injury, and HIV Susceptibility. AIDS Res Hum Retroviruses 2017; 32:1149-1158. [PMID: 27726428 DOI: 10.1089/aid.2016.0206] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Adolescent boys and girls are disproportionately affected in the current HIV epidemic. Numerous sociobehavioral studies have addressed the indirect drivers surrounding this vulnerability-for example, socioeconomic, geographical locale, and all forms of violence. However, the direct factors that may influence infection, such as the anatomical and physiological maturation of the anogenital tracts of adolescents or the trauma and wound-healing processes of injured mucosal tissue, are understudied and represent a gap within the HIV prevention field. This article reviews the epidemiology of HIV infection and violence in adolescents and the available basic science knowledge attending this research area. More importantly, this review highlights the most critical gaps that need to be addressed to design preventive interventions that are safe and effective for this population, which is key to ending the HIV pandemic.
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Scott RK, Chakhtoura N, Burke MM, Cohen RA, Kreitchmann R. Delivery After 40 Weeks of Gestation in Pregnant Women With Well-Controlled Human Immunodeficiency Virus. Obstet Gynecol 2017; 130:502-510. [PMID: 28796679 PMCID: PMC5656396 DOI: 10.1097/aog.0000000000002186] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate whether there is increased mother-to-child transmission of human immunodeficiency virus (HIV)-1 associated with deliveries at 40 weeks of estimated gestational age (EGA) or greater in pregnant women with HIV-1 viral loads of 1,000 copies/mL or less. METHODS We performed a secondary analysis of the Eunice Kennedy Shriver National Institute of Child Health and Human Development International Site Development Initiative Perinatal and Longitudinal Study in Latin American Countries and International Maternal Pediatric Adolescent AIDS Clinical Trials P1025 cohorts. We included pregnant women with HIV-1 with recent viral loads of 1,000 copies/mL or less at the time of delivery and compared delivery outcomes at between 38 and less than 40 weeks EGA with delivery outcomes at 40 weeks EGA or greater, the exposure of interest. Our primary outcome of interest was mother-to-child transmission, and secondary outcomes included indicators of maternal and neonatal morbidity. We examined the association between EGA and mother-to-child transmission using Poisson distribution. Associations between EGA and secondary outcomes were examined through bivariate analyses using Pearson χ and Fisher exact test or the nonparametric Mann-Whitney U test. RESULTS Among the 2,250 eligible neonates, eight neonates were infected with HIV-1 (overall transmission rate 0.4%, 95% CI 0.2-8.1%, 40 weeks EGA or greater 0.5% [3/621, 95% CI 0.2-1.4%], less than 40 weeks EGA 0.3% [5/1,629, 95% CI 0.1-0.7%]); there was no significant difference in transmission by EGA (rate ratio 1.57, 95% CI 0.24-8.09, P=.77). There was no difference in maternal viral load between the two groups nor was there a difference in timing of transmission among neonates born with HIV-1. CONCLUSION In pregnant women with well-controlled HIV-1, the risk of mother-to-child transmission did not differ significantly by EGA at delivery, although we were not powered to demonstrate equivalence of proportions of mother-to-child transmission between EGA groups.
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Currier JS, Britto P, Hoffman RM, Brummel S, Masheto G, Joao E, Santos B, Aurpibul L, Losso M, Pierre MF, Weinberg A, Gnanashanmugam D, Chakhtoura N, Klingman K, Browning R, Coletti A, Mofenson L, Shapiro D, Pilotto J. Randomized trial of stopping or continuing ART among postpartum women with pre-ART CD4 ≥ 400 cells/mm3. PLoS One 2017; 12:e0176009. [PMID: 28489856 PMCID: PMC5425014 DOI: 10.1371/journal.pone.0176009] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 04/03/2017] [Indexed: 11/24/2022] Open
Abstract
Background Health benefits of postpartum antiretroviral therapy (ART) for human immunodeficiency virus (HIV) positive women with high CD4+ T-counts have not been assessed in randomized trials. Methods Asymptomatic, HIV-positive, non-breastfeeding women with pre-ART CD4+ T-cell counts ≥ 400 cells/mm3 started on ART during pregnancy were randomized up to 42 days after delivery to continue or discontinue ART. Lopinavir/ritonavir plus tenofovir/emtricitabine was the preferred ART regimen. The sample size was selected to provide 88% power to detect a 50% reduction from an annualized primary event rate of 2.07%. A post-hoc analysis evaluated HIV/AIDS-related and World Health Organization (WHO) Stage 2 and 3 events. All analyses were intent to treat. Results 1652 women from 52 sites in Argentina, Botswana, Brazil, China, Haiti, Peru, Thailand and the US were enrolled (1/2010-11/2014). Median age was 28 years and major racial categories were Black African (28%), Asian (25%) White (15%). Median entry CD4 count was 696 cells/mm3 (IQR 575–869), median ART exposure prior to delivery was 19 weeks (IQR 13–24) and 94% had entry HIV-1 RNA < 1000 copies/ml. After a median follow-up of 2.3 years, the primary composite endpoint rate was significantly lower than expected, and not significantly different between arms (continue arm 0.21 /100 person years(py); discontinue 0.31/100 py, Hazard ratio (HR) 0.68, 95% CI: 0.19, 2.40). WHO Stage 2 and 3 events were significantly reduced with continued ART (2.08/100 py vs. 4.36/100 py in the discontinue arm; HR 0.48, 95%CI: 0.33, 0.70). Toxicity rates did not differ significantly between arms. Among women randomized to continue ART, 189/827 (23%) had virologic failure; of the 155 with resistance testing, 103 (66%) failed without resistance to their current regimen, suggesting non-adherence. Conclusions Overall, serious clinical events were rare among young HIV-positive post-partum women with high CD4 cell counts. Continued ART was safe and was associated with a halving of the rate of WHO 2/3 conditions. Virologic failure rates were high, underscoring the urgent need to improve adherence in this population. Trial registration ClinicalTrials.gov NCT00955968
