HIV care for geographically mobile populations

The interaction between geographic mobility and risk for human immunodeficiency virus infection is well recognized, but what happens to those same individuals, once infected, as they transition to living with the infection? Does mobility affect their transition into medical care? If so, do mobile and nonmobile populations achieve similar success with antiretroviral treatment? The definition of mobility has changed over the centuries to encompass a complex phenotype including permanent migration, frequent travel, circular migration, and travel to and from treatment centers. The heterogeneity of these definitions leads to discordant findings. Investigations show that mobility has an impact on infection risk, but fewer data exist on the impact of geographic mobility on medical care and treatment outcomes. This review will examine existing data regarding the impact of geographic mobility on access to and maintenance in medical care and on adherence to antiretroviral therapy for those living with human immunodeficiency virus infection. It will also expand the concept of mobility to include data on the impact of the distance from residence to clinic on medical care and treatment adherence. Our conclusions are that the existing literature is limited by varying definitions of mobility and the inherent oversimplification necessary to apply a "mobility measure" in a statistical analysis. The impact of mobility on antiretroviral treatment outcomes deserves further exploration to both define the phenomenon and target interventions to these at-risk populations.     

Luteal phase characteristics following GnRH antagonist or agonist treatment - a comparative study

Due to inherent differences between gonadotrophin-releasing hormone (GnRH) antagonists and agonists, their late effect on ovarian steroidal production during the luteal phase of IVF cycles may differ. The aim of this study was to characterize and compare the luteal phase hormonal profile after the use of GnRH antagonists or agonists in ovarian stimulation protocols for IVF, in non-conception cycles, to avoid the effect of human chorionic gonadotrophin (HCG) during the luteal phase in conception cycles. Seventy-eight normo-ovulatory patients <35 years old, undergoing IVF due to male or tubal infertility were randomly allocated either to a GnRH antagonist (study group) or GnRH agonist treatment (control group). Similar standard luteal support was given to all patients, using vaginal micronized progesterone. In non-conception cycles, no statistically significant differences were found comparing luteal phase. oestradiol or progesterone levels in the study and control groups. No statistically significant differences were found comparing the hormonal profile dynamics, the mid-luteal (HCG day +8) oestradiol/progesterone ratio and the percentage of mid-luteal oestradiol decline between the study and control groups. In conclusion, similar characteristics and dynamics of luteal phase oestradiol and progesterone were demonstrated comparing ovarian stimulation for IVF using GnRH agonist or antagonists, under similar luteal support.     

Prenatal screening characteristics in Emanuel syndrome: a case series and review of the literature

Purpose

Emanuel syndrome is a rare chromosomal disorder characterized by severe mental retardation and multiple anomalies. The syndrome is caused by chromosomal imbalance due to a supernumerary derivative chromosome 22. Little is known regarding the characteristics of prenatal biochemical screening, or ultrasonographic markers in this syndrome. We aimed to identify a prenatal screening pattern characteristic of Emanuel Syndrome.

Methods

We report the prenatal characteristics of five fetuses with Emanuel syndrome, four of which were diagnosed prenatally.

Results

We found no consistent pattern of prenatal biochemical markers or other prenatal characteristics. Nevertheless, increased NT, low PAPP-A and ultrasound features such as intra uterine growth restriction, posterior fossa, cardiac and bowel abnormalities may be helpful in raising the suspicion for this rare genetic syndrome.

Conclusion

Review of the biochemical screening results, ultrasound findings, and demographic characteristics of this Emanuel syndrome case series, as well as of the relevant literature fail to suggest a characteristic prenatal pattern.     

Human chorionic gonadotropin serum levels following ovulation triggering and IVF cycle outcome

Purpose

The clinical significance of serum hCG levels after ovulation triggering was studied previously with conflicting results. Our aim was to study the correlation of hCG levels on the day after ovulation triggering using recombinant hCG (r-hCG) with treatment outcome.

Methods

A prospective observational study of all fresh IVF/ICSI cycles in a single medical center, between January 2015 and June 2016, was performed. hCG serum levels were obtained 10–12 h following ovulation triggering with 250 mcg r-hCG. Clinical and laboratory outcome parameters were compared between cycles with serum hCG above and below median level. A multivariate regression analysis was performed in order to study the association between hCG levels and live birth rate, after controlling for confounders.

Results

Overall, 326 cycles were included. Median serum hCG level was 91.35 IU/L. hCG levels were lower as age and BMI were higher (p?=?0.004, p?<?0.001, respectively). The study groups did not differ with regard to clinical pregnancy rate (p?=?0.14), live birth rate (p?=?0.09), fertilization rate (p?=?0.45), or metaphase II oocyte rate (p?=?0.68). On multivariate regression analysis, hCG level was not associated with live birth (aOR 0.99, 95% CI 0.98–1.005), after controlling for patient’s age and BMI.

Conclusions

hCG levels on the day after ovulation triggering with 250 mcg r-hCG are inversely correlated with patient age and BMI. However, they are not correlated with any clinical or laboratory outcome parameter. Therefore, testing for hCG levels after ovulation induction seems futile and cannot be recommended.

     

Fetal growth restriction and maternal smoking in the Macedonian Roma population: a causality dilemma

Purpose

Macedonia is one of the top five countries globally in reported smoking rates. Over 10 % of the population consists of the underprivileged Roma minority. We aimed to determine whether Roma ethnicity is an independent risk factor for adverse pregnancy outcome or merely mediating maternal smoking.

