Drug-Drug Interactions between Antiretrovirals and Hormonal Contraception: An Updated Systematic Review

OBJECTIVE

To summarize and update information regarding drug-drug interactions (DDIs) between antiretrovirals (ARVs) and hormonal contraceptives (HCs).

DESIGN

Systematic review METHODS: We searched seven databases for peer-reviewed publications from January 1, 2015, through December 31, 2023, including studies of women using ARVs and HCs concurrently with outcomes including therapeutic effectiveness or toxicity, pharmacokinetics (PK), or pharmacodynamics. We summarized findings and used checklists to assess evidence quality.

RESULTS

We included 49 articles, with clinical, ARV or HC PK outcomes reported by 39, 25, and 30 articles, respectively, with some articles reporting outcomes in two or more categories. Fifteen of 18 articles assessing DDIs between efavirenz and progestin implants, emergency contraception, or combined hormonal intravaginal rings found higher pregnancy rates, luteal progesterone levels suggesting ovulation, or reduced progestin PK values. Five studies documented that CYP2B6 single nucleotide polymorphisms exacerbated this DDI. One cohort detected doubled bone density loss with concomitant depot medroxyprogesterone acetate (DMPA) and tenofovir disoproxil fumarate (TDF)-containing ART use versus TDF alone. No other studies described DDIs impacting clinical outcomes. Few adverse events were attributed to ARV-HC use with none exceeding Grade 2. Evidence quality was generally moderate, with dis-similar treatment and control groups, identifying and controlling for confounding, and minimizing attrition bias in the study design being the most frequent limitations.

CONCLUSION

Most ARVs and HCs may be used safely and effectively together. TDF-DMPA DDIs warrant longer-term study on bone health and consideration of alternate combinations. For efavirenz-based ART, client counselling on relative risks, including both potential increase in pregnancy rate with concomitant efavirenz and implant use and lower pregnancy rates compared to other HCs even with concomitant efavirenz use, should continue to allow users comprehensive method choice.

Use of Expedited Partner Therapy for Pregnant Women Treated for Sexually Transmitted Infections in Gaborone, Botswana

BACKGROUND

Partner notification and treatment for sexually transmitted infections are critical to prevent reinfection and reduce transmission. However, partner treatment rates are low globally. Expedited partner therapy (EPT), in which the patient delivers treatment directly to their partner, may result in more partners treated. We assessed partner notification and treatment outcomes among pregnant women in Gaborone, Botswana, including EPT intent, uptake, and effectiveness.

METHODS

The Maduo study was a cluster-controlled trial evaluating the effect of antenatal Chlamydia trachomatis and Neisseria gonorrhoeae infection screening in pregnant women. The intervention arm received screening at first antenatal care (ANC), third-trimester, and postnatal care visits. The standard-of-care arm received screening postnatally. Participants screening positive were given options for partner treatment: contact slips, in-clinic treatment, or EPT. Self-reported partner notification and treatment outcomes were assessed at test-of-cure visit.

RESULTS

Of 51 women who screened positive for C. trachomatis / N. gonorrhoeae at first ANC and returned for test of cure, 100% reported notifying their partner and 48 (94.1%) reported their partner received treatment. At third trimester 100% (n = 5), reported partners were treated. Before testing, EPT intent was lower than EPT uptake at all time points (first ANC: 17.9% vs. 80.4%; third-trimester: 57.1% vs. 71.4%; postnatal care: 0% vs. 80.0%). Partner treatment success was 100% among EPT users compared with 70% among nonusers ( P = 0.006).

CONCLUSIONS

Partner notification and treatment success was high in this population. Despite low pretest intent to use EPT, uptake was high and associated with greater partner treatment success. Our findings suggest that EPT may be a successful partner treatment strategy to pursue in low- and middle-income countries.

Syphilis Prevalence Among People Living With and Without HIV in Sub-Saharan Africa: A Systematic Review and Meta-Analysis

BACKGROUND

Syphilis is a curable sexually transmitted infection that, untreated, is associated with significant morbidity and mortality. In people living with HIV (PLWH), syphilis carries greater risks of disease progression. We estimated syphilis prevalence among PLWH in the general population in sub-Saharan Africa and compared the prevalence among PLWH and without HIV.

METHODS

We searched for studies published January 1, 2011, to March 28, 2022, reporting syphilis prevalence among PLWH in sub-Saharan Africa (PROSPERO No. CRD42020167328). We excluded studies in high-risk subpopulations. We estimated pooled syphilis prevalence among PLWH using random-effects modeling and compared the prevalence with people without HIV when included in the same study. We examined influences of region, study setting, and test type in subgroup analyses.

RESULTS

We identified 926 studies; 53 were included in the meta-analysis. Pooled syphilis prevalence among PLWH was 7.3% (95% confidence interval [CI], 6.3%-8.5%). Prevalence differed by region: 3.1% (95% CI, 2.2%-4.0%) in Southern, 5.5% (95% CI, 2.3%-9.3%) in West/Central, and 10.5% (95% CI, 8.0%-13.1%) in Eastern Africa. Prevalence also differed by study setting: 13.8% (95% CI, 5.7%-23.0%) in sexual and reproductive health/sexually transmitted infection care, 8.7% (95% CI, 5.0%-12.8%) in HIV care, 7.1% (95% CI, 5.8%-8.5%) in antenatal care, and 3.8% (95% CI, 2.0%-5.8%) in household/community-based settings. Syphilis prevalence was higher among PLWH than without HIV (relative risk, 3.5; 95% CI, 2.8-4.5).

CONCLUSIONS

Syphilis is highly prevalent among PLWH in sub-Saharan Africa and is more common among PLWH than without HIV. Integration of syphilis screening and management into HIV care may reduce complications of HIV-syphilis coinfection among PLWH in sub-Saharan Africa.

Case series and literature review of chlamydial ophthalmia neonatorum in Botswana

BACKGROUND

We describe 12 cases of chlamydial ophthalmia neonatorum and the current scientific evidence on its prevention and treatment. The data presented were obtained from the "Maduo" study, a prospective observational study of the relationship between curable sexually transmitted infections and adverse neonatal outcomes at four antenatal clinics in Gaborone, Botswana.

METHODS

Infants of mothers with perinatal chlamydia infection were evaluated for chlamydial ophthalmia neonatorum based on clinical presentation of conjunctivitis or positive test via GeneXpert CT/NG assay. Data on 29 infants born to mothers with postnatal C. trachomatis infection were analysed.

RESULTS

12 infants were diagnosed with chlamydial ophthalmia neonatorum. Eight of those cases were confirmed with the GeneXpert CT/NG assay while four were identified as probable cases based on clinical history and presentation. Overall, nine infants presented with signs of conjunctivitis, while three who had a positive diagnostic test result had asymptomatic infection. All but one infant had received ocular 1% tetracycline prophylaxis at birth, and four infants had signs suggestive of chlamydial pneumonia at presentation. Two out of five symptomatic cases whose mothers reported completion of their treatment course with erythromycin had lingering symptoms.

CONCLUSIONS

Our findings affirm that the current prophylaxis and treatment modalities for chlamydial ophthalmia neonatorum are inadequate. To the extent feasible in low- and middle-income countries, we recommend implementation of routine C. trachomatis screening and treatment in pregnant women.

Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae infection and associated factors among asymptomatic pregnant women in Botswana

BACKGROUND

Chlamydia trachomatis (C. trachomatis) and Neisseria gonorrhoeae (N. gonorrhoeae) are curable sexually transmitted infections (STIs) that cause adverse pregnancy and neonatal outcomes. Most countries, including Botswana, do not offer C. trachomatis or N. gonorrhoeae screening during antenatal care (ANC) and instead use a syndromic approach for management of STIs.

METHODS

The Maduo Study is a prospective, cluster-controlled trial in Botswana evaluating the impact of diagnostic screening for antenatal C. trachomatis and N. gonorrhoeae infections to prevent adverse neonatal outcomes. Using baseline data from the Maduo Study (March 2021-March 2022), we determined the prevalence of C. trachomatis and N. gonorrhoeae infection among asymptomatic pregnant women in Botswana and correlates of infection using multivariable logistic regression.