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Kapogiannis BG, Chakhtoura N, Hazra R, Spong CY. Bridging Knowledge Gaps to Understand How Zika Virus Exposure and Infection Affect Child Development. JAMA Pediatr 2017; 171:478-485. [PMID: 28241263 DOI: 10.1001/jamapediatrics.2017.0002] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The Zika virus (ZIKV) epidemic has profoundly affected the lives of children and families across the Americas. As the number of children born with ZIKV-related complications continues to grow, the long-term developmental trajectory for these children and the effect on their families remains largely unknown. In September 2016, the Eunice Kennedy Shriver National Institute of Child Health and Human Development and partner National Institutes of Health institutes convened a workshop to develop a research agenda to improve the evaluation, monitoring, and management of neonates, infants, or children affected by ZIKV and its complications. The agenda also aims to optimally address the prospective effect of ZIKV exposure on the developing child. OBSERVATIONS The full clinical spectrum of congenital ZIKV syndrome has yet to be elucidated. In addition to the well-described anatomic and neurologic manifestations, clinicians are now describing infants with exaggerated primitive reflexes, epilepsy, acquired hydrocephalus and microcephaly, neurodevelopmental delay, gastrointestinal motility problems, and respiratory complications, such as pneumonia. While we are still learning more about the myriad clinical presentations in these severely affected children, it is also paramount to address the larger proportion of ZIKV-exposed infants who are asymptomatic at birth but, we assume, may develop problems later in life. The available evidence for neurologic, neurodevelopmental, neurobehavioral, auditory, and vision assessments and management for infants with congenital ZIKV syndrome was critically evaluated. Lessons from other congenital infections provide valuable clues about the complexities of management and the optimal approaches for evaluating, treating, and caring for the children, which include engaging and involving parents and caregivers in their treatment. CONCLUSIONS AND RELEVANCE Rigorous research is key to improving the identification of ZIKV-infected mothers and babies. Research also is critical to increasing basic understanding of the neuropathogenesis of congenital ZIKV disease and of the spectrum of clinical presentations of ZIKV infection so that agents to prevent and treat this devastating disease can be rapidly developed and studied.
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Baeten JM, Palanee-Phillips T, Brown ER, Schwartz K, Soto-Torres LE, Govender V, Mgodi NM, Matovu Kiweewa F, Nair G, Mhlanga F, Siva S, Bekker LG, Jeenarain N, Gaffoor Z, Martinson F, Makanani B, Pather A, Naidoo L, Husnik M, Richardson BA, Parikh UM, Mellors JW, Marzinke MA, Hendrix CW, van der Straten A, Ramjee G, Chirenje ZM, Nakabiito C, Taha TE, Jones J, Mayo A, Scheckter R, Berthiaume J, Livant E, Jacobson C, Ndase P, White R, Patterson K, Germuga D, Galaska B, Bunge K, Singh D, Szydlo DW, Montgomery ET, Mensch BS, Torjesen K, Grossman CI, Chakhtoura N, Nel A, Rosenberg Z, McGowan I, Hillier S. Use of a Vaginal Ring Containing Dapivirine for HIV-1 Prevention in Women. N Engl J Med 2016; 375:2121-2132. [PMID: 26900902 PMCID: PMC4993693 DOI: 10.1056/nejmoa1506110] [Citation(s) in RCA: 578] [Impact Index Per Article: 72.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Antiretroviral medications that are used as prophylaxis can prevent acquisition of human immunodeficiency virus type 1 (HIV-1) infection. However, in clinical trials among African women, the incidence of HIV-1 infection was not reduced, probably because of low adherence. Longer-acting methods of drug delivery, such as vaginal rings, may simplify use of antiretroviral medications and provide HIV-1 protection. METHODS We conducted a phase 3, randomized, double-blind, placebo-controlled trial of a monthly vaginal ring containing dapivirine, a non-nucleoside HIV-1 reverse-transcriptase inhibitor, involving women between the ages of 18 and 45 years in Malawi, South Africa, Uganda, and Zimbabwe. RESULTS Among the 2629 women who were enrolled, 168 HIV-1 infections occurred: 71 in the dapivirine group and 97 in the placebo group (incidence, 3.3 and 4.5 per 100 person-years, respectively). The incidence of HIV-1 infection in the dapivirine group was lower by 27% (95% confidence interval [CI], 1 to 46; P=0.046) than that in the placebo group. In an analysis that excluded data from two sites that had reduced rates of retention and adherence, the incidence of HIV-1 infection in the dapivirine group was lower by 37% (95% CI, 12 to 56; P=0.007) than that in the placebo group. In a post hoc analysis, higher rates of HIV-1 protection were observed among women over the age of 21 years (56%; 95% CI, 31 to 71; P<0.001) but not among those 21 years of age or younger (-27%; 95% CI, -133 to 31; P=0.45), a difference that was correlated with reduced adherence. The rates of adverse medical events and antiretroviral resistance among women who acquired HIV-1 infection were similar in the two groups. CONCLUSIONS A monthly vaginal ring containing dapivirine reduced the risk of HIV-1 infection among African women, with increased efficacy in subgroups with evidence of increased adherence. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01617096 .).
