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Saleem MU, Farman M, Nisar KS, Ahmad A, Munir Z, Hincal E. Investigation and application of a classical piecewise hybrid with a fractional derivative for the epidemic model: Dynamical transmission and modeling. PLoS One 2024; 19:e0307732. [PMID: 39208269 PMCID: PMC11361697 DOI: 10.1371/journal.pone.0307732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 07/09/2024] [Indexed: 09/04/2024] Open
Abstract
In this research, we developed an epidemic model with a combination of Atangana-Baleanu Caputo derivative and classical operators for the hybrid operator's memory effects, allowing us to observe the dynamics and treatment effects at different time phases of syphilis infection caused by sex. The developed model properties, which take into account linear growth and Lipschitz requirements relating the rate of effects within its many sub-compartments according to the equilibrium points, include positivity, unique solution, exitance, and boundedness in the feasible domain. After conducting sensitivity analysis with various parameters influencing the model for the piecewise fractional operator, the reproductive number R0 for the biological viability of the model is determined. Generalized Ulam-Hyers stability results are employed to preserve global stability. The investigated model thus has a unique solution in the specified subinterval in light of the Banach conclusion, and contraction as a consequence holds for the Atangana-Baleanu Caputo derivative with classical operators. The piecewise model that has been suggested has a maximum of one solution. For numerical solutions, piecewise fractional hybrid operators at various fractional order values are solved using the Newton polynomial interpolation method. A comparison is also made between Caputo operator and the piecewise derivative proposed operator. This work improves our knowledge of the dynamics of syphilis and offers a solid framework for assessing the effectiveness of interventions for planning and making decisions to manage the illness.
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Affiliation(s)
| | - Muhammad Farman
- Mathematics Research Center, Near East University, Nicosia, North Cyprus, Turkey
- Department of Computer Science and Mathematics, Lebanese American University, Beirut, Lebanon
| | - Kottakkaran Sooppy Nisar
- Department of Mathematics, College of Science and Humanities in Alkharj, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
- Saveetha School of Engineering, SIMATS, Chennai, India
| | - Aqeel Ahmad
- Mathematics Research Center, Near East University, Nicosia, North Cyprus, Turkey
- Department of Mathematics, Ghazi University, D G Khan, Pakistan
| | - Zainab Munir
- Institute of Mathematics, Khwaja Fareed University of Engineering and Information Technology, Rahim Yar Khan, Pakistan
| | - Evren Hincal
- Mathematics Research Center, Near East University, Nicosia, North Cyprus, Turkey
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Salomè S, Cambriglia MD, Montesano G, Capasso L, Raimondi F. Congenital Syphilis: A Re-Emerging but Preventable Infection. Pathogens 2024; 13:481. [PMID: 38921779 PMCID: PMC11206692 DOI: 10.3390/pathogens13060481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 05/31/2024] [Accepted: 06/03/2024] [Indexed: 06/27/2024] Open
Abstract
Congenital syphilis presents a significant global burden, contributing to fetal loss, stillbirth, neonatal mortality, and congenital infection. Despite the target established in 2007 by the World Health Organization (WHO) of fewer than 50 cases per 100,000 live births, the global incidence is on the rise, particularly in low- and middle-income regions. Recent data indicate a rate of 473 cases per 100,000 live births, resulting in 661,000 total cases of congenital syphilis, including 355,000 adverse birth outcomes such as early fetal deaths, stillbirths, neonatal deaths, preterm or low-birth-weight births, and infants with clinical congenital syphilis. Alarmingly, only 6% of these adverse outcomes occurred in mothers who were enrolled, screened, and treated. Unlike many neonatal infections, congenital syphilis is preventable through effective antenatal screening and treatment of infected pregnant women. However, despite available screening tools, affordable treatment options, and the integration of prevention programs into antenatal care in various countries, congenital syphilis remains a pressing public health concern worldwide. This review aims to summarize the current epidemiology, transmission, and treatment of syphilis in pregnancy, as well as to explore global efforts to reduce vertical transmission and address the reasons for falling short of the WHO elimination target.
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Affiliation(s)
- Serena Salomè
- Division of Neonatology, Department of Translational Medical Sciences, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy; (M.D.C.); (G.M.); (L.C.); (F.R.)
