A case report highlighting drug-drug interactions between 3 life-saving treatments: Feminizing hormones, antiretrovirals and antituberculosis drugs

We here present a case providing valuable insights for clinicians who deliver care to patients identifying as transgender or nonbinary. A 30-year-old trans woman presented to sexual health services requesting a routine sexual health screen and was subsequently diagnosed with HIV and syphilis. She started antiretrovirals for HIV (bictegravir/tenoforvir alafenamide/emtricitabine) 12 days later and was treated with benzathine penicillin G. The patient also had a positive tuberculosis (TB) ELIspot blood test result and further investigations proved the presence of active TB in the chest with mediastinal involvement. She commenced treatment for TB with quadruple therapy, including rifampicin. Due to the clinically significant interaction between rifampicin and bictegravir, the patient's antiretroviral treatment was switched to dolutegravir 50 mg twice daily in combination with tenofovir disoproxil fumarate and emtricitabine. As the patient had transitioned from male to female and was self-medicating with oestrogen-containing feminizing hormone therapy, her hormonal treatment was optimized and blood levels of oestradiol were closely monitored and titrated to manage the drug-drug interaction between rifampicin and oestrogen to ensure the latter would be maintained within the expected therapeutic range. Our case report demonstrates the importance of combining treatment of multiple conditions under 1 team ideally integrated with gender services to prevent multiple attendances and mismanagement of feminizing hormone therapies.

Vaginal gonorrhoea in a transgender man reporting no vaginal sex

We present a case of a transgender man symptomatic of vaginal Neisseria gonorrhoeae infection despite reporting no receptive vaginal sex in his recent history.

Rapid ART start in early HIV infection: Time to viral load suppression and retention in care in a London cohort

OBJECTIVES

Rapid antiretroviral therapy (ART) initiation is recommended in early HIV infection (EHI), even in the absence of baseline viral resistance test result. We analysed time to viral suppression according to ART regimen started in a cohort of patients diagnosed with EHI.

METHODS

Clinical records of individuals consecutively diagnosed with EHI between July 2016-June 2018 were reviewed. The distribution of clinical, virological and immunological factors was compared in treatment groups using the Mann-Whitney U-test.

RESULTS

262 individuals (97% MSM) were diagnosed with EHI. 58% of patients agreed to start ART within 14 days of diagnosis. Tenofovir-based combinations were prescribed to all patients. DRV/b was the most commonly prescribed third agent (78%), when genotypic resistance testing was not available at time of ART choice. Switching to INSTI was encouraged once VRT became available and 27% switched from DRV/b to INSTI (mainly RAL) within 28 days from ART start. Those receiving INSTI were more likely to have a baseline viral load exceeding 1 million HIV-1 RNA copies/mL compared with those starting with DRV/b. Rapid start with INSTI regimens resulted in quicker viral suppression than when DRV/b was chosen in EHI, even when that was subsequently switched to INSTI. Retention in care following rapid ART start was achieved by all patients at 24 weeks.

CONCLUSIONS

Starting an INSTI-based ART combination was associated with quicker viral suppression than when a protease inhibitor-based combination was chosen. No differences in the achievement of viral suppression or in retention in care were observed.

Serum IgE specific to indoor moulds, measured by basophil histamine release, is associated with building-related symptoms in damp buildings

OBJECTIVE

To study the relationship between basophil histamine release (HRT) to indoor moulds, indicating specific IgE, and building-related symptoms (BRS), asthma, and hay fever in individuals working in damp and mouldy buildings.

METHODS

A cross-sectional study was performed among 86 school staff members, who on average had worked 143 months (range: 3-396) in moist buildings with mould growth in the constructions. A questionnaire concerning mucous membrane symptoms, facial skin symptoms, central nervous system symptoms, hay fever, and asthma was fulfilled by the participants, and blood samples were taken. Eight mould species growing on building constructions were identified and cultivated to obtain allergenic materials for testing. The presence in serum of IgE specific to moulds was verified by histamine release test (HRT) based on passive sensitization of basophil leukocytes. The validity of the method was confirmed by parallel testing of patients allergic to grass- and birch pollen and by the shift from positive to negative response after removal of serum IgE and by using sham sensitization.