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Jones DL, Cook R, Potter JE, Miron-Shatz T, Chakhtoura N, Spence A, Byrne MM. Fertility Desires among Women Living with HIV. PLoS One 2016; 11:e0160190. [PMID: 27610626 PMCID: PMC5017599 DOI: 10.1371/journal.pone.0160190] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 07/14/2016] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Rates of pregnancy among women living with HIV (WLHIV) have increased with the availability of effective HIV treatment. Planning for pregnancy and childbirth is an increasingly important element of HIV care. Though rates of unintended pregnancies are high among women in general, among couples affected by HIV, significant planning and reproductive decisions must be considered to prevent negative health consequences for WLHIV and their neonates. To gain insight into this reproductive decision-making process among WLHIV, this study explored women's knowledge, attitudes and practices regarding fertility planning, reproductive desires, and safer conception practices. It was hypothesized that pregnancy desires would be influenced by partners, families, the potential risk of HIV transmission to infants, and physicians' recommendations. METHODS WLHIV of childbearing age were recruited from urban South Florida, and completed an assessment of demographics (N = 49), fertility desires and a conjoint survey of factors associated with reproductive decision-making. RESULTS Using conjoint analysis, we found that different decision paths exist for different types of women: Younger women and those with less education desired children if their partners wanted children; reproductive desires among those with less education, and with less HIV pregnancy-related knowledge, displayed a trend toward additional emphasis on their family's desires. Conversely, older women and those with more education appeared to place more importance on physician endorsement in their plans for childbearing. CONCLUSIONS Results of this study highlight the importance of ongoing preconception counselling for all women of reproductive age during routine HIV care. Counselling should be tailored to patient characteristics, and physicians should consider inclusion of families and/or partners in the process.
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Mulligan N, Schalkwijk S, Best BM, Colbers A, Wang J, Capparelli EV, Moltó J, Stek AM, Taylor G, Smith E, Hidalgo Tenorio C, Chakhtoura N, van Kasteren M, Fletcher CV, Mirochnick M, Burger D. Etravirine Pharmacokinetics in HIV-Infected Pregnant Women. Front Pharmacol 2016; 7:239. [PMID: 27540363 PMCID: PMC4972814 DOI: 10.3389/fphar.2016.00239] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 07/21/2016] [Indexed: 01/05/2023] Open
Abstract
Background: The study goal was to describe etravirine pharmacokinetics during pregnancy and postpartum in HIV-infected women. Methods: IMPAACT P1026s and PANNA are on-going, non-randomized, open-label, parallel-group, multi-center phase-IV prospective studies in HIV-infected pregnant women. Intensive steady-state 12-h pharmacokinetic profiles were performed from 2nd trimester through postpartum. Etravirine was measured at two labs using validated ultra performance liquid chromatography (detection limits: 0.020 and 0.026 mcg/mL). Results: Fifteen women took etravirine 200 mg twice-daily. Etravirine AUC0–12 was higher in the 3rd trimester compared to paired postpartum data by 34% (median 8.3 vs. 5.3 mcg*h/mL, p = 0.068). Etravirine apparent oral clearance was significantly lower in the 3rd trimester of pregnancy compared to paired postpartum data by 52% (median 24 vs. 38 L/h, p = 0.025). The median ratio of cord blood to maternal plasma concentration at delivery was 0.52 (range: 0.19–4.25) and no perinatal transmission occurred. Conclusion: Etravirine apparent oral clearance is reduced and exposure increased during the third trimester of pregnancy. Based on prior dose-ranging and safety data, no dose adjustment is necessary for maternal health but the effects of etravirine in utero are unknown. Maternal health and infant outcomes should be closely monitored until further infant safety data are available. Clinical Trial registration: The IMPAACT protocol P1026s and PANNA study are registered at ClinicalTrials.gov under NCT00042289 and NCT00825929.
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Tran AH, Best BM, Stek A, Wang J, Capparelli EV, Burchett SK, Kreitchmann R, Rungruengthanakit K, George K, Cressey TR, Chakhtoura N, Smith E, Shapiro DE, Mirochnick M. Pharmacokinetics of Rilpivirine in HIV-Infected Pregnant Women. J Acquir Immune Defic Syndr 2016; 72:289-96. [PMID: 26918544 PMCID: PMC4911231 DOI: 10.1097/qai.0000000000000968] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Rilpivirine pharmacokinetics is defined by its absorption, distribution, metabolism, and excretion. Pregnancy can affect these factors by changes in cardiac output, protein binding, volume of distribution, and cytochrome P450 (CYP) 3A4 activity. Rilpivirine is metabolized by CYP3A4. The impact of pregnancy on rilpivirine pharmacokinetics is largely unknown. METHODS International Maternal Pediatric Adolescent AIDS Clinical Trials P1026s is a multicenter, nonblinded, prospective study evaluating antiretroviral pharmacokinetics in HIV-infected pregnant women that included a cohort receiving rilpivirine 25 mg once daily as part of their combination antiretrovirals for clinical care. Thirty-two women were enrolled in this study. Intensive pharmacokinetic sampling was performed at steady state during the second trimester, the third trimester, and postpartum. Maternal and umbilical cord blood samples were obtained at delivery. Plasma rilpivirine concentration was measured using liquid chromatography-mass spectrometry; lower limit of quantitation was 10 ng/mL. RESULTS Median (range) AUC0-24 were 1969 (867-4987, n = 15), 1669 (556-4312, n = 28), and 2387 (188-6736, n = 28) ng·h/mL in the second trimester, the third trimester, and postpartum, respectively (P < 0.05 for either trimester vs postpartum). Median (range) C24 were 63 (37-225, n = 17), 56 (<10-181, n = 30), and 81 (<10-299, n = 28) ng/mL (P < 0.05 for either trimester vs postpartum). High variability in pharmacokinetic parameters was observed between subjects. Median (range) cord blood/maternal concentration ratio was 0.55 (0.3-0.8, n = 21). Delivery HIV-1 RNA was ≤50 copies per milliliter in 70% and ≤400 copies per milliliter in 90% of women. Cmin were significantly lower at 15 visits with detectable HIV-1 RNA compared with 61 visits with undetectable HIV-1 RNA, 29 (<10-93) vs 63 (15-200) ng/mL (P = 0.0001). Cmin was below the protein binding-adjusted EC90 concentration (12.2 ng/mL) at 4 visits in 3 of 31 women (10%). CONCLUSIONS Rilpivirine exposure is lower during pregnancy compared with postpartum and highly variable. Ninety percent of women had minimum concentrations above the protein binding-adjusted EC90 for rilpivirine.
