Spontaneous bacterial peritonitis (SBP) is a serious complication in infants and children with chronic liver disease (CLD); however its diagnosis might be difficult. We aimed to study the feasibility of diagnosing SBP by routine ascitic fluid tapping in infants and children with CLD.We enrolled thirty infants and children with biopsy-proven CLD and ascites. Ascitic fluid was examined for biochemical indices, cytology and cell count. Aerobic and anaerobic bacteriological cultures of ascitic fluid were preformed. Direct smears were prepared from ascitic fluid deposit for Gram and Zheil-Nelson staining.3 and culture was positive (16.7%), Group II, eight patients with culture negative neutrocytic ascites (CNNA) with cells ≥ 250/mm3 and negative culture (26.7%) and Group III, seventeen negative patients (56.6%) in which cells were <250/mm3 and culture was negative. None of our patients had bacteriascites (i.e. culture positive with cells <250/mm3). Presence of fever was significantly higher in SBP and CNNA. The mean lactate dehydrogenase (LDH) level was significantly higher in ascitic fluid in the infected versus sterile cases (p < 0.002). A ratio of ascitic/serum LDH ≥ 0.5 gave a sensitivity of 80%, specificity of 88%, positive predictive value (PPV) of 66.7%, negative predictive value (NPV) of 93.7% and accuracy of 63.3%. The mean pH gradient  was significantly higher in SBP and CNNA cases when compared to the negative cases (p < 0.001). Ascitic fluid protein level of ≤ 1 gm/dl was found in 13/30 (43.3%) of studied cases with a sensitivity of 100%, specificity of 64.7%, PPV of 45.5%, NPV of 100% and diagnostic accuracy of 53.3% (p = 0.0001).Patients were divided into three groups: Group I included five patients with SBP in which the cell count was ≥ 250/mmSBP is a rather common complication in children with CLD. Culture of the ascitic fluid is not always diagnostic of infection. Biochemical parameters of the ascitic fluid definitely add to the diagnostic accuracy. LDH ascitic/serum ratio ≥ 0.5, an arterial-ascitic pH gradient ≥ 0.1 and total ascitic fluid protein ≤ 1 gm/dl are the most significant parameters suggesting infection. Patients with chronic liver disease (CLD) are particularly susceptible to infections with a higher prevalence in cirrhotics . AscitesThe aim of this study was to prospectively evaluate the feasibility of diagnosing SBP by routine ascitic fluid tapping in a cohort of Egyptian infants and children with biopsy-proven CLD associated with ascites in order to study the prevalence of SBP in them, its different clinical presentations, causative organisms, diagnosis and prognosis. We also aimed to study the value of biochemical parameters including ascitic fluid pH, lactate dehydrogenase (LDH), glucose and total proteins compared to their blood levels in diagnosing culture-negative patients.We prospectively enrolled thirty hospitalized infants and children from the Pediatric Hepatology Unit of Cairo University Children Hospital with CLD confirmed by liver biopsy and associated with ascites.All patients were subjected to the following:1) Full history-taking2) Thorough clinical examination3) Routine laboratory investigations including: complete blood count, biochemical tests of liver function, total plasma proteins and serum albumin, and kidney function tests.3, C4 and immunoglobulins (Igs) M, G and A .4) Serum complement (C) C5) Diagnostic paracentesis was performed under strict aseptic conditions and the amount of fluid withdrawn for the diagnosis did not exceed 40 ml. Therapeutic large volume paracentesis followed immediately when indicated.Ascitic fluid was examined for:I. Biochemical indices, including pH, glucose, LDH and total proteins.II. Cytology and cell count.III. Bacteriological examination. A portion of ascitic fluid (20 ml) was allocated into two test tubes containing thioglycollate broth medium, which were incubated at 37°C. The remainder of ascitic fluid was immediately centrifuged and the deposit was inoculated on trypcase soy blood agar for aerobic and anaerobic cultures and on to MacConkey's and Thio sulfate Citrate Bile Salts Sucrose (TCBS) agar medium for aerobic culture. Plates were examined after 24 hours (hr) and again after 48 hr. If they showed no growth, subcultures were done from thioglycollate broth and nutrient broth and on to blood agar and Mac Conkey's medium for aerobic cultivation; broth media were incubated up to 10 days. Anaerobic colonies were identified by API-20 A kit. Direct smears were prepared from ascitic fluid deposit for Zheil-Nelson (ZN) and Gram staining. Following cytological and bacteriological examination, patients were classified into 3 groups according to the long-accepted classification ,7,9:-Group I spontaneous bacterial peritonitis (SBP) in which the cell count was ≥ 250/mm3 and culture was positive (five cases or 16.7%).Group II culture negative neutrocytic ascites (CNNA) with cells ≥ 250/mm3 and culture negative (eight cases or 26.7%).Group III negative cases (seventeen cases or 56.6%) in which cells ≤ 250/mm3 and culture negative.6) Arterial blood samples were taken for pH determination by Bayer Ciba-Corning 288 Blood Gas Analyzer7) Blood and ascitic fluid were examined for the following biochemical parameters:A) pH.B) LDH was measured by ultraviolet kinetic method based on the following equation:C) Glucose was measured by an Express Plus automated random access autoanalyzer, using an enzymatic method depending on the following equation:D) Total proteins and albumin were measured by automated auto-analyzer 550 express plus (Ciba Corning Diagnostics).All procedures were in accordance with the current revision of the Helsinki Declaration . ParentsThe power of work of the study was more than 90%. All results were statistically analyzed. Qualitative variables, expressed as percentages, were compared in different groups using the Chi-square test. For all the statistical tests done, a p-value < 0.05 indicated a significant result. Diagnostic accuracy of different biochemical tests were measured by multi-variate analysis.3. The etiology of CLD in study group is summarized in Table This study included thirty infants and children with CLD confirmed by liver biopsy and associated with ascites. Their ages ranged from 6 months to 11 years, with a mean age of 5.1 ± 3.3 years. There were nineteen males (63.4%) and eleven females (36.6%). The study groups were classified into: Group I, five patients with SBP (16.7%), Group II, eight patients with CNNA (26.7%) and Group III, seventeen negative patients (56.6%). None of our patients had bacteriascites, i.e., culture positive with cells < 250/mmThere were no statistically significant differences in the clinical characteristics between the three studied groups with the exception of fever which was more evident in patients with SBP (100%) and CNNA (87.5%) when compared to negative cases (53%) {p < 0.05}. Oral broad spectrum antibiotics  were given in 4/8 (50%) of those with CNNA before presentation. None of the positive or negative cases received oral antibiotics in the immediate pre-presentation time.3 level was highest in CNNA (118.5 ± 51.5) when compared to negative cases (78.8 ± 29.4) (p < 0.05), but C4 did not significantly differ in the three groups. Leucocytosis with shift to the left, as an indicator of infection, was observed in 20% of SBP group, in 29.4% of negative cases, and in 50% of those with CNNA.The standard biochemical liver function tests, total plasma proteins and serum albumin and kidney function tests were comparable between the study groups. The mean serum IgG, IgM, and IgA level did not differ between the three groups. The CNNA group exhibited significantly higher levels of serum IgM and IgG when compared to negative cases (p < 0.05); this was not observed in the SBP group. CBacteroides, gram negative anaerobes (40%), coagulase positive Staphylococcus in one case (20%), anaerobic Streptococcus in one case (20%) and one case had Streptococcus pnemoniae (20%).In this study, positive culture was detected in five cases (SBP), two of them reveled The mean cell count in ascitic fluid was significantly higher (p < 0.01) in SBP (906 ± 1178.8) and CNNA ( 1013.7 ±1322.5) when compared to negative cases (60.6 ± 72.8). Mean pH of the ascitic fluid was 7.37 ± 0.03 in SBP cases, 7.36 ± 0.05 in CNNA, which were significantly lower than 7.43 ± 0.05 in negative cases (p < 0.05).The mean pH gradient  was significantly higher in SBP and CNNA cases when compared to the negative cases p < 0.001)  is presented in Figure LDH level in ascitic fluid had a mean of 132 ± 50.7 and 110.8 ± 47.3 in SBP and CNNA respectively, which was significantly high if compared to 61.5 ± 33.6 in negative cases (p < 0.002). The ratio of LDH (ascitic/serum) was 0.5 ± 0.08 and 0.5 ± 0.16 in SBP and CNNA respectively, which is significantly higher than 0.3 ± 0.18 in negative cases (p < 0.05). An LDH ratio at cut off ≥ 0.5 , 2.9 ± 2 gm/dl in CNNA and 1.7 ± 0.09 in negative cases (p < 0.05). A protein level of ≤ 1 gm/dl was found in 13/30 (43.3%) of studied cases  of them diagnosed as SBP and 8 (26.7%) had CNNA, i.e., total cases with evidence of peritonitis were 43.4%.The incidence of peritonitis whether SBP or CNNA is relatively high in this study if compared with Syed et al, who reported an incidence of 20/81 (24.6%) peritonitis in cases with CLD. Classical SBP was noted in four cases, CNNA was present in thirteen cases and bacterascites was found in three of their patients . The preClinical signs and symptoms such as fever and abdominal pain are considered the most prevalent features of SBP . In the Escherichia coli and Klebsiella species were the most common pathogens encountered in infected cases [Song et al. and Christou et al. reported that bacteria of enteric origin, especially ed cases ,17. SimiThe biochemical liver function tests, serum albumin and total proteins did not differ significantly between the three groups. Natarajan et al. and Wojtacha et al., reported a high incidence of bilirubin, liver enzymes, albumin, total protein disturbance in patients with SBP when compared to the non-infected cases ,19. LiveThe most important predictor of renal failure and hospital mortality after SBP is the presence of renal impairment at infection diagnosis . Serum u3 and C4 levels did not differ significantly in SBP cases when compared to CNNA or negative cases. Yildirim et al., reported decreased levels of serum and ascitic C3 and C4 in patients with SBP when compared to those without, but the serum Igs were similar in the patients with and without SBP [3 and are more predisposed to SBP [3 and C4 levels must be determined in the ascitic fluid itself as the possibility of alternative complement pathway activity occurring within the peritoneal cavity cannot be ruled out.The immunological status of patients, demonstrated by the serum Igs , Chout SBP . The comd to SBP . TherefoThe pH of ascitic fluid was significantly lower in both SBP and CNNA when compared to negative cases. On the other hand, Vieira et al., reported a median pH level of 7.4 in the non-infected as well as in the infected ascites group . The ascIn this study, an ascitic fluid pH lower than 7.35 and a blood-ascitic fluid pH gradient of 0.1 or greater were the most accurate thresholds for diagnosing SBP as evidenced by having the highest diagnostic odds ratio. Conversely, a blood-ascitic fluid pH gradient of lower than 0.1 lowers the likelihood of SBP .The ascities median glucose level was lower in infected cases (88.5 mg/dl) when compared to the non-infected cases (104 mg/dl) in a study conducted by Vieira and colleagues, but this difference was not statistically significant (p = 0.07) . YilidriThe mean LDH level in this study was significantly higher in the infected versus sterile cases (p < 0.002). No significant differences in LDH level between infected and non-infected cases of ascites was reported in Vieira study .The total proteins estimated in ascitic fluid were significantly lower in cases with SBP when related to the CNNA or negative cases. Such et al., reported that patients with SBP, had a significantly decreased serum albumin and ascitic fluid total proteins. Total proteins ≤ 1 gm/dl was found to be the most important risk factor for development of SBP in cirrhotic patients . It is rMortality rate observed in this study was 16.7% (5/30) and it did not differ significantly in the three groups 40%, 12.5%, 12%, respectively (p > 0.05). In reports from the 1970s, the mortality rate from SBP exceeded 90% but recent data show a lower mortality rate of 30% ,25.We conclude that SBP is a rather common problem in children with CLD. Apart from fever, symptoms and signs are not always conclusive of the diagnosis and a high index of suspicion is needed in all cases with ascites for early diagnosis of cases. Routine culture of the ascitic fluid is not always diagnostic of infection. Biochemical parameters of the ascitic fluid will add to the diagnostic accuracy. A pH gradient  ≥ 0.1, LDH ratio ascitic/serum ≥ 0.5 and total proteins of ascitic fluid of ≤ 1 gm/dl are the most important parameters highly suggestive of the presence of infection.(CLD): Chronic liver disease; (C): Complement; (CNNA): Culture negative neurocytic ascites; (Igs): Immunoglobulins; (LDH): Lactate dehydrogenase; (NPV): Negative predictive value; (PPV): Positive predictive value; (SBP): Spontaneous bacterial peritonitis; (TCBS): Thio sulfate Citrate Bile Salts Sucrose and (ZN): Zheil-Nelson.The authors declare that they have no competing interests.All authors read and approved the final manuscript.MS and ZA contributed equally to this work;MS, SO and ZA recruited the patients;MS, SO, IE and SA clinically supervised the patients;OS contributed reagents/analytic tools;MI analyzed the data;MS and MI wrote up the manuscript.