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Heggie C, Al-Diwani H, Arundel P, Balmer R. Diagnosis and initial management of children presenting with premature loss of primary teeth associated with a systemic condition: A scoping review and development of clinical aid. Int J Paediatr Dent 2024. [PMID: 38609350 DOI: 10.1111/ipd.13188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/21/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Premature loss of primary teeth (PLPT) can be a rare presentation of systemic medical conditions. Premature loss of primary teeth may present a diagnostic dilemma to paediatric dentists. AIMS To identify systemic conditions associated with PLPT and develop a clinical aid. DESIGN OVID Medline, Embase and Web of Science were searched up to March 2023. Citation searching of review publications occurred. Exclusion occurred for conference abstracts, absence of PLPT and absence of English-language full text. RESULTS Seven hundred and ninety-one publications were identified via databases and 476 by citation searching of review articles. Removal of 390 duplicates occurred. Following the exclusion of 466 records on abstract review, 411 publications were sought for retrieval, of which 142 met inclusion criteria. Thirty-one systemic conditions were identified. For 19 conditions, only one publication was identified. The majority of publications, 91% (n = 129), were case reports or series. Most publications, 44% (n = 62), were related to hypophosphatasia, and 25% (n = 35) were related to Papillon-Lefèvre. Diagnostic features were synthesised, and a clinical aid was produced by an iterative consensus approach. CONCLUSIONS A diverse range of systemic diseases are associated with PLPT. Evidence quality, however, is low, with most diseases having a low number of supporting cases. This clinical aid supports paediatric dentists in differential diagnosis and onward referral.
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Fortin O, DeBiasi RL, Mulkey SB. Congenital infectious encephalopathies from the intrapartum period to postnatal life. Semin Fetal Neonatal Med 2024:101526. [PMID: 38677956 DOI: 10.1016/j.siny.2024.101526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
Congenital infections are a common but often underrecognized cause of fetal brain abnormalities, as well as fetal-neonatal morbidity and mortality, that should be considered by all healthcare professionals providing neurological care to fetuses and newborns. Maternal infection with various pathogens (cytomegalovirus, Toxoplasmosis, Rubella virus, Parvovirus B19, lymphocytic choriomeningitis virus, syphilis, Zika virus, varicella zoster virus) during pregnancy can be transmitted to the developing fetus, which can cause multisystem dysfunction and destructive or malformative central nervous system lesions. These can be recognized on fetal and neonatal imaging, including ultrasound and MRI. Imaging and clinical features often overlap, but some distinguishing features can help identify specific pathogens and guide subsequent testing strategies. Some pathogens can be specifically treated, and others can be managed with targeted interventions or symptomatic therapy based on expected complications. Neurological and neurodevelopmental complications related to congenital infections vary widely and are likely driven by a combination of pathophysiologic factors, alone or in combination. These include direct invasion of the fetal central nervous system by pathogens, inflammation of the maternal-placental-fetal triad in response to infection, and long-term effects of immunogenic and epigenetic changes in the fetus in response to maternal-fetal infection. Congenital infections and their neurodevelopmental impacts should be seen as an issue of public health policy, given that infection and the associated complications disproportionately affect woman and children from low- and middle-income countries and those with lower socio-economic status in high-income countries. Congenital infections may be preventable and treatable, which can improve long-term neurodevelopmental outcomes in children.
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Affiliation(s)
- Olivier Fortin
- Zickler Family Prenatal Pediatrics Institute, Children's National Hospital, Washington DC, USA
| | - Roberta L DeBiasi
- Division of Pediatric Infectious Disease, Children's National Hospital, Washington DC, USA; Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington DC, USA; Department of Tropical Medicine, Microbiology and Infectious Diseases, The George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Sarah B Mulkey
- Zickler Family Prenatal Pediatrics Institute, Children's National Hospital, Washington DC, USA; Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington DC, USA; Department of Neurology and Rehabilitation Medicine, The George Washington University School of Medicine and Health Sciences, Washington DC, USA.
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Ekselius L, Gerdin B, Vahlquist A. The Syphilis Pandemic Prior to Penicillin: Origin, Health Issues, Cultural Representation and Ethical Challenges. Acta Derm Venereol 2024; 104:adv34879. [PMID: 38436430 PMCID: PMC10926575 DOI: 10.2340/actadv.v104.34879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 01/16/2024] [Indexed: 03/05/2024] Open
Abstract
Syphilis is currently a treatable disease, with a low incidence in most developed countries, although the prevalence has increased recently, especially among men-who-have-sex-with-men. In many of the least developed countries, however, syphilis is still a major health problem, although the problem is not comparable to the desperate situation worldwide less than 80 years ago. At that time, and for many centuries previously, syphilis dramatically affected the lives and health of individuals and threatened the well-being of many societies. This review examines the aetiology, transmission, and many manifestations of syphilis from a historical perspective, emphasizing morbidity, treatment, psychosocial and cultural manifestations, as well as ethical issues uncovered in the clinical search for knowledge about the manifestations of the disease.
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Affiliation(s)
- Lisa Ekselius
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Bengt Gerdin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Vahlquist
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
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Stafford IA, Workowski KA, Bachmann LH. Syphilis Complicating Pregnancy and Congenital Syphilis. N Engl J Med 2024; 390:242-253. [PMID: 38231625 DOI: 10.1056/nejmra2202762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Affiliation(s)
- Irene A Stafford
- From the Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, McGovern Medical School at UT Health, Houston (I.A.S.); and the Department of Medicine, Division of Infectious Diseases, Emory University (K.A.W.), and the Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention - both in Atlanta (K.A.W., L.H.B.)
| | - Kimberly A Workowski
- From the Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, McGovern Medical School at UT Health, Houston (I.A.S.); and the Department of Medicine, Division of Infectious Diseases, Emory University (K.A.W.), and the Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention - both in Atlanta (K.A.W., L.H.B.)
| | - Laura H Bachmann
- From the Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, McGovern Medical School at UT Health, Houston (I.A.S.); and the Department of Medicine, Division of Infectious Diseases, Emory University (K.A.W.), and the Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention - both in Atlanta (K.A.W., L.H.B.)