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Coll AS, Potter JE, Chakhtoura N, Alcaide ML, Cook R, Jones DL. Providers' perspectives on preconception counseling and safer conception for HIV-infected women. AIDS Care 2015; 28:513-8. [PMID: 26577664 PMCID: PMC4764433 DOI: 10.1080/09540121.2015.1112349] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Unplanned pregnancy among HIV-infected women can have negative health consequences for women, partners, and neonates. Despite recommendations, preconception counseling (PCC) appears to be infrequently addressed in HIV care. This study explored knowledge, attitudes, and practices among health-care providers regarding PCC, safer conception and pregnancy among HIV-infected women. METHODS Physicians, physician assistants, and nurse practitioners (n = 14) providing obstetric/gynecological and HIV care in urban south Florida public and private hospitals completed structured qualitative interviews. Dominant themes arising included provider perceptions of patient knowledge and practices, provider knowledge and attitudes regarding safer conception, and provider practices regarding reproductive health. RESULTS Providers perceived patients to have limited reproductive knowledge. Patients' internalized HIV stigma was a barrier to patient initiation of conception-focused discussions. Provider knowledge and utilization of PCC protocols were limited. PCC barriers included competing medical priorities, failure to address fertility desires, limited knowledge, time limitations, and unclear standard of care. Providers routinely used condom-based HIV prevention as a proxy for addressing reproductive intentions. DISCUSSION Provider, patient, and structural factors prevented implementation of PCC and provision of information on safer conception; neither were routinely discussed during consultations. Both providers and patients may benefit from interventions to enhance communication on conception.
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Einstein MH, Takacs P, Chatterjee A, Sperling RS, Chakhtoura N, Blatter MM, Lalezari J, David MP, Lin L, Struyf F, Dubin G. Comparison of long-term immunogenicity and safety of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine and HPV-6/11/16/18 vaccine in healthy women aged 18-45 years: end-of-study analysis of a Phase III randomized trial. Hum Vaccin Immunother 2015; 10:3435-45. [PMID: 25483701 PMCID: PMC4514070 DOI: 10.4161/hv.36121] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The observer-blind, randomized, age-stratified, head-to-head study (NCT00423046) comparing immunogenicity and safety of HPV-16/18 and HPV-6/11/16/18 vaccines in healthy women aged 18-45 y was completed. Five y after vaccination, in subjects from the Month 60 according-to-protocol cohort (seronegative and DNA negative for HPV type analyzed at baseline), serum neutralizing antibody (nAb) responses induced by HPV-16/18 vaccine remained 7.8-fold (18-26-y stratum), 5.6-fold (27-35-y stratum) and 2.3-fold (36-45-y stratum) higher than those induced by HPV-6/11/16/18 vaccine for HPV-16. For HPV-18, the fold differences were 12.1, 13.0 and 7.8, respectively. At Month 60, all (100%) subjects in HPV-16/18 vaccine group and the majority (95.7%-97.5%) in HPV-6/11/16/18 vaccine group were seropositive for HPV-16. For HPV-18, the majority (98.1%-100%) of subjects in HPV-16/18 vaccine group were seropositive; however, seropositivity rates in HPV-6/11/16/18 vaccine group decreased considerably (61.1%-76.9%) across the 3 age strata. In the total vaccinated cohort (received ≥1 dose regardless of baseline HPV serostatus and DNA status), geometric mean titers for anti-HPV-16 and anti-HPV-18 nAb were higher in HPV-16/18 vaccine group than in HPV-6/11/16/18 vaccine group. Based on the 5-y data, piece-wise and modified power-law models predicted a longer durability of nAb response for HPV-16/18 vaccine compared to HPV-6/11/16/18 vaccine. Beyond the differences apparent between the vaccines in terms of immunogenicity and modeled persistence of antibody responses, comparative studies including clinical endpoints would be needed to determine whether differences exist in duration of vaccine-induced protection.