RESULTS

Of 251 women who underwent C. trachomatis and N. gonorrhoeae screening at first ANC visit, 55 (21.9%, 95%CI 17.0-27.5) tested positive for C. trachomatis, 1 (0.4%, 95%CI 0-2.2) for N. gonorrhoeae; and 2 (0.8%, 95%CI 0-2.8) for dual C. trachomatis and N. gonorrhoeae infection. Older age was associated with lower odds (aOR 0.93; 95%CI 0.88-0.98; p = 0.011) while any alcohol use during pregnancy was associated with higher odds (aOR = 3.53; 95%CI 1.22-10.16; p = 0.020) of testing positive for C. trachomatis or N. gonorrhoeae.

CONCLUSIONS

A high frequency of C. trachomatis infections was detected among asymptomatic pregnant women in Botswana indicating that many antenatal STIs are missed by the syndromic management approach. Our results highlight the need for diagnostic C. trachomatis screening during ANC in Botswana and other low- and middle-income countries that rely solely on the syndromic approach for management of STIs.

Measuring the impact of COVID-19 social distancing measures on sexual health behaviours and access to HIV and sexual and reproductive health services for people living with HIV in Botswana

Introduction

Uninterrupted access to HIV and sexual and reproductive health (SRH) services is essential, particularly in high HIV prevalence settings, to prevent unintended pregnancy and vertical HIV transmission. Understanding the challenges that COVID-19 and associated social distancing measures (SDMs) posed on health service access is imperative for future planning.

Methods

This cross-sectional study was conducted in Botswana between January-February 2021. A web-based questionnaire was disseminated on social media as part of the International Sexual Health and REproductive Health (I-SHARE) Survey. Respondents answered questions on SRH, before and during COVID-19 SDMs. Subgroup analysis and comparison of descriptive data was performed for people living with HIV (PLWH).

Results

Of 409 participants, 65 were PLWH (80% female, 20% male). During SDMs, PLWH found it more difficult to access condoms and treatment for HIV and STIs; attend HIV appointments; and maintain adherence to antiretroviral therapy. Compared to HIV-negative women, a higher proportion of women living with HIV used condoms as their primary method of contraception (54% vs. 48%), and had lower use of long-acting reversible contraception (8% vs. 14%) and dual contraception (8% vs. 16%).

Discussion

Mirroring global trends, COVID-19 disrupted HIV and SRH service access in Botswana. However, in high HIV-prevalence settings, disruption may more severely impact population health with disproportionate effects on women. Integration of HIV and SRH services could build health system capacity and resilience, reduce missed opportunities for delivering SRH services to PLWH and limit the consequences of future restrictions that may cause health system disruption.

High Cure Rate Among Pregnant Women in a Chlamydia trachomatis and Neisseria gonorrhoeae Testing and Treatment Intervention Study in Gaborone, Botswana

A high cure rate was observed after testing and treatment of Chlamydia trachomatis and Neisseria gonorrhoeae infection among pregnant women in a nonrandomized cluster trial in Gaborone, Botswana.

Between March 2021 and March 2022, 251 pregnant women were tested for Chlamydia trachomatis and Neisseria gonorrhoeae infection in Botswana. Fifty-eight (23%) tested positive for at least 1 infection, and 57 (98%) were treated. No participants tested positive at test of cure. In some settings, cost of test of cure may outweigh the benefits.

Incident HIV acquisition among pregnant women in Botswana: findings from the Tsepamo birth outcomes surveillance study

INTRODUCTION

In Botswana, where almost all pregnant women known to have HIV receive antiretroviral therapy, a large proportion of vertical HIV transmission may occur among women with incident undiagnosed HIV infection during pregnancy. Botswana guidelines recommend repeat HIV testing every 3 months in pregnancy, with at least one test in the third trimester. We evaluated the rate of repeat HIV testing, calculated HIV incidence during pregnancy and estimated missed seroconversions.

METHODS

In the Botswana Tsepamo Study, we abstracted HIV test dates and results from obstetric records of all women who delivered at maternity wards in 18 communities between 7th May 2017 and 20th August 2021. We defined seroconversion as an initial negative/indeterminate HIV test in pregnancy followed by a positive test during pregnancy/at delivery. The incidence rate (IR) of seroconversion was calculated among women with > = 2 known test dates. Missed seroconversions were estimated among women without a test in the third trimester by applying the IR to the time after the last HIV test until delivery.

RESULTS

Among 103,529 women delivering in the study period testing negative at the first test and with known conception and HIV test dates, 29,085 (28%) were tested in one trimester of pregnancy, 73,156 (71%) were tested in ≥ 2 trimesters of pregnancy and 9628 (9%) had a test in all trimesters. A total of 78,162 (75%) women had a third-trimester test. There were 223 seroconversions (2.58/1000 pregnancies, 0.26%) among those with ≥ 2 known HIV test dates, yielding an IR of 0.69/100 person-years. Among 25,289 women who did not have a test in the third trimester, we estimate approximately 58 seroconversions may have been missed during pregnancy due to a lack of repeat testing. Factors associated with seroconversion during pregnancy included younger age, less education and not being married.

CONCLUSIONS

More than two-thirds of women had repeat HIV testing in pregnancy and HIV incidence was low. However, an estimated 21% of seroconversions in pregnancy were likely missed due to a lack of re-testing. To reach the goal of zero new paediatric HIV infections, Botswana will need to intensify repeat HIV testing in the third trimester of pregnancy.

Personal radiofrequency electromagnetic field exposure of adolescents in the Greater London area in the SCAMP cohort and the association with restrictions on permitted use of mobile communication technologies at school and at home

Personal measurements of radiofrequency electromagnetic fields (RF-EMF) have been used in several studies to characterise personal exposure in daily life, but such data are limitedly available for adolescents, and not yet for the United Kingdom (UK). In this study, we aimed to characterise personal exposure to RF-EMF in adolescents and to study the association between exposure and rules applied at school and at home to restrict wireless communication use, likely implemented to reduce other effects of mobile technology (e.g. distraction). We measured exposure to RF-EMF for 16 common frequency bands (87.5 MHz-3.5 GHz), using portable measurement devices (ExpoM-RF), in a subsample of adolescents participating in the cohort Study of Cognition, Adolescents and Mobile Phones (SCAMP) from Greater London (UK) (n = 188). School and home rules were assessed by questionnaire and concerned the school's availability of WiFi and mobile phone policy, and parental restrictions on permitted mobile phone use. Adolescents recorded their activities in real time using a diary app on a study smartphone, while characterizing their personal RF-EMF exposure in daily life, during different activities and times of the day. Data analysis was done for 148 adolescents from 29 schools who recorded RF-EMF data for a median duration of 47 h. The majority (74%) of adolescents spent part of their time at school during the measurement period. Median total RF-EMF exposure was 40 μW/m2 at home, 94 μW/m2 at school, and 100 μW/m2 overall. In general, restrictions at school or at home made little difference for adolescents' measured exposure to RF-EMF, except for uplink exposure from mobile phones while at school, which was found to be significantly lower for adolescents attending schools not permitting phone use at all, compared to adolescents attending schools allowing mobile phone use during breaks. This difference was not statistically significant for total personal exposure. Total exposure to RF-EMF in adolescents living in Greater London tended to be higher compared to exposure levels reported in other European countries. This study suggests that school policies and parental restrictions are not associated with a lower RF-EMF exposure in adolescents.

Prolonged Cotrimoxazole Prophylaxis Has No Impact on Child Growth in the First Two Years of Life: Findings from a Randomized Controlled Trial in Botswana

We investigated the impact of prolonged cotrimoxazole prophylaxis on growth in 2848 HIV-exposed uninfected children enrolled in the Mpepu study, a randomized, placebo-controlled trial in Botswana. No significant differences in mean weight-for-age, length-for-age, or weight-for-length z scores between placebo and cotrimoxazole arms were observed overall through 18 months.