Online or Web-based measurement systems have been proposed as convenient methods for collecting physical activity data. We developed two Web-based physical activity systems—the 24-hour Physical Activity Record Web (24hPAR WEB) and 7 days Recall Web .To examine the validity of two Web-based physical activity measurement systems using the doubly labeled water (DLW) method.We assessed the validity of the 24hPAR WEB and 7daysRecall WEB in 20 individuals, aged 25 to 61 years. The order of email distribution and subsequent completion of the two Web-based measurements systems was randomized. Each measurement tool was used for a week. The participants’ activity energy expenditure (AEE) and total energy expenditure (TEE) were assessed over each week using the DLW method and compared with the respective energy expenditures estimated using the Web-based systems.r = .679 (P < .001). The Bland-Altman 95% limits of agreement ranged from –2.10 to 2.57 MJ between the two methods. The Pearson correlation for TEE between the two methods was r = .874 (P < .001). The mean AEE was 4.29 (SD 1.94) MJ using the 7daysRecall WEB and 3.80 (SD 1.36) MJ by the DLW method. The Pearson correlation for AEE between the two methods was r = .144 (P = .54). The Bland-Altman 95% limits of agreement ranged from –3.83 to 4.81 MJ between the two methods. The Pearson correlation for TEE between the two methods was r = .590 (P = .006). The average input times using terminal devices were 8 minutes and 10 seconds for the 24hPAR WEB and 6 minutes and 38 seconds for the 7daysRecall WEB.The mean AEE was 3.90 (SD 1.43) MJ estimated using the 24hPAR WEB and 3.67 (SD 1.48) MJ measured by the DLW method. The Pearson correlation for AEE between the two methods was Both Web-based systems were found to be effective methods for collecting physical activity data and are appropriate for use in epidemiological studies. Because the measurement accuracy of the 24hPAR WEB was moderate to high, it could be suitable for evaluating the effect of interventions on individuals as well as for examining physical activity behavior. Despite the known hazards of physical inactivity, it continues to be a major risk in the development of chronic diseases . PhysicaPhysical activity questionnaires are the most frequently used instruments in epidemiological studies for estimating physical activity or energy expenditure . HoweverTherefore, it is necessary to develop new, inexpensive methods of evaluating the levels of physical activity in large populations. Web-based measurement systems have been suggested as being convenient for collecting self-reported physical activity data compared with traditional questionnaires. In addition, Web-based systems may improve measurement accuracy because of the interactive communication associated with responses to questions. Responses can be obtained from individuals anywhere and at any time because Web-based systems can be completed using terminal devices, such as cell phones and smartphones. Two recent studies validated Web-based systems for measuring physical activity against the DLW method and found their validity was equivalent to that of traditional questionnaires ,12. MoreWe recruited 20 healthy people  to participate in the study. Participants were recruited by email through advertisements in a local email newsletters of 5000 registrants and a campus of the university in Fukuoka, Japan.The participants received a ¥10,000 gift certificate for participating in the experiments. Inclusion criteria were that each participant should have one of the following: smartphone, tablet device, personal computer, or mobile phone; they also had to have Internet and email access. Exclusion criteria were metabolic disease, pregnancy, currently lactating, or being a competitive athlete; this was because these conditions alter normal energy expenditure. The study was conducted with the approval of the Ethics Committee of Fukuoka University, Fukuoka, Japan. All participants received a full explanation of the study’s purpose and content, and we confirmed that they understood this before they gave their written consent.We developed two Web systems that functioned via a website and allowed for the automatic delivery of email. Diary  and 7-daThe diary method  requiredWe explained to the participants how to use the system during a briefing session. Since this system operates in JAVA script, launching the software requires access to the URL of the email address that was registered.–3 ) divided by 1.007 for dilution space (estimated by18O) [The time 0) ,21. Nd/N studies . Therefod by18O) .2 production rates were determined using the following equation: 0.4554 × total body water × (1.007 ×18O elimination rate – 1.041 ×2H elimination rate). For this calculation, we used assumptions of isotope fractionation applied to breath water using equation A6 of Schoeller et al [2 production rates, and the assumed respiratory quotient was 0.85. PAL was calculated as TEE/BMR [COer et al . The TEEer et al  based on TEE/BMR .2 production and O2 consumption were measured after an overnight fast and 30 minutes of rest. Participants were required to be transported to the laboratory by car to keep physical activity to a minimum. CO2 production and O2 consumption were converted to BMR through the Weir equation [2 consumption of less than 25 mL/min to determine whether the collection was acceptable [We measured BMR between 6:00 and 6:30 AM on day 0 of the study using indirect calorimetry . COequation . We usedceptable . Each pat test.All statistical analyses were performed using SPSS for Windows 19.0 . All data are shown as mean (SD); for participant characteristics, a range is also given. We compared men versus women for general characteristics by the independent P <. 01.We calculated zero-order and partial Pearson correlation coefficients as measures of association between AEE measured by DLW and by 24hPAR WEB; TEE measured by DLW and by 24hPAR WEB; PAL measured by DLW and by 24hPAR WEB; AEE measured by DLW and by 7daysRecall WEB; TEE measured by DLW and by7daysRecall WEB; and PAL measured by DLW and by 7daysRecall WEB. Using Bland-Altman plots, we related the difference in AEE between 24hPAR WEB and DLW (y-axis) to the arithmetic mean of AEE for 24hPAR WEB and DLW (x-axis) . In addi2). A total of 10 (50%) were employed full-time, 2 (10%) were employed part-time, 4 (20%) were self-employed, and 4 (20%) were full-time homemakers. Men had significantly greater BMRs (P < .001), DLW-derived AEE (P < .001), and DLW-derived TEE (P < .001) than women. There was no significant difference between men and women in PAL, as determined by the DLW method (P = .09).Average input times using the terminal devices were 8 minutes and 10 seconds for the 24hPAR WEB and 6 minutes and 38 seconds for the 7daysRecall WEB system. The average number of input data in the 24hPAR WEB was 8.6 (SD 2.6) types; this refers to the average number of types of behavior, such as reading a book, watching television, and walking. The average number of inputted hours in 7daysRecall WEB was 6.0 (SD 1.5) times; this refers to the average number of inputs for each intensity of activity in the morning, afternoon, and evening. Compliance relating to data input using the terminal devices was 122 of 140 days (87.1%) with the 24hPAR WEB and 133 of 140 days (95.0%) with the 7daysRecall WEB. When the system administrator identified a participant who was not compliant, this was recorded, and the participant received a phone call the next day to remind him or her to complete the input. Using this method, 100% data were collected in this study. The mean AEE was 3.90 (SD 1.43) MJ measured by the 24hPAR WEB method and 3.67 (SD 1.48) MJ by the DLW method. The mean TEE was 10.65 (SD 2.57) MJ by the 24hPAR WEB method and 10.39 (SD 2.68) MJ by the DLW method. Mean PAL was 1.87 (SD 0.20) by 24hPAR WEB and 1.82 (SD 0.22) by DLW. Mean AEE was 4.29 (SD 1.94) MJ by the 7daysRecall WEB method and 3.80 MJ (SD 1.36) by DLW. The mean TEE was 11.08 (SD 2.82) MJ by the 7daysRecall WEB method and 10.53 (SD 2.58) MJ by DLW, and mean PAL was 1.96 (SD 0.32) for the 7daysRecall WEB method and 1.84 (SD 0.19) by DLW. There were no significant differences between the Web-based measurements and the DLW method for the above energy expenditure variables.r = .679, P < .001). Correlation coefficients for TEE and PAL by the 24hPAR WEB and the DLW methods were r = .874 (P < .001) and r = .404 (P = .08), respectively. r = –.382, P = .87). In the Bland-Altman plot for TEE measured by 24hPAR WEB compared with DLW, the mean difference between the two methods was small (0.26 MJ), and the limits of agreement were 2.59 MJ (±1.96 SD). The test for trend was not statistically significant. The regression equation was y = –0.04x + 0.72 .r = .144 (P = .54). TEE as measured by 7daysRecall WEB and DLW was correlated . The correlation coefficient for PAL as measured by the 7daysRecall WEB and DLW methods was r = –.085, with no significant correlation.The Pearson correlation for AEE between the 7daysRecall WEB and DLW methods was r = .343, P = .14). In the Bland-Altman plot for TEE measured by 7daysRecall WEB compared with DLW, the mean difference between the two methods was small (0.55 MJ), and the limits of agreement were large at 4.80 MJ (±1.96 SD). The test for trend was not statistically significant. The regression equation was y = 0.11x – 0.66 .r = .673, P = .001). The figure demonstrates the profile of the methods regarding overestimation or underestimation of TEE. Most of the women and 1 man overestimated TEE in both the 24hPAR WEB and the 7daysRecall WEB methods  [r = .742  [The correlation