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Key Words
- 50 μg) adsorbed on aluminum salt (500 μg Al3+)
- AAHS, amorphous aluminum hydroxyphosphate sulfate
- ANOVA, analysis of variance
- AS04, Adjuvant System containing 3-O-desacyl-4’-monophosphoryl lipid A (MPL
- ATP, according-to-protocol
- CI, confidence interval
- Cervarix®
- ED50, effective dose producing 50% response
- ELISA, enzyme-linked immunosorbent assay
- GMT, geometric mean titer
- Gardasil®
- HPV, human papillomavirus
- MSC, medically significant condition
- NOAD, new onset autoimmune disease
- NOCD, new onset chronic disease
- PBNA, pseudovirion-based neutralization assay
- SAE, serious adverse event
- SP, seropositivity
- TVC, total vaccinated cohort
- antibodies
- human papillomavirus
- immunogenicity
- models
- nAb, neutralizing antibodies
- neutralizing
- safety
- statistical
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Einstein MH, Levin MJ, Chatterjee A, Chakhtoura N, Takacs P, Catteau G, Dessy FJ, Moris P, Lin L, Struyf F, Dubin G. Comparative humoral and cellular immunogenicity and safety of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine and HPV-6/11/16/18 vaccine in healthy women aged 18-45 years: follow-up through Month 48 in a Phase III randomized study. Hum Vaccin Immunother 2015; 10:3455-65. [PMID: 25483700 PMCID: PMC4514093 DOI: 10.4161/hv.36117] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
We previously reported higher anti-HPV-16 and -18 immune responses induced by HPV-16/18 vaccine compared with HPV-6/11/16/18 vaccine at Month 7 (one month after completion of full vaccination series) in women aged 18–45 y in an observer-blind study NCT00423046; the differences of immune response magnitudes were maintained up to Month 24. Here we report follow-up data through Month 48. At Month 48, in according-to-protocol cohort for immunogenicity (seronegative and DNA-negative for HPV type analyzed at baseline), geometric mean titers of serum neutralizing antibodies were 2.0- to 5.2-fold higher (HPV-16) and 8.6- to 12.8-fold higher (HPV-18) in HPV-16/18 vaccine group than in HPV-6/11/16/18 vaccine group. The majority of women in both vaccine groups remained seropositive for HPV-16. The same trend was observed for HPV-18 in HPV-16/18 vaccine group; however, seropositivity rates in HPV-6/11/16/18 vaccine group decreased considerably, particularly in the older age groups. In the total vaccinated cohort (regardless of baseline serological and HPV-DNA status), anti-HPV-16 and -18 neutralizing antibody levels induced by HPV-16/18 vaccine were higher than those induced by HPV-6/11/16/18 vaccine. CD4+ T-cell response for HPV-16 and HPV-18 was higher in HPV-16/18 vaccine group than in HPV-6/11/16/18 vaccine group. Memory B-cell responses appeared similar between vaccine groups. Both vaccines were generally well tolerated. Overall, the higher immune response observed with the HPV-16/18 vaccine was maintained up to Month 48. A head-to-head study incorporating clinical endpoints would be required to confirm whether the observed differences in immune response between the vaccines influence the duration of protection they provided.
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Key Words
- 50 μg) adsorbed on aluminum salt (500 μg Al(OH)3)
- ANOVA, analysis of variance
- AS04, Adjuvant System containing 3-O-desacyl-4’-monophosphoryl lipid A (MPL
- ATP, according-to-protocol
- CI, confidence interval
- CMI, cell-mediated immune
- CVS, cervicovaginal secretion
- Cervarix®
- ED50, effective dose producing 50% response
- ELISA, enzyme-linked immunosorbent assay
- GM, geometric mean
- GMR, geometric mean (titer) ratio
- GMT, geometric mean titer
- Gardasil®
- HPA, Health Protection Agency
- HPV, human papillomavirus
- IgG, immunoglobulin G
- MSC, medically significant condition
- NOAD, new onset autoimmune disease
- NOCD, new onset chronic disease
- PBMC, peripheral blood mononuclear cells
- PBNA, pseudovirion-based neutralization assay
- SAE, serious adverse event
- TVC, total vaccinated cohort
- VLP, virus-like particle
- human papillomavirus
- immunogenicity
- nAb(s), neutralizing antibody(ies)
- safety
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Crespo FA, Ganesh D, Lo K, Chin K, Norris P, Chakhtoura N. Surgical, Ultrasound Guided Drainage, and Medical Management of Tuboovarian Abscesses. ISRN INFECTIOUS DISEASES 2014; 2014:501729. [PMID: 33564491 PMCID: PMC7869844 DOI: 10.1155/2014/501729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare surgical, ultrasound guided drainage, and medical management of tuboovarian abscesses (TOA) and determine if different characteristics in patient presentation influence treatment and outcome. METHODS Retrospective cohort study of 158 patients admitted to Jackson Memorial Hospital between 2007 and 2012 with a TOA. RESULTS Patients treated with IV antibiotics (IV) alone were hospitalized for 5.59 days (SD 2.52), IV antibiotics and US guided drainage (IV/US) were hospitalized for 9.63 days (SD 7.58), and IV antibiotics and surgery (IV/surgery) were hospitalized for 8.14 days ((SD3.9), (P < 0.001)). A total of 52 patients were readmitted with TOA; 41.8% were treated with IV; 26.9% were readmitted with IV/US; 7.1% were readmitted with IV/surgery (P < 0.022). Patients with a TOA measuring 0-8 cm were hospitalized for 5.97 days (SD 4.24), while those greater than 8 cm were hospitalized for 7.71 days ((SD 4.69), (P < 0.029)). Patients treated with a triple antibiotic regimen were hospitalized for 8.42 days (SD 5.70) versus 5.8 days (SD 3.24) when receiving an alternative regimen (P < 0.002). CONCLUSIONS Longer hospitalization in patients treated uniformly with either triple antibiotics, ultrasound guided drainage, or surgery represents a delay in optimal treatment. Tailoring treatment plans based on patient presentation may allow for shorter hospital stays and improved morbidity.
