Historical epidemiology of hepatitis C virus in select countries-volume 4

Due to the introduction of newer, more efficacious treatment options, there is a pressing need for policy makers and public health officials to develop or adapt national hepatitis C virus (HCV) control strategies to the changing epidemiological landscape. To do so, detailed, country-specific data are needed to characterize the burden of chronic HCV infection. In this study of 17 countries, a literature review of published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates was conducted, and inputs were validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Hong Kong to 2.4% in Taiwan, while the largest viraemic populations were in Nigeria (2 597 000 cases) and Taiwan (569 000 cases). Diagnosis, treatment and liver transplant rates varied widely across the countries included in this analysis, as did the availability of reliable data. Addressing data gaps will be critical for the development of future strategies to manage and minimize the disease burden of hepatitis C.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm: Volume 4

Factors influencing the morbidity and mortality associated with viremic hepatitis C virus (HCV) infection change over time and place, making it difficult to compare reported estimates. Models were developed for 17 countries (Bahrain, Bulgaria, Cameroon, Colombia, Croatia, Dominican Republic, Ethiopia, Ghana, Hong Kong, Jordan, Kazakhstan, Malaysia, Morocco, Nigeria, Qatar and Taiwan) to quantify and characterize the viremic population as well as forecast the changes in the infected population and the corresponding disease burden from 2015 to 2030. Model inputs were agreed upon through expert consensus, and a standardized methodology was followed to allow for comparison across countries. The viremic prevalence is expected to remain constant or decline in all but four countries (Ethiopia, Ghana, Jordan and Oman); however, HCV-related morbidity and mortality will increase in all countries except Qatar and Taiwan. In Qatar, the high-treatment rate will contribute to a reduction in total cases and HCV-related morbidity by 2030. In the remaining countries, however, the current treatment paradigm will be insufficient to achieve large reductions in HCV-related morbidity and mortality.

Strategies to manage hepatitis C virus infection disease burden-Volume 4

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 17 countries in Africa, Asia, Europe, Latin America and the Middle East, and interventions for achieving the Global Health Sector Strategy on viral hepatitis targets-"WHO Targets" (65% reduction in HCV-related deaths, 90% reduction in new infections and 90% of infections diagnosed by 2030) were considered. Scaling up treatment and diagnosis rates over time would be required to achieve these targets in all but one country, even with the introduction of high SVR therapies. The scenarios developed to achieve the WHO Targets in all countries studied assumed the implementation of national policies to prevent new infections and to diagnose current infections through screening.

The European Innovation Partnership on Active and Healthy Ageing Synergies: Protocol for a Prospective Observational Study to Measure the Impact of a Community-Based Program on Prevention and Mitigation of Frailty (ICP - PMF) in Community-Dwelling Older Adults

Aim of this paper is to describe the protocol of the study "Impact of a Community-based Program on Prevention and Mitigation of Frailty in community-dwelling older adults" developed in the framework of the European Innovation Partnership on Active and Healthy Ageing. This proposal has been developed by the Partnership Action groups on frailty, fall prevention and polypharmacy in older. The proposal wants to assess the impact of community-based programs aimed to counteract three main outcomes related to frailty: hospitalization, institutionalization and death. Bringing together researchers from seven European countries, the proposal aims to achieve the critical mass and the geographical extension enough to provide information useful to all older European citizens. An observational study will be carried out to calculate the incidence of the different outcomes in relation to the various interventions that will be assessed; results will be compared with data coming from already established national, regional and local dataset using the observed/expected approach. The sample will be made up by at least 2000 citizens for each outcome. All the citizens will be assessed at the baseline with two multidimensional questionnaires: the RISC questionnaire and the Short Functional Geriatric Evaluation questionnaire. The outcomes will be assessed every six-twelve months.

Hepatitis E in patients with hepatic disorders and HIV-infected patients in Croatia: is one diagnostic method enough for hepatitis E diagnosis?