Effects of Depot Medroxyprogesterone Acetate Intramuscular Injection, Copper Intrauterine Device and Levonorgestrel Implant Contraception on Estradiol Levels: An Ancillary Study of the ECHO Randomized Trial

Introduction

Hormonal contraception affects endogenous sex steroid levels. Robust evidence from randomized trials of the relative effects of different contraceptive methods is scarce. We compared the effects of three contraceptive methods on serum estradiol levels using data from women (18–35 years) requesting contraception in the Evidence for Contraceptive Options and HIV Outcomes (ECHO) randomized trial.

Methods

Women were randomly allocated to the depot medroxyprogesterone acetate intramuscular (DMPA-IM) injection, copper intrauterine device (IUD) or levonorgestrel (LNG) implant. In this sub-study, stored baseline and 6-month serum samples were analyzed in 401 participants from East London, South Africa (DMPA-IM: 131, IUD: 135 and LNG: 135).

Results

Baseline median (interquartile range, IQR) estradiol levels were similar between the three groups [DMPA-IM 229 (152–455), IUD 235 (168–426) and LNG 216 (153–419 pmol/L)]. At 6-months, median estradiol in the IUD group was unchanged (298 (163–467) pmol/L), whilst levels in the DMPA-IM and implant groups were significantly reduced from baseline. The median estradiol level in the DMPA-IM group [139 (97–193) pmol/L] was significantly lower than in both IUD (p < 0.0001) and implant (p = 0.005) groups; and level in the implant group [156 (112–250) pmol/L] was significantly lower than in the IUD group (p = 0.004).

Conclusions

At 6-months (DMPA-IM nadir), median estradiol with DMPA-IM was 53% lower and with the LNG implant, 48% lower than with the IUD. The greater reduction in estradiol levels with the DMPA-IM injection compared to the LNG implant and IUD has implications for the relative psychological, sexual as well as physiological side-effects of these contraceptive methods.

ECHO Study Registration

ClinicalTrials.gov, identifier: NCT02550067.

Developing an Assessment of Contraceptive Preferences in Botswana: Piloting a Novel Approach Using Best-Worst Scaling of Attributes

Introduction

To develop an attribute-based method for assessing patient contraceptive preferences in Botswana and pilot its use to explore the relationship between patient contraceptive preferences and the contraceptive methods provided or recommended to patients by clinicians.

Methods

A list of contraceptive attributes was developed with input from patients, clinicians, and other stakeholders. We assessed patient preferences for attributes of contraceptives using a discrete choice "best-worst scaling" approach and a multi-attribute decision-making method that linked patient attribute preferences to actual contraceptive method characteristics. Attribute-based patient method preferences and clinician recommendations were compared in 100 women seeking contraceptive services, and 19 clinicians who provided their care. For 41 of the patients, the short-term reliability of their preference scores was also examined.

Results

For 57 patients who wanted more children in the future, the degree of concordance between patients and clinicians was 7% when comparing the top attribute-based contraceptive preference for each woman with the clinician-provided/recommended method. When the top two model-based preferred contraceptive methods were considered, concordance was 28%. For 43 women who did not want more children, concordance was 0% when using the patient's model-based "most-preferred" method, and 14% when considering the top two methods. Assessment of the short-term reliability of preference scores yielded an intraclass correlation coefficient of 0.93.

Conclusions

A best-worst scaling assessment of attributes of contraceptives was designed and piloted in Botswana as a Contraceptive Preference Assessment Tool. The preference assessment was found to have high short-term reliability, which supports its potential use as a measurement tool. There was very low concordance between women's attribute-based contraceptive preferences and their clinician's provision/recommendations of contraceptive methods. Using such a preference assessment tool could encourage greater patient involvement and more tailored discussion in contraceptive consultations.

High risk of adverse birth outcomes among adolescents living with HIV in Botswana compared to adult women living with HIV and adolescents without HIV

Background

Adolescent girls are three times more likely to be living with HIV than boys of the same age. Prior studies have found associations between adolescent pregnancies and increased maternal morbidity and infant mortality, but few studies have assessed the impact of HIV infection on maternal and infant outcomes in adolescents.

Methods

The Tsepamo Study abstracts maternal and infant data from obstetric records in government maternity wards in Botswana. We assessed maternal complications and adverse birth outcomes for all singleton pregnancies from August 2014 to August 2020 at eighteen Tsepamo sites among adolescents (defined as 10–19 years of age) and adults (defined as 20–35 years of age), by HIV status. Univariate and multivariate logistic regression using a complete case analysis method were used to evaluate differences in outcomes.

Results

This analysis included 142,258 singleton births, 21,133 (14.9%) to adolescents and 121,125 (85.1%) to adults. The proportion of adults living with HIV (N = 22,114, 22.5%) was higher than adolescents (N = 1593, 7.6%). The proportion of most adverse birth outcomes was higher in adolescents. Among adolescents, those with HIV had increased likelihoods of anemia (aOR = 1.89, 95%CI 1.66, 2.15) and cesarean sections (aOR = 1.49, 95%CI 1.3,1.72), and infants with preterm birth (aOR = 1.15, 95%CI 1.0, 1.32), very preterm birth (aOR = 1.35, 95%CI 1.0,1.8), small for gestational age (aOR = 1.37, 95%CI 1.20,1.58), and very small for gestational age (aOR = 1.46, 95%CI 1.20, 1.79).

Conclusions

Adolescent pregnancy and adolescent HIV infection remain high in Botswana. Adolescents have higher risk of adverse maternal and infant birth outcomes than adults, with the worst outcomes among adolescents living with HIV. Linking HIV prevention and family planning strategies for this age group may help minimize the number of infants with poor birth outcomes among this already vulnerable population.

Curable sexually transmitted infections among women with HIV in sub-Saharan Africa

OBJECTIVES

Sexually transmitted infections (STIs) cause significant morbidity among women with HIV and increase HIV transmission. We estimated the prevalence of four STIs among women with HIV in sub-Saharan Africa (SSA) and compared prevalence among women with and without HIV.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched for studies published 1 January 1999 to 19 December 2019 reporting prevalence of gonorrhea, chlamydia, trichomoniasis, or Mycoplasma genitalium among women with HIV in SSA. We excluded studies conducted in high-risk groups (e.g. female sex workers). We extracted data on laboratory-confirmed STIs among women with HIV, and when included, among women without HIV. We estimated pooled prevalence for each STI among women with HIV using inverse variance heterogeneity meta-analysis, compared prevalence to women without HIV, and examined the influences of region, clinical setting, and pregnancy status in subgroup analyses.

RESULTS

We identified 3756 unique records; 67 studies were included in the meta-analysis. Prevalence of gonorrhea, chlamydia, trichomoniasis, and M. genitalium was 3.5, 4, 15.6, and 10.2%, respectively. Chlamydia prevalence was lower in Eastern (2.8%) than in Southern (12.5%) and West/Central (19.1%) Africa combined. Prevalence of chlamydia and trichomoniasis was higher among pregnant (8.1%, 17.6%) than nonpregnant (1.7%, 12.3%) women. All STIs were more prevalent among women with than without HIV (relative risks ranging 1.54-1.89).

CONCLUSION

STIs are common among women with HIV in SSA, and more common among women with than without HIV. Integrated STI and HIV care could substantially impact STI burden among women with HIV, with potential downstream impacts on HIV transmission.

Cross-sectional trends in HIV prevalence among pregnant women in Botswana: an opportunity for PrEP?

Introduction

Young women in sub‐Saharan Africa are at particularly high risk of HIV acquisition. Recent shifts towards “test and treat” strategies have potential to reduce transmission in this age group but have not been widely studied outside of clinical trials. Using data from nationwide surveillance among pregnant women in Botswana, where a “test and treat” program was implemented in 2016, we describe trends in HIV prevalence over time and highlight opportunities for targeted prevention.