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Villar-Loubet OM, Cook R, Chakhtoura N, Peltzer K, Weiss SM, Shikwane ME, Jones DL. HIV knowledge and sexual risk behavior among pregnant couples in South Africa: the PartnerPlus project. AIDS Behav 2013; 17:479-87. [PMID: 23161209 PMCID: PMC4724214 DOI: 10.1007/s10461-012-0360-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In sub-Saharan Africa, 60 % of people living with HIV are women and most are of childbearing age. Alarmingly, seroconversion rates during pregnancy are high and increase as pregnancy progresses, highlighting the importance of increasing HIV-knowledge among pregnant women and their partners. This study compared sexual risk behavior, HIV knowledge and condom use pre- to post-partum among South African couples (n = 239 couples) randomly assigned to an intervention or an enhanced standard of care with the PMTCT protocol at rural community health antenatal clinics. Consistent condom use and HIV-related knowledge increased baseline to post-intervention and was maintained at long term follow up post-partum among participants in the intervention condition. HIV knowledge mediated the relationship between the intervention and consistent condom use. Results from this pilot study provide support for the integration of HIV risk reduction interventions for both women and men into existing PMTCT services during and following pregnancy.
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Chakhtoura N, Zhang Y, Candiotti K, Medina CA, Takacs P. Estrogen inhibits vaginal tropoelastin and TGF-β1 production. Int Urogynecol J 2012; 23:1791-5. [DOI: 10.1007/s00192-012-1828-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Accepted: 05/10/2012] [Indexed: 12/01/2022]
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Einstein MH, Baron M, Levin MJ, Chatterjee A, Fox B, Scholar S, Rosen J, Chakhtoura N, Meric D, Dessy FJ, Datta SK, Descamps D, Dubin G. Comparative immunogenicity and safety of human papillomavirus (HPV)-16/18 vaccine and HPV-6/11/16/18 vaccine: follow-up from months 12-24 in a Phase III randomized study of healthy women aged 18-45 years. HUMAN VACCINES 2011; 7:1343-58. [PMID: 22048173 DOI: 10.4161/hv.7.12.18281] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In this observer-blind study (NCT00423046), women (N=1,106), stratified by age (18-26, 27-35, 36-45 y), were randomized (1:1) to receive the HPV-16/18 vaccine (Cervarix®, GlaxoSmithKline Biologicals, Months 0, 1, 6) or the HPV-6/11/16/18 vaccine (Gardasil® Merck & Co., Inc., Months 0, 2, 6). Month 7 results were previously reported; we now report Month 24 results. In the according-to-protocol cohort for immunogenicity (seronegative and DNA-negative at baseline for HPV type analyzed), seropositivity rates of neutralizing antibodies (nAbs) [pseudovirion-based neutralization assay] were, across all age strata, 100% (HPV-16/18 vaccine) and 97.5-100% (HPV-6/11/16/18 vaccine) for HPV-16, and 99.0-100% (HPV-16/18 vaccine) and 72.3-84.4% (HPV-6/11/16/18 vaccine) for HPV-18. Corresponding geometric mean titers (GMTs) were 2.4-5.8-fold higher for HPV-16 and 7.7-9.4-fold higher for HPV-18 with the HPV-16/18 vaccine versus the HPV-6/11/16/18 vaccine; HPV-16 and HPV-18 GMTs were significantly higher with the HPV-16/18 vaccine than the HPV-6/11/16/18 vaccine (p< 0.0001) in the total vaccinated cohort (received ≥1 vaccine dose, irrespective of baseline sero/DNA-status). Similar results were obtained using enzyme-linked immunosorbent assay (ELISA). Positivity rates and GMTs of antigen-specific IgG antibodies in cervicovaginal secretions (ELISA) were not significantly different between vaccines. At Month 24, CD4⁺ T-cell responses for HPV-16 and HPV-18 were higher with the HPV-16/18 vaccine; memory B-cell response was higher for HPV-18 with the HPV-16/18 vaccine and similar between vaccines for HPV-16. Both vaccines were generally well tolerated. Although an immunological correlate of protection has not been defined, differences in the magnitude of immune response between vaccines may represent determinants of duration of protection.
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Einstein MH, Baron M, Levin MJ, Chatterjee A, Fox B, Scholar S, Rosen J, Chakhtoura N, Lebacq M, van der Most R, Moris P, Giannini SL, Schuind A, Datta SK, Descamps D. Comparison of the immunogenicity of the human papillomavirus (HPV)-16/18 vaccine and the HPV-6/11/16/18 vaccine for oncogenic non-vaccine types HPV-31 and HPV-45 in healthy women aged 18-45 years. HUMAN VACCINES 2011; 7:1359-73. [PMID: 22048172 PMCID: PMC3338933 DOI: 10.4161/hv.7.12.18282] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Revised: 09/27/2011] [Accepted: 10/03/2011] [Indexed: 12/24/2022]
Abstract
Protection against oncogenic non-vaccine types (cross-protection) offered by human papillomavirus (HPV) vaccines may provide a significant medical benefit. Available clinical efficacy data suggest the two licensed vaccines (HPV-16/18 vaccine, GlaxoSmithKline Biologicals (GSK), and HPV-6/11/16/18 vaccine, Merck & Co., Inc.) differ in terms of protection against oncogenic non-vaccine HPV types -31/45. The immune responses induced by the two vaccines against these two non-vaccine HPV types (cross-reactivity) was compared in an observer-blind study up to Month 24 (18 mo post-vaccination), in women HPV DNA-negative and seronegative prior to vaccination for the HPV type analyzed (HPV-010 [NCT00423046]). Geometric mean antibody titers (GMTs) measured by pseudovirion-based neutralization assay (PBNA) and enzyme-linked immunosorbent assay (ELISA) were similar between vaccines for HPV-31/45. Seropositivity rates for HPV-31 were also similar between vaccines; however, there was a trend for higher seropositivity with the HPV-16/18 vaccine (13.0-16.7%) versus the HPV-6/11/16/18 vaccine (0.0-5.0%) for HPV-45 with PBNA, but not ELISA. HPV-31/45 cross-reactive memory B-cell responses were comparable between vaccines. Circulating antigen-specific CD4+ T-cell frequencies were higher for the HPV-16/18 vaccine than the HPV-6/11/16/18 vaccine (HPV-31 [geometric mean ratio [GMR] =2.0; p=0.0002] and HPV-45 [GMR=2.6; p=0.0092]), as were the proportion of T-cell responders (HPV-31, p=0.0009; HPV-45, p=0.0793). In conclusion, immune response to oncogenic non-vaccine HPV types -31/45 was generally similar for both vaccines with the exception of T-cell response which was higher with the HPV-16/18 vaccine. Considering the differences in cross-protective efficacy between the two vaccines, the results might provide insights into the underlying mechanism(s) of protection.