We assessed hepatitis E virus (HEV) seroprevalence in patients with hepatic disorders as well as in human immunodeficiency virus (HIV)-infected patients and emphasised the issue of possible non-specific anti-HEV seroresponse and need for combining diagnostic methods for hepatitis E diagnosis. Over a two-year period, from March 2011 to February 2013, we determined anti-HEV immunoglobulin M (IgM) and IgG by enzyme immunoassays (EIA; Mikrogen, Germany) in 504 hepatitis patients negative for acute viral hepatitis A-C. Furthermore, 88 samples from randomly selected consecutive HIV-infected patients were also analysed. All EIA reactive samples were additionally tested by line immunoblot assays (LIA; Mikrogen, Germany). HEV nested reverse transcription polymerase chain reaction (RT-PCR) was carried out in 14 anti-HEV IgM LIA-positive patients. Anti-HEV IgM or IgG were detected in 16.9 % of patients by EIA and confirmed by LIA in 10.7 % [95 % confidence interval (CI) 8.3-13.7 %] of hepatitis patients. HEV RNA was detected in five patients. The agreement between EIA and LIA assessed by Cohen's kappa was 0.47 (95 % CI 0.55-0.75) for IgM and 0.83 (95 % CI 0.78-0.93) for IgG. Anti-HEV IgM and IgG seroprevalence in HIV-infected patients was 1.1 %, respectively. Our findings show a rather high HEV seroprevalence in patients with elevated liver enzymes in comparison to HIV-infected patients. Discordant findings by different methods stress the need to combine complementary methods and use a two-tier approach with prudent interpretation of reactive serological results for hepatitis E diagnosis.

The state of hepatitis B and C in the Mediterranean and Balkan countries: report from a summit conference

The burden of disease due to chronic viral hepatitis constitutes a global threat. In many Balkan and Mediterranean countries, the disease burden due to viral hepatitis remains largely unrecognized, including in high-risk groups and migrants, because of a lack of reliable epidemiological data, suggesting the need for better and targeted surveillance for public health gains. In many countries, the burden of chronic liver disease due to hepatitis B and C is increasing due to ageing of unvaccinated populations and migration, and a probable increase in drug injecting. Targeted vaccination strategies for hepatitis B virus (HBV) among risk groups and harm reduction interventions at adequate scale and coverage for injecting drug users are needed. Transmission of HBV and hepatitis C virus (HCV) in healthcare settings and a higher prevalence of HBV and HCV among recipients of blood and blood products in the Balkan and North African countries highlight the need to implement and monitor universal precautions in these settings and use voluntary, nonremunerated, repeat donors. Progress in drug discovery has improved outcomes of treatment for both HBV and HCV, although access is limited by the high costs of these drugs and resources available for health care. Egypt, with the highest burden of hepatitis C in the world, provides treatment through its National Control Strategy. Addressing the burden of viral hepatitis in the Balkan and Mediterranean regions will require national commitments in the form of strategic plans, financial and human resources, normative guidance and technical support from regional agencies and research.

Variation in clinical presentation of childhood group A streptococcal pharyngitis in four countries

We conducted a cross-sectional study from September 2001 to August 2003 during which children between 2 and 12 years of age presenting with complaint of sore throat were recruited from urban pediatric clinics in Brazil, Croatia, Egypt and Latvia. The objective of the study was to compare clinical signs and symptoms of children presenting to urban pediatric clinics with sore throat in and between countries and to identify common clinical criteria predicting group A beta hemolytic streptococcal (GAS) pharyngitis. Using a single standard protocol in all four sites, clinical data were recorded and throat swabs obtained for standard GAS culture in 2040 children. Signs and symptoms were tested for statistical association with GAS positive/negative pharyngitis, and were compared using chi(2) tests, ANOVA and Odds Ratios. Clinical signs of GAS pharyngitis in children presenting to clinics varied significantly between countries, and there were few signs or symptom that could statistically be associated with GAS pharyngitis in all four countries, though several were useful in two or three countries. Our results indicate that the clinical manifestations of pharyngitis in clinics may vary by region. It is therefore critical that clinical decision rules for management of pharyngitis should have local validation.

Chemokines CXCL10 and CXCL11 in the cerebrospinal fluid of patients with tick-borne encephalitis

OBJECTIVES

The aim of our study was to determine whether cerebrospinal fluid (CSF) of patients with tick-borne encephalitis (TBE) contains CXCL10, CXCL11, p40 subunit of interleukin-12 (IL-12)/IL-23, IL-18 and IL-15. We compared serum and CSF concentrations of CXCL10 and analysed the possible concentration gradient of this chemokine between the periphery and central nervous system.

MATERIALS AND METHODS

The study enrolled 19 TBE patients and 10 patients with non-inflammatory neurological diseases.