RESULTS

The prevalence of most BRS was between 32% and 62%. Positive HRT, showing serum IgE specific to one or more of the moulds, was observed in 37% of the individuals. The highest frequency of positive HRT was found to Penicillium chrysogenum and then to Aspergillus species, Cladosporium sphaerospermum and Stachybotrys chartarum. A significant association was found between most BRS and positive HRT, whereas no association was observed between positive HRT to moulds and self reported hay fever or asthma.

CONCLUSION

Positive HRT to indoor moulds, showing the presence in serum of IgE specific to the fungi, was found to be related to BRS in individuals working in damp and mouldy buildings. Whether the association is of causal character is a question for further studies. The test may be useful in the evaluation and study of possible mould induced BRS.

Preliminary clinical results of posterior lamellar keratoplasty through a sclerocorneal pocket incision

PURPOSE

To report the preliminary results of a surgical technique for transplantation of posterior corneal tissue through a sclerocorneal pocket incision for corneal endothelial disorders.

DESIGN

Retrospective, noncomparative, interventional cases series.

PARTICIPANTS AND INTERVENTION

In seven sighted human eyes, a deep stromal pocket was created across the cornea through a 9.0-mm superior scleral incision. A 7.0- or 7.5-mm diameter, posterior lamellar disc was excised and replaced by a 'same size' donor posterior disc, without suture fixation. The scleral incision was sutured.

MAIN OUTCOME MEASURES

Intra- and postoperative complications, best spectacle-corrected visual acuity, keratometry, topography, biomicroscopy, pachymetry, and endothelial cell density were evaluated.

RESULTS

Six to 12 months after surgery, all transplants were clear and in position. Best spectacle-corrected visual acuity was limited by preexisting maculopathies in two eyes and varied from 20/80 to 20/20. Postoperative astigmatism averaged 1. 54 diopters (D; standard deviation [SD] +/- 0.81 D), pachymetry averaged 0.49 mm (SD +/- 0.09 mm), and postoperative endothelial cell density averaged 2520 cells/mm(2) (SD +/- 340 cells/mm(2)). In one eye, a microperforation occurred during stromal pocket dissection so that the procedure was converted into a penetrating keratoplasty.

CONCLUSIONS

Posterior lamellar keratoplasty through a sclerocorneal pocket incision is a feasible surgical approach to manage corneal endothelial disorders.

Manganese exposure in foundry furnacemen and scrap recycling workers

OBJECTIVES

Cast iron products are alloyed with small quantities of manganese, and foundry furnacemen are potentially exposed to manganese during tapping and handling of smelts. Manganese is a neurotoxic substance that accumulates in the central nervous system, where it may cause a neurological disorder that bears many similarities to Parkinson's disease. The aim of the study was to investigate the sources and levels of manganese exposure in foundry furnacemen by a combined measuring of blood-manganese (B-Mn) and manganese in ambient air (air-Mn).

METHODS

During a period of 16 months, Air-Mn and B-Mn (denoted 'exposure values') were measured involving 24 furnacemen employed in three small size foundries and 21 scrap recycling workers from one plant. In the study period, 18 furnacemen had B-Mn measured 3-4 weeks after decreasing or stopping exposure (denoted 'post-exposure values'). The reference group for the B-Mn measurements consisted of 90 Danish male subjects.

RESULTS

Furnacemen who work in insufficiently ventilated smelting departments inhale, absorb, and retain significant amounts of manganese in their blood (approx. 2.5-5 microg/l above reference values) despite a generally low measured airborne level of manganese fumes (0.002-0.064 mg/m(3)). The 'exposure values' compared with 'post-exposure values' revealed a significant decrease in the B-Mn (on average 3.7 microg/l) level of the most exposed furnacemen. Two persons in our study were suspected of suffering clinically subacute manganese intoxication as both had B-Mn levels beyond the normal limit (25 and 29 microg/l, respectively). The potential problem disappeared completely after cessation of exposure, and the B-Mn levels decreased to 9.4 and 14.1 microg/l, respectively.

CONCLUSIONS

Risk assessment based on combined measurements of B-Mn and air-Mn seems to be valid in the interpretation of workers' hazard. Our study indicates that B-Mn may be a valuable parameter for estimating recent exposure (within 1-2 weeks). However, more knowledge is needed about the B-Mn level and its relation to neurological symptoms.