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Lima MG, Bahia JC, Oliveira FS, Vieira FV, Cavalcante AMR, Matos MA, Guimarães JV. Educational intervention improves knowledge and adherence to treatment amongst puerperal women with syphilis: randomized clinical trial. Int J STD AIDS 2023; 34:969-977. [PMID: 37464586 DOI: 10.1177/09564624231188750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Gestational syphilis requires early detection and proper treatment to prevent negative maternal-fetal outcomes. This study aimed to evaluate the effectiveness of an educational intervention on treatment adherence and knowledge about syphilis in postpartum women with positive Treponema pallidum results. METHODS A randomized, parallel, and open clinical trial was conducted with 64 postpartum women who tested positive for T. pallidum, assigned to two groups (1:1 ratio). The Intervention Group (IG) received an educational intervention on syphilis, including an explanatory leaflet and hands-on demonstrations, along with standard guidelines. The Control Group (CG) received standard guidelines alone. Pre-test and post-test assessments were conducted to measure knowledge and treatment adherence. Statistical analyses included descriptive and inferential methods, assessing group homogeneity using the Chi-square or Fishers exact test. The interventions effectiveness was determined using relative risk, and pre- and post-test scores were compared using the independent t test. RESULTS The post-test revealed improvements in knowledge scores for general knowledge, treatment, and prevention domains (p < .05). The IG demonstrated an increase in post-test knowledge scores (p = .001), with association between post-test scores and treatment adherence (p = .001). CONCLUSION The educational intervention on syphilis improved knowledge and treatment adherence in postpartum women with syphilis.
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Affiliation(s)
- Maira Gr Lima
- Master in Nursing, Faculdade de Enfermagem da Universidade Federal de Goiás (FEN - UFG), Goiânia/Goiás, Brazil
| | - Julyana C Bahia
- Master in Nursing, Faculdade de Enfermagem da Universidade Federal de Goiás (FEN - UFG), Goiânia/Goiás, Brazil
| | - Flávia S Oliveira
- Master in Nursing, Faculdade de Enfermagem da Universidade Federal de Goiás (FEN - UFG), Goiânia/Goiás, Brazil
| | - Flaviana Vm Vieira
- PhD in nursing, professor at Faculdade de Enfermagem da Universidade Federal de Goiás (FEN - UFG), Goiânia/Goiás, Brazil
| | - Agueda Maria Rz Cavalcante
- PhD in nursing, professor at Faculdade de Enfermagem da Universidade Federal de Goiás (FEN - UFG), Goiânia/Goiás, Brazil
| | - Marcos André Matos
- PhD in nursing, professor at Faculdade de Enfermagem da Universidade Federal de Goiás (FEN - UFG), Goiânia/Goiás, Brazil
| | - Janaína V Guimarães
- PhD in nursing, professor at Faculdade de Enfermagem da Universidade Federal de Goiás (FEN - UFG), Goiânia/Goiás, Brazil
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Abstract
PURPOSE OF REVIEW Congenital infections are a major cause of childhood multidomain neurodevelopmental disabilities. They contribute to a range of structural brain abnormalities that can cause severe neurodevelopmental impairment, cerebral palsy, epilepsy, and neurosensory impairments. New congenital infections and global viral pandemics have emerged, with some affecting the developing brain and causing neurodevelopmental concerns. This review aims to provide current understanding of fetal infections and their impact on neurodevelopment. RECENT FINDINGS There are a growing list of congenital infections causing neurodevelopmental issues, including cytomegalovirus, Zika virus, syphilis, rubella, lymphocytic choriomeningitis virus, and toxoplasmosis. Fetal exposure to maternal SARS-CoV-2 may also pose risk to the developing brain and impact neurodevelopmental outcomes, although studies have conflicting results. As Zika virus was a recently identified congenital infection, there are several new reports on child neurodevelopment in the Caribbean and Central and South America. For many congenital infections, children with in-utero exposure, even if asymptomatic at birth, may have neurodevelopmental concerns manifest over time. SUMMARY Congenital infections should be considered in the differential diagnosis of a child with neurodevelopmental impairments. Detailed pregnancy history, exposure risk, and testing should guide diagnosis and multidisciplinary evaluation. Children with congenital infections should have long-term follow-up to assess for neurodevelopmental delays and other neurosensory impairments. Children with confirmed delays or high-risk should be referred for rehabilitation therapies.