RESULTS

CSF of TBE patients contained CXCL10 (median 217 pg/ml), CXCL11 (8.3 pg/ml), p40 subunit of IL-12/IL-23 (38.9 pg/ml), IL-18 (30.1 pg/ml) and IL-15 (5.9 pg/ml). CXCL10 in the CSF of TBE patients was higher compared with serum (median 62 pg/ml, P < 0.001).

CONCLUSION

CSF of TBE patients contains CXCL10, CXCL11, p40 subunit of IL-12/IL-23, IL-18 and IL-15. Increased CXCL10 concentration in CSF suggests a role for this chemokine in the recruitment of CXCR3-expressing T-cells into the CSF of TBE patients.

Evaluation of the WHO clinical decision rule for streptococcal pharyngitis

AIMS

To prospectively assess the WHO clinical decision rule (CDR) for group A beta haemolytic streptococcal (GABHS) pharyngitis in three countries.

METHODS

A prospective, observational cohort study in urban outpatient clinics in Rio de Janeiro, Cairo, and Zagreb. There were 2225 children aged 2-12 years with cough, rhinorrhoea, red or sore throat; 1810 of these with sore throat were included in the analysis.

RESULTS

The proportion of children presenting with sore throat and found to have GABHS pharyngitis ranged from 24.6% (Brazil) to 42.0% (Croatia). WHO CDR sensitivity was low for all sites in both age groups. In children age 5 or older, sensitivity ranged from 3.8% in Egypt to 10.8% in Brazil. In children under 5, sensitivity was low (0.0-4.6%) Specificity was high in both age groups in all countries (93.8-97.4%).

CONCLUSIONS

In these populations, the current WHO CDR has high specificity, but low sensitivity; it did not detect up to 96.0% of children who have laboratory confirmed GABHS pharyngitis. A CDR with higher sensitivity should be developed for use in regions where rheumatic fever and rheumatic heart disease are still major health problems.

Increased numbers of CD38 molecules on bright CD8+ T lymphocytes in infectious mononucleosis caused by Epstein-Barr virus infection

The aim of this study was to quantify the expression of CD38 on CD8+ T lymphocytes of patients with infectious mononucleosis (IM) caused by Epstein-Barr virus (EBV) and cytomegalovirus (CMV). CD38 quantification technique chosen for this study was based on the enumeration of CD38 antibody binding sites in comparison to the quantification standards rather than determining relative fluorescence, which is difficult to standardize. The study enrolled 19 patients with typical clinical and laboratory parameters compatible with EBV-induced IM as well as 10 patients with atypical clinical presentation of this disease. Furthermore, CD38 expression was analysed in a group of 13 patients with IM caused by CMV infection. CD38 quantification was performed within 6 days of the presentation of symptoms. All three groups of IM patients showed a statistically significant increase in the number of anti-CD38 antibody binding sites (which correspond to the number of CD38 molecules) on bright CD8+ T lymphocytes compared to healthy controls. The numbers of CD38 molecules expressed on CD8+ T lymphocytes did not differ significantly between IM patients with typical and atypical clinical presentation of the disease. Patients with CMV-induced IM had significantly lower numbers of CD38 molecules expressed on CD8+ T lymphocytes. Therefore, we conclude that CD38 quantification could be helpful in differential diagnostics of IM cases with atypical clinical presentation.

Low prevalence of hepatitis C virus infection among human immunodeficiency virus type 1-infected individuals from Slovenia and Croatia

The prevalence of hepatitis C virus (HCV) infection in the population of human immunodeficiency virus 1 (HIV-1)-infected individuals from Slovenia and Croatia was determined. One hundred and sixty-six out of a total of 188 Slovenian HIV-1-infected individuals and 120 subjects who were randomly chosen out of a total 342 Croatian HIV-1 antibodies-positive individuals were tested for HCV infection. Detection of HCV antibodies was carried out by a third generation enzyme-linked immunoassay (ELISA) and the positive samples were additionally tested by a third generation immuno-blot assay. Additionally, the presence of HCV RNA was determined in all serum samples by a qualitative polymerase chain reaction (PCR). Twenty-four (14.5%) out of 166 Slovenian and 18 (15.0%) out of 120 Croatian HIV-1-infected individuals were HCV antibodies-positive. Nineteen out of 24 (79.2%) Slovenian and 13 out of 18 (72.2%) Croatian anti-HCV positive individuals were also viremic. HCV RNA was not detected in any of 244 HCV antibodies-negative/HIV-1-infected individual from both countries. A significant difference in the prevalence of HCV infection between blood (77.8% in Slovenia and 66.7% in Croatia) and sexual exposure risk groups (1.6% in Slovenia and 6.6% in Croatia) was found in both countries. In a study carried out on the highest proportion of entire population of HIV-1-infected individuals from a certain country or geographic region, Slovenia and Croatia were identified as countries with the second and third lowest prevalence of HCV infection among HIV-1/HIV-2 infected individuals worldwide.