Methods

The Tsepamo study abstracted data from obstetric records of all women delivering at eight government hospitals in Botswana between 2015 and 2019, accounting for 45% of all births in the country (n = 120,755). We used a stratified analysis to identify prevalence trends and evaluated decreases in HIV prevalence over time using the Cochrane–Armitage test for linear trend. A multivariable logistic regression analysis was also performed to identify factors associated with declines in HIV prevalence.

Results

Overall HIV prevalence was 24.1% among 120,755 women who delivered during the study period. Prevalence differed by site of delivery, ranging from 16.1% to 28.2%, and increased markedly with age. Lower educational attainment (adjusted odds ratio [aOR] = 3.28; 95% confidence interval [CI] 3.07–3.50) and being unmarried (aOR = 1.98; 95% CI 1.88–2.08) were associated with HIV infection. HIV prevalence was 10.0% with a first pregnancy, 21.0% with a second and 39.2% with a third or greater (aOR = 2.20; for any prior pregnancy; 95% CI 2.10–2.29). The same age‐adjusted trends were seen when data were limited to women aged 15–24, with a two‐ to three‐fold increase in HIV prevalence between a first and third pregnancy. Prevalence decreased linearly during the 5‐year study period from 25.8% to 22.7% (p <0.001). Among age‐specific strata, the greatest absolute decline occurred in those aged 35–39, with an 8.7% absolute decrease in HIV prevalence from 2015 to 2019. Minimal declines were seen in those 15–24, with a decrease of only 1.5% over the same period.

Conclusions

While overall trends in Botswana show HIV prevalence declining among pregnant women, prevalence among the youngest age group has remained stagnant. Preventative interventions utilizing pre‐exposure prophylaxis should be prioritized during the high‐risk period surrounding a woman's first pregnancy.

Evaluating the diagnosis and treatment of Chlamydia trachomatis and Neisseria gonorrhoeae in pregnant women to prevent adverse neonatal consequences in Gaborone, Botswana: protocol for the Maduo study

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are extremely common sexually transmitted infections (STIs) that are associated with adverse birth and neonatal outcomes, and the risk of vertical transmission of CT and NG during delivery is high. The majority of CT and NG infections are asymptomatic and missed by the standard of care in most countries (treatment based on symptoms). Thus, it is likely that missed maternal CT and NG infections contribute to preventable adverse health outcomes among women and children globally. This study aims to assess the effectiveness of CT and NG testing for asymptomatic pregnant women to prevent adverse neonatal outcomes, understand the inflammatory response linking CT and NG infections to adverse neonatal outcomes, and conduct an economic analysis of the CT and NG testing intervention.

METHODS

The Maduo ("results" in Setswana) is a prospective, cluster-controlled trial in Gaborone, Botswana to compare a near point-of-care CT and NG testing and treatment intervention implemented in "study clinics" with standard antenatal care (World Health Organization-endorsed "syndromic management" strategy based on signs and symptoms without laboratory confirmation) implemented in "standard of care clinics" among asymptomatic pregnant women. The primary outcome is vertical transmission of CT/NG infection. Secondary outcomes include preterm birth (delivery < 37 completed weeks of gestation) and/or low birth weight (< 2500 g). The trial will also evaluate immunological and inflammatory markers of adverse neonatal outcomes, as well as the costs and cost-effectiveness of the intervention compared with standard care.

DISCUSSION

The Maduo study will improve our understanding of the effectiveness and cost-effectiveness of CT and NG testing among asymptomatic pregnant women. It will also increase knowledge about the CT/NG-related immune responses that might drive adverse neonatal outcomes. Further, results from this study could encourage expansion of STI testing during antenatal care in low resource settings and improve maternal and neonatal health globally.

TRIAL REGISTRATION

This trial is registered with ClinicalTrials.gov (Identifier NCT04955717, First posted: July 9, 2021)).

The International Sexual Health And REproductive Health during COVID-19 (I-SHARE) Study: A Multicountry Analysis of Adults from 30 Countries Prior to and During the Initial Coronavirus Disease 2019 Wave

BACKGROUND

There is limited evidence to date about changes to sexual and reproductive health (SRH) during the initial wave of coronavirus disease 2019 (COVID-19). To address this gap, our team organized a multicountry, cross-sectional online survey as part of a global consortium.

METHODS

Consortium research teams conducted online surveys in 30 countries. Sampling methods included convenience, online panels, and population-representative. Primary outcomes included sexual behaviors, partner violence, and SRH service use, and we compared 3 months prior to and during policy measures to mitigate COVID-19. We conducted meta-analyses for primary outcomes and graded the certainty of the evidence.

RESULTS

Among 4546 respondents with casual partners, condom use stayed the same for 3374 (74.4%), and 640 (14.1%) reported a decline. Fewer respondents reported physical or sexual partner violence during COVID-19 measures (1063 of 15 144, 7.0%) compared to before COVID-19 measures (1469 of 15 887, 9.3%). COVID-19 measures impeded access to condoms (933 of 10 790, 8.7%), contraceptives (610 of 8175, 7.5%), and human immunodeficiency virus/sexually transmitted infection (HIV/STI) testing (750 of 1965, 30.7%). Pooled estimates from meta-analysis indicate that during COVID-19 measures, 32.3% (95% confidence interval [CI], 23.9%-42.1%) of people needing HIV/STI testing had hindered access, 4.4% (95% CI, 3.4%-5.4%) experienced partner violence, and 5.8% (95% CI, 5.4%-8.2%) decreased casual partner condom use (moderate certainty of evidence for each outcome). Meta-analysis findings were robust in sensitivity analyses that examined country income level, sample size, and sampling strategy.

CONCLUSIONS

Open science methods are feasible to organize research studies as part of emergency responses. The initial COVID-19 wave impacted SRH behaviors and access to services across diverse global settings.

Experiences of Accessing and Providing Contraceptive Implant Removal Services in Gaborone, Botswana: A Qualitative Study Among Implant Users and Healthcare Providers

Introduction: This study explored implant user and healthcare provider experiences of accessing and providing contraceptive implant removal services in Gaborone, Botswana, following introduction of the implant in the public sector in 2016. We sought to understand reasons for satisfaction and dissatisfaction with services and their potential impact on wider perceptions of the implant, including influence on future uptake.

Methods: Qualitative data were collected through in-depth interviews. Participants comprised ten women who had previously undergone implant removal, and ten providers whose work included provision of implant insertion and removal. Data were analyzed using thematic content analysis.

Results: Seven of the ten users in this study had experienced a delay between initial request and undergoing implant removal. This interval ranged from <1 week to 3 months. Users identified the principal barriers to accessing implant removal services as lack of access to trained removal providers, inconvenient appointment times, and provider resistance to performing removal. Nine of the ten providers in this study had experienced barriers to providing implant removal, including insufficient training, lack of equipment, lack of time, and lack of a referral pathway for difficult removals. Despite experiencing barriers in accessing removal, users' perceptions of the implant remained generally positive. Providers were concerned that ongoing negative user experiences of removal services would damage wider perceptions of the implant.

Conclusion: Introduction of the contraceptive implant in Botswana has been an important strategy in increasing contraceptive choice. Following an initial focus on provision of insertion services, the development of comparable, accessible removal services is critical to ensuring that the implant remains a desirable contraceptive option and is vital to upholding women's reproductive health rights. The experiences of users and providers in this study can inform the ongoing development of services for implant insertion and removal in Botswana and other lower-resource settings.

False-negative real-time polymerase chain reaction tests in COVID-19 patients: an epidemiological analysis of 302 patients

OBJECTIVES

Patients who arrive at the emergency department (ED) with COVID-19, who test negative at the first real-time polymerase chain reaction (RT-PCR), represent a clinical challenge. This study aimed to evaluate if the clinical manifestation at presentation, the laboratory and imaging results, and the prognosis of COVID-19 differ in patients who tested negative at the first RT-PCR compared with those who tested positive and also to evaluate if comorbid conditions patient-related or the period of arrival are associated with negative testing.