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Affiliation(s)
- Olivier Fortin
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
| | - Sarah B. Mulkey
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
- Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, DC
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
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Santos-Baltuilhe S, Mallmann GS, França ALN, Azambuja KCO, Andrade PHM, Oliveira EF, Soares-Marangoni DA. Motor repertoire in 3- to 5- month-old infants with prenatal exposure to syphilis and toxoplasmosis. Early Hum Dev 2023; 183:105822. [PMID: 37454445 DOI: 10.1016/j.earlhumdev.2023.105822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/07/2023] [Accepted: 07/08/2023] [Indexed: 07/18/2023]
Abstract
AIM To characterize the motor repertoire of 3- to 5-month-old infants who were prenatally exposed to the infectious agents of syphilis and toxoplasmosis. METHODS Exploratory observational study that evaluated 15 exposed infants (34.4 ± 3.5 weeks gestation) recruited from a referral center. Age assessment ranged 12-20 (median 12) weeks post-term. General Movement Assessment, including the Motor Optimality Score-Revised (MOS-R), was used to assess the global quality of fidgety movements (FMs) and to quantify and detail coexisting motor patterns. Clinical variables were also collected. Later motor outcomes were obtained from medical reports when possible. RESULTS MOS-R ranged 10-26 (median 24). There was a higher proportion of infants with normal (80.0 %) than aberrant FMs, but the proportion of infants with reduced MOS-R (80.0 %) was higher compared to optimal MOS-R. One infant with aberrant FMs was later diagnosed with cerebral palsy. Only 13.3 % of the infants showed smooth and fluent movement character. All observed tongue movements were abnormal. CONCLUSION Infants had predominantly normal FMs, but with reduced MOS-R and abnormalities in the coexisting motor repertoire.
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Affiliation(s)
- Sarita Santos-Baltuilhe
- Graduate Program in Movement Sciences, Institute of Health, Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil; Specialized Rehabilitation Center, Association of Parents and Friends of Exceptional Children, Campo Grande, MS, Brazil
| | - Geruza Souza Mallmann
- Graduate Program in Movement Sciences, Institute of Health, Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil
| | - Andressa Lagoa Nascimento França
- Graduate Program in Health and Development, Faculty of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil
| | | | - Paulo Henrique Muleta Andrade
- Specialized Rehabilitation Center, Association of Parents and Friends of Exceptional Children, Campo Grande, MS, Brazil
| | - Everton Falcão Oliveira
- Graduate Program in Infectious and Parasitic Diseases, Faculty of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil
| | - Daniele Almeida Soares-Marangoni
- Graduate Program in Movement Sciences, Institute of Health, Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil; Graduate Program in Health and Development, Faculty of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil.
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George EA, Nwankwo C, Castelo-Soccio L, Oboite M. Disorders in Children. Dermatol Clin 2023; 41:491-507. [PMID: 37236717 DOI: 10.1016/j.det.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Pediatric dermatoses can present at birth or develop over time. When managing dermatology conditions in children, caregiver involvement is important. Patients may have lesions that need to be monitored or need assistance with therapeutic administration. The following section provides a subset of pediatric dermatoses and notable points for presentation in skin of color patients. Providers need to be able to recognize dermatology conditions in patients of varying skin tones and provide therapies that address the condition and any associated pigmentary alterations.
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Affiliation(s)
| | - Christy Nwankwo
- University of Missouri, Kansas City School of Medicine, 2411 Holmes Street, Kansas City, MO 64108, USA
| | - Leslie Castelo-Soccio
- National Institute of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | - Michelle Oboite
- University of Pennsylvania, Perelman School of Medicine, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA; Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Petric UB, Ordonez J, Thomas C. Perianal plaques, acral bullae, and desquamation in a neonate. Pediatr Dermatol 2023; 40:718-720. [PMID: 37440193 DOI: 10.1111/pde.15244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 12/24/2022] [Indexed: 07/14/2023]
Affiliation(s)
- Ursa Bezan Petric
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Janett Ordonez
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Cristina Thomas
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Freyne B, Nourse C, Walls T. Congenital Syphilis: Controversies and Questions: A Global Perspective. Pediatr Infect Dis J 2023; 42:e166-e169. [PMID: 36728111 DOI: 10.1097/inf.0000000000003808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Bridget Freyne
- From the Department of Paediatric Infectious Diseases, Children's Health Ireland, Dublin, Ireland
- Division of Women & Children's Health, School of Medicine, University College Dublin, Ireland
| | - Clare Nourse
- Division of Women & Children's Health, School of Medicine, University College Dublin, Ireland
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Tony Walls
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
- Research for Children Aotearoa, New Zealand https://www.healthprecinct.org.nz/research-for-children-aotearoa/