Comparative analysis of azithromycin and clarithromycin efficacy and tolerability in the treatment of chronic prostatitis caused by Chlamydia trachomatis

A total of 123 patients, older than 18 years of age, with symptoms of chronic prostatitis and inflammatory findings as well as the presence of Chlamydia trachomatis confirmed by DNA/RNA DIGENE hybridization method in expressed prostatic secretion or in voided bladder urine collected immediately after prostatic massage, were examined. The patients were randomized to receive a total of 4.5 g of azithromycin for 3 weeks, given as a 3-day therapy of 1 x 500 mg weekly or clarithromycin 500 mg b.i.d. for 15 days. Patients' sexual partners were treated at the same time. Clinical and bacteriological efficacy were evaluated 4-6 weeks after the end of therapy. In the group of patients with chronic chlamydial prostatitis the eradication rates (azithromycin 37/46, clarithromycin 36/45) and the clinical cure rates (azithromycin 32/46, clarithromycin 32/45) were not significantly different with regards to the administered drug (p > 0.05). In the group of patients with asymptomatic chlamydial prostatitis the eradication rates (azithromycin 11/16, clarithromycin 10/15) were not significantly different with regards to the administered drug (p = 1.00, OR = 1.1).

Non-radioactive digoxigenin DNA labeling and immunologic detection of HSV PCR products

BACKGROUND

Herpes simplex virus (HSV) is a common cause of human skin and mucous membrane infections, and also causes sporadic meningoencephalitis. As a new method for rapid HSV diagnostics, polymerase chain reaction (PCR) has been introduced in clinical laboratories. Radioactive labeling of DNA probes has become a common practice in experimental laboratories. To avoid radioactive labeling of HSV oligonucleotide probes or PCR products, non-radioactive compounds, which are easily detected by enzyme or immunoassay techniques, are introduced.

OBJECTIVES

The aim of our study was (1) to introduce non-radioactive labeling of HSV DNA probe by digoxigenin-labeled dUTP; (2) to establish a rapid and reliable laboratory method for rapid HSV diagnostics; (3) to compare the PCR method with the standard virology techniques, such as cell culture virus isolation and HSV direct fluorescent antibody test (DFA).

STUDY DESIGN

We have tested the efficiency of PCR method and non-radioactive labeling of HSV DNA probe for detection of HSV from 30 clinical specimens (skin and mucous membrane swabs). HSV was detected in the specimens by standard virology techniques and PCR. Replicated HSV DNA was non-radioactively labeled by random incorporation of digoxigenin-labeled deoxyuridine triphosphate (DIG-dUTP), and the hybrids were detected by the antibody conjugates and the appropriate enzyme-mediated staining reaction (DIG DNA labeling and detection kit non-radioactive, Boehringer Mannheim GmbH).

RESULTS

Non-radioactive labeling of hybridization DNA probes with digoxigenin-dUTP was obtained. HSV DNA was successfully multiplied and detected in the HSV-infected cell culture supernatant; however, it was not detected in the clinical specimen supernatant or sediment. HSV DNA was detected by direct PCR method in non-centrifugated clinical specimens.

CONCLUSIONS

The PCR method could be successfully used for diagnoses of HSV infections. Since the sensitivity of this method is partly limited by the virus quantity in the specimen, we recommend cultivating the virus in the cell culture at least 24 h prior to PCR. The use of non-radioactive labeling of hybridization DNA probes, such as random primed DNA labeling with digoxigenin-dUTP, has proven both sensitive and specific, and more appropriate for diagnostic purposes than radioactive DNA labeling to be used until standardized commercial tests appear.

Second-generation Hybrid capture test and Amplicor monitor test generate highly correlated hepatitis B virus DNA levels

The performance of the Digene Hybrid Capture II HBV DNA Test HC II and the Roche Cobas Amplicor Monitor Test (Cobas-HBV) was evaluated on 252 serum samples. One hundred and seventy-three samples were HBV DNA positive and 75 HBV DNA negative by both assays. Four samples were HBV DNA positive by Cobas-HBV only. Linear regression analysis showed that the HBV DNA concentrations obtained from both assays were significantly related (n=173, r=0.976, P<0.0001). The results of the study show that Hybrid capture II and Cobas-HBV could be used equally in the management for patients with chronic HBV infection.