STUDY DESIGN

We retrospectively collected clinical data of patients who accessed the ED from March 1 to May 15, 2020.

METHODS

We compared clinical variables, comorbid conditions, and clinical outcomes in the two groups by univariate analysis and logistic regression.

RESULTS

Patients who tested negative at the first RT-PCR showed a higher prevalence of cardiopathy, immunosuppression, and diabetes, as well as a higher leukocyte and lower lymphocyte counts compared with patients who tested positive. A bilateral interstitial syndrome and a typical pattern at computed tomography scan were prevalent in the test-negative group. Test-negative patients were more likely to be admitted to the hospital but less likely to need admission in a high level of care ward. The false-negative rate increased from March to May.

CONCLUSION

False-negative RT-PCR COVID-19 patients present a similar spectrum of symptoms compared with positive cohort, but more comorbidities. Imaging helps to identify them. True positives had a higher risk of serious complications.

Integrating Sexually Transmitted Infection Testing and Treatment With Routine HIV Care in Gaborone, Botswana

BACKGROUND

Sexually transmitted infection (STI) testing is not routinely offered in many countries, and management is symptoms based. Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are associated with an increased risk of HIV transmission. We assess the feasibility and acceptability of integrating CT/NG testing into routine HIV care in Botswana, as well as the prevalence and correlates of CT/NG infections.

METHOD

A prospective study was conducted at an HIV clinic in Gaborone between February and October 2019. Eligibility criteria included the following: ≥18 years, HIV infected, and not treated for CT/NG in the past month. Participants self-collected samples and responded to a questionnaire on sociodemographic and health characteristics. Samples were processed using the GeneXpert. Patients were offered same-day results in person or by telephone. Those who tested positive were treated.

RESULTS

Of 806 patients informed of the study, 526 (65%) expressed interest and 451 (60%) were enrolled. The median age was 48 years, and 66% were women. All participants provided self-collected samples, were successfully tested, and received results. Almost all reported sample self-collection was easy. The prevalence of CT/NG was 5%. Most participants (73%) with a positive result were asymptomatic. Among infected, 20 (91%) received same-day results and all were treated. Younger age, female sex, and pain during sex were associated with having CT/NG.

CONCLUSIONS

Integrating STI testing into routine HIV care was feasible, self-collecting specimens was highly acceptable, but uptake of testing was low. Where blanket screening to the entire clinic population may not be feasible because of resource limitation, one strategy could be to prioritize sexually active patients, younger patients, and women.

The International Sexual Health And Reproductive Health Survey (I-SHARE-1): A Multi-Country Analysis of Adults from 30 Countries Prior to and During the Initial COVID-19 Wave

Background

The COVID-19 pandemic forced billions of people to shelter in place, altering social and sexual relationships worldwide. In many settings, COVID-19 threatened already precarious health services. However, there is limited evidence to date about changes to sexual and reproductive health (SRH) during the initial wave of COVID-19 disease. To address this gap, our team organized a multi-country, cross-sectional online survey as part of a global consortium.

Methods

Consortium research teams conducted online surveys in 30 countries. Sampling methods included convenience, online panels, and population-representative. Primary outcomes included sexual behaviors, partner violence, and SRH service utilization, and we compared three months prior to and three months after policy measures to mitigate COVID-19. We used established indicators and analyses pre-specified in our protocol. We conducted meta-analyses for primary outcomes and graded the certainty of the evidence using Cochrane methods. Descriptive analyses included 22,724 individuals in 25 countries. Five additional countries with sample sizes <200 were included in descriptive meta-analyses.

Results

Respondents were mean age 34 years; most identified as women (15160; 66.7%), cis-gender (19432; 86.6%) and heterosexual (16592; 77.9%). Among 4546 respondents with casual partners, condom use stayed the same for 3374 (74.4%) people and 640 (14.1%) people reported a decline. Fewer respondents reported physical or sexual partner violence during COVID-19 measures (1063/15144, 7.0%) compared to the period before COVID-19 measures (1469/15887, 9.3%). COVID-19 measures impeded access to condoms (933/10790, 8.7%), contraceptives (610/8175, 7.5%), and HIV/STI testing (750/1965, 30.7%). Pooled estimates from meta-analysis indicate during COVID-19 measures, 32.3% (95% CI 23.9-42.1) of people needing HIV/STI testing had hindered access, 4.4% (95% CI 3.4-5.4) experienced partner violence, and 5.8% (95% CI 5.4-8.2) decreased casual partner condom use (moderate certainty of evidence for each outcome). Meta-analysis findings were robust in sensitivity analyses that examined country income level, sample size, and sampling strategy.

Conclusion

Open science methods are feasible to organize research studies as part of emergency responses. The initial COVID-19 wave impacted SRH behaviors and access to services across diverse global settings.

Lack of HIV RNA test result is a barrier to breastfeeding among women living with HIV in Botswana

Background

Botswana updated its antiretroviral treatment (ART) guidelines in May 2016 to support breastfeeding for women living with HIV (WLHIV) on ART who have documented HIV RNA suppression during pregnancy.

Methods

From September 2016 to March 2019, we evaluated feeding method at discharge among WLHIV at eight government maternity wards in Botswana within the Tsepamo Study. We validated the recorded feeding method on the obstetric record using the prevention of mother-to-child transmission of HIV (PMTCT) counsellor report, infant formula dispensing log or through direct observation. Available HIV RNA results were recorded from the obstetric record, and from outpatient HIV records (starting February 2018). In a subset of participants, we used electronic laboratory records to verify whether an HIV RNA test had occurred. Univariable and multivariable logistic regression analyses were performed to identify factors associated with infant feeding choice.

Results

Among 13,354 WLHIV who had a validated feeding method at discharge, 5303 (39.7%) chose to breastfeed and 8051 (60.3%) chose to formula feed. Women who had a documented HIV RNA result in the obstetric record available to healthcare providers at delivery were more likely to breastfeed (50.8%) compared to women who did not have a documented HIV RNA result (35.4%) (aOR 0.59; 95% CI 0.54, 0.65). Among women with documented HIV RNA, 2711 (94.6%) were virally suppressed (< 400 copies/mL). Breastfeeding occurred in a substantial proportion of women who did not meet criteria, including 46 (30.1%) of 153 women with HIV RNA > 400 copies/mL, and 134 (27.4%) of 489 women with no reported ART use. A sub-analysis of electronic laboratory records among 150 women without a recorded result on the obstetric record revealed that 93 (62%) women had an HIV RNA test during pregnancy.

Conclusions

In a setting of long-standing use of suppressive ART, with majority of WLHIV on ART from the time of conception, requiring documentation of HIV RNA suppression in the obstetric record to inform infant feeding decisions is a barrier to breastfeeding but unlikely to prevent a substantial amount of HIV transmission.

Factors Associated with Infant Feeding Choices Among Women with HIV in Botswana

INTRODUCTION

In resource-constrained settings, infant feeding decisions among women with HIV (WHIV) must balance the risk of infant HIV acquisition from breastfeeding with increased mortality associated with formula feeding. WHO guidelines recommend countries principally promote a single feeding method for WHIV, either breastfeeding or formula feeding. In 2016, Botswana revised its policy of formula feeding for infants born to WHIV, instead promoting exclusive breastfeeding during the first 6 months of life.

METHODS

We sought to understand factors influencing infant feeding choices among WHIV by administering a questionnaire to pregnant and postpartum WHIV (2013-2015) participating in a clinical trial in Botswana (the Mpepu Study). Logistic regression analyses were used to identify factors associated with infant feeding choices.

RESULTS

Of 810 surveyed participants, 24.0% chose breastfeeding and 76.0% chose formula feeding. Women were more likely to choose formula feeding if advised by a health worker to formula feed (aOR 1.90; 95% CI 1.02-3.57) or if they harboured doubts about the potency of antiretroviral treatment (ART) to prevent infant HIV acquisition (aOR 9.06; 95% CI 4.78-17.17). Women who reported lack of confidence in preparing infant formula safely (aOR 0.09; 95% CI 0.04-0.19) or low concerns about infant HIV acquisition (aOR 0.35; 95% CI 0.22-0.55) were significantly less likely to formula feed.