between 24hPAR WEB and DLW measurements of TEE in the present study was similar to that found in previous research . The pre n = 37) ; similarn = 226) . A weaknThe 7-day physical activity recall method was originally developed in 1979 for use in the Stanford Five-City Project . An advaCompared with previous studies that examined the 7-day recall -31 methor = .788 (P <.001). AEE measured by 7daysRecall WEB and DLW was not significantly correlated (r = .346); nor was and PAL measured by 7daysRecall WEB and DLW (r = -.001). After completion of the study, we found that the reason for energy expenditure being overestimated by the male participant was that, regardless of his physical activity, the intensity level he inputted corresponded to light-intensity child care time. To prevent this type of mistake, we programmed the system to request that the participant confirm each input. However, accurate recording of physical activity behavior appears to be a limitation of self-reported physical activity assessment methods [In using the 7daysRecall WEB, 1 man greatly overestimated (3SD above the average) energy expenditure. Therefore, we excluded his data and reanalyzed the data (n = 19). The recalculated Pearson correlation coefficient for TEE between the 7daysRecall WEB and DLW methods was  methods .P = .32) between the group that used 24hPAR WEB during the first week  and the group that used 24hPAR WEB during the second week . There was likewise no difference (P = .68) between the group that used 7daysRecall WEB during the first week  and the group that used 7daysRecall WEB during the second week . In The present study employed a crossover design, whereby participants alternately used two Web-based methods. With respect to response time, there was no difference (With both systems, women tended to overestimate energy expenditure . Of the Another limitation of this study was that conventional cell phones cannot support JavaScript. Therefore, conventional cell phones could not operate the 24hPAR WEB. In Japan, 95% of people aged 30-49 years have access to the Internet, whereas just 32.9% of those aged 70-79 years have such access . TherefoIn recent years, public health research has focused on disease prevention and community intervention to promote physical activity . Over thIn conclusion, the 24hPAR WEB appears to be valid for estimating AEE and TEE, and the 7daysRecall WEB appears to be valid for estimating TEE. Both methods are effective for collecting physical activity data in epidemiological studies. The 24hPAR WEB is more accurate than the 7daysRecall WEB, and it is useful for evaluating physical activity behavior and the effect of interventions. The input time for the 7daysRecall WEB is short. The system is easy to operate and suitable for evaluating physical activity in large communities.


Introduction. Clinical presentation of viral hepatitis ranges from mild symptoms to fulminant hepatitis. Our aim is to describe clinical presentation and outcomes of children with viral hepatitis from the Eastern Ontario/Western Quebec regions of Canada. Methods. Retrospective chart review of children diagnosed with viral hepatitis at our institution from January 1, 1998, to December 31, 2007. Results. There were 261 charts reviewed, only 64 had a confirmed viral etiology: 34 (53%) hepatitis B (HBV), 16 (25%) hepatitis C (HCV), 4 (6.3%) hepatitis A (HAV), 7 (11%) cytomegalovirus (CMV), and 3 (4.7%) Epstein-Barr virus (EBV). Children with HBV presented at a mean age of 6.4 ± 4.6 years. Spontaneous seroconversion (appearance of HBVeAb and loss of HBVeAg) occurred in 21/34 (61.7%). Children with acute hepatitis  presented with mild abdominal pain, jaundice, and fevers. Overall outcome was excellent. Conclusion. Acute and chronic hepatitis in children has a benign course; moreover, HBV spontaneous seroconversion is common in pediatric patients. Hepatitis in childhood is largely caused by viral etiology. Clinical presentation of acute hepatitis generally includes jaundice and vague abdominal pain, though some children may present with vomiting and fever. These symptoms are reported to be milder and the disease course is shorter in children compared to adults . ChildreThe incidence of viral hepatitis varies according to geographical areas  as well  Our aim is to describe clinical presentation and outcome of patients diagnosed with viral hepatitis in the national capital region of Canada.We conducted a retrospective chart review of all patients diagnosed with viral hepatitis including hepatitis A, B, and C, EBV, and CMV from January 1998 to January 2008 at the Children's Hospital of Eastern Ontario.Demographics included age at diagnosis, gender, and ethnic background . SymptomAll statistical analyses were conducted using SAS 9.1 . Normally distributed continuous variables were summarized using mean and standard deviations. Nonnormally distributed continuous variables were summarized using median and interquartile range. Categorical variables were summarized using frequency and percentage. The percentages of seroconversion in the HBV group were calculated along with an exact 95% confidence interval. The Kruskal-Wallis test was used in the overall comparison of ALT level among the three acute hepatitis groups due to the small number of patients and large differences in the variance of ALT among groups.A total of 261 charts were reviewed; however, only 64 patients had confirmed etiology. One patient was diagnosed with herpes simplex virus hepatitis and was not included in the analysis. There were 34 (53%) children with hepatitis B virus (HBV), 16 (25%) with hepatitis C virus (HCV), 4 (6.3%) with hepatitis A virus (HAV), 7 (11%) with CMV, and 3 (4.7%) with EBV. Demographics and clinical presentation of patients with acute hepatitis  are reported in α − 2b at 3 years of age for 24 weeks without success. This child spontaneously seroconverted at 7 years of age.Children with chronic hepatitis were symptom-free and were screened after positive family history. Mean age of children with HBV was 6.4 ± 4.6 years. Ethnic background included Black 11 (32.4%), Caucasian 6 (17.7%), South East Asian 6 (17.7%), Arab 5 (14.7%), Chinese 3 (8.8%), West Asian 2 (5.9%), and Korean 1 (2.9%). Children with an HBV infection had mild elevation of liver function tests with a median AST of 62 IU/mL (interquartile range: 37–113 IU/mL) and a median ALT of 66 IU/mL (interquartile range: 32–105 IU/mL). Nearly one third of patients  with chronic HBV infection had spontaneous seroconversion at the first clinic visit; mean age was 9.9 ± 4.5 years. Another 35% (95% CI: 20–54%) of children seroconverted spontaneously at a mean followup of 5.0 ± 3.5 years (mean age 9.9 ± 3.1 years). Seroconversion rates are reported in Children with HCV had a mean age of 8.4 ± 4.1 years. Ethnic backgrounds included Caucasian 9 (56.2%), Chinese 6 (37.5%), and Southeast Asian 1 (6.3%). No patient received antiviral therapy against HCV. Elevation of liver enzymes was mild with a median AST of 58 IU/mL (interquartile range: 36–80 IU/mL) and a median ALT of 42 IU/mL (interquartile range: 33–65 IU/mL).The number of children diagnosed with viral hepatitis with a confirmed etiology was low in our study. One possibility is that a specific serology was not done and children were discharged with a diagnosis of viral hepatitis of unknown etiology. From those who had confirmed viral etiology, we found that only a quarter presented with acute hepatitis related to HAV, EBV, and CMV, and most of them presented with jaundice and abdominal pain. It was found that the elevation of liver enzymes in children with HAV was by far the highest among the three acute hepatitis groups. The CMV group had the lowest elevation of liver enzymes although the overall test did not reach statistical significance, likely due to the small sample size.The clinical course for children with acute hepatitis was benign, and very few patients needed hospital admission. There were no cases with acute liver failure or need for liver transplantation. Contrary to our findings, Ciocca et al.  reportedOn the other hand, infection with EBV can be associated with abnormal liver function tests in up to 80–90% of cases and is often underdiagnosed . It is lSimilarly, CMV is also a well-recognized cause of hepatitis, particularly in immunocompromised children  . Seven cChildren with chronic viral hepatitis generally have a different course of disease. The majority are symptom-free, and most of them had vertically transmitted infection . The incNotably, there were more children with chronic HBV than HAV, both potentially preventable conditions with the use of vaccination; this could be explained by the high immigration rate from high HBV prevalent countries and the chronicity it represents as opposed to the acute clinical presentation on children with HAV infection. Approved therapies in the United States for HBV include standard interferon-alpha, lamivudine, and most recently adefovir in adolescents . SuccessAll children with HCV had vertical transmission and were asymptomatic. Elevation of liver enzymes was mild, and no child received antiviral therapy. Mild transaminitis in childhood HCV was reported by Guido et al.  where thIn summary, viral hepatitis is frequently seen in our clinical practice; however, most children with a discharge diagnosis of viral hepatitis have no confirmed etiology. Children with acute or chronic viral hepatitis had a benign course and had no long-term complications or need for liver transplantation.The authors have no conflict of interests to declare nor any financial interests with pharmaceutical companies related to this study.