Dynamised cast management of Achilles tendon ruptures

Non-operative treatment of closed ruptures of the Achilles tendon within 48 h of injury has been shown to produce results comparable with surgical treatment [1,2]. We report 49 patients treated using a dynamised cast, with a mean follow-up of 42 months, in which there has been only one case of re-rupture. A total of 33 patients were reviewed clinically and measurements revealed a mean calf circumference deficit of 1 cm and a mean functional range of ankle motion deficit of 3 degrees and plantar-flexion strength of 81-90%, when compared with the contra-lateral uninjured limb. Early mobilisation of the injured Achilles tendon using a dynamised cast has produced a re-rupture rate and functional recovery that compare favourably with previously published results for patients treated operatively. Non-operative management, in this way, is well tolerated by patients and is of low cost.

AIDS-related body cavity-based lymphoma. A case report

BACKGROUND

Body cavity-based lymphomas are rare malignancies in human immunodeficiency virus (HIV)-infected patients, but because of their unusual clinical, morphologic and immunophenotypic features, they are recognized as a distinct subgroup of lymphomas connected to human herpesvirus 8 (HHV-8) infection.

CASE

A 39-year-old, HIV-positive, homosexual man was admitted to the hospital because of a left-sided pleural effusion that contained malignant lymphoid cells. He responded partially to a low-dose cyclophosphamide/doxorubycin/vincristine/prednisone regimen and died five months after the diagnosis of lymphoma. On cytology, the sediments contained exclusively large, round, neoplastic, lymphoid cells with abundant basophilic cytoplasm and large, round nuclei with prominent nucleoli. Many cells had immunoblastic features, and some had plasmocytoid differentiation. Mitotic figures were numerous. On flow cytometry, the homogeneous population of large cells expressed CD45, CD38, HLA-DR and CD7 positivity. Other specific T-, B- and NK-cell markers tested negative. Polymerase chain reaction demonstrated Epstein-Barr virus (EBV) and HHV-8 in the malignant effusion.

CONCLUSION

Primary effusion from lymphoma with molecular evidence of HHV-8 and EBV coinfection represents a distinct clinical and morphologic entity in AIDS patients. However, immunophenotypic markers of malignant clones can be diverse in different cases.

Molecular detection of human papillomavirus in women with minor-grade cervical cytology abnormalities

BACKGROUND

Human papillomavirus (HPV) has been shown to be the major risk factor for the development of cervical carcinoma, the second most common cancer among women worldwide. Cervical cytology has been the main screening tool for detection of premalignant lesions in last 50 years.

OBJECTIVE

The utility of a molecular assay for detection of HPV in cervical smears was evaluated.

STUDY DESIGN

A total of 466 women with minor-grade cervical cytology abnormality supposed to be produced by HPV were included. Patients were classified into three groups: Patients with reactive changes, patients with cervical intraepithelial neoplasia grade 1 (CIN 1), and patients with cervical intraepithelial neoplasia grade 2 (CIN 2). In all patients, another cervical swab was obtained and tested for the HPV genome using the Digene Hybrid Capture II. This assay is able to distinguish between high-risk and low-risk HPV types.

RESULTS

Based on cytology results, 44 patients showed reactive changes, 250 patients displayed CIN 1, and 172 patients displayed CIN 2. With the molecular assay, HPV was detected in 289/466 (62%) patients. The high-risk HPV type was present in 263 (56.4%) patients and the low-risk type in 26 (5,5%) patients. In 25% of patients with reactive changes, the HPV genome was detected. Corresponding rates for patients with CIN 1 and CIN 2 were 55 and 81%, respectively.

CONCLUSION

Molecular detection of HPV should additionally be used to cytology in patients whose cervical smears display reactive changes, CIN 1, or CIN 2. The employed assay allows identification of patients who are at risk for development of high-grade cervical lesions.

Risk factors for conduct disorder among Navajo Indian men and women

OBJECTIVES

To describe the risk factors for conduct disorder before age 15 among Navajo Indians.