DISCUSSION

Perceptions about ART effectiveness, social circumstances and health worker recommendations were key influencers of infant feeding choices among WHIV. Health system factors and maternal education interventions represent ideal targets for any programmatic actions aiming to shape informed decision-making towards HIV-free survival of infants.

Facilitators and Barriers to Implementation of Long-Acting Reversible Contraceptive Services for Adolescent Girls and Young Women in Gaborone, Botswana

STUDY OBJECTIVE

Botswana has a high pregnancy rate among adolescent girls and young women (AGYW). Long-acting reversible contraceptive (LARC) use among AGYW in Botswana is low, despite its high effectiveness for preventing pregnancy. Using an implementation science framework, we assessed barriers and facilitators to LARC implementation among AGYW in Botswana.

DESIGN

Cross-sectional mixed methods.

SETTING

Gaborone, Botswana.

PARTICIPANTS

Twenty sexually active AGYW ages 18-24 years; 20 health system stakeholders.

INTERVENTIONS

Surveys and semistructured interviews grounded in the Consolidated Framework for Implementation Research.

MAIN OUTCOME MEASURES

Themes reflecting barriers and facilitators of LARC implementation.

RESULTS

The median age for AGYW was 22 (interquartile range, 21-23) years. Twenty percent were using an implant and none had ever used an intrauterine device. Barriers and facilitators of LARC implementation spanned factors at each Consolidated Framework for Implementation Research domain: (1) LARC characteristics like side effects; (2) the clinics' inner settings, including availability of youth-friendly services; (3) characteristics of health system stakeholders, such as LARC skills, and AGYW experiences, attitudes, and beliefs about LARCs; (4) the outer setting external to clinics and Botswana's health system including reproductive health law and policy for minor adolescents; and (5) the implementation process level such as the availability of free or low-cost LARCs.

CONCLUSION

We identified multilevel, context-specific factors that affect LARC implementation. Our findings can inform the development of interventions to increase LARC implementation in Botswana by addressing intersecting factors across patient, clinic, health system, and sociopolitical levels, such as providing confidential services to minors and improving LARC training and supply chain pipelines.

Experiences and preferences with sexually transmitted infection care and partner notification in Gaborone, Botswana

Partner notification and treatment are essential to sexually transmitted infection (STI) management. However, in low- and middle-income countries, half of partners do not receive treatment. A mixed methods study was conducted to explore experiences and preferences around partner notification and treatment in patients seeking STI care in Gaborone, Botswana. Thirty participants were administered a quantitative survey, followed by a semi-structured interview on partner notification, treatment, and expedited partner therapy (EPT). Among the 30 participants, 77% were female with a median age of 28 years (IQR = 24-36), 87% notified their partner, and 45% of partners requiring treatment received treatment. Partners who received a contact slip were more likely to have been treated than those who did not (75% vs. 25%). Contact slips were identified as facilitators of notification and treatment, while asymptomatic partners and limited clinic resources were identified as barriers to treatment. Few participants expressed a preference for EPT and concerns included preference for medical supervision, a belief their partner would refuse, and an inability to explain the treatment. Despite successful notification, partner treatment was modest within this population. Information for partners, provider counseling, and improved access to services may increase partner treatment. Education on STIs and treatment options may improve EPT acceptability.

Using a dual antibody point-of-care test with visual and digital reads to diagnose syphilis among people living with HIV in Botswana

Syphilis data from low- and middle-income countries are lacking due to limited testing. Point-of-care tests (POCTs) have been promoted to expand testing but previously only included treponemal tests, which cannot distinguish active from past infection. We aimed to assess the feasibility of using a combined treponemal and non-treponemal POCT in HIV clinic patients in Gaborone, Botswana, and estimate syphilis prevalence in our clinic sample using this approach. We recruited 390 non-pregnant patients. Participants underwent a combined treponemal and non-treponemal POCT (Dual Path Platform (DPP®) Syphilis Screen and Confirm Assay (Chembio Diagnostic Systems)) on finger-prick blood sample and a questionnaire. Median age 45 years, 30% men, median CD4 count 565 cells/μL, and 91% had an HIV viral load <400 copies/mL. Five participants had active syphilis (1.3%, 95% CI 0.5–3.0%) and 64 had previous syphilis (16.4%, 95% CI 13.0–20.4%) using the DPP POCT. There was a reasonable level of agreement between digital and visual reading of the POCT (kappa statistic of 0.81); however, visual reading missed three active infections (60%). The level of active syphilis was similar to local antenatal data. The DPP POCT led to five participants with active syphilis being diagnosed and starting same-day treatment. The digital reader should be used.

Integration of family planning services into health care for HIV-positive women in Botswana

OBJECTIVE

To create and assess a clinic model to address the unmet need for effective contraception among women living with HIV in Botswana, where half of all pregnancies are unintended and 30% of women of reproductive age are living with HIV.

METHODS

We introduced family planning services into an HIV clinic in Gaborone, Botswana. Our intervention gave HIV providers brief training on contraceptive counseling plus the option of immediate referral of interested patients to an on-site contraception provider. We administered a survey to patients and providers before and after intervention. Patients were female, aged 18-45 years and using antiretrovirals.

RESULTS

At baseline, 6% of 141 patients discussed contraception with their HIV-care provider, compared with 61% of 107 post intervention (P < 0.001). At baseline, 6% of patients reported wanting to use long-acting reversible contraception (LARC). Post intervention, 45% of patients chose to meet with the contraception provider, and 29% wanted to use LARC (P < 0.001 versus baseline). All providers strongly agreed that they were better informed about contraception post intervention and were satisfied with their ability to counsel and refer women for contraception.

CONCLUSIONS

Provision of on-site contraceptive services in this HIV clinic encouraged family planning discussions and increased interest in LARC.

Comparison of plasma etonogestrel concentrations sampled from the contralateral-to-implant and ipsilateral-to-implant arms of contraceptive implant users

OBJECTIVE

To compare plasma etonogestrel concentrations sampled from the contralateral- versus ipsilateral-to-implant arm.

STUDY DESIGN

Sub-analysis of a cross-sectional study in Botswana in 33 participants who provided contralateral and ipsilateral blood samples.

RESULTS

Plasma etonogestrel concentrations in contralateral and ipsilateral specimens were highly correlated (correlation coefficient = 0.99; p < 0.0001). Bland-Altman analysis of agreement showed that etonogestrel levels were on average 5.9 pg/mL higher (2.1%) in ipsilateral compared to contralateral specimens (95% confidence interval: -4.1, 15.9 pg/mL).

CONCLUSIONS

We found no meaningful differences in plasma etonogestrel concentrations between samples taken from the contralateral- versus ipsilateral-to-implant arm.

IMPLICATIONS

Our data suggest that etonogestrel plasma concentrations are unlikely to be meaningfully different between samples drawn from the ipsilateral- versus the contralateral-to-implant arms in etonogestrel contraceptive implant users.

Rhizospheric bacterial isolates of grass pea (Lathyrus sativus L.) endowed with multiple plant growth promoting traits

AIM

The main aim of this work was to examine the plant growth promoting, biocontrol activities and stress competency of grass pea rhizobacterial strains from Ethiopia.