Streptococcus pneumoniae serotypes, we analyzed isolates from blood cultures of sick children residing in the West Bank before initiation of pneumococcal vaccination. Of 120 serotypes isolated, 50.8%, 73.3%, and 80.8% of the bacteremia cases could have been prevented by pneumococcal conjugate vaccines. Serotype 14 was the most drug-resistant serotype isolated.To determine antimicrobial drug resistance of  Streptococcus pneumoniae infection is a common cause of illness and death worldwide, responsible for an estimated 1.2 million infant deaths each year , serotypes included in this vaccine were responsible for ≈90% of pneumococcal infections in children living in industrialized countries; in developing countries, coverage has been reported as low as 26%  during January 2001–April 2010 or Maqassed Islamic Hospital (n = 7) during January 2009–April 2010. Both hospitals are well-equipped and are the major hospitals that perform blood cultures in the West Bank. Blood cultures are overused at both institutions; thus, isolated S. pneumoniae are representative of circulating serotypes. Because S. pneumoniae meningitis and invasive pneumonia are rare, these IPDs were not included in the study.In the Palestinian Territories, West Bank, the epidemiology of IPD is not well defined. Our study characterized the serotypes and antimicrobial drug resistance patterns of 120 consecutive Blood cultures were collected from patients suspected of having sepsis or endocarditis. Criteria for collecting blood cultures included leukocytosis with left shift, elevated C-reactive protein level, fever, signs of toxicity, hypotension, and hemodynamic instability. One isolate per patient was included in the study. Patients’ ages ranged from 1 day to 11 years; most (71.7%) were <2 years of age.S. pneumoniae colonies were identified on the basis of colony morphologic appearance, α-hemolysis on 5% sheep blood agar, Gram stain appearance, bile solubility, and optochin susceptibility. All strains were stored at −80°C until further testing.All BACTEC –positive blood culture samples were placed on 5% sheep blood agar, chocolate agar, and MacConkey agar obtained from Hy-Laboratories Ltd. . Suspected S. pneumoniae isolates were serotyped by performing a series of PCRs using primers described by Pai et al  were serotyped; 3 (2.5%) could not be typed. These results are similar to those of Pai et al., who successfully typed 95.5% of the S. pneumoniae stains by using the same PCR technique  are covered by PCV7 (6A/B not differentiated).Of the 120  strains . OverallS. pneumoniae strains were isolated from children <2 years of age; 34 (28.3%) were isolated from children >2 years of age. High S. pneumoniae serotype coverage by PCV13 was noted for each age group, 77.9% and 76.5%, respectively. Conversely, serotype coverage provided by PCV7 for each age group was 60.5% and 26.5%, respectively. Of the 6 additional serotypes included in PCV13 and not in PCV7, serotypes 1, 3, and 5 appeared to be common in our study population. Notably, S. pneumoniae serotype 1 was not seen in children <2 years of age.After serotypes were stratified by age groups, 86 (71.7%) S. pneumoniae serotypes was similar to that in a study by Fraser et al. in Israeli and in Bedouin children residing in southern Israel  (1 µg), erythromycin (15 µg), ofloxacin (5 µg), co-trimoxazole (25 µg), and vancomycin (30 µg) according to the Clinical and Laboratory Standards Institute (CLSI) guidelines , and the meningitis guidelines were applied for penicillin   were penicillin susceptible; 70 (58.3%) were resistant based on the 1-μg oxacillin disk-diffusion results. However, MICs for penicillin showed that 118 (98.3%) isolates were susceptible and only 2 (1.7%) S. pneumoniae isolates were intermediately resistant .The small sample size is a limitation in this study and mandates caution when comparing the results with those of other studies. The use of broth microdilution to determine penicillin MIC, as reported in the Germany study or Etest as performed in this study, has been documented to produce comparable results  were resistant to erythromycin, and 53 (44.2%) were resistant to co-trimoxazole (S. pneumoniae erythromycin resistance in the West Bank differed from that in Israel (10%); however, each location had similar co-trimoxazole (51%) resistance patterns. The spread of the co-trimoxazole–resistant clones is alarming because the World Health Organization has recommended use of this antimicrobial drug for treatment of nonsevere pneumoniae in children >2 months of age. No resistance was noted for cefotaxime, ofloxacin, and vancomycin (Unlike the low penicillin resistance rate, higher resistance rates were noted for erythromycin and co-trimoxazole. Of the 120 moxazole . After smoxazole . S. pneuncomycin .S. pneumoniae serotypes in blood cultures of children residing in the West Bank. This study favors use of PCV13 because 80.8% vaccine coverage of the causative serotypes can be achieved compared with 50.8% with PCV7. In the West Bank, the increased serotype coverage of PCV13 in part results from inclusion of S. pneumoniae serotypes 1, 5, and 19A, which account for 23.4% of the serotypes not in PCV7. The introduction of PCV13 in the vaccination program will not only help reduce the incidence of IPD but will also help reduce infections caused by drug-resistant S. pneumoniae serotypes, such as serotype 14. Continuous monitoring of serotype distribution in this population will ensure that available vaccines can provide adequate coverage of circulating pneumococcal serotypes.Our study reports the distribution of


The use of extracorporeal membrane oxygenation (ECMO) after cardiac surgery in child has continued to increase. However, the survivals have remained less than 50% with a significant rate of complications. We aim to assess the morbidity and mortality in children requiring ECMO after cardiotomy and determine factors affecting outcomes.Sixty-two ECMO operations in 58 children who required post-cardiotomy ECMO between January 2002 and December 2012 were reviewed. The Cox proportional hazards model was used for the univariate and multivariate prognostic risk analyses for the weaning of ECMO or the discharge of hospital.Age and weight were 12±17months and 6.4±3.3kg, respectively. Twenty patients had single ventricle and 38 had biventricular physiology. The duration of ECMO was 8.4±4.4 days. Fifty-two (84%) were successfully weaned off ECMO and 34 (55%) survived to hospital discharge. The weaning from ECMO was affected by peak serum lactate during ECMO  and the diagnosis of isomerism  by multivariate analysis. Indication for ECMO and surgical procedures were not significant predictors. Factors associate with failure of hospital discharge despite successful decannulation were as follows: weight , ECMO duration , the duration of the day between decannulation and the first day of negative water balance after ECMO , the use of nitric oxide gas after ECMO . Survivor vs. non-survivor to the hospital discharge was 7.1±4.1 vs. 10.0±4.2 (days) in ECMO duration (p=0.0073) and 2.1±1.5 vs. 8.3±10.2 (days) in the negative water balance (p=0.0004).Higher lactate levels and isomerism are significant factors associated with mortality during ECMO. Unable to obtain earlier negative balance and the inhalation of nitric oxide increase risk of death after successful decannulation.


Human papillomavirus (HPV) is associated with different malignancies but its role in the pathogenesis of ovarian cancer is controversial. This study investigated the prevalence, genotyping and physical state of HPV in ovarian cancer Saudi patients.Hundred formalin fixed paraffin embedded (FFPE) ovarian carcinoma tissues and their normal adjacent tissues (NAT) were included in the study. HPV was detected by nested polymerase chain reaction (PCR) using degenerated HPVL1 consensus primer pairs MY09/MY11 and GP5+/GP6 + to amplify a broad spectrum of HPV genotypes in a single reaction. The HPV positive samples were further genotyped using DNA sequencing. The physical state of the virus was identified using Amplification of Papillomavirus Oncogene Transcripts (APOT) assay in the samples positive for HPV16 and/or HPV18.High percentage of HPV (42%) was observed in ovarian carcinoma compared to 8% in the NAT. The high-risk HPV types 16, 18 and 45 were highly associated with the advanced stages of tumor, while low-risk types 6 and 11 were present in NAT. In malignant tissues, HPV-16 was the most predominant genotype followed by HPV-18 and -45. The percentage of viral integration into the host genome was significantly high (61.1%) compared to 38.9% episomal in HPV positive tumors tissues. In HPV18 genotype the percentage of viral integration was 54.5% compared to 45.5% episomal.The high risk HPV genotypes in ovarian cancer may indicate its role in ovarian carcinogenesis. The HPV vaccination is highly recommended to reduce this type of cancer. Human papillomavirus (HPV) belongs to Papillomaviridae family that consists of small double stranded DNA viruses associated with cutaneous and mucosal squamous epithelial lesions. HPV infOvarian carcinoma is the most lethal gynecological malignancy because it is detected in advanced stages with 5-year survival rate is <40%,13. The The genetic alterations associated with ovarian carcinomas are well known,18. The The integration site of HPV is extensively investigated in cell lines and clinical samples of HPV related cancers at various sites of the body. The integration site for HPV is random throughout the genome but the Integration mechanisms are not fully understood. IntegraGenomic DNA was isolated from 100 FFPE ovarian carcinoma and their normal adjacent tissues. All samples were positive for β-globin gene amplification. The amplified HPV DNA with MY09/MY11 followed by GP5+/GP6+ were considered HPV positive and were subjected to DNA sequencing. The negative samples by nested PCR were subjected to HPV-type specific PCR to confirm that the samples were negative. Forty two out of 100 tumor samples and 8 out of 100 NAT were positive for HPV by nested PCR as shown in Figure The patients’ mean age was 50 ± 11 years . The patients’ age distribution was analyzed and the prevalence of HPV genotypes was detected among them. There was no significant difference (P > 0.5) observed in HPV infection among patients with age <45 compared to >45 years old, in which 15/35 (42.8%) of the patients with age <45 years old and 27/65 (41.5%) were positive for HPV. The HPV infection in relation to histological grade, HPV was detected in 25% (7/28) of cases with grade I, 50% (21/42) of cases with grade II and 46.7% (14/30) of cases with grade III.By using sequencing technique, the most common detected HPV genotype was HPV-16 in 18/42 (42.9%), followed by HPV-18 in 11/42 (26.2%), finally HPV-45 in 7.1% as in Figures As the sequencing technique failed to identify the specific mixed HPV genotypes, therefore type specific PCR assay was used. Mixed infection with HPV-16/18, HPV-16/45, HPV-18/45 or HPV = 