METHODS

The study was based on a survey of a stratified random sample of adult Navajo Indians between the ages of 21 and 65 living on and adjacent to two different areas of the Navajo Reservation. There were 531 male and 203 female respondents. The average age (SD) of the men was 38.7 (10.5) years and of the women 35.5 (9.0) years. Conduct disorder was diagnosed retrospectively using the Diagnostic Interview Schedule first developed for the Epidemiological Catchment Area study. The responses were combined into a continuous scale.

RESULTS

Significant risk factors for increased scores on the conduct disorder scale were: histories of physical and sexual abuse in childhood; abusive maternal drinking; a small number of households per camp; younger age; and being male rather than female. Measures of social status and religion in which subjects were raised were not significant.

CONCLUSIONS

Many of the risk factors that are associated with conduct disorder in other populations are also risk factors in the Navajo population. There is suggestive evidence that some of these risk factors have become more common since World War II, raising the possibility that conduct disorder has become more prevalent, as is thought to be the case nationwide.

Comparative evaluation of first- and second-generation digene hybrid capture assays for detection of human papillomaviruses associated with high or intermediate risk for cervical cancer

In the present study we comparatively evaluated the first- and second-generation Digene Hybrid Capture assays for detection of human papillomaviruses (HPV) associated with high or intermediate risk for cervical cancer in cervical specimens. Concordant results were obtained with 468 of 483 (96.8%) specimens. All 15 specimens which gave repeatedly discordant results were positive by the second-generation test only, and 14 of them tested PCR positive. The enhanced sensitivity of the second-generation assay is mainly a result of the reformulation of hybridization reagents and, to a lesser extent, a result of the addition of new HPV probes.

Alcohol dependence and conduct disorder among Navajo Indians

OBJECTIVE

The purpose of this study is to examine the association between conduct disorder before age 15 and subsequent alcohol dependence, and to describe the lifetime prevalence of alcohol dependence among Navajo Indian women and men.

METHOD

This was a case-control design which included both men (n = 735) and women (n = 351) and in which the Diagnostic Interview Schedule was used for the diagnosis of the lifetime history of alcohol dependence and conduct disorder. Alcohol dependent cases were selected from inpatient and outpatient treatment programs (204 men, 148 women). Whenever possible, controls were matched for age, sex and community of residence and were randomly selected and interviewed until a nonalcohol dependent individual was found. Among the men, there were 374 alcohol dependent controls and 157 nonalcohol dependent controls. Among the women, the figures were 60 and 143, respectively. When combined, the controls comprise samples of the adult male and female populations from which estimates of lifetime prevalence of alcohol dependence, and of the amount of alcohol dependence in the population attributable to conduct disorder, may be inferred.

RESULTS

Conduct disorder is a risk factor for alcohol dependence among both men and women. Lifetime prevalence of alcohol dependence in this population is high (70.4% for men and 29.6% for women), but the amount of alcohol dependence in the population attributable to conduct disorder is low. On the other hand, among the alcohol dependent, those with conduct disorder had the most severe alcohol- and nonalcohol-related problems.

CONCLUSIONS

The potential limitations of the study are those common to case-control designs, especially biased recall by cases. There are also potential sampling biases among the controls. It is shown that none of the potential biases invalidate the findings, which support the hypothesis that in this population conduct disorder is a risk for alcohol dependence. The implications for primary prevention of alcohol dependence are discussed.

HCV genotypes in patients with chronic hepatitis C in Croatia

The determination of hepatitis C virus (HCV) genotype is an important epidemiological parameter in patients with chronic hepatitis C, while its clinical significance is still a matter of debate. The HCV genotypes in a group of 203 Croatian patients with chronic hepatitis C were examined. Genotypes were correlated to different risk factors, age, duration of the disease, liver histology activity and level of viremia. HCV-RNA was detected in each serum by means of reverse transcription PCR. Genotypes were determined from the amplificate by reverse hybridization in a line probe assay. The level of viremia was assessed by branched DNA (bDNA) signal amplification. The most common genotype was 1b (61.1% of patients), followed by 3a (26.1%), and 1a (10.8%). Other genotypes such as 2a and 4 were only rarely found in our patients (2%). Genotype 1b was most commonly acquired via blood transfusion, while genotype 3a was strongly related to intravenous drug use. Genotype 1b was associated with older age (mean 42.6 vs 29.3 years), longer duration of the disease (mean 6.0 vs 3.5 years), higher histologic activity score (mean 13.2 vs 10.6) and higher viremia (mean 9.06 vs 5.93 Meq/ml) at statistically significant levels (p < 0.001) when compared to genotype 3a. The prevalence of HCV genotypes follows the patterns of southeastern European countries, except for a lower prevalence of genotype 2. The observation that genotype 1b is associated with higher viremia and more severe liver injury is confirmed.