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Takacs P, Zhang Y, Yavagal S, Candiotti K, Chakhtoura N, Medina CA. TGF-beta 1 is a potential regulator of vaginal tropoelastin production. Int Urogynecol J 2011; 23:357-63. [PMID: 22068323 DOI: 10.1007/s00192-011-1589-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Accepted: 10/17/2011] [Indexed: 11/25/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Our aims were to correlate transforming growth factor (TGF)-β1 and elastin mRNA expression in the vagina of women and to measure the effects of TGF-β1 on vaginal smooth muscle cell (SMC) proliferation and tropoelastin production. METHODS Vaginal walls were sampled in women (n = 20). TGF-β1 and elastin mRNA expression was assessed by RT-PCR. SMC cultures were performed from vaginal wall biopsies. SMC were incubated with TGF-β1, and cell proliferation was assessed by MTT-assay. Tropoelastin production was measured by the Fastin Elastin Assay. RESULTS There was a significant positive correlation between TGF-β1 and elastin mRNA (r = 0.784, P < 0.01). SMC proliferation was significantly increased by 10 ng/mL TGF-β1 [relative cell number, mean ± SD, 198% ± 32% of control (P = 0.01)]. Tropoelastin production was significantly increased by TGF-β1 [mean ± SD, 645% ± 180% of control (P = 0.01)]. CONCLUSIONS There is a positive correlation between TGF-β1 and elastin mRNA expression in the vaginal wall. In vitro, TGF-β1 increases vaginal tropoelastin production in vaginal SMC.
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Barnhart K, Hummel AC, Sammel MD, Menon S, Jain J, Chakhtoura N. Use of “2-dose” regimen of methotrexate to treat ectopic pregnancy. Fertil Steril 2007; 87:250-6. [PMID: 17097649 DOI: 10.1016/j.fertnstert.2006.06.054] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2006] [Revised: 06/24/2006] [Accepted: 06/24/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the safety and acceptability of a novel dosing regimen of methotrexate to treat ectopic pregnancy. DESIGN Prospective study. SETTING Three academic medical centers. PATIENT(S) One hundred one patients with ectopic pregnancy who elected to have medical therapy. INTERVENTION(S) Intramuscular methotrexate 50 mg/m(2) was administered on days 0 and 4; additional doses of methotrexate were given on day 7 and/or day 11 if hCG levels did not decrease by 15% during the follow-up period. MAIN OUTCOME MEASURE(S) Adverse events, acceptability, and resolution of pregnancy without surgical treatment. RESULT(S) With this protocol, 87% of patients were treated successfully. Of those protocols that were considered failures, only 3% of patients experienced rupture of ectopic pregnancy. Treatment was well-tolerated; most side effects were reported as mild and transient. Ninety-one percent of the 61.5% of patients who responded to the satisfaction questionnaire reported satisfaction with this regimen. CONCLUSION(S) This "2-dose" protocol minimizes the number of injections and surveillance visits, compared with the "multiple dose" regimen, and methotrexate is administered more frequently than with the "single dose" regimen. The protocol may optimize the balance between convenience and efficacy. In a limited number of women, no safety concerns were noted with up to 4 doses of methotrexate in a 2-week period without leucovorin rescue.
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DeSantis T, Chakhtoura N, Twiggs L, Ferris D, Lashgari M, Flowers L, Faupel M, Bambot S, Raab S, Wilkinson E. Spectroscopic Imaging as a Triage Test for Cervical Disease. J Low Genit Tract Dis 2007; 11:18-24. [PMID: 17194946 DOI: 10.1097/01.lgt.0000230207.50495.05] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of the study was to evaluate the potential safety and effectiveness of tissue spectroscopy for the diagnosis of cervical cancer in a prospective multicenter study of women scheduled for colposcopy on the basis of an abnormal Pap test or other risk factor. MATERIALS AND METHODS Five hundred seventy-two women underwent spectroscopy of the cervix during their colposcopy visit. Spectroscopy measurements taken over a scan period of 4 minutes and 30 seconds were integrated by a cross-validated pattern recognition model and compared with biopsy results to yield sensitivity and specificity of cervical spectroscopy. RESULTS The median age of subjects enrolled in the study was 27.7 years. The sensitivity of cervical spectroscopy was 95.1% with a corresponding 55.2% specificity for benign lesions. Several potential confounding factors (eg, mucous, blood, patient motion, ambient light) were examined to determine their potential impact on the accuracy of the test. Ambient light seemed to have the greatest effect, but no single factor contributed significantly to the results. The subjects did not experience any adverse events from undergoing the test. CONCLUSIONS Spectroscopy of the cervix has the potential to accurately detect cervical moderate and high-grade dysplasia while also reducing the false-positive rate for benign cervices. The test is relatively simple to implement and was well accepted by subjects enrolled in the study.