16/18/45 were observed in 7/42 (16.6%), 2.4%, 2.4%, 2.4% respectively as showed in Table The clinical stages were determined according to the International Federation of Gynecology and Obstetrics system (FIGO). The ovarian cancer samples were classified as followed: stage 1-23%, stage II-37%, stage III-29% and stage IV-11%. HPV was detected in 21.7% (5/23) stage 1, 40.5% (15/37) stage II, 41% (16/39) stage III and 75% (9/11) stage IV as showed in Figure The HPV genotypes were distributed among different FIGO stages as followed: HPV-16 were (7/37) 18.9%, (9/39) 23% and (2/11) 18.2% in stage II, III and IV respectively as showed in Figure E1 or E2 open reading frames and deletion of viral early-region from the viral oncogene-encoding sequences. Thirty six HPV-16, HPV-18 or HPV-16/-18 positive samples with good quality RNA, were subjected to study the physical states by APOT assay. The viral genome was found to be integrated in 22/36 (61.1%), whereas the episomal transcripts were found in 38.9%. Out of the 22 cases with integrated viral genome the episomal form of HPV was also detected in 5/22 (22.7%). In HPV-18 genotype positive samples the percentage of viral integration was 54.5% compared to 45.5% episomal. On the other hand in HPV-16 genotype positive samples the percentage of viral integration was 65% compared to 35% episomal. The integrated state of the virus was significantly found in 90% in advanced stages III and IV compared to 10% in localized stages I and II (p < 0.05) showing that the integrated form was associated with the advanced stages of cancer.The APOT assay is based on the structural differences among the 3′-ends of viral oncogene transcripts. The integration of HR-HPV genomes into the host genome results in both disruption of the The role of HPV infection in cervical cancer and otheHPVs are classified as high and low risk, according to their relationship with benign or malignant proliferative lesions. The oncIn many studies, molecular assays were used to identify different types of HPV in cells and tissues-47. The In the current study, the high-risk HPV types 16, 18 and 45 were associated with advanced stages of the disease, while low-risk types 6 and 11 were associated with normal tissues adjacent to the tumor. This finding was in agreement with other study found that the presence of high-risk types of HPV was found in the serous histological subtype and advanced stages of the disease (FIGO stages III and IV). Other sThere is no statistical significant difference in HPV infection in relation to age group more/or less than 45 years. The current study are consistent with those reports based the detection of HPV in relation to age, they found that the median age of diagnosis of ovarian cancer patients infected with HPV was 57 years for patients with HPV and 59 years for patients without HPV infection for HPV16 and [P1-18] for HPV18 as forward primers and linker p3 as the reverse primer. The PCR was performed in 50 μL reaction volume containing 5 μL of the RT reaction mixture (cDNA), 2.5 units Taq polymerase , 1× PCR buffer , 200 μM each of the deoxyribonucleotide triphosphate and 0.25 μM of each primer. The reaction mixture was subjected to initial denaturation for 2 min, followed by 35 cycles of denaturation at 94°C for 45 s, annealing at 58°C for 45 s, elongation at 72°C for 2 min, and a final elongation step at 72°C for 7 min. Five μl of the amplified products were used as template for nested PCR under the same conditions at annealing temperature 65°C using forward HPVE7-specific primer [p2-16] specific for HPV16 and [P2-18] specific for HPV18 as forward primers and (dT)17-p3 as reverse primer.To identify the HPV genotypes and the integration, all positive PCR products were analyzed by direct DNA sequencing. PCR products were purified using QIAquick Purification Kit according to manufacturer’s instructions . Purified PCR products were labeled with fluorescent dyes using BigDye Terminator v3.1 Cycle Sequencing Kit Applied Biosystem. Labeled oligonucleotides were purified using BigDye X Terminator Purification Kit .The samples were sequenced by automatic ABI 3500 genetic analyzer . Chromatograms with sharp peaks and quality values ≥20 with little or no background noise consider as single HPV infection. When the samples contain more than one HPV genotype, direct sequencing gave mixed chromatograms, with overlapping peaks or two or more fluorescent signals. Samples with mixed chromatogram were subsequently subjected to type-specific PCR. The nucleotide sequences were subsequently subjected to Basic Local Alignment Search (BLAST) provided by the National Cancer Institute, USA.Chi-square test used to test prevalence differences in HPV genotypes and integration frequencies between different HPV types in cancerous tissues and NAT in relation to age, tumor stage and tumor grade. A p value of < 0.05 was considered statistically significant. SPSS, version 17.0 was used for these analyses.The authors declare that they have no competing interests.MMH and ZK shared in molecular studies and their statistical analysis and draft the manuscript. MMH, OA, MS, WN, SM and AA participated in study design, sample and data collection and shared in revising the manuscript. SS shared in sample and data collections. All authors read and approved the final manuscript.


Rickettsia felis–associated illness in the initial days of infection in febrile Senegalese patients without malaria.During November 2008–July 2009, we investigated the origin of unknown fever in Senegalese patients with a negative malaria test result, focusing on potential rickettsial infection. Using molecular tools, we found evidence for  Binding and washing of samples with QIAGEN columns was performed with an adapted manual pump . Columns were stored at 4°C until final elution was performed in Marseille, France.Medical examination and blood sampling were conducted for each person who had a fever >37.5°C. Approximately 200 µL (3–4 drops) of whole blood was collected from each patient by lancet stick of a fingertip for malaria tests and DNA extraction. Our study used only samples negative for Rickettsia-specific gltA gene–based RKND03 system. Positive results were confirmed by a newly designed real-time PCR primer and probe combination based on the RC0338 gene  for all spotted fever group rickettsiae with 338 gene . Appropr338 gene . We analA total of 103 patients were from Dielmo (391 inhabitants), and 31 were from Ndiop (313 inhabitants). Seventy-two patients were female, and 90 (67%) were >10 years of age. No one died during the study, and all patients with identified rickettsiae infection completely recovered.. The following sequencing of nested PCR gltA gene amplicons from all positive samples showed 100% homology with R. felis URRWXCal2 (GenBank accession no. CP000053) .We identified 9 samples from 8 patients (6%) positive by both genus-specific qPCR systems . The folThe prevalence of flea-borne spotted fever in all tested samples was 4.4% (9/204). Monthly incidence for positive samples was 4.76% (1/21) in December, 4.76 % (2/42) in January, 16.66% (3/18) in April, 6.89% (2/29) in June, and 2.38% (1/42) in July. Seven patients lived in Dielmo, and 1 lived in in Ndiop. The overall incidence was 1.7% in Dielmo and 0.3% in Ndiop , and for children <10 years of age 3.5% (5/143) in Dielmo and 0.9% (1/109) in Ndiop. The incidence of flea-borne spotted fever was highest among children <10 years of age . The average age of infected patients was 15 years (range 2–57 years). Clinical manifestations are detailed in R. felis infection in West Africa in the initial days of infection in febrile Senegalese patients who did not have malaria. This infection can be easily misdiagnosed because it lacks specific signs  (Interestingly, a 6-year-old child had 2 positive blood samples for ,R. felis, have not been reported as background organisms that may circulate undetected in the blood of humans and thus be detected by chance. Nevertheless, future work on the clarification of the role of Rickettsia spp. in public health will include the study of healthy controls from appropriate cohorts.The incidence of flea-borne spotted fever was higher in Dielmo than in Ndiop. Notably, tick-borne relapsing fever, malaria, and Q fever also are more prevalent in Dielmo than in Ndiop (R. felis infection is largely underestimated and may be responsible in Africa for many cases of uneruptive fevers of unknown origin, including those associated with respiratory, digestive, and neurologic signs. We can speculate that flea-borne spotted fever might be an important neglected public health concern not only in North Africa but also in sub-Saharan Africa. Children are particularly vulnerable to this emerging infection.Finally, we believe that the incidence of


Objective. To evaluate whether diabetes mellitus (DM) and hemoglobin A1c (HbA1c) are risk factors for ventilator-associated pneumonia (VAP) and bloodstream infections (BSI) in critically ill patients. Methods. Prospective observational study; patients were recruited from the intensive care unit (ICU) of a general district hospital between 2010 and 2012. Inclusion criteria: ICU hospitalization >72 hours and mechanical ventilation >48 hours. HbA1c was calculated for all participants. DM, HbA1c, and other clinical and laboratory parameters were assessed as risk factors for VAP or BSI in ICU. Results. The overall ICU incidence of VAP and BSI was 26% and 30%, respectively. Enteral feeding OR (95%CI) 6.20  and blood transfusion 3.33  were independent risk factors for VAP. BSI in ICU (P = 0.044) and ICU mortality (P = 0.038) were significantly increased in diabetics. Independent risk factors for BSI in ICU included BSI on admission 2.45  and stroke on admission2.77 . Sepsis 3.34  and parenteral feeding 6.29  were independently associated with ICU mortality. HbA1c ≥ 8.1% presented a significant diagnostic performance in diagnosing repeated BSI in ICU. Conclusion. DM and HbA1c were not associated with increased VAP or BSI frequency. HbA1c was associated with repeated BSI episodes in the ICU. Ventilator-associated pneumonia (VAP) often complicates the clinical course of the critically ill patients and it may be associated with considerable morbidity and mortality . VAP canHyperglycemia and diabetes mellitus (DM) are conditions which have been linked to alterations of immune response and are often encountered in the critical care setting . HoweverIn this respect, we hypothesized that DM and HbA1c, which are an index of overall glycemic exposure relatively unaffected by acute changes , might be associated with nosocomial infections which are most commonly encountered in the ICU such as VAP or bloodstream infections (BSI). We, therefore, aimed to assess nosocomial infections in the ICU patients prospectively and to investigate whether DM and increased HbA1c levels are independent risk factors for VAP and BSI .The present prospective observational study was conducted in a general district hospital in Greece between 2010 