DNA extraction from archival Giemsa-stained bone-marrow slides: comparison of six rapid methods

The ability of six rapid DNA extraction procedures to provide DNA for the polymerase chain reaction from archival Giemsa-stained bone marrow slides was tested on 120 samples. Boiling in distilled water, freeze-thaw method, boiling in 10% Chelex-100 resin solution, proteinase K/Tween 20/NP-40 method coupled with simplified phenol/ chloroform/isoamyl alcohol protocol or salting-out procedure using saturated NaCl and modification of commercial QIAamp procedure (Qiagen. Chatsworth, Calif.) gave DNA extraction efficiencies of 50%, 70%, 85%, 95%, 100% and 100%, respectively. Our results demonstrate that rough DNA extraction methods have decreased efficiencies compared to complete DNA extraction protocols and that the latter are required to ensure highly reproducible results from archival Giemsa-stained bone marrow slides.

Cytologic and immunoenzymatic findings in CSF from patients with tick-borne encephalitis

OBJECTIVE

To evaluate the dynamics of cytologic changes in the cerebrospinal fluid (CSF) of patients with tick-borne encephalitis (TBE) and to determine the various forms of mononuclear cells by immunocytochemical methods.

STUDY DESIGN

To perform a cytologic analysis of 200 cells in stained sediment of CSF. To determine the population and subpopulation of mononuclear cells by using monoclonal antibodies.

RESULTS

Pleocytosis in CSF in patients with TBE during the first three days of illness was, on average, 570 cells per cubic millimeter with about 60% neutrophils. Mononuclear cells predominated from the fifth day of illness. Among lymphoid cells, 18% carried marker CD20 and 60% of them marker CD3. Among monocytoid cells, 66% carried marker CD32.

CONCLUSION

CSF cytology findings reflect the immunologic and inflammatory changes in the CNS during TBE.

Rapid diagnosis of enterovirus infection by a new one-step reverse transcription-PCR assay

The AMPLICOR Enterovirus Test was evaluated with 103 cerebrospinal fluid (CSF) specimens. Twenty-seven CSF specimens were culture positive. With the AMPLICOR test, enterovirus RNA was detected in 34 specimens. Compared with culture, the AMPLICOR test gave a sensitivity of 96.3% and a specificity of 100%. The sensitivity of culture was 79.4% in comparison with the AMPLICOR test.

[Kawasaki disease--case reports of 2 female patients]

Clinical and laboratory features of two female patients with Kawasaki disease, aged 9 and 12 years are presented. The main pathogenetic, differential diagnostic and therapeutic considerations are discussed.

Whipple's disease with unusual clinical, bacteriologic, and immunologic findings

A middle-aged man was found to have Whipple's disease after episodes of nephritis and arthralgia. While on antibiotic therapy, and in the absence of worsening of the histologic appearances of the jejunum, aortic valve endocarditis developed, presumably due to Whipple's disease. Observations during the course of his illness included the isolation of Corynebacterium bovis from an inguinal lymph node, and detection of circulating antibodies against material within the characteristic abnormal macrophages present in the gastrointestinal mucosa. This antigen-antibody reaction was specifically blocked by the monosaccharide rhamnose, a component of the polysaccharide surface coat of many bacteria, including C. bovis.

The metabolism of tartrate in man and the rat

1. Sodium tartrate labelled with 14C was given orally and parenterally to man and rats, and by direct injection into the caecum in rats. From the differences in urinary excretion after oral and parenteral administration intestinal absorption of tartrate was calculated as 18% of the dose in man and 81% in rats. Urinary tartrate was equivalent to 14% of the dose in man and 70% in rats, the difference between absorption and urinary excretion representing metabolism in body tissues.

2. Both man and the rat excreted part of the 14C as respiratory carbon dioxide. This occurred to a small extent after parenteral injection, suggesting metabolism of tartrate by body tissues, but was greater after oral or intracaecal administration, indicating that the main site of tartrate metabolism is the intestine.

3. Several genera of intestinal bacteria were shown to liberate [14C]carbon dioxide from labelled tartrate, and in a faecal incubation system l-tartrate, the natural isomer, was metabolized five times as rapidly as d-tartrate.