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Serra G, Carta M, Di Pace MR, La Sala E, Piro E, Salerno S, Schierz IAM, Vassallo A, Giuffrè M, Corsello G. Congenital syphilis in a preterm newborn with gastrointestinal disorders and postnatal growth restriction. Ital J Pediatr 2022; 48:205. [PMID: 36581899 PMCID: PMC9801585 DOI: 10.1186/s13052-022-01404-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/27/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Congenital syphilis (CS) depends on the placental transmission of Treponema pallidum (TP) spirochetes from an infected mother to fetus during pregnancy. It shows a wide clinical variability with cutaneous and visceral manifestations, including stillbirths, neonatal death, and asymptomatic cases. Preterm infants with CS may have more severe features of disease than the term ones, due to the combined pathogenic effect of both CS and prematurity. CASE PRESENTATION We report on a female preterm (32+6 weeks of gestation) newborn showing most of the typical CS manifestations, in addition to gastrointestinal disorders including feeding difficulties, colon stenosis and malabsorption leading to postnatal growth restriction. The mother resulted positive at the syphilis screening test of the first trimester of pregnancy, but she did not undergo any treatment. At birth, our newborn was VDRL positive (antibody titer four times higher compared to the mother), and she was treated with intravenous benzathine benzylpenicillin G for 10 days (50,000 IU/Kg three times per day). Poor tolerance to enteral nutrition (abdominal distension, increased biliary type gastric secretions) was observed. A barium enema X-Ray identified a colon stenosis within the descending tract. However, the poor general conditions due to a concurrent fungal sepsis did not allow to perform any surgical procedure, and a conservative approach with total parenteral nutrition was started. The following evolution was marked by difficulties in enteral feeding including refusal of food and vomiting, to which also contributed the neurological abnormalities related to a perinatal asphyxia, and the affective deprivation for the physical absence of the mother during hospitalization. At 5 months of age, after the introduction of an amino acid-based formula (Neocate LCP Nutricia ®), an improvement of enteral feeding was observed, with no further and significantly decreased episodes of abdominal distension and vomiting respectively, and regular stool emission. A psychological support offered to the family allowed a more stable bond between the mother and her baby, thus providing a significant additional benefit to food tolerance and growth. She was discharged at 5 months of age, and included in a multidisciplinary follow-up. She at present shows global growth delay, and normal development apart from mildly increased tone of lower limbs. CONCLUSIONS Our report highlights less common clinical CS manifestations like gastrointestinal disorders including feeding difficulties, colon stenosis and malabsorption leading to postnatal growth delay. Moreover, it underlines how prematurity may worsen the clinical evolution of such congenital infection, due to the additional pathogenic effect of possible associated diseases and/or conditions like sepsis, hypoxic/ischemic injury, or use of drugs. CS may be observed also in high-income countries, with high rates of antenatal screening and availability of prenatal treatment. A multidisciplinary network must be guaranteed to the affected subjects, to ensure adequate care and improve the quality of life for patients and their families.
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Affiliation(s)
- Gregorio Serra
- grid.10776.370000 0004 1762 5517Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G. D’Alessandro”, University of Palermo, Palermo, Italy
| | - Maurizio Carta
- grid.10776.370000 0004 1762 5517Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G. D’Alessandro”, University of Palermo, Palermo, Italy
| | - Maria Rita Di Pace
- grid.10776.370000 0004 1762 5517Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G. D’Alessandro”, University of Palermo, Palermo, Italy
| | - Eleonora La Sala
- grid.10776.370000 0004 1762 5517Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G. D’Alessandro”, University of Palermo, Palermo, Italy
| | - Ettore Piro
- grid.10776.370000 0004 1762 5517Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G. D’Alessandro”, University of Palermo, Palermo, Italy
| | - Sergio Salerno
- grid.10776.370000 0004 1762 5517Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G. D’Alessandro”, University of Palermo, Palermo, Italy
| | - Ingrid Anne Mandy Schierz
- grid.10776.370000 0004 1762 5517Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G. D’Alessandro”, University of Palermo, Palermo, Italy
| | - Alessia Vassallo
- grid.10776.370000 0004 1762 5517Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G. D’Alessandro”, University of Palermo, Palermo, Italy
| | - Mario Giuffrè
- grid.10776.370000 0004 1762 5517Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G. D’Alessandro”, University of Palermo, Palermo, Italy
| | - Giovanni Corsello
- grid.10776.370000 0004 1762 5517Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G. D’Alessandro”, University of Palermo, Palermo, Italy
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Eppes CS, Stafford I, Rac M. Syphilis in pregnancy: an ongoing public health threat. Am J Obstet Gynecol 2022; 227:822-838. [PMID: 35932881 DOI: 10.1016/j.ajog.2022.07.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 07/08/2022] [Accepted: 07/18/2022] [Indexed: 01/26/2023]
Abstract
Syphilis is a treponemal infection that can be acquired sexually, hematogenously, or via vertical transmission from mother to infant. Despite evidence-based curative treatment options with penicillin, it remains a public health threat with increasing prevalence over recent years. Congenital syphilis, a condition where a fetus acquires the infection during pregnancy, can lead to stillbirth, miscarriage, preterm birth, birth defects, and lifelong physical or neurologic changes. Congenital syphilis rates in the United States increased by 261% from 2013 to 2018 and continue to increase in 2021. The only recommended treatment for syphilis in pregnancy is benzathine penicillin G because evidence of decreased risk of congenital syphilis with other modalities is lacking. Testing for syphilis is complex and includes either the reverse-sequence algorithm or the traditional algorithm. Determination of the clinical stage of syphilis includes incorporation of the previous treatment sequence and physical examination. The goal of this review was to discuss the current evidence about optimal treatment and testing during pregnancy to optimize maternal health and prevent congenital syphilis.