and 2012. Consecutive sampling was used to recruit patients admitted to the general ICU of the hospital. The study was approved by the University of Thessaly (UT 08-02-10/568) and the International Centre of Services of Health Ministry (UT 01-06-10/2124).Inclusion criteria were (a) intubation for more than 48 hours and (b) ICU hospitalization for more than 72 hours. Exclusion criteria were (a) presence of hemoglobinopathies, (b) blood transfusion prior to ICU admission with 2 or more RBCs units [Patients were classified based on their medical history as diabetics and nondiabetics. Diabetics were further classified as having normal glycemic control (NGC) or abnormal glycemic control (AGC) and if they had HbA1c < 7% or HbA1c ≥ 7%, respectively, according to American Diabetes Association (ADA) guidelines . PatientThe main outcome evaluated was the relationship between HbA1c levels and VAP or BSI. Secondly, we assessed the relationship between HbA1c and ICU mortality.Baseline demographic data including age, sex, body mass index (BMI), and medical history including APACHE II score, previous antibiotic exposure, previous hospitalizations, and corticosteroids exposure were recorded. All patients admitted to the ICU, except those that did not meet criteria for entry in analysis, were then followed until hospital discharge for early or late onset VAP, BSI, other types of infection, and sepsis. Clinical pulmonary infection score (CPIS) was evaluated as reported . PotentiA whole blood glucose specimen was taken during the first 24 hours of ICU admission for HbA1c measurement. HbA1c was measured by Cobas Integra 400 Plus TQ HbA1c Gen. 2 (Roche Diagnostics Ltd. Switzerland/Windows XP) which is an immunoassay method for the quantitative determination of percent HbA1c and the laboratory range of HbA1c was 4.4–7%. Blood, urine, and tracheal aspirates with a sterile sputum trap for semiquantitative cultures were collected routinely on ICU admission but also during the hospital stay whenever there were clinical and laboratory signs of infection .4/mm3), and purulent tracheal aspirate [Staphylococcus aureus, ceftazidime or imipenem resistant Pseudomonas aeruginosa, colistin sensitive Acinetobacter baummannii and Stenotrophomonas maltophilia, and gram-negative bacilli producing extended spectrum beta lactamase [VAP was defined as a new persistent chest-radiographic infiltrate in conjunction with one of the following: a positive blood or pleural fluid culture or two of the following: fever (temperature > 38.3°C), leukocytosis  would indicate a good fit for the model. The overall accuracy (discrimination) of the model has been evaluated too. Data were analyzed using SPSS version 17.Data are presented as frequency (%) for qualitative parameters or mean ± SD for quantitative variables. Comparisons between groups were performed by using P = 0.001) and more obese (P = 0.026), they had more elevated glucose on admission (P < 0.001) and Apache II score (<0.001) and higher HbA1c (P < 0.001), and presented significantly higher percentage of cardiac disease (P < 0.001), hypertension (P = 0.002), and chronic kidney disease (P = 0.008) in their medical history compared to nondiabetics.One hundred and eighty-four patients out of 247 admissions were eligible and entered the study. Sixty-three patients were excluded, 51 patients were intubated <48 hours or hospitalized <72 hours, and 12 patients had received ≥2 units of RBCs prior to HbA1c analysis. There were 70 diabetics: 43 (61%) were classified as AGC and 27 (39%) as NGC . There wVAP was diagnosed in 47 patients (26%). In the majority of cases, the cause of admission was respiratory failure (38%) or neurologic disorders (23%). The frequency of VAP was similar among the study groups. The mean time for VAP diagnosis was 12 ± 8 days.Acinetobacter baummanni (39%). NGC patients and nondiabetics presented significantly more frequent gram-negative MDR bacterial VAP compared to patients with AGC; AGC patients presented more frequently gram-positive bacterial VAP (P = 0.02).The pathogens associated with VAP for all patients are shown in P = 0.041) or in ICU (95% CI) 2.892 (1.267–6.597), P = 0.009, enteral (95% CI) 6.474 (3.020–13.881), P < 0.001, or parenteral feeding (95% CI) 7.892 (2.683–23.221), P < 0.001, and blood transfusion (95% CI) 3.746 (1.727–8.127), P = 0.001, were significantly associated with the presence of VAP, whereas HbA1c ≥ 7% was not (P = 0.685)  6.205 (1.909–20.170), P = 0.002, and blood transfusion (95% CI) 3.327 (1.227–9.022), P = 0.018, were significantly associated with VAP  3.691 (1.328–10.256), P = 0.012, were the only independent risk factors for developing MDR-VAP.BSIs on admission (OR (95% CI) 2.218 (1.023–4.808), = 0.685) . After ewith VAP . FurtherP = 0.044). In addition, NGC patients presented significantly increased incidence of BSI caused by MDR bacteria compared to AGC patients (22% versus 5% P = 0.025).BSI was diagnosed in 55 (30%) patients. In the majority of cases it concerned patients with respiratory failure (40%) and neurologic disorders (20%). BSI was significantly increased in diabetics (39% versus 25% P = 0.044), BSI on admission (95% CI) 2.590 , and the medical history of stroke (95% CI) 2.994  (P = 0.022) and medical history of stroke (95% CI) 2.768  were identified as the only independent risk factors for BSI in ICU (Risk factors for BSI were DM (95% CI) 1.929  . HoweverI in ICU .P = 0.04).When ROC curve analysis was applied to examine whether there is any correlation between levels of HbA1c and the incidence of BSI in those patients who had more than one episode of BSI during their ICU stay, analysis showed that the diagnostic performance of HbA1c in the diagnosis of repeated episodes of BSI (>one episode) in ACG patients was significant . Risk factors for death in all analyzed patients were age (71 ± 12 versus 59 ± 18 P < 0.001), Apache II score , previous hospitalization (95% CI) 1.964 , DM (OR (95% CI) 1.953 , hypertension (95% CI) 2.044 , cardiac disease (95% CI) 2.018 , chronic kidney disease (95% CI) 4.760 , parenteral feeding (95% CI) 5.127 , and the development of sepsis (95% CI) 2.544 . Multivariate analysis showed that sepsis (95% CI) 3.336  and parenteral feeding (95% CI) 6.295  were independently associated with ICU mortality. For the selected model, the Hosmer-Lemeshow chi-square = 6.327, df = 8, P = 0.611 was not significant denoting that it was well calibrated and fitted the data well. The overall accuracy of the model was 74.5%.The mean ICU stay was 16 ± 15 days; ICU stay was similar among different groups. Overall, ICU mortality was significantly higher in diabetics compared to nondiabetics (95% CI) 1.953 (1.033–3.693; There were no other differences between diabetics and nondiabetics, between nondiabetics and AGC patients, or between NGC and AGC patients regarding other types of infection, such as urinary tract infection, catheter related infection, and sepsis.Our findings do not support the hypothesis that HbA1c is associated with increased risk of VAP or BSI in the ICU. To our knowledge, this is the first study to examine such a relationship. However, a significant association between HbA1c and BSI was found in this study, while a threshold of HbA1c ≥ 8.1% was found to be significant in the diagnosis of repeating an episode of BSI among patients with uncontrolled diabetes.In the present study there was no significant relationship between DM or HbA1c and VAP. According to the literature, hyperglycemia in diabetics predisposes to infections because of the impairment of innate cellular immunity, especially in diabetics with poor glycemic control , 15, 16.Nevertheless, our findings provide evidence that DM might be significantly associated with the incidence of BSI in the ICU. DM was identified as a risk factor for BSI. In addition, patients with increased HbA1c were at significant risk of repeated BSI and a cut-off level of ≥8.1% presented significant diagnostic performance in diagnosing repeated BSI. This association between DM and BSI has been underlined previously . Our finIn the present study, we evaluated several risk factors for increased frequency of VAP. VAP was related to enteral feeding and blood transfusion which have been previously suggested as risk factors for VAP. Enteral nutrition has been indicated as an independent risk factor for VAP from several existing studies, since it might increase the risk of aspiration of gastric contents , 21. SevBlood transfusion was also a risk factor for VAP. This relationship has been reported in previous studies , 25. It On the other hand, in contrast to previous studies, tracheostomy was not identified as an independent risk factor for VAP , 27. BasDM and AGC were not associated with VAP due to MDR. NGC diabetic patients and nondiabetics presented significantly increased incidence of VAP due to MDR than AGC diabetics. However, MDR-VAP was not independently associated with known risk factors such as previous antibiotic therapy and previous hospitalization . In thisBSI in ICU was significantly associated with the presence of DM. In contrast to other similar studies, only BSI on admission and a history of stroke were independently associated with BSI . A possiDiabetic patients presented significantly increased mortality than nondiabetics in this study. ICU mortality was independently associated with factors that have been known to affect ICU mortality such as sepsis, age, and parenteral feeding, but DM was not an independent risk factor for mortality. ICU morality is multifactorial and the impact of DM in mortality might be not straight forward. Previous studies showed that mortality in critically ill patients has been found to be related to DM only in cardiac surgery patients or in patients with acute organ failure or septicemia , 32; yetIn this study, we found that parenteral feeding was associated with increased mortality. Parenteral feeding has been associated with higher risks of intravascular catheter related infections and metabolic disturbances such as hyperglycemia and enteral microbial translocation because of the loss of intestinal villous architecture. The fact that this may potentially lead to a poor outcome is a matter of conflict , 36. In There are some points that have to be taken into consideration when interpreting the results of the present study. First, patients with hemoglobinopathies and blood transfusion patients were excluded from the study. This was due to the possible interference of the hemoglobin trait with the assay method and because, according to NGSP recommendations, any condition that changes red cell turnover will falsely lower HbA1c test results regardless of the assay method used . This meIn conclusion, our study suggests that DM and glucose regulation before the ICU admission might be not related to VAP. However, our data also showed that increased HbA1c levels might be predictive of increased risk for repeating BSI in the ICU. In this respect, HbA1c might be useful as a diagnostic biomarker in critical care patients.