[A quality assessment of notified occupational diseases submitted to the National Occupational Environment Service]

The aim of this study was to assess the quality of a consecutive sample of occupational disease notifications submitted to the National Working Environment Service during 1994. The sample consisted of 860 notifications describing occupational diseases among persons working in companies situated in the county of Vejle. The data information e.g. company name and address, time of employment, harmful exposure and disease, were registered. An overall data quality assessment was performed including evaluation of the etiological connection between described occupational exposure and disease and potential preventive perspectives. The study showed that the notified informations in general were adequate, but doctors need to pay more attention to dose description of the harmful exposure. About 80% of the notifications presented an adequate connection between occupational exposure and disease. Only half of the notifications described preventable and recent (less than five years) harmful exposure. In conclusion, the Danish occupational disease notification system is in general of a high standard, and the National Working Environment Service could make more use of doctors' information provided in these notifications.

A new surgical technique for deep stromal, anterior lamellar keratoplasty

AIMS

To describe a new surgical technique for deep stromal anterior lamellar keratoplasty.

METHODS

In eye bank eyes and sighted human eyes, aqueous was exchanged by air, to visualise the posterior corneal surface--that is, the "air to endothelium" interface. Through a 5.0 mm scleral incision, a deep stromal pocket was created across the cornea, using the air to endothelium interface as a reference plane for dissection depth. The pocket was filled with viscoelastic, and an anterior corneal lamella was excised. A full thickness donor button was sutured into the recipient bed after stripping its Descemet's membrane.

RESULTS

In 25 consecutive human eye bank eyes, a 12% microperforation rate was found. Corneal dissection depth averaged 95.4% (SD 2.7%). Six patient eyes had uneventful surgeries; in a seventh eye, perforation of the lamellar bed occurred. All transplants cleared. Central pachymetry ranged from 0.62 to 0.73 mm.

CONCLUSION

With this technique a deep stromal anterior lamellar keratoplasty can be performed with the donor to recipient interface just anterior to the posterior corneal surface. The technique has the advantage that the dissection can be completed in the event of inadvertent microperforation, or that the procedure can be aborted to perform a planned penetrating keratoplasty.

Posterior lamellar keratoplasty for a case of pseudophakic bullous keratopathy

PURPOSE

To describe a new surgical technique for posterior corneal transplantation.

METHODS

An elderly patient had painful, pseudophakic bullous keratopathy with low visual potential. Through a 9.0-mm scleral tunnel incision, a midstromal pocket was dissected across the cornea, and a posterior lamellar disk 7.0-mm in diameter, which consisted of posterior stroma, Descemet membrane, and endothelium, was excised. A similarly shaped donor posterior disk was implanted in the recipient opening without suture fixation, and the scleral incision was sutured.

RESULTS

Throughout the postoperative period, the posterior corneal transplant remained clear and in position. Three months after surgery, the "suture-in" astigmatic error was 3.5 diopters. Pachymetry measured 0.44 mm.

CONCLUSION

Posterior lamellar keratoplasty may be a new surgical approach with which to manage corneal endothelial disorders.

A surgical technique for posterior lamellar keratoplasty

PURPOSE

To design a surgical technique for transplantation of posterior corneal tissue, while leaving the recipient anterior cornea intact.

METHODS

In human cadaver eyes, and in a cat and monkey model, recipient eyes had an 8.0-mm limbal incision made with a diamond blade set to 50% of central pachymetry. A stromal pocket was created across the cornea, and a 6.0-mm diameter posterior lamellar disc was excised. A donor posterior disc was implanted into the recipient opening, and the limbal incision was sutured. The procedure was evaluated with keratometry, biomicroscopy, endothelial (supra)vital staining, and light microscopy.

RESULTS

In human cadaver eyes, post-operative astigmatism averaged 1.2 D (SD, +/- 0.6 D). Posterior transplants showed an intact endothelial cell layer with 1.0% (SD, +/- 1.2%) of cell death. In the animals, six (75%) eyes had clear transplants 2 weeks after surgery; one of these eyes later developed an allograft rejection. Two (25%) eyes showed corneal decompensation, because of inverted implantation of the donor disc. Microscopy showed minimal scarring at the donor-to-host interface and a normal wound-healing response at the posterior stromal wound edges.