4. Oral sodium l-tartrate, 1·5 mmol day—1 kg—1, was given to two subjects and was shown to alkalinize the urine like sodium salts of other organic acids which are metabolized in the body. The reduction in renal hydrogen ion excretion showed that an average of 84% of the dose was metabolized.

5. Only 5% of labelled tartrate given by mouth appeared in faeces, and pharmacological doses of unlabelled l-tartrate had little or no aperient effect.

6. No evidence of toxicity of l-tartrate was encountered.

Effect of lactulose on ammonia production in a fecal incubation system

An in vitro fecal incubation system was used to demonstrate how lactulose influences ammonia metabolism in the colon. Lactulose and other fermentable substrates (glucose, mannitol, and sorbitol), pH and organic acid were varied independently so that their different effects could be determined. Fermentable substrate caused a fall in ammonia concentration during the period of fermentation. Acidification to pH 5.0 or less, with hydrochloric acid or a lactic-acetic acid mixture, significantly reduced ammonia generation, but unlike fermentable substrates, did not lower the existing ammonia concentration. The lactic-acetic acid mixture did not reduce ammonia generation significantly below that found with acidification by hydrochloric acid. The effect of lactulose in reducing ammonia concentration is attributed to its role as a bacterial substrate in either increasing bacterial assimilation of ammonia or reducing deamination of nitrogenous compounds. The effect of low pH in reducing generation of ammonia appears to be part of a general reduction in bacterial metabolism.

Generation of ammonia from non-urea sources in a faecal incubation system

1. A 25% faecal suspension in sodium chloride solution, incubated anaerobically at 37 degrees C for 48 h, showed excellent survival of all the main groups of faecal bacteria. 2. All faecal incubation systems studied generated large amounts of ammonia, particularly those in which bacterial counts fell during incubation. As normal faeces contain negligible amounts of urea this ammonia must have been generated from sources other than urea. 3. Ammonia was also generated by faeces delivered by sodium chloride enema, and by ileostomy fluid, indicating that the phenomenon is not confined to distal colonic contents. 4. Ammonia generation by incubated faeces was inhibited by prior autoclaving of the sample, but not by sterilization with gamma-irradiation. 5. Generation of ammonia by incubated stool was accompanied by release of large amounts of organic anion and a fall in pH. 6. These observations are interpreted as evidence that ammonia generated within the colon in situ is not derived exclusively from urea, but also from bacterial deamination of amino acids, peptides and proteins. Simultaneously bacterial activity generates large amounts of organacid. The presence of living bacteria is not essential for ammonia generation, provided that bacterial enzymes are present. 7. Bacterial generation of organic solute in faeces which have left the body is sufficiently rapid to cast serious doubts on the validity of faecal centrifugation, or other time-consuming techniques involving lengthy handling of faeces, as methods of obtaining extracellular faecal fluid for measurements of organic constituents or ammonia.

The effect of perfusion on the flora of the excluded colon

The bacterial flora of excluded colonic segments of three patients has been examined in the normal resting state and following perfusion.The flora of the excluded colon was substantial and qualitatively similar to that of faeces. Perfusion for two hours at 10 ml per minute usually reduced counts of organisms present in the issuing effluent by 1 to 1(1/2) logs in two patients, but rises in the counts of some organisms were recorded from the third patient. Prolonged rapid perfusion or the inclusion of antibiotics in the perfusing solution was necessary to obtain a substantial reduction in counts. Rapid perfusion resulted in the appearance of organisms that had not been recovered during slower perfusions.

Ammonia production by intestinal bacteria

Bacterial growth and the production of ammonia from urea and by deamination of peptone has been examined at various pHs in both conventional static bacterial cultures and in a continuous cultivation system. Growth occurred on primary testing of 93 out of 100 strains of aerobic Gram-negative bacteria at pH 5, and 48 out of 50 strains of Esch. coli at pH 4.6. Hydrolysis of urea by Proteus mirabilis decreased steadily from pH 7.2 to pH 5.3; below pH 5.3 little hydrolysis occurred. Ammonia production from peptones by Esch. coli decreased from pH 7.2 to pH 4.6. Considerable variation was noted in the ability of different strains to produce ammonia. Experiments with cultures containing both Esch. coli and Pr. mirabilis showed that more ammonia was produced at low pH than was produced by cultures of single organisms. At low pH reduction in the count of organisms was not found to be an essential prerequisite for reduction of ammonia formation.