The objectives of this study were to compare and analyze the results of right anterolateral thoracotomy and median sternotomy approach for primary mitral valve replacement with reference to the exposure during Valve Replacement , length of surgical incision, mean cross clamp time, mean bypass time, intensive care unit (ICU) stay, hospitalization, overall comorbidity with sternotomy; sepsis, dehiscence, healing cosmetic issues and cost effectiveness.The present study comprised 68 patients with rheumatic mitral valve disease who underwent mitral valve replacement in the Department ofCardiovascular and Thoracic Surgery at Sher‑i‑Kashmir Institute of Medical Sciences from September 2009 to August 2011.This study comprised 64 patients with 23 (35.9%) males and 41 (64.1%) females. Sternotomy group had 10 males (31.3%) and 22 females (68.7%). Thoracotomy group had 13 males (40.6%) and 19(59.4%) females. The length of incision between the two groups was statistically significant (P<0.0001). Mean incision length were 24.6±2.1 cm and 14.8±2.3 cm in sternotomy and thoracotomy respectively. Statistically significant difference regarding duration of ICU stay was found between the two groups (P<0.0001). Scar visibility was 100% in sternotomy and around 25% in thoracotomy( P<0.0001).Thoracotomy through a right anterolateral aspect was easy to perform while maintaining maximum security for the patients. Besides its satisfactory cosmetic result especially in female patients, this approach proved to have several advantages. It offers a better exposure to the mitral apparatus even in patients with small left, allowing easy mitral valve replacement which is apparent from the lower cross‑clamp time in the test group. The invaluable advantage of the above- mentioned thoracotomy is total eradication of the risk of deep sternal infection. The shorter hospital stay and cost effectiveness of thoracotomy approach are additional relief to the family. Heart valves function is to maintain pressure gradients between cardiac chambers and ensuring unidirectional flow of blood without reflux through the heart. Among the heart valves, the aortic and mitral valve, are by far most vulnerable to disease. In regard to public health, medical diagnostic and surgical technique mitral valve diseases have been considered as the most interesting human maladies to be treated in this century , 2. RheuIn 1965 Jai Si Haung performed first open heart mitral valve replacement at Shanghai hospital, China. The ensuing years witnessed the rapid development of various valvular prostheses placed via a conventional approach,a full sternotomy with cardiopulmonary bypass (CBP) . A varieThe study was carriedout in the Department of Cardiovascular and Thoracic Surgery Sheri Kashmir Institute of Medical Sciences and comprised of a prospective study from September 2009 to August 2011. The patients were followed for a period of 22.5years.In the prospective study, patients were examined and evaluated A detailed clinical examination was carried out with special references to cardiovascular system .Patients were randomly allocated into two groups using computer generated random numbers. who required mitral valve replacement (MVR) according to the ACC/AHA guidelines  were inc2.1 Surgical procedureThe study group comprised 50% of patients who underwent MVR via right anterolateral thoracotomy and contol group including another 50% were subjected to MVR via median sternotomy. The same general anesthetic techniques with routine arterial and venous monitoring were utilized for both groups.In regard to thoracotomy group incision was made in the right sub-mammary fold starting 3–5 cm from the lateral border of the sternum. The breast tissue in females was gently mobilized and the right chest cavity was entered through the fourth intercostal space. Aortic and bicaval cannulation was then performed in the usual manner and cardiopulmonary bypass instituted. After cooling to 32°C, the aorta was cross clamped using a long curved aortic clamp in order to keep it out of the surgeon’s field, and aortic root blood cardioplegia was delivered. The left atrium was opened through an incision posterior and parallel to the interatrial groove that accessed the mitral valve. The diseased mitral valve was excised and then replaced by a prosthetic valve secured to annulus using continuous 20 prolene suture. The left atriotomy was closed by a single layer of 3/0 silk suture and deairing was performed through the suture line before removing the aortic crossclamp. Following re-warming to 37°C, the heart was allowed to take over the circulation. Decannulation was then performed and the suture line secured before giving the protamine. This was followed by complete closure of the pericardium by continuous sutures, leaving a small drain. The chest was then closed in layers leaving a separate thoracic drain.As for the control group, the approach was through the standard median sternotomy, but otherwise the operative technique was essentially the same.2.2 Postoperative managementPatients were electively ventilated overnight. Post extubation patients were shifted from ICU after completely assessing the general condition and hemodynamics of the patients along with baseline investigations and blood gases. Oral anticoagulant was started on second postoperative day with acenocoumarol to maintain a n International normalized ratio(INR) of 2.02.5.Intravenous antibiotics, a combination of ceftriaxone/sulbactam and amikacin were administered during hospitalization and changed according to clinical situation. Intravenous antibiotics were continued during the hospital stay.2.3 Statistical AnalysisThe results were presented as mean ±2 standard deviation. Statistical analysis was performed between the two groups using the independent sample ttest and Chi square test. A significant difference was recorded if the P value was less than or equal to 0.05. SPSS 17 for Windows was used for statistical analysis.All patients patients were operated for mitral valve disorder and underwent mitral valve replacement. One patient from thoracotomy group and 3 patients from sternotomy group expired during the course of study and were excluded from the study. Study was completed in 64 patients.Mean age in sterntomy group was 42.56 ± 6.2 years and in thoracotomy group it was 44.41 ± 8.2 years. In our study 64 patients 23 (35.9%) were males and 41 were females (64.1%). Sternotomy group had 10 males (31.3%) and 22 females (68.7%). Thoracotomy group had 13 males (40.6%) and 19 females (59.4%).In our study 20 (62.5%) and 24 (75%) of the cases were class III in sternotomy and thoracotomy groups respectively while the remaining patients were class IV .The two groups were comparable with respect to ejection fraction. Most patients had an ejection fraction between 30%-50%; 68.7% in sternotomy and 78.1% in thoracototmy groups.P<0.001). Mean incision length were 24.6±2.1 cm and 14.8±2.3 cm in sternotomy and thoracotomy respectively. A statistically significant difference in cross clamp time was found between the two groups (P=0.047). Cross clamp time was 45.3±8.3 minutes in sternotomy group and 41.7±5.7 minutes in thoracotomy group.A statistically significant difference in length of incision was found between the two groups . Total operating time was 4.6±0.3 and 4.7±0.4 hours for sternotomy and thoracotomy respectively (P=0.245).Statistically significant difference in duration of ICU stay was seen between the two groups.Duration of ICU stay was 21.9±3.7 hours in sternotomy and 17.1±4.2 hours in thoracotomy groups (P <0.0001).Difference in Duration in post operative hospital stay was statistically significant (P<0.001) with 11.1± 1.8 days and 9.2±1.1 days for sternotomy and thoracotomy respectively.P <0.0001).Wound infection was seen in 3 (9.3%) patients and in 1(3.1%) cases of sternotomy and thoracotomy groups respectively. Wound dehiscence was found in one patient of sternotomy group. Scar visibility was 100% in sternotomy and around 25% in thoracotomy groups ( Scar complication was found in18 (56.3%) patients of sternotomy and in only 2 (6.3%) of thoracotomy groups. Scar hypertrophy and stretching was seen more frequently in sternotomy group (31.3% and 21.8% respectively). Thorocotomy had an only incidence of 3.1% for each of these complications. 80%of females in thorocotomy group were satisfied with their scar appearance and cosmetic quality.P=0.002). There was no Conversion during surgery from thorocotomy to sternotomy for need of adequate exposure at the time of valve replacement.Postoperative drug cost in sternotomy group was 10.9±2.4 and in thoracotomy group 9.2±1.5 thousand( Indian Rupies)  patients in sternotomy group were NYHA class III, and the remaining 37% were in class IV and 24 (75%) patients in thoracotomy group were class III while the rest were class IV. This is consistent with the study by Apostolos D, et al. (% patientMajority of the patients had an ejection fraction (EF) below 60% which is the indication for surgical intervention according to ACC/ AHA guidelines for management of patients with valvular heart disease. Sternotomy group had 7(21.9%) patients with EF >50%, 22 (68.7%) subjects with EF 30-50% and 3 (9.4%) having EF below 30%. In regard to thorocotomy group, EF were >50%, 30-50% and below30% in 5(15.1%),25 (78.1%) and2 (6.3%) patients respectively. Hence the groups were almost comparable with respect to ejection fraction.Mean aortic crossclamp time was 45.3±8.3 minutes in sternotomy group and 41.7±5.7 minutes in thoracotomy group( p=.0.04). The observed values were well below the highest cutoff value for crossclamp time of 150 min which is significantly associated with postoperative morbidity, and particularly with postoperative stroke. The lesMean bypass time in case of sternotomy was 82.3±9.1 hours and 83.3±10.7 in case of thoracotomy (P=0.69). The observed values were well below the highest cutoff value for total bypass time of 240 min and were significantly associated with postoperative morbidity, and in particular with postoperative stroke(13). The total bypass time in our study is comparable with those of Mohammed El-Fiky et al. (59±11 min) (14), Zapolanski A, et al. (77.0±25.8 hours), Grossi Total operating times were 4.6±.4 hours (276±24 min) and 4.7±0.4 hours (282±24 min) in sternotomy and thoracotomy groups respectively P=0.245). William L. Holman et al. reported a mean operating time of 185±73 minutes . Riess F. WilliamOverall surgical exposure was comparable between the two groups including cannulation of the vessels, aortic clamping, instituting cardioplegia using standard techniques as well as atriotomy, valve excision and replacement. There was no technical difficulty during aortic and major vessel cannulation in thoracotomy group. Left atrium was sufficiently exposed while the accessibility to valve during excision of valve and valve replacement was adequate. This was supported by conversion rate to sternotomy, for need of adequate exposure to valve apparatus was zero, and bycomparable results of bypass time, crossclamp time and total operating time between the two study groups. This observation is consistent with the studies by Kumar AS et al, CallejaStatistically significant difference was seen in the duration of ICU stay (P<0.001).In our study we had a choice of shifting the patients early to high dependency area of our general post operative ward. Duration ICU stay was 21.9±3.7 hours in sternotomy and 17.1±4.2 hours in thoracotomy. This is consistent with studies by Yung MC et al. 36.3±5.0 hours) , Reiss F.0 hours Significant difference in duration of postoperative hospital stay was observed (P= 0.02) between the two groups (11.1±0.8 days and 9.2±1.7 days with sternotomy and thoracotomy respectively). Result was consistent with studies by Mohamed El-Fiky et al. (7±2) , Yung MCThoracotomy approach utilizes a smaller incision length that improves the cosmetic result due to small scar which is less visible especially in females. The length of incision was significantly lesser in thoracotomy with a mean length of 15 cm as compared to 25cm for sternotomy (P<0.0001). El- Fiky et al.  reportedIn our study 3 (9.3%) out of 32 patients in sternotomy group and 1 out of 32 (3.1%) cases in thoracotomy group had wound infection. Thoracotomy wounds were less prone to infection while sternal wounds were more vulnerable to infection. This was in agreement with the studies by Zapolanski A, et al.  and AybeCosmetically the incision in thoracotomy group was better than the sternotomy group. The scar was 100% visible in frontal view in sternotomy while in thoracotomy it was less obvious and more laterally placed even in males. In females most of the incision length was hidden under the breast. This made it more convenient psychologically. According to EL-FIKY, et al., the wound was totally inapparent in their patients and more patients were in favor of this approach . The scaImproved cosmetic quality is an undisputed advantage of minimally invasive valve surgery. Statistically no significant difference was found in the patient satisfaction when the two overall group populations were compared in regard to cosmetic aspects. However 15(80%) out of 19 females in thoracotomy group especially young women were satisfied with the postoperative scar appearance, whereas this was seen in only 12 out of 22 (54%) females in sternotomy group. On the other hand, there was no such difference found between males patients, with approximately 70% in each group. Higher percentage of patients in thoracotomy group appeared to be satisfied with the approach, and the rest remained indifferent to the type of approach used. This is consistent with the study by Cheng, Davy C. H. et al. In a stPostoperative drug cost was significantly lower in thoracotomy group than in sternotomy patients (P= 0.002). Less postoperative pain due to the use of intercostal nerve block reduced the need for frequent analgesia. Lesser inhibition of respiratory movements due to less pain helped early ambulation and rehabilitation, with subsequent lower cost of drug use and hospital stay. Post operative drug cost was about 15% less in the study group than in control group, a finding consistent with the study done by Melih Hulusi Us et al.  Chitwood


By introducing a blood-saving-bundle (BSB) consisting of a closed-loop arterial blood sampling system, smaller tubes and an attempt to reduce the number of blood samples, we aimed to reduce blood loss caused by diagnostic blood sampling and to minimize the development of anemia in a high-risk group of mechanically ventilated intensive care patients.Included were all patients from our medical ICU who were ventilated for more than 72 hours. Exclusion criteria were acute or chronic anemia on admission, a bleeding episode during the ICU stay or end-of-life therapy. The BSB was introduced in 2009 with training and educational support. Patients treated in the year 2008 before the introduction of the BSB served as a control group and were compared to patients treated in 2010 after introduction of the BSB (BSB group). Daily blood loss was calculated on the basis of the documentation of blood samples and laboratory values in the patient data management system and by using data from two representative study periods in which the sample volumes of all diagnostic blood tests were measured.P < 0.001). The introduction of a closed-loop arterial blood sampling system contributed most to this effect. Mean hemoglobin values showed a similar decrease in both groups during the ICU stay. However, hemoglobin values <9 g/dl were measured in 21.2% of observation days in the controls versus 15.4% in the BSB group (P = 0.01). In the control group 31.7% (18.1 to 48.1%) of the patients received red blood cell transfusions in contrast to only 8.0% (2.2 to 19.2%) in the BSB group (P = 0.006), while the hemoglobin concentration triggering transfusion was not significantly different (8.2 vs. 7.8 g/dl). The mean number of intubation days was 7.1 days (6.1 to 8.3 days) in the controls and 7.5 days (6.6 to 8.5) in the BSB group (P = NS). However, patients in the BSB group stayed with a mean of 9.8 days (8.6 to 11.3 days) significantly shorter in the ICU than controls with 13.2 days (10.9 to 15.4 days) (P = 0.014).The control group comprised of 41 patients (614 observation days), the BSB group of 50 patients (559 observation days). Mean blood loss per ICU day decreased from 43.3 ml (95% CI 41.2 to 45.3 ml) in the controls to 15.0 ml (14.3 to 15.7 ml) in the BSB group (Our BSB could easily be implemented and was able to reduce diagnostic blood loss by 65%. After introduction of the BSB we observed less transfusions and a shorter ICU stay in mechanically ventilated patients; this, however, has to be interpreted with caution due to the longitudinal study design.