METHODS AND RESULTS

Serial dilutions were carried out to isolate rhizobacterial strains from the rhizosphere soil samples. The isolates were characterized for their plant growth promoting, biocontrolling and stress tolerance potential. The isolates that showed better performance in the tested parameters were identified by 16S rRNA gene sequencing. Among the isolates tested on Pikovskaya agar medium, 22 isolates that showed solubilization index of >2·41 cm were selected for further screening tests. Isolate AAUGPR-53 identified as Enterococcus species, Enterococcus casseliflavus strain showed the highest phosphate solubilization index and indole-3-acetic acid production efficiency of 4·81 ± 0·02 (μg ml-1 ) and 56·55 ± 0·45 (μg ml-1 ), respectively. Sixteen (72·7%) of the isolates showed in vitro antifungal inhibition against Fusarium oxysporum f. sp. lentis with isolates AAUGPR-92 and AAUGPR-91 identified as Enterococcus species, E. casseliflavus strain and Enterococcus gallinarum strain exhibiting the highest inhibition of 83 and 78%, respectively. Likewise, 68·2%, 91·30%, 45·5%, 77·3% and 100% of the isolates produced chitinase, protease, cellulase, HCN and NH3 , respectively. Most of the isolates showed good tolerance to the tested stress factors. The 16S rRNA partial sequencing of the rhizobacterial isolates proved their taxonomic position in the existing bacterial isolates.

CONCLUSION

The results indicated that three strains, AAUGPR-53, 91 and 92, that showed maximum sequence identity (99%) to Enterococcus species, E. casseliflavus and E. gallinarum were recommended as microbial inoculants for trials under greenhouse and field conditions.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study illustrates an effective alternative to conventional fertilizers that may contribute to crop disease reduction. Our results provide a foundation for future research that will lead to identifying potentially useful biocontrol strains found in the rhizosphere of grass pea.

Cellular Immunity in Two Familial Cases of Thyroid Carcinoma

Cellular immunity in two brothers with thyroid carcinoma in a family presenting pathological thyroid changes was investigated. In these brothers a low PHA lymphocyte blast-transformation and an elevated number of surface membrane Ig bearing lymphocytes were observed. These data are discussed in relation to the question of immunological defects which frequently are present in carcinoma patients.

Sentinel Lymph Node and Breast Cancer Staging: Final Results of the Turin Multicenter Study

Aim of the study

Validation of the sentinel node (SN) technique in breast cancer by means of lymphoscintigraphy.

Materials and methods

From December 1996 to January 1999 102 T1-T2 breast carcinoma cases were recruited in Turin. 99mTc-human serum albumin colloids were injected subdermally the day before surgery (mean activity, 5.2 ± 2.5 MBq). Scintigraphic imaging was performed after injection. After identification of the SN during surgery by a hand-held gamma probe, the SN was excised and sent for histologic examination. SN histology was compared with that of other axillary nodes.

Results

The SN detection rate was 86.3%; among 88 cases with an identified SN, 37 (42%) had axillary metastases; the SN was metastatic in 35 cases (sensitivity, 94.6%); in 51.3% of pN+ cases (19/37) the SN was the only metastatic site. In two of the 53 negative SNs, SN histology did not match with that of the remaining axilla (negative predictive value, 96.2%; staging accuracy, 97.7%).

Conclusions

Our results agree with those reported in the literature; however, except in clinical trials and experienced structures axillary lymph node dissection should not be abandoned when mandatory for prognostic purposes, considering that at present SN biopsy alone is not completely accurate for axillary staging, especially in the absence of an adequate learning period.

Fetal growth patterns in Beckwith-Wiedemann syndrome

We provide data on fetal growth pattern on the molecular subtypes of Beckwith-Wiedemann syndrome (BWS): IC1 gain of methylation (IC1-GoM), IC2 loss of methylation (IC2-LoM), 11p15.5 paternal uniparental disomy (UPD), and CDKN1C mutation. In this observational study, gestational ages and neonatal growth parameters of 247 BWS patients were compared by calculating gestational age-corrected standard deviation scores (SDS) and proportionality indexes to search for differences among IC1-GoM (n = 21), UPD (n = 87), IC2-LoM (n = 147), and CDKN1C mutation (n = 11) patients. In IC1-GoM subgroup, weight and length are higher than in other subgroups. Body proportionality indexes display the following pattern: highest in IC1-GoM patients, lowest in IC2-LoM/CDKN1C patients, intermediate in UPD ones. Prematurity was significantly more prevalent in the CDKN1C (64%) and IC2-LoM subgroups (37%). Fetal growth patterns are different in the four molecular subtypes of BWS and remarkably consistent with altered gene expression primed by the respective molecular mechanisms. IC1-GoM cases show extreme macrosomia and severe disproportion between weight and length excess. In IC2-LoM/CDKN1C patients, macrosomia is less common and associated with more proportionate weight/length ratios with excess of preterm birth. UPD patients show growth patterns closer to those of IC2-LoM, but manifest a body mass disproportion rather similar to that seen in IC1-GoM cases.

(Epi)genotype-phenotype correlations in Beckwith-Wiedemann syndrome: a paradigm for genomic medicine

Beckwith-Wiedemann syndrome (BWS) is the commonest overgrowth cancer predisposition disorder and represents a model for human imprinting dysregulation and tumorigenesis. BWS features can variably combine and present a widely variable range of severity in the phenotypic expression. This wide spectrum is paralleled at molecular level by complex (epi)genetic defects on chromosome 11p15.5 leading to disrupted expression of imprinted genes controlling growth and cellular proliferation. In this review, we outline the spectrum of clinical manifestations of BWS analyzing their (epi)genotype-phenotype correlations. The differences observed in the phenotypic profiles of BWS molecular subtypes allow a composite view of this syndrome with implications on clinical care, diagnosis, follow-up, and management, and provide directions for future disease monitoring.

Subclinical hyperthyroidism when presenting as initial manifestation of juvenile Hashimoto's thyroiditis: first report on its natural history

BACKGROUND

Due to the lack of specific pediatric studies, no data are available about natural history of endogenous subclinical hyperthyroidism (SH) in childhood.

AIMS

(a) To investigate for the first time the natural history of SH [suppressed thyrotropin (TSH) and normal free thyroxine free thyroxine (FT4) levels] when presenting as initial manifestation of Hashimoto's thyroiditis (HT) in childhood (group A); (b) to compare spontaneous evolution of HT-related SH with that observed in age-matched patients with HT-related frank hyperthyroidism (suppressed TSH and elevated FT4 levels), i.e., Hashitoxicosis Htx (group B).

RESULTS

In the 11 patients of group A, TSH normalization spontaneously occurred 1-24 months after diagnosis, while in the 10 patients of group B it occurred 3-9 months after diagnosis, with no differences between the 2 groups in terms of time interval from entry to TSH normalization. In group A, this time interval was related to baseline thyroid peroxidase antibodies (r=0.78, p = 0.04). During follow-up, eight patients of each group remained euthyroid, whereas two became hypothyroid (in both groups) and one developed Graves' disease (in group A).

CONCLUSION

(a) HT should be included among the causes of endogenous SH in pediatric age; (b) in children with HT-related SH, spontaneous normalization of TSH levels occurs within the first 24 months after diagnosis, as well as in age-matched patients with Htx; (c) in both these conditions, a further deterioration of thyroid function might re-present in some patients during follow-up; (d) Ht-related SH and Htx might be possibly seen as different biochemical stages along the same continuum.

Phalangeal quantitative ultrasound in 1,719 children and adolescents with bone disorders

SUMMARY

We measured bone properties by phalangeal quantitative ultrasound in 1,719 pediatric patients with bone disorders, classifying them according to fracture status. Quantitative ultrasound discriminated fractured and nonfractured pediatric patients and enabled us to stratify fractured patients into classes according to the severity of the causative trauma (spontaneous, minimal trauma, appropriate trauma fractures).

INTRODUCTION

The correlation between quantitative bone measurements and fractures is poorly established in pediatric patients with bone disorders. We correlated phalangeal quantitative ultrasound (QUS) and fracture history in children and adolescents with bone disorders and evaluated the ability of QUS to recognize fractured patients.

METHODS

Amplitude-dependent speed of sound (AD-SoS) and bone transmission time (BTT) were measured in 1,719 pediatric patients with bone disorders and related to fracture history. The patients were classified as (1) spontaneously (77), (2) minimal trauma (101), or (3) appropriate trauma fractured (206), and (4) nonfractured (1,335). The likelihood of fracture according to QUS was calculated as odds ratio per SD decrease (OR/SD), and the effectiveness in discriminating fractured patients was evaluated by receiver operating characteristic (ROC) analysis. The influence of age, sex, puberty, height, and BMI was explored by respective adjustments and multiple logistic regression.

