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Low sensitivity of total lymphocyte count as a surrogate marker to identify antepartum and postpartum Indian women who require antiretroviral therapy.
Journal of Acquired Immune Deficiency Syndromes. 2007 Nov; 46(3):338-342.Some studies support the use of total lymphocyte count (TLC) as a surrogate marker for CD4 cell count to guide antiretroviral therapy (ART) initiation. However, most of these studies have focused on nonpregnant adults. In light of expanding ART access through prevention of mother-to-child transmission (PMTCT)-plus programs in resource-limited settings, we assessed the sensitivity, specificity, and positive predictive value (PPV) of TLC for predicting low CD4 counts in antepartum and postpartum women in Pune, India. CD4, TLC, and hemoglobin were measured at third trimester, delivery, and 6, 9, and 12 months postpartum (PP) in a cohort of 779 HIV-infected women. Optimal TLC cutoff for predicting CD4 < 200 cells/mm3 was determined via logistic regression where sensitivity, specificity, PPV, and an area under the receiver operating characteristic (ROC) curve were calculated. Among the 779 women enrolled, 16% had WHO clinical stage 2 or higher and 7.9% had CD4 < 200 cells/mm3. Using 2689 TLC-CD4 pairs,the sensitivity, specificity, and PPV of TLC < 1200 cells/mm3 for predicting CD4 < 200 cells/mm3 was 59%, 94%, and 47%, respectively. The sensitivity of TLC < 1200 cells/mm3 cutoff ranged between 57% and 62% for time points evaluated. Addition of hemoglobin < 12 g/dL or < 11 g/dL increased the sensitivity of TLC to 74% to 92% for predicting CD4 < 200 cells/mm3 but decreased the specificity to 33% to 69% compared to TLC alone. A combination of TLC, hemoglobin, and WHO clinical staging had the highest sensitivity but lowest specificity compared to other possible combinations or use of TLC alone. The sensitivity and specificity of TLC < 1200 cells/mm3 to predict a CD4 < 350 cells/mm3 was 31% and 99%, respectively. Our data suggest that antepartum and PP women with TLC < 1200 cells/mm3 are likely to have CD4 < 200 cells/mm3. However, the sensitivity of this TLC cutoff was low. Between 45% and 64% of antepartum and PP women requiring initiation of ART may not be identified by using TLC alone as a surrogate markerfor CD4 < 200 cells/mm3. The WHO-recommended TLC cutoff of < 1200 cells/mm3 is not optimal for identifying antepartum and PP Indian women who require ART. (author's)
Are the WHO (1980) criteria for the 75 g oral glucose tolerance test appropriate for pregnant women?
BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY. 1993 Jul; 100(7):645-8.To assess the normal response to the 75 gm oral glucose tolerance test (OGTT) in normal pregnant women, healthy Chinese and Malay women who had been referred to the antenatal clinic of the Department of Reproductive Medicine, Kandang Kerbau Hospital, Singapore, were evaluated. The women were selected on the basis of having none of the generally accepted risk factors for diabetes mellitus: their age was < 35 years, they weighed < 80 kg, they did not have a personal history of diabetes or a family history of diabetes or a family history of diabetes in first degree relatives, nor did they have a history of babies weighing > 4000 gm at birth, still-births, neonatal deaths, congenital malformations, or recurrent miscarriages. All OGTTs were performed after 28 weeks of gestation. The fasting blood sample was taken from the antecubital vein. Further samples were taken 1 and 2 hours after the glucose drink. A glucose analyzer using 5 mcl of plasma was employed. The analytical method was based on the glucose oxidase/peroxidase/aminophenazone process. There was no significant difference in mean glucose levels at corresponding points of the OGTT in Chinese and Malay women. correlation calculations confirmed the absence of any influence of gestational age after 28 weeks on glucose tolerance. Of the 64 women, 47 were Chinese and 17 Malays; 20 wee nulliparous, and 44 were parous. Their mean age was 27.2 years (range 18-35). The mean birthweight of the infants was 3140 gm (range 2094-4240 gm). There were 33 female and 31 male infants. The mean apgar scores at 1 and 5 min were 8.8 (range 7-9) and 9.0 (range 6-10). The mean values and the proposed upper limits of normality for the 75 gm OGTT were 3.9 and 4.9 mmol/1, respectively. 6 women had abnormal OGTT results according to the WHO criteria (fasting glucose > 6 mmol/1; 2 hour glucose > 8 mmol/1).