CONCLUSION

In experimental models, posterior lamellar keratoplasty can be performed through a limbal incision and a mid-stromal pocket. The procedure may be a potential alternative in the surgical management of corneal endothelial disorders.

Neuropsychometric evaluation of long-term survivors of adult brain tumours: relationship with tumour and treatment parameters

BACKGROUND

Cognitive deficits are the hallmark of dose limiting late radiation morbidity in the CNS. Little is known about the neuropsychometric morbidity of treatment in adults with primary brain tumours. We set out to evaluate systematically the neuropsychometric function of all long-term survivors in order to document the frequency and severity of impairment and study its relationship with tumour and treatment related parameters.

MATERIALS AND METHODS

30 patients surviving in clinical and radiological remission for > 4 years following irradiation were recalled for clinical examination, CT/MRI scan and neuropsychometric testing. The 14 males, 16 females, (mean age 42.5 years), represented all but one long term survivors treated with radiotherapy in the Department of Clinical Oncology between 1971 and 1990. Twenty-five patients had a histological diagnosis of glioma. Patients treated before 1987 (n = 16) received whole brain irradiation (WBI); focused irradiation (FI) has been used since (n = 14).

RESULTS

The two groups were similar were in age, initial tumour type and surgical treatment, but the WBI group showed more evidence of neuropsychometric impairment than the FI group with significantly lower group median scores in tests of visuospatial organisation (WAIS Block Design, P = 0.01), visual memory (Rey Complex figure, P = 0.003) and complex information processing (Trails A, P = 0.003; Trails B, P = 0.002). Pre-morbid IQ estimated from sociodemographic variables, was comparable in the 2 groups which were not significantly different in their emotional state as assessed by the HADS. On univariate analysis radiation volume (P = 0.05) and time from treatment (P = 0.02) were the main factors associated with neuropsychometric deficit. Multivariate analysis by logistic regression confirmed WBI as the only independent predictor of neuropsychometric impairment (WBI vs. FI, odds ratio = 7.1, 95% C.I. 1.2-42.3, P = 0.03).

CONCLUSIONS

Neuropsychometric deficits are common and can be related to time from treatment and radiation technique. Neuropsychometric testing can be a useful tool in the evaluation of different treatment strategies.

Frequency of sister chromatid exchange and hematological effects in pesticide-exposed greenhouse sprayers

OBJECTIVES

A cross-sectional study was conducted to investigate whether exposure to pesticides in greenhouses causes hemato- or genotoxic damage in sprayers.

METHODS

The frequency of sister chromatid exchange (SCE) in cultured lymphocytes and the number of blood erythrocytes, leucocytes, and thrombocytes were studied among 134 greenhouse sprayers exposed to a complex mixture of almost 50 insecticides, fungicides, and growth regulators and among 157 referents.

RESULTS

The hematological profiles did not differ between the exposed and unexposed groups. The SCE frequency was elevated in nonsmoking, but not in currently smoking sprayers when compared with the referents. There was a slight tendency towards an increased SCE frequency with decreasing degree of protection during pesticide applications. The frequency of pesticide applications, lifetime pesticide exposure, and in-season plasma-cholinesterase inhibition (as an estimate of current exposure to organophosphates and carbamates) did not influence the SCE frequency or any of the hematological parameters.

CONCLUSIONS

The present results suggest a genotoxic effect from combined subtoxic occupational pesticide exposure, whereas no hematogenic effects could be observed at the current exposure level.

Antimicrobial antibodies in Danish slaughterhouse workers and greenhouse workers

As a consequence of contact with animals and animal products slaughterhouse workers might be at risk of infection with pathogenic microorganisms. This hypothesis has been supported by some earlier studies. In this study 217 slaughtermen and a control group of 113 greenhouse workers were investigated for the prevalence of serum antibodies to Toxoplasma gondii, Campylobacter jejuni (IgA and IgG), Yersinia enterocolitica types 3 and 9, Yersinia pseudotuberculosis types I, II, III, IV, and V, Salmonella typhi, Salmonella paratyphi, Salmonella enteritidis, Salmonella typhimurium, and Borrelia burgdorferi. No significant differences were found concerning either frequency of positive tests or magnitude of titers. The prevalence of toxoplasma antibodies was remarkably high in both groups.

