Vaginal deliveries in a tertiary centre: a current profile

Background: A normal delivery is what every woman wishes to have. The objective of this study was to find out the maternal and neonatal outcome and background characteristics of women delivering vaginally in a tertiary care center in Chennai, South India.Methods: For this one-year study, with power above 80%, Parturition records were selected by computerized random numbers, for a calculated sample size. Salient demographic features such as age, residential background and religion were noted. Details of obstetric history, past and current, delivery and baby details and admission to NICU were analyzed. Acceptance of postpartum contraception was noted.Results: A total of 338 women delivered vaginally. Majority of 63%, were from urban background. Late referrals were 19.2% of women,38.5% women had antenatal complications. Primigravida were 49.7%. Nearly 91.4% of women delivered naturally. Previous pregnancy loss was noted in 14.8%. Term deliveries were in 72% of women, and 2.7% of women delivered twins. Average birth weight among primi was 2.5kg and in multi it was 2.8 kg. There were no maternal deaths. Perinatal deaths of 2.96%, of which 90% were preterm births, and all among babies with birth weight below 1.5 kg.Conclusions: The larger majority of 91.4% of women had natural vaginal delivery. Primigravida were 49.7%, and 63% were from urban background. Antenatal complications, obstetric, medical or other complications were noted in 38.5 % of women. Most often observed complications were Gestational hypertension, Gestational diabetes, and Hypothyroidism. NICU care was required for 18% of babies. Preterm births were16.6%. Perinatal deaths were seen in 2.96% of babies. There were no maternal deaths.

Lack of association between plasma levels of non-nucleoside reverse transcriptase inhibitors & virological outcomes during rifampicin co-administration in HIV-infected TB patients.

Background & objectives: Among patients with HIV-associated tuberculosis (TB), reduced plasma non-nucleoside reverse transcriptase inhibitors (NNRTI) concentrations during rifampicin (RMP) co-administration could lead to HIV treatment failure. This study was undertaken to examine the association between plasma nevirapine (NVP) and efavirenz (EFV) concentrations and virological outcomes in patients infected with HIV-1 and TB. Methods: This was a nested study undertaken in a clinical trial of patients with HIV-1 and TB, randomized to two different once-daily antiretroviral treatment (ART) regimens along with anti-TB treatment (ATT). Trough concentrations of plasma NVP and EFV were estimated at months 1 (during ATT and ART) and 6 months (ART only) by HPLC. Plasma HIV-1 RNA level >400 copies/ml or death within 6 months of ART were considered as unfavourable outcomes. Genotyping of CYP2B6 516G>T polymorphism was performed. Results: Twenty nine per cent of patients in NVP arm had an unfavourable outcome at 6 months compared to 9 per cent in EFV arm (P<0.08). The mean NVP and EFV levels estimated at 1 and 6 months did not significantly differ between favourable and unfavourable responders. Logistic regression analysis showed CYP2B6 516G>T polymorphism significantly associated with virologic outcome in patients receiving EFV–based regimen. Interpretation & conclusions: Trough plasma concentrations of NVP and EFV did not show any association with response to ART in patients on ATT and once-daily ART. CYP2B6 516G>T polymorphism was associated with virologic outcome among patients on EFV.

Luciferase reporter phage phAE85 for rapid detection of rifampicin resistance in clinical isolates of Mycobacterium tuberculosis

OBJECTIVE@#To evaluate luciferase reporter phage (LRP) phAE85 in rapid detection of rifampicin resistance in a region where TB is endemic.@*METHODS@#One hundred and ninety primary isolates on Lowenstein-Jensen medium were tested. Middlebrook 7H9 complete medium with and without rifampicin at 2 μg/mL was inoculated with standard inoculum from suspensions of the clinical isolate. After incubation for 72 h, LRP was added. Following 4 h of further incubation, light output from both control and test was measured as relative light units. Strains exhibiting a reduction of less than 50% relative light units in the drug containing vial compared to control were classified as resistant. Results were compared with the conventional minimum inhibitory concentration method (MIC) of drug susceptibility testing.@*RESULTS@#The two methods showed high level of agreement of 97% (CI 0.94, 0.99) and P value was 0.000 1. The sensitivity and specificity of LRP assay for detection of rifampicin resistance were 91% (CI 0.75, 0.98) and 99% (CI 0.95, 1.00) respectively. Time to detection of resistance by LRP assay was 3 d in comparison with 28 d by the minimum inhibitory concentration method.@*CONCLUSIONS@#LRP assay with phAE85 is 99% specific, 91% sensitive and is highly reproducible. Thus the assay offers a simple procedure for drug sensitivity testing, within the scope of semi-automation.

Long term follow up of HIV-infected patients with tuberculosis treated with 6-month intermittent short course chemotherapy.