Methods

Maternal data were retrieved from the perinatal computerized database for all deliveries during 2007–2011 at the only Clinical Hospital in Bitola, Macedonia. Multivariable regression models were constructed to control for confounders.

Results

Of nearly 7,000 deliveries, 8.65 % were of maternal Roma ethnicity and 40 % of the Romani women admitted to regularly smoke during pregnancy. Both Roma ethnicity and maternal smoking were significantly associated with the absence of maternal education, history of abortions and intra uterine growth restriction (IUGR) in the univariate analysis. Both maternal Roma ethnicity (OR 2.46, 95 % CI 1.79–3.38) and smoking status (OR 1.37, 95 % CI 1.02–1.85) were found to be independent predictors of IUGR using the multivariate analysis. Lower birthweight and smaller head circumference were both independently associated with Roma ethnicity and smoking.

Conclusions

Underprivileged ethnic background is a significant risk factor for IUGR, independent of maternal smoking status. To the best of our knowledge, this is the first publication focusing on pregnancy outcome in Romani Macedonian parturients.     

Outcome of IVF pregnancies following severe OHSS

Because severe ovarian hyperstimulation syndrome (OHSS) is a potentially life-threatening iatrogenic complication, much effort is made to prevent it and the anticipated pregnancy naturally becomes of secondary importance. There are many publications on OHSS, but very few on pregnancy outcomes. This work is to review the effect of OHSS on pregnancy outcome along the pregnancy course. Hospitalized patients with severe OHSS are exposed to several insults that could affect pregnancy outcome in its early stages: the ovarian hyperstimulation for IVF itself, haemodynamic instability that involve haemoconcentration, hypoxia, liver and renal dysfunction, and exposure to high endogenous oestrogens, cytokines, renin, angiotensin and prostaglandins. There is a paucity of data on the relation of OHSS and pregnancy complications. The incidence of multiple pregnancies, gestational diabetes mellitus, placental abruption prematurity and low birthweight is higher in cases of pregnancy complicated by severe OHSS. Therefore, these pregnancies should be considered as high-risk pregnancies, and followed/treated as such. As prevention is the best ‘treatment’ for OHSS, this may imply the need for more patient-friendly or mild stimulation protocols.     

Uncertainties in inverse dynamics solutions: a comprehensive analysis and an application to gait

This paper presents a comprehensive analysis of the uncertainties in joint torque estimates derived through inverse dynamics. The analysis considered most of the quantifiable sources of inaccuracy in the input variables for inverse dynamics solutions (i.e., errors in body segment parameter estimates, joint center of rotation locations, force plate measurements, motion capture system measurements, and segment angle calculations due to skin movement artifacts). Estimates of inaccuracies were synthesized from existing literature and from a complementary set of experimental data. The analysis was illustrated and tested via an inverse dynamic analysis of gait, in which kinematic and force plate data from 10 adult subjects were recorded and used to calculate the planar (flexion/extension) torques at the ankle, knee, hip, elbow, shoulder, and bottom of torso. The results suggested that the uncertainties in torque estimates derived through inverse dynamics can be substantial (6–232% of the estimated torque magnitude); the time-varying uncertainty patterns do not resemble the torque profiles, and the magnitudes are smaller for more distal joints; the main contributors to these uncertainties were identified to be the inaccuracies in estimated segment angles and body segment parameters. The empirical test also showed that the uncertainty predicted by a more conservative (smaller) set of inaccuracy estimates was comparable to the statistical (3σ) bound of the error. Implications in terms of how inverse dynamics solutions should be interpreted and improved, along with the limitations of the current work, are discussed.     

The “Warfarin Window” in Pregnancy: The Importance of Half-life

Anticoagulation therapy during pregnancy in women with prosthetic cardiac valves is a therapeutic challenge. The use of vitamin K antagonists such as warfarin during pregnancy carries the potential for serious risks to the fetus, especially if these drugs are administered during the first trimester or at term. Between 6 and 12 weeks’ gestation, fetal synthesis of proteins crucial for bone and cartilage formation may be impaired by warfarin, resulting in the well-defined “warfarin embryopathy.” One of the most commonly suggested regimens involves the substitution of heparin for warfarin between 6 and 12 weeks’ gestation to minimize the risk of warfarin embryopathy. Warfarin has a long half-life; following a single dose, the terminal elimination half-life is about one week, with a mean effective half-life of 40 hours. To date, all existing guidelines have ignored this long elimination half-life. If a policy of substituting heparin for warfarin between 6 and 12 weeks’ gestation is followed, we suggest that substitution should begin at a much earlier gestational age. Substitution starting at 6 weeks’ gestation may be too late to avoid embryopathy.     

Unilateral hydrothorax as a sole and recurrent manifestation of ovarian hyperstimulation syndrome following in-vitro fertilization

Acute unilateral hydrothorax may appear as the sole extra-ovarian expression of severe ovarian hyperstimulation syndrome (OHSS). This case report describes two such cases, in one of which the patient developed this rare complication in two consecutive ovarian stimulation cycles. Awareness is needed for the timely and appropriate diagnosis of this rare complication that occurs 9-14 days following human chorionic gonadotrophin (HCG) administration and may recur in consecutive stimulation cycles. Thoracocentesis and fluid balance maintenance are efficient modes of therapy resulting in good outcome.