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Affiliation(s)
| | - Irene Stafford
- The University of Texas Health Science Center, Houston, TX
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15
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Schwemberger R, Joe P. Upper Extremity Hypotonia in a 5-week-old Infant. Neoreviews 2022; 23:e692-e695. [PMID: 36180734 DOI: 10.1542/neo.23-10-e692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Rachel Schwemberger
- Department of Pediatrics, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Priscilla Joe
- Department of Neonatology, UCSF Benioff Children's Hospital Oakland, Oakland, CA
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16
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Faure EE, Noriega L, Seminara C, Carranza G, Herrero M, Mukdsi JH. A rare cause of full-house membranous glomerulopathy in an infant: Answers. Pediatr Nephrol 2022; 37:2357-2359. [PMID: 35445973 DOI: 10.1007/s00467-022-05538-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Erica Elizabeth Faure
- Centro de Microscopía Electrónica, Facultad de Ciencias Médicas, Universidad Nacional de Córdoba, Reforma, esq. Haya de la Torre, 5000, Cordoba, Argentina.
| | - Leonela Noriega
- Centro de Microscopía Electrónica, Facultad de Ciencias Médicas, Universidad Nacional de Córdoba, Reforma, esq. Haya de la Torre, 5000, Cordoba, Argentina.,Instituto de Investigaciones en Ciencias de La Salud (INICSA), Consejo Nacional de Investigaciones Científicas Y Técnicas, Cordoba, Argentina
| | - Claudia Seminara
- Servicio de Nefrología, Hospital de Niños de La Santísima Trinidad, Cordoba, Argentina
| | - Gisella Carranza
- Servicio de Anatomía Patológica, Hospital de Niños de La Santísima Trinidad, Cordoba, Argentina
| | - Mónica Herrero
- Servicio de Anatomía Patológica, Hospital Córdoba, Cordoba, Argentina
| | - Jorge Humberto Mukdsi
- Centro de Microscopía Electrónica, Facultad de Ciencias Médicas, Universidad Nacional de Córdoba, Reforma, esq. Haya de la Torre, 5000, Cordoba, Argentina.,Instituto de Investigaciones en Ciencias de La Salud (INICSA), Consejo Nacional de Investigaciones Científicas Y Técnicas, Cordoba, Argentina
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17
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New trends in congenital syphilis: epidemiology, testing in pregnancy, and management. Curr Opin Infect Dis 2022; 35:452-460. [PMID: 36066379 DOI: 10.1097/qco.0000000000000875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW In light of alarming increases in the incidence of congenital syphilis in many middle and higher income countries across the globe, this review summarizes recent changes in the epidemiology of syphilis, highlights recommended changes to testing in pregnancy and provides an update for the management of syphilis infection in pregnancy (SIP) and of the infant born to a mother with SIP. RECENT FINDINGS The re-emergence of congenital syphilis is a result of increasing infectious syphilis in women of childbearing age, which is in turn a result of increasing syphilis in the general population particularly in Indigenous and marginalized populations. Potential reasons for the increase include changing sexual practices and increased travel and migration, as well as factors that limit healthcare access, particularly access to antenatal care and limited awareness and education amongst mothers and maternity services. A single antenatal test for syphilis is insufficient; more frequent testing in pregnancy is necessary even for women deemed to be low risk. The management of SIP and of the newborn is complex and guidelines should be readily available with clear recommendations. SUMMARY Congenital syphilis is preventable. The current crisis calls for a global and national multipronged, co-ordinated approach involving public health and hospital systems which includes education of individuals and healthcare workers, availability of updated guidelines for prevention and treatment, prioritization of antenatal testing, assurance of accessible and prompt treatment and appropriate assessment and follow-up of infants.
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18
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Rosenthal M, Poliquin V. Exploring management of antenatally diagnosed fetal syphilis infection. CANADA COMMUNICABLE DISEASE REPORT = RELEVE DES MALADIES TRANSMISSIBLES AU CANADA 2022; 48:111-114. [PMID: 35342369 PMCID: PMC8890477 DOI: 10.14745/ccdr.v48i23a09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND The incidence of syphilis among Canadian women of childbearing age has risen dramatically in the past decade, with a resurgence of infants born with congenital syphilis. While guidelines exist to guide maternal infection during pregnancy, there is little evidence available to guide management in situations where the developing fetus is found to be severely affected. CASE REVIEW Our patient presented in the second trimester of her pregnancy as syphilis contact. Positive serologic tests (venereal disease research laboratory titre of 1:64) and a chancre suggested primary infection. Ultrasound demonstrated a fetus at 19+3 weeks gestation with hydrops fetalis and a markedly abnormal brain. Amniocentesis confirmed congenital syphilis infection on polymerase chain reaction testing. After nine days of intravenous penicillin G, the fetal status had worsened, and the family ultimately chose a medical termination of the pregnancy. DISCUSSION Evolving ultrasound technology has allowed us to identify severely affected fetuses, who may historically have been delivered stillborn. Following routine syphiliotherapy with benzathine penicillin, these abnormal ultrasound features may take weeks or months to reverse, which poses a challenge in prognostication and counselling. Case reports data suggests intensive treatment with intravenous penicillin may be effective in severe cases where fetal hydrops is present. CONCLUSION This case highlights the potential morbidity of fetal syphilis infection and underscores the paucity of current literature. Information sharing will be essential to build a modern knowledge base on treating this ancient disease.