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Takacs P, Chakhtoura N. Laparotomy to laparoscopy: changing trends in the surgical management of ectopic pregnancy in a tertiary care teaching hospital. J Minim Invasive Gynecol 2006; 13:175-7. [PMID: 16698520 DOI: 10.1016/j.jmig.2006.01.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2005] [Revised: 01/10/2006] [Accepted: 01/15/2006] [Indexed: 02/01/2023]
Abstract
STUDY OBJECTIVE To review the changing trends in the surgical management of ectopic pregnancy and to evaluate the effect of an ongoing training program for resident surgeons on the rate and success of laparoscopic surgery. DESIGN Retrospective chart review (Canadian Task Force classification II-3). SETTING University tertiary medical center. PATIENTS One thousand forty-six patients with ectopic pregnancy treated at Jackson Memorial Hospital from January 1, 1995, through December 31, 2004. INTERVENTION A formal, ongoing laparoscopic training program was established in 1999. MEASUREMENTS The rate of laparoscopy, laparotomy, and conversion for each year was compared with the baseline year of 1995 and between the years before and after the establishment of the training program. RESULTS Four hundred sixty-eight laparotomies and 578 laparoscopies were successfully completed. The laparoscopic approach rate has increased from 40.9% in 1995 to 86.3% in 2004. By year 2000 and thereafter, significantly more ectopic surgeries were approached through the laparoscope compared with in 1995 (p<.01). By 2000 and thereafter, significantly less conversions occurred compared with the baseline year of 1995 (4.0% vs 18.5%; p = .01). CONCLUSION Laparoscopy became the primary approach for the management of ectopic pregnancy in part because of resident participation in an ongoing laparoscopy training program.
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Takacs P, Chakhtoura N, De Santis T, Verma U. Evaluation of the relationship between endometrial thickness and failure of single-dose methotrexate in ectopic pregnancy. Arch Gynecol Obstet 2005; 272:269-72. [PMID: 16001188 DOI: 10.1007/s00404-005-0009-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2004] [Accepted: 02/09/2005] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To test the hypothesis that endometrial stripe thicker than 12 mm increases treatment failure of single-dose methotrexate for the management of ectopic pregnancy. STUDY DESIGN Seventy-three patients with ectopic pregnancy and measured pretreatment endometrial stripe were divided into two groups based on the endometrial stripe thickness (> 12 mm or < or = 12 mm). All patients were candidates for single-dose methotrexate treatment. Variables analyzed between the two groups were endometrial stripe thickness, initial beta human chorionic gonadotropin level (hCG), size of the ectopic mass, presence of fetal heart tones, previous ectopic pregnancy, and clinical outcomes. RESULTS Sixty patients had endometrial stripe thickness < or = 12 mm and 13 patients > 12 mm. The two groups were similar in initial hCG, size of ectopic mass, presence of fetal heart tones and rate of previous ectopic pregnancy. The failure rate was significantly higher in the group with endometrial stripe > 12 mm compared to the group < or = 12 mm (n=7, 53% vs. n=3, 5%, P<0.01). The endometrial stripe was significantly thicker in the group with endometrial stripe thickness > 12 mm compared to the group < or = 12 mm (mean +/- SD, 17.64+/-5.82 mm vs. 7.69+/-2.82 mm, P<0.01). CONCLUSION Endometrial stripe thicker than 12 mm increases the risk for treatment failure with single-dose methotrexate.
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Takacs P, Chakhtoura N. 88. J Minim Invasive Gynecol 2005. [DOI: 10.1016/j.jmig.2005.07.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Barnhart K, Sammel M, Hummel A, Jain J, Chakhtoura N, Strauss J. A Novel “Two Dose” Regimen of Methotrexate to Treat Ectopic Pregnancy. Fertil Steril 2005. [DOI: 10.1016/j.fertnstert.2005.07.319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Takacs P, Latchaw G, Gaitan L, Chakhtoura N, De Santis T. Risk factors for conversion to laparotomy during laparoscopic management of an ectopic pregnancy. Arch Gynecol Obstet 2005; 273:32-4. [PMID: 15991011 DOI: 10.1007/s00404-005-0008-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2004] [Accepted: 02/09/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To identify risk factors for conversion to laparotomy during laparoscopic management of ectopic pregnancy. METHODS A retrospective chart review of patients who underwent laparoscopy for treatment of ectopic pregnancy, during a 32-month period (6/1999-2/2002), at the University of Miami Jackson Memorial Hospital. We identified 229 patients; 201 had a successful laparoscopy (non-converted group) and 28 who were converted to laparotomy (converted group). Variables analyzed between the two groups were demographic data, patient-related risk factors available to the surgeon prior to the surgery (previous laparotomy, previous laparoscopy, history of PID, history of endometriosis, diameter of ectopic pregnancy as measured by ultrasound, amount of free fluid on ultrasound, BMI), and surgeons' experience. RESULTS Out of the 229 laparoscopies, 28 were converted to laparotomy (12.2%). The rate of conversion was significantly higher for less experienced compared to experienced surgeon (OR = 6.1, 95% CI = 2.35-15.88). Significantly more women had a BMI > 30 kg/m2 in the converted group compared to the non-converted group (42% vs. 14%; OR = 4.28, 95% CI = 1.7-10.75) and the converted group had significantly higher rate of large free fluid reported on ultrasound compared to the non-converted group (21.42% vs. 7.46%; OR = 3.38, 95% CI = 1.04-10.61). CONCLUSION Less experienced surgeon, BMI > 30 kg/m2, and large amount of free fluid on ultrasound increase the risk of conversion to laparotomy during laparoscopic management of ectopic pregnancy.
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