RESULTS

Fractured patients showed significantly reduced AD-SoS and BTT standard deviation score (-0.32 ± 1.54 and -0.78 ± 1.49) compared to nonfractured subjects (0.43 ± 1.63 and -0.11 ± 1.34). QUS measurements paralleled the causative trauma severity, ranging from the lowest values in spontaneously fractured patients to normal values in appropriate trauma fractured subjects. The OR/SD were increasingly higher in appropriate trauma fractured, minimal trauma fractured, and spontaneously fractured patients. At ROC analysis, both parameters proved to have significant discrimination power in recognizing spontaneously and minimal trauma-fractured patients.

CONCLUSIONS

QUS identifies fractured pediatric patients with bone disorders, reflecting the severity of the causative trauma with a high discrimination power for fragility fractures.

Metabolic syndrome in children with Prader-Willi syndrome: the effect of obesity

BACKGROUND AND AIMS

Prader-Willi syndrome (PWS), the most frequent syndromic obesity, is associated with elevated morbidity and mortality in pediatric and adult ages. In PWS, the presence of metabolic syndrome (MS) has not yet been established. The aim of the study was to estimate the frequency of MS and its components in pediatric subjects according to obesity status.

METHODS AND RESULTS

A cross-sectional study was performed in 109 PWS children aged 2-18 years (50 obese and 59 non-obese) and in 96 simple obese controls matched for age, gender, and also for BMI with obese PWS. Obesity was defined when SDS-BMI was >2. Non-obese PWS showed significantly lower frequency of hypertension (12%) than obese PWS (32%) and obese controls (35%)(p=0.003). The same was observed for low HDL-cholesterol (3% vs 18% and 24%, p=0.001) and high triglycerides (7% vs 23% and 16%, p=0.026). Frequency of altered glucose metabolism was not different among groups (2% vs 10% and 5%), but type 2 diabetes (four cases) was present only in obese PWS. Non-obese PWS showed lower insulin and HOMA-index respect to obese PWS and obese controls (p ≤ 0.017). Overall MS frequency in PWS was 7.3%. None of the non-obese PWS showed MS compared with 16% of obese PWS and controls (p<0.001). When obesity was excluded from the analysis, a significantly lower frequency for clustering of ≥ 2 factors was still found in non-obese PWS (p=0.035).

CONCLUSION

Non-obese PWS showed low frequency of MS and its components, while that observed in obese PWS was very close to those of obese controls, suggesting the crucial role of obesity status. Prevention of obesity onset remains the most important goal of PWS treatment. Early identification of MS could be helpful to improve morbidity and mortality in such patients.

Immunostimulation to reduce recurrence after surgery for anal condyloma acuminata: a prospective randomized controlled trial

AIM

Human papillomavirus is the most common cause of sexually transmitted disease. It is associated with immunosuppression and shows a marked tendency to recur. We investigated a natural immunostimulant aimed to reduce recurrence.

METHOD

A randomized controlled study was carried out including 261 patients allocated to surgical excision alone (control group; n = 122) and surgical excision plus postoperative immunostimulation for 30 days with a natural product (STET; study group; n = 139). Patients with HIV positivity were excluded. All patients gave fully informed consent.

RESULTS

The patients were followed for 6 months after surgery. Recurrence occurred in 7.2% (10/139) in the study group and in 27.1% (33/122) in the control group (P < 0.0001). There were no significant differences in the sex, sexual orientation, number of lesions, time to diagnosis and treatment or localization of lesions in the two groups.

CONCLUSIONS

Immunostimulation using a natural product significantly reduced the incidence of recurrence of anal condylomata in patients undergoing surgical excision.

Sperm count of young men surgically treated for cryptorchidism in the first and second year of life: fertility is better in children treated at a younger age

INTRODUCTION

Recent data has indicated the usefulness of performing orchiopexy in the first years of life. In this study, we evaluated testicular function in young men operated on for cryptorchidism in the first year of life. To our knowledge, this is the first report on the effects of such an early treatment.

MATERIALS AND METHODS

Testicular function was assessed in a group of young men operated for cryptorchidism during the first year of life (Group A, n=13) and during the second year of life (Group B, n=16).

RESULTS

Total sperm counts were clearly higher in Group A (52.3+/-14.3 million/ml vs. 30.4+/-23.5 million/ml, p=0.005) as was sperm motility (36.2+/-8.7 vs. 23.1+/-15.7%, p=0.009). A clear inverse relationship was found between age at orchiopexy and total sperm count (r=-0.394, p=0.034) and sperm motility (r=-0.382, p=0.041). The relationship between volume of testes, position at surgery, uni/bilaterality of cryptorchidism, evidence of Ad spermatogonia at biopsy performed during surgery and treatment with LHRH and hCG performed before surgery and fertility was not significant. The latter findings may be partially explained by the low number of patients participating in the study and need further investigation.

CONCLUSIONS

We obtained, for the first time, results showing the benefit of treating cryptorchidism during the first year of life rather than in the second year or even later.

Feasibility of the sentinel node biopsy in anal cancer

AIM

Anal cancer is a rare neoplasm. According to a European Organization for Research and Treatment of Cancer multivariate analysis, synchronous inguinal lymph node metastasis occurs in 10-25% of patients and constitutes an independent prognostic factor for local failure and overall mortality.

METHODS

Inguinal lymph node status was assessed using the sentinel node technique in 35 patients with anal cancer.

RESULTS

Histology revealed 23 squamous carcinomas, 10 basaloid carcinomas, 1 squamous carcinoma with basaloid areas and 1 spinocellular epithelioma associated with areas of Bowen's disease. Disease stage was T1 in 5 patients, T2 in 18, T3 in 11 and T4 in 1 patient. Lympho-scintigraphy using a GE Millennium gamma camera was performed after peritumoral injection of 37 MBq of 99mTc colloid. Surgical sentinel node biopsy with a portable Scintiprobe MR 100 (Politech, Carsoli, Italy) had a detection rate of 97.1%. Inguinal metastases were detected in 7 (20%) patients, in 2 of which metastasis was bilateral.

CONCLUSIONS

Given the correlation between prognosis and node involvement, sentinel node biopsy can be considered a simple method for adequate pretreatment staging of anal carcinoma. Use of the technique could avert the need for prophylactic inguinal radiotherapy in N0-N1 patients, thus reducing the morbidity associated with inguinal radiotherapy. Consistent follow-up is required to evaluate long-term results:

Increased spontaneous osteoclastogenesis from peripheral blood mononuclear cells in phenylketonuria

Phenylketonuria (PKU) is commonly complicated by a progressive bone impairment of uncertain aetiology. The therapeutic phenylalanine (Phe)-restricted diet and the possible noxious effects of high plasma Phe concentrations on bone have previously been suggested as possible determinant factors. Since osteoclasts are involved in bone reabsorption, they could play a role in determining bone damage in PKU. The reported increased excretion of bone resorption markers in PKU patients is consistent with this hypothesis. Although different diseases characterized by bone loss have been related to increased spontaneous osteoclastogenesis from peripheral blood mononuclear cells (PBMCs), to date there is no evidence of increased osteoclast formation in PKU. In this study, we compared the spontaneous osteoclastogenesis from PBMCs in 20 patients affected by PKU with that observed in age- and sex-matched healthy subjects. Phenylketonuric patients showed the number of osteoclasts to be almost double that observed in controls (159.9 ± 79.5 and 87.8 ± 44.7, respectively; p = 0.001). Moreover, a strict direct correlation between the spontaneous osteoclastogenesis in PKU patients and the mean blood Phe concentrations in the preceding year was observed (r = 0.576; p = 0.010). An imbalance between bone formation and bone resorption might explain, at least in part, the pathogenesis of bone loss in this disease. These findings could provide new insights into the biological mechanisms underlying bone damage in PKU.