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Affiliation(s)
- Margot Rosenthal
- Department of Obstetrics, Gynecology and Reproductive Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB
| | - Vanessa Poliquin
- Department of Obstetrics, Gynecology and Reproductive Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB
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19
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Stubbs LA, Saliba CK, Schallert EK, John SD, Khatua S, Valencia Deray KG, Stevens AM, Rocha MEM. A Lucky Break: A Case of a 3-Month-Old Female With a Pathologic Fracture. Clin Pediatr (Phila) 2022; 61:76-80. [PMID: 34823408 DOI: 10.1177/00099228211059039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Leigh Anna Stubbs
- Baylor College of Medicine, Houston, TX, USA.,Texas Children's Hospital, Houston, TX, USA
| | - Cynthia K Saliba
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Erica K Schallert
- Baylor College of Medicine, Houston, TX, USA.,Texas Children's Hospital, Houston, TX, USA
| | - Susan D John
- Division of Diagnostic and Intervention Imaging McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Sutapa Khatua
- Division of Pediatric Hospital Medicine McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Kristen G Valencia Deray
- Section of Infectious Disease and Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Alexandra M Stevens
- Section of Pediatric Hematology, Oncology and Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Mary Esther M Rocha
- Baylor College of Medicine, Houston, TX, USA.,Texas Children's Hospital, Houston, TX, USA
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20
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Moraes BQSD, Feitosa ADO, Wanderley RA, Machado MF. Trend analysis of clinical aspects of congenital syphilis in Brazil, 2009-2018. Rev Assoc Med Bras (1992) 2021; 67:991-996. [PMID: 34817512 DOI: 10.1590/1806-9282.20210432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/06/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Congenital syphilis is caused by the vertical transmission of bacteria, Treponema pallidum, from nontreated or inappropriately treated pregnant to the fetus. OBJECTIVE To evaluate the clinical aspects of Congenital syphilis in Brazil, between 2009-2018. METHOD It is an analytical cross-sectional study whose data were collected from the Department of Chronical Conditions and Sexually Transmitted Infections of Brazilian Health Ministry. Clinical variables were analyzed using the software Joinpoint Regression, which makes a segmented linear regression. RESULTS In the study period, 156,969 cases of Congenital syphilis and 1642 deaths by this disease were reported. The trend analysis indicates growing in diagnosis of maternal syphilis during prenatal care, appropriate treatment of pregnant, realization of prenatal care, maternal partner treatment, diagnosis of syphilis in children under seven days, and diagnosis of recent syphilis. CONCLUSIONS Although the trend analysis presents relative improvement in Congenital syphilis panorama in Brazil, the disease still related to high numbers of evitable perinatal morbidity and mortality. Therefore, the prenatal assistance with quality is fundamental to have a possible change in this field in the country.
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Affiliation(s)
| | - Alexya de Oliveira Feitosa
- Universidade Federal de Alagoas, Nucleus of Studies in Social and Preventive Medicine - Arapiraca (AL), Brazil
| | | | - Michael Ferreira Machado
- Universidade Federal de Alagoas, Nucleus of Studies in Social and Preventive Medicine - Arapiraca (AL), Brazil
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21
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Abstract
Maternal pathogens can be transmitted to the fetus resulting in congenital infection with sequelae ranging from asymptomatic infection to severe debilitating disease and still birth. The TORCH pneumonic (toxoplasmosis, rubella, cytomegalovirus, and herpes simplex virus) is used widely, but it provides a limited description of the expanding list of pathogens associated with congenital infection. This article focuses on the evaluation and management of infants with common congenital infections such as cytomegalovirus, and infections that warrant early diagnosis and treatment to prevent serious complications, such as toxoplasmosis, human immunodeficiency virus, and syphilis. Zika virus and Chagas disease remain uncommon.
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Affiliation(s)
- Amaran Moodley
- Department of Pediatrics, Rady Childrens Hospital & University of California San Diego, 3020 Children's Way, MC 5041, San Diego, CA 92123, USA
| | - Kurlen S E Payton
- David Geffen School of Medicine at University of California Los Angeles, Division of Neonatology, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, NT Suite 4221, Los Angeles, CA 90048, USA.