BACKGROUND: Tuberculosis occurs in 60%-70% of HIV-positive persons in India. The outcome of HIV-positive patients treated with 6-month intermittent short course antituberculosis regimens in India is not well described. METHODS: This was a prospective observational feasibility study of 71 patients with HIV and tuberculosis who were treated with category I regimen of the Revised National Tuberculosis Control Programme (ethambutol, isoniazid, rifampicin and pyrazinamide thrice weekly for the initial 2 months followed by rifampicin and isoniazid thrice weekly for the next 4 months). Sputum was examined by smear and culture for Mycobacterium tuberculosis every month up to 24 months. Chest X-ray, CD4 cell count and viral load were done prior to and at the end of treatment. None of the patients received antiretroviral therapy. RESULTS: We present here the treatment response of patients with sputum culture-positive pulmonary tuberculosis to category I regimen. By efficacy analysis, among 43 patients treated with category I regimen, sputum smear conversion was observed in 79% and culture conversion in 82% at the second month. A favourable response was seen in 72% of patients. The mean (SD) CD4% fell from 12.6 (5.9) to 8.9 (4.9) (p < 0.001) with no significant change in mean (SD) CD4 cell count (169 [126] to 174 [158]; ns) at the end of treatment. Viral load change from 1.8 x 10(5) at baseline to 1.3 x 10(5) at the end of treatment was not statistically significant. Thirty-one patients, who completed the full course of treatment, were declared cured and were followed up for 24 months. Twelve had recurrent tuberculosis (39%); 16 of 43 (37%) patients had died by the end of 24 months, two-thirds due to causes other than tuberculosis. CONCLUSION: Though the early bacteriological response to intermittent short course antituberculosis regimen was satisfactory, the overall outcome was adversely affected by the high mortality (during and after completion of treatment) and recurrence rate among HIV-infected patients with tuberculosis. Immune status deteriorated in spite of antituberculosis treatment, highlighting the need for antiretroviral treatment in addition to antituberculosis treatment to improve the long term outcome. The results of this pilot study need to be confirmed by larger studies.

Miliary tuberculosis in human immunodeficiency virus infected patients not on antiretroviral therapy: clinical profile and response to shortcourse chemotherapy.

BACKGROUND: An increase in tuberculosis (TB) incidence has been associated with human immunodeficiency virus (HIV). AIMS: To describe the clinical characteristics and treatment outcome of patients with HIV and miliary TB treated with short-course intermittent chemotherapy in the absence of access to highly active antiretroviral therapy (HAART). SETTINGS AND DESIGN: Prospective study of HIV infected adults referred to a TB clinic between July 1999 and July 2004. MATERIALS AND METHODS: On diagnosis of miliary TB, patients were treated with a standard regimen of two months of isoniazid, rifampicin, ethambutol and pyrazinamide followed by four months of isoniazid and rifampicin (2EHRZ 3 /4RH 3 ) thrice weekly and followed up for 24 months. Patients were reviewed clinically every month and two sputa were collected. Chest radiographs and blood investigations were done at two months, end of treatment and every six months thereafter. RESULTS: Of 498 patients with HIV and tuberculosis, 31 (6%) were diagnosed as miliary tuberculosis. At diagnosis, sputum smear was positive for acid-fast bacilli (AFB) in 14 patients (45%) and Mycobacterium tuberculosis was isolated in 21 (68%). The mean CD4 cell count was 129 +/- 125 cells/mm3 . Twenty-five patients were declared cured at the end of treatment (81%) while one (3%) died and five (16%) failed. The recurrence rate was 19.4/100 person-years and the median survival was 17 months (95% CI 14 to 20). None of the patients received antiretroviral therapy. CONCLUSIONS: Miliary TB tends to occur among HIV infected patients with severe immunosuppression. Though the initial response to short-course chemotherapy was encouraging, a high recurrence rate and mortality was observed indicating poor prognosis in HIV.

Evaluation of Directly Observed Treatment Providers in the Revised National Tuberculosis Control Programme.

Background: Non-governmental personnel such as Anganwadi workers and community volunteers have been used as directly observed treatment (DOT) providers in the Revised National Tuberculosis Control Programme (RNTCP), but their effectiveness has not been documented. Aim: To assess the treatment outcome and problems encountered by patients managed by different DOT providers in the RNTCP. Material and Methods: Patients diagnosed with tuberculosis at 17 Primary Health Institutions (PHIs) in Tiruvallur District during a 3-year period received DOT from one of the four types of trained DOT providers (PHI staff, governmental outreach workers, Anganwadi workers, community volunteers), and their treatment outcomes were compared. Of the 1131 new smear-positive patients treated between May 1999 through June 2002, 199 (18%) received DOT from PHI staff, 238(21%) from outreach workers, 496 (44%) from Anganwadi workers, and 170 (15%) from community volunteers. Twenty-eight patients (2%) collected drugs for self-administration. Results: Treatment success rates among patients treated by different DOT providers, Anganwadi workers (80%), governmental outreach workers (81%), community volunteers (76%) and PHI staff (76%), were statistically similar. Patients who received drugs for self-administration were significantly more likely to fail to treatment or die than patients who were treated by a DOT provider (5/28 versus 84/1103; odds ratio=4.1; 95% confidence interval=1.2-12.6; p=0.02). Conclusion: In addition to governmental staff, Anganwadi workers and community volunteers can be effectively utilized as DOT providers.