Background. Cystic echinococcosis (CE) is a chronic, clinically complex, and neglected disease. Its prevalence in Italy, a country of medium to high endemicity, remains poorly defined, as notification has long ceased to be mandatory. Methods. We set up a retrospective cohort study involving all CE patients followed at our institute between January 2005 and December 2012. Demographical and clinical features were recorded and analyzed. Results. CE was found in 28 patients (64.3%), mostly Italians from the central regions (50%), followed by subjects from the islands (33.3%) and Southern Italy (16.7%). Their median age was 45 years (IQR: 38.5–66.5), with Eastern Europeans being significantly younger  than other patients (P ≤ 0.0001). A total of 149 cysts, mostly with hepatic localization (96%), were described. Based on the WHO classification, the cysts were mainly small (80.5%) and active (CE1 (73.8%); CE2 (7.4%)). Active cysts were more common in Eastern Europeans (85.7%) than Italians (66.7%). Conclusion. Our data confirm CE occurrence in Italy. We emphasize the importance to have a national CE registry, opportunely recently introduced. This is essential to assess CE prevalence in this country, implement appropriate control measures, and improve patient management. Echinococcus granulosus whose adults and eggs are found in the small intestine of carnivores. CE is a neglected disease causing substantial morbidity and mortality in endemic areas ..23].Echinococcus granulosus at INMI was performed using IHA  and Western blot IgG  kits. IHA results equal to or greater than 1 : 64 were considered positive when hemagglutinins against type O erythrocytes were absent. IHA-low positive titers of 1 : 32 to 1 : 128 could only be accepted as positive for echinococcosis if confirmed in conjunction with a second diagnostic method. Echinococcus granulosus Western blot IgG  was used to evaluate bands detecting antibodies against Echinococcus granulosus antigens. These antigens were nonspecific antigens p39 (39 kDa), genus-specific but cross-reactive antigens with other Echinococcus species p24/26 (24–26 kDa), p16/18 (16–18 kDa), and also Echinococcus granulosus specific p7 (7 kDa) antigen. Manufacturer procedures were followed to evaluate the band patterns.Serological diagnosis of M. tuberculosis (Mtb) from sputa. “Past TB” was defined as culture-positive pulmonary TB in which completion of a 6-month course of treatment led to culture-negative sputa. “Radiological signs of probable past TB” included apical fibronodular lesions and/or apical calcifications.“Active TB” was defined by a positive culture for ARCHITECT HIV Ag/Ab Combo  was used for HIV screening.P value of 0.05 was considered significant. For categorical variables, results were expressed as absolute numbers or percentages.Data were double entered and cross-checked, and statistical analyses were performed using SPSS v.19 for Windows . Gender, age, geographic origin, number and size of cysts, and treatment information in relationship to the WHO stage of the cysts were analyzed by univariate (Pearson's Chi-squared test for independence) statistical analysis. A We reviewed the data from 28 patients (18 inpatients with CE as a “discharge diagnosis” and 10 outpatients identified by the radiologists and clinicians as having CE) who were followed at INMI between January 2005 and December 2012. Demographic and clinical features are shown in P ≤ 0.0001). Only five of these patients (17.9%) had been tested for HIV, and all of them were negative. Regarding TB status, 1 (3.6%) Italian patient had active pulmonary TB and 1 (3.6%) from Asia reported a past-cured pulmonary TB. Moreover, we evaluated the chest X-rays and lung images in 24/28 (85.7%) patients. Two out of the 24 (8.3%) patients showed radiological signs of probable past TB  although history of a previous disease was not reported in the clinical charts. Patients were not evaluated for latent TB infection (LTBI) by immune diagnostic tests.Most patients were females [16 (57.1%)]. The median age was 45 years (IQR: 38.5–66.5); the median age of the Italian patients  was significantly higher than that of the non-Italians. In particular, Eastern European patients were significantly younger  than Italian, Asian, and African patients . Most patients (21 (75%)) were receiving albendazole and/or were scheduled for surgery at the time of study inclusion. Among them, 16 (57.2%) were treated with albendazole, 3 (10.7%) underwent surgical resection of the cysts, and 2 (7.1%) received a combination of medical and surgical treatments . InformaSerological diagnosis was performed using the IHA test and was confirmed by Western blot. Based on the manufacturer's instructions, IHA titers lower than 1 : 16 are scored negative for echinococcosis. In our survey, 10 patients (35.7%) had an IHA titer ranging from 1 : 16 to 1 : 128 and 15 patients (53.6%) had an IHA titer higher than 1 : 128 . Only 3 We performed a detailed analysis of the US reports available for all 28 CE infected subjects. As shown in We evaluated the chest X-ray for all the CE patients reported in the study with the exception of 4 (14.3%) who did not have lung images in the hospital records. However, in 2 out of 4 of these patients, we found a lung localization of cysts reported in their clinical chart. However, these cysts were not definitely identified as pulmonary CE cysts (data not shown). Among the 24 patients with lung images, 5 (20.8%) had pulmonary CE cysts  pulmonary cysts) and 19 (79.2%) did not show any sign of CE in the lungs. Moreover, one liver cyst eroded the diaphragm and extended into the lung (1 (0.7%)). Based on the WHO classification, 120 (80.5%) cysts were small, with a diameter smaller than 5 cm; 23 (15.5%) were medium sized, with a diameter ranging from 5 cm to 10 cm, and 6 (4%) cysts were large (>10 cm).Most of the cysts were active, with 110 CE1 (73.8%) and 11 CE2 (7.4%), with far fewer CE4 and CE5 (2 (1.3%) and 16 (10.8%), resp.). There were 2 (1.3%) transitional CE3a cysts and 5 CE3b cysts (3.4%). Active cysts were more common among patients coming from Eastern Europe (85.7%) than in Italian patients (66.7%). Three cysts (2%) from 2 patients were undifferentiated and initially staged as CL. These cysts were later confirmed to be echinococcal, by surgery in 1 patient and by response to albendazole in the other patient. Cyst characteristics evaluated for each patient are shown in Cystic echinococcosis is a chronic and neglected disease, and its pathogenesis and natural history are still poorly understood. CE, which occurs worldwide and causes significant losses in endemic areas, has a renewed importance in Europe, as reemerging cases have been documented . The mosEchinococcus granulosus-infected subjects were mostly Italians coming from central regions, in particular from Latium , followed by subjects coming from the islands (Sardinia and Sicily) and Southern Italy.This retrospective study shows that at our hospital CE was found in 28 patients over the course of 7 years. These patients had a US diagnosis of CE, complemented or not by positive serology. CE is often an occupational disease, and farming and raising sheep seem to be risk factors . TherefoPrevalence rates of human CE turned out to be higher than expected, also in regions considered nonendemic, such as Lombardy , indicatA low IHA titer was found in 35.7% of the CE subjects included in our study. In addition, 3 subjects (10.7%) had a negative IHA titer, although echinococcal cysts were documented and confirmed by surgery in 2 out of 3. This is in line with the literature on the poor performance of conventional serodiagnosis of CE. In fact, a key problem for immunodiagnosis is the high proportion of false-negative results (more than 25%) , 29 ofteEchinococcus granulosus cysts in the liver. Most cysts were active  with a small diameter. This is an interesting finding, which points to active parasitic pressure in the areas where those patients acquired the infection [The majority of the subjects evaluated in this study had nfection . In addiCurrently, it is under investigation whether helminths may negatively impact TB disease and HIV due to the rarity of available systematic studies , 33.Also, among the CE patients evaluated in this study, TB was found as active TB or past TB in 1 patient, respectively, and “probable past TB” in 2, as defined by radiological signs; finally, only few patients were evaluated for HIV status. Therefore, it is difficult to analyze the impact of coinfections in CE. Recent papers suggest an association between CE and the immune suppression induced by HIV, since cases of severe disseminated disease have been reported with HIV coinfection , 35. TheThe limitations of this study, such as the small number of subjects, the lack of information on occupational risks, and residency  of the subjects prevent us from drawing conclusions. However, we provide a realistic picture of CE as seen in a hospital of infectious diseases in Italy and show that CE cases still occur in our country. This is especially important because there are no official European reports of human cases in Italy from 2004–2008 , a perioInformation on CE prevalence in Italy is essential for implementing appropriate control measures and proper patient management. Our data confirm CE occurrence in Italy and the need to set up the prospective study within the IDEA initiative. A National Registry of Cystic Echinococcosis would be the key to fill the many gaps existing in the assessment of CE in Italy.