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22
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Hui L, Shand A. Is it time to adopt routine cytomegalovirus screening in pregnancy? No! Am J Obstet Gynecol MFM 2021; 3:100355. [PMID: 33766808 DOI: 10.1016/j.ajogmf.2021.100355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 11/17/2022]
Abstract
Congenital cytomegalovirus is caused by maternal primary or nonprimary infection during pregnancy and is a major preventable cause of neurodisability. The proposed strategies to reduce congenital cytomegalovirus include primary prevention with maternal hygiene measures and secondary prevention by serologic screening for detecting maternal primary infection. A recent randomized trial found that high-dose valaciclovir treatment resulted in a significant reduction in fetal infection after first-trimester maternal primary infection, leading to calls to start routine serologic screening in pregnancy. Previously, observational studies have found a reduction in fetal infection with after maternal primary cytomegalovirus infection when hyperimmune globulin is administered twice weekly during the first trimester of pregnancy; however, this has not been replicated in randomized trials that have used different regimens. Furthermore, some evidence from a single intervention trial and observational studies do not provide us with the necessary data required for rolling out an appropriate screening program. All screening tests may be associated with harm; in the case of congenital cytomegalovirus, there is the well-recognized potential for increasing terminations of pregnancy without diagnostic confirmation of fetal infection or sequelae. Although valaciclovir and hyperimmune globulin treatments may significantly reduce fetal infection rates, they do not prevent severe cytomegalovirus-related fetal brain damage in all pregnancies. Therefore, it is not clear that the offer of a prenatal intervention will provide sufficient reassurance to screen-positive women. In addition, the effectiveness of a prenatal screening and treatment strategy is predicated on a high rate of maternal primary infection, which is limited to regions with low cytomegalovirus seroprevalence, such as Western Europe. In some countries, such as the United States, Finland, and Brazil, nonprimary maternal infections are responsible for most congenital cytomegalovirus health burdens, limiting the potential impact of pregnancy screening. In this invited clinical perspective, we reviewed the evidence and outlined the steps needed to be taken before determining whether the benefits of routine screening for cytomegalovirus in pregnancy outweigh the harms. Until we have the necessary evidence, we should follow the current advice of multiple national health authorities and focus on promoting primary prevention through maternal hygiene precautions.
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Affiliation(s)
- Lisa Hui
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia (Dr Hui); Department of Perinatal Medicine, Mercy Hospital for Women, Heidelberg, Victoria, Australia (Dr Hui); Reproductive Epidemiology Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia (Dr Hui); Northern Health, Epping, Victoria, Australia (Dr Hui).
| | - Antonia Shand
- Child Population and Translational Health Research, Children's Hospital at Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia (Dr Shand); Department of Maternal-Fetal Medicine, Royal Hospital for Women, Randwick, New South Wales, Australia (Dr Shand); Department of Maternal-Fetal Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia (Dr Shand)
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23
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Waltmann A, McKinnish TR, Duncan JA. Nonviral sexually transmitted infections in pregnancy: current controversies and new challenges. Curr Opin Infect Dis 2021; 34:40-49. [PMID: 33337618 PMCID: PMC8634851 DOI: 10.1097/qco.0000000000000702] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review provides an update of nonviral, curable sexually transmitted infections (STIs) in pregnancy and summarizes our understanding of the current issues and controversies surrounding risk factors, screening, and treatment of STIs in pregnancy primarily in high-income countries (using the United States and the United Kingdom as examples). The infections covered in this review are syphilis, gonorrhea, chlamydia, trichomoniasis, and Mycoplasma genitalium infections. RECENT FINDINGS Overall, limited modern data is available to update researchers and clinicians on the epidemiology and care of STIs in pregnancy. Though common risk factors can be identified among these STIs, like socioeconomic status and inadequate antenatal care, specific screening and treatment challenges vary by geography and pathogen. Wherever available, surveillance data and research evidence are often limited to nonpregnant patients, leading to imperfect pregnancy-specific risk estimates and obstetric lags in the development and adoption of new guidelines. We have identified three areas of opportunity that may enhance the effectiveness of current approaches and inform new ones: improved data collection and evidence-based screening practices; prompt and comprehensive therapy, including partner services, and evaluations of new treatment modalities; and equitable antenatal and sexual healthcare for all pregnant persons and their partners. SUMMARY These findings highlight the need to revisit standards of screening and management of STIs in pregnancy in high-income countries.
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Affiliation(s)
- Andreea Waltmann
- Institute for Global Health and Infectious Disease, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Tyler R McKinnish
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St Louis, Missouri
| | - Joseph A Duncan
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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24
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Hui L, Ghidini A. 40 years of prenatal diagnosis in 2020. Prenat Diagn 2020; 40:1623-1626. [PMID: 33373073 DOI: 10.1002/pd.5867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/15/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Lisa Hui
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia.,Reproductive Epidemiology Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Alessandro Ghidini
- Perinatal Diagnostic Center, Inova Alexandria Hospital, Alexandria, Virginia, USA
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