Efficacy and safety of a single-tablet regimen containing tenofovir disoproxil fumarate 300 mg, lamivudine 300 mg and efavirenz 400 mg as a switch strategy in virologically suppressed HIV-1-infected subjects on nonnucleoside reverse transcriptase inhibitor-containing first-line antiretroviral therapy in Pune, India

OBJECTIVES

As per National AIDS Control Organization (NACO) estimates, there are 2.1 million people living with HIV (PWH) in India, of whom 1.2 million are on first-line antiretroviral therapy (ART). This study explored the use of a single-tablet regimen containing tenofovir disoproxil fumarate 300 mg + lamivudine 300 mg + efavirenz 400 mg (TLE400 STR) as a first-line switch strategy in PWH in Pune, India.

METHODS

This retrospective cohort study was conducted in private sector ART clinics in three tertiary-level hospitals in Pune, India. PWH > 12 years of age (n = 502) who initiated first-line ART (predominantly TLE600 STR), completed ≥ 6 months of follow-up and achieved virological suppression [plasma viral load (VL) < 1000 HIV-1 RNA copies/mL] were identified and switched to TLE400 STR. The virological and immunological efficacy of TLE400 STR at 6 and 12 months of follow-up were noted. Grade 3/4 adverse events (especially efavirenz-related neuropsychiatric adverse events) leading to regimen discontinuation were also noted.

RESULTS

Of 502 PWH who switched to TLE400 STR, complete virological suppression (VL < 20 copies/mL) was maintained in more than 97% of patients at follow-up. TLE400 STR was successful in maintaining CD4 counts within the range observed at the start of the regimen. Grade 3/4 adverse events leading to TLE400 STR discontinuation were seen in 11 (2.2%) patients. Virological failure (VL > 1000 copies/mL) and treatment regimen failure were seen in six (1.2%) and 49 (9.8%) subjects, respectively.

CONCLUSIONS

TLE400 STR exhibits excellent efficacy and safety as a switch strategy and should be introduced in the Indian National ART Program, especially for PWH who are virologically suppressed on TLE600 STR.

Copper levels & reactive oxygen species in uterine flushings in copper intrauterine contraceptive device users

Copper levels were estimated in the uterine flushings in 15 copper 'T' 200 device acceptors. There was a statistically significant difference in the preinsertion and one week post insertion values (P < 0.001). This also corresponded to a high level of generation of reactive oxygen species. The levels of reactive oxygen species were similar to preinsertion values at 4 and 12 wk. The copper values declined over the 3 months but were still higher at 12 wk as compared to preinsertion levels and this difference was statistically significant. Hence addition of copper to the intrauterine device besides enhancing the contraceptive efficacy, perhaps also plays an important role in microbicidal activity and helps in overcoming the infection introduced at the time of insertion.

Asymptomatic axial torsion of the pregnant uterus: a cause of the failure of induction of mid-trimester abortion

Torsion of gravid uterus is a rare obstetric condition in which diagnosis is usually made only on laparotomy. A case of asymptomatic axial torsion of uterus during mid-trimester, because of an ovarian cyst is reported. This presented as a failure of induction of abortion by extra-amniotic isotonic saline instillation and oxytocin infusion.

A continuum model of elephant trunks

A continuum model is presented that relates the trunk parameters of loading, geometry, and muscle structure to the necessary conditions of static equilibrium. Linear theory for stress-strain behavior is used to describe an elephant trunk for an incremental displacement as the animal slowly lifts a weight at the trunk tip. With this analysis and experimental values for the trunk parameters, the apparent trunk stiffness Ea is estimated for the living animal. For an Asian elephant with a maximum compression strain of 33 percent, Ea is of the order of 10(6) N/m2. The continuum model is quite general and may be applied to similar nonskeletal appendages and bodies of other animals.

Macroscopic tuboplasty: reversal of female sterilization

Data is presented regarding 57 women who underwent reversal of sterilization procedure. In the majority (90%), the reason for request for reversal of procedure was loss of male child or more than one child. Thirteen subjects never came back for follow-up. Out of 39 subjects in whom follow-up is available for more than 3 months, in 35 (90%) the tubes are patent. There were 25 pregnancies in 21 subjects and incidence of viable pregnancy was 88% with only ectopic pregnancy (4%). In these 35 cases whose tubes were found to be patent post tuboplasty, 18 had laparoscopic ring application, 16 had abdominal tubal ligation and one had undergone vaginal tubal ligation. Thirteen subjects (62%) conceived within 6 months after reversal. In this series, no loupe or operating microscope was used.