A cohort study on cancer incidence among Danish gardeners

This study was performed to examine the cancer risk of Danish gardeners having been highly exposed to pesticides. We have followed a cohort of 4,015 employed gardeners (859 females and 3,156 males) from May 1975 until the end of 1984 with regard to cancer incidence. The observed incidence was compared with expected numbers calculated from national incidence rates. For all cancer sites combined, the standardized morbidity ratio (SMbR) was 104. Among male gardeners a significantly increased incidence was seen for soft tissue sarcoma (SMbR = 526, 95% confidence interval (CI): 109-1,538), an chronic lymphatic leukemia (SMbR = 275, 95% CI: 101-599). The incidence of non-Hodgkin's lymphoma was twice that which was expected (SMbR = 200, 95% CI: 86-393). We suggest that some of the pesticides to which the gardeners have been exposed are capable of initiating or promoting the development of malignant neoplasms in tissues of mesenchymal origin.

Chronic subclinical intake of dietary anticholinesterase agents during the spraying season

The dietary intake of anticholinesterase (anti-ChE) agents was estimated in 331 schoolteachers during the spraying season. Summer plasma-cholinesterase (ChE) activity was compared with the baseline value obtained during winter. Intraindividual plasma-ChE activity varied independently of factors such as drugs, non-malignant diseases, alcohol and smoking. A depressed mean plasma-ChE, indicating an intake of anti-ChE agents (P = 0.04), was observed in individuals who consumed exclusively agriculturally-grown fruits and vegetables without an additional intake of unsprayed, home-grown products. It remains to be determined whether a subclinical but chronic intake of anti-ChE agents in the diet can be hazardous to humans.

[Social and health inequality in an area of community housing in Odense]

This investigation is a cross-sectional investigation based on the registers available which describe the conditions of health in children born in 1978 and resident in 1987 in two different social districts, one of which was socially, stressed while the other was slightly less stressed. The vaccination coverage was found to be lower in the socially stressed district and lower among immigrant children. More unvaccinated children were observed among children of mothers who received public assistance and of single parents. Hospital admissions on account of diagnoses due to infection were thrice as frequent from the socially stressed district. As regards height, weight and psychomotor status, no differences were observed between the districts. The investigation indicates that social inequalities cause health inequalities and that, in particular, there appears to be a need for health-promoting efforts where the socially stressed environments are concerned e.g. immigrant families.

[Are health and disease equally distributed among children?]

Living conditions for children and young people are of great interest. In previous investigations, differences in sickness among social groups have been found. WHO plans to reduce differences in health conditions among groups within the countries by at least 25%. In this article, attention is drawn to inequalities in health among children in Denmark. Parameters such as the risk of stillbirth, congenital malformations and death during the first year of life do not differ between social groups. Where the less harsh data are concerned, inequalities still exist between social groups, also among Danish children. In relation to the goals set by WHO, it is important to be aware that the existing ways of measurement may not be sufficient.

Variation in plasma cholinesterase activity among greenhouse workers, fruitgrowers, and slaughtermen

The purpose of the study was to compare the plasma cholinesterase (ChE) activities of 100 greenhouse workers and 43 fruitgrowers engaged in spraying insecticides with those of 113 slaughtermen who served as controls. The ChE activity in the greenhouse workers and fruitgrowers was not significantly lower than in the controls. Nevertheless the ChE activity of greenhouse workers declined with increasing exposure. The wearing of protective gloves appears to be of particular value for the safety of workers.

Morbidity of pulmonary tuberculosis among silicotic and nonsilicotic foundry workers in Denmark

Increased tuberculosis risk associated with silicosis is well described. The present study defines the incidence of pulmonary tuberculosis among 5424 nonsilicotic and 155 silicotic male foundry workers observed between 1967 and 1986. For the 18-year follow-up period, the following groups had statistically significant increased standard incidence rates (SIR) for pulmonary tuberculosis: silicotics, SIR = 1000 (95% CI = 272 to 2561, P less than .01); nonsilicotics employed at least 25 years, SIR = 353 (95% CI = 130 to 768, P less than .01); and for the entire cohort, SIR = 201 (95% CI = 125 to 397, P = .01). These results suggest that silica exposure may cause an increased pulmonary tuberculosis risk among nonsilicotic foundry workers.