Ultrasound guided intrauterine transfusion

Intrauterine transfusion was performed on 12 occasions in 9 Rh-sensitizedwomen. Under constant real-time ultrasound guidance, a 17G Touhy needle was negotiated through a placenta-free area and advanced into the foetal abdomen to reach the peritoneal cavity. After confirming the position of the needle, either by aspiration of foetal ascitic fluid or by injecting air into the peritoneal cavity, an epidural catheter was passed through the needle and the transfusion was accomplished. This procedure was successful in 11 (91%) of the 12 instances. In one patient the needle could not be placed in the foetal peritoneal cavity despite repeated. attempts; she developed pyrexia and went into spontaneous labour. The neonatal survival rate was 22% (2/9). The ultrasound guided technique not only eliminates the risk of radiation hazards, but also helps in precise placement of the needle in the uterus and foetal peritoneal cavity, which makes intrauterine transfusion safe.

A comparison of extra-amniotic physiological saline and ethacridine dye instillation for induction of mid-trimester abortion

In a prospective, randomized study of 209 patients, we induced mid-trimester abortion by instilling either normal saline (105cases) or ethacridine dye (Emcredil^®) (104cases) extra-amniotically. The mean induction-abortion interval for saline was 18 hours 25 minutes and for emcredil20 hours 12minutes. For a 'cut-off' time of30 hours there were 9 failures with normal saline and 7 failures with ethacridine but all women eventually aborted without surgical intervention. In the saline group the induction-abortion interval was longer in the more advanced than in the less advanced pregnancies. No difference was observed in bacteriological studies from samples collected before and 24 hours after instillation of the solution. We conclude that normal saline is a cheap, easily available and safe abortifacient.

Spectrophotometric analysis of amniotic fluid in Rh immunised pregnancies

A total of 307 amniotic fluid analysis done in 344 Rh negative immunised mothers showed that 46, 83 and 178 delta OD values at 450 millimicrons fell in the upper, middle and lower zones of Liley's charts respectively. The correlation of spectrophotometric analysis with the condition of the baby at birth was about 95 per cent in the upper and lower zones. In the middle zone, however, it was about 75 per cent only. Also, in 7 women in whom the OD at 450 millimicrons fell in the middle zone, the babies were found to be Rh negative; in another baby, the OD difference fell in upper zone. In spite of these limitations amniotic fluid examination seems to be an important single guide to severity, being superior to other parameters like previous obstetric history, antibody titre alone and Liley's charts, which are still widely used.

Laparoscopic removal of translocated intrauterine contraceptive devices

Data is presented regarding 20 translocated intrauterine contraceptive devices (IUCD). Successful laparoscopic removal was made in 13 (65%) cases though all these devices were Copper 'T' 200 model which tend to produce dense adhesions. Only when the IUCD was suspected to be partially or fully in the gut lumen or thick adhesions were present, or the device was not visualised, was laparotomy performed. Hence it is advocated that laparoscopy should be performed as a routine in patients with suspected translocated IUCD, as it obviates the need for laparotomy and thus decreases the duration of the hospital stay as well as preventing morbidity associated with laparotomy.

The Mechanics and Positioning of Highly Flexible Manipulator Limbs

This paper deals with the analysis of lightweight, flexible robotic limbs. A typical limb is a series of polymeric tube elements. One end is fixed and the payload at the other end is manipulated by varying the internal pressure in each element. The theoretical derivations relating limb position and its payload incorporate the nonlinear elastic properties of the element material and large deflections. A computer program stores information about limb position and after each successive limb manipulation the program adaptively upgrades itself to improve positioning accuracy. Results are illustrated with a numerical example.

Management of translocated and incarcerated intrauterine contraceptive devices

Thirty-seven consecutive patients who reported with absent or snapped strings and failed attempts at removal of intrauterine contraceptive devices (IUCD) by hooks or curette were posted for hysteroscopy/laparotomy following a plain X-ray of the pelvis to exclude unrecognized spontaneous expulsion. Direct visualization of the endometrial cavity was invaluable in locating and removing IUCDs, particularly the embedded and fragmented ones. Translocated medicated devices were associated with dense adhesions, suggesting the need for their prompt removal. There appears to be an increased risk of translocation in lactating women.