Tuberculosis disease in immunocompromised children and adolescents: a pTBnet multi-centre case-control study

BACKGROUND

In high-resource settings the survival of immunocompromised (IC) children has increased and immunosuppressive therapies are increasingly being used. This study aimed to determine the clinical characteristics, performance of diagnostic tools and outcome of IC children with TB in Europe.

METHODS

Multicentre, matched case-control study within the Paediatric Tuberculosis Network European Trials Group (ptbnet), capturing TB cases <18 years diagnosed 2000-2020.

RESULTS

417 TB cases were included, comprising 139 children with IC (HIV, inborn errors of immunity, drug-induced immunosuppression and other immunocompromising conditions) and 278 non-IC children as controls. Non-respiratory TB was more frequent among cases than controls (32.4% vs. 21.2%; p = 0.013). IC patients had an increased likelihood of presenting with severe disease (57.6% vs. 38.5%; p < 0.001; OR [95% CI]: 2.073 [1.37-3.13]). Children with IC had higher rates of false-negative tuberculin skin test (31.9% vs. 6.0%; p < 0.001) and QuantiFERON-TB Gold assay (30.0% vs. 7.3%; p < 0.001) results at diagnosis. Overall, the microbiological confirmation rate was similar in IC and non-IC cases (58.3% vs. 49.3%; p = 0.083). Although the mortality in IC children was <1%, the rate of long-term sequelae was significantly higher than in non-IC cases (14.8% vs. 6.1%; p = 0.004).

CONCLUSIONS

IC children with TB disease in Europe have increased rates of non-respiratory TB, severe disease, and long-term sequelae. Immune-based TB tests have poor sensitivity in those children. Future research should focus on developing improved immunological TB tests that perform better in IC patients, and determining the reasons for the increased risk of long-term sequelae, with the aim to design preventive management strategies.

Treatments for multi-system inflammatory syndrome in children - discharge, fever, and second-line therapies

Scarce evidence exists about the best treatment for multi-system inflammatory syndrome (MIS-C). We analyzed the effects of steroids, intravenous immunoglobulin (IVIG), and their combination on the probability of discharge over time, the probability of switching to second-line treatment over time, and the persistence of fever 2 days after treatment. We did a retrospective study to investigate the effect of different treatments on children with MIS-C from 1 March 2020 to 1 June 2021. We estimated the time-to-event probability using a Cox model weighted by propensity score to balance the baseline characteristics. Thirty of 132 (22.7%) patients were initially treated with steroids alone, 29/132 (21.9%) with IVIG alone, and 73/132 (55%) with IVIG plus steroids. The probability of early discharge was higher with IVIG than with IVIG plus steroids (hazard ratio [HR] 1.65, 95% CI 1.11-2.45, p = 0.013), but with a higher probability of needing second-line therapy compared to IVIG plus steroids (HR 3.05, 95% CI 1.12-8.25, p = 0.028). Patients on IVIG had a higher likelihood of persistent fever than patients on steroids (odds ratio [OR] 4.23, 95% CI 1.43-13.5, p = 0.011) or on IVIG plus steroids (OR 4.4, 95% CI 2.05-9.82, p < 0.001). No differences were found for this endpoint between steroids or steroids plus IVIG.    Conclusions: The benefits of each approach may vary depending on the outcome assessed. IVIG seemed to increase the probability of earlier discharge over time but also of needing second-line treatment over time. Steroids seemed to reduce persistent fever, and combination therapy reduced the need for escalating treatment. What is Known: • Steroids plus intravenous immunoglobulin, compared with intravenous immunoglobulin alone for multi-system inflammatory syndrome (MIS-C) might reduce the need for hemodynamic support and the duration of fever, but the certainty of the evidence is low. What is New: • Intravenous immunoglobulin, steroids, and their combination for MIS-C may have different outcomes. • In this study, intravenous immunoglobulin increased the probability of discharge over time, steroids reduced persistent fever, while combination therapy reduced the need for second-line treatments.

The position during urine sample collection from young precontinent children through a bag does not limit contamination rates: Results from a randomized controlled trial: Does infant position influence quality of urine collection?

AIM

Despite its limitation, bag collection is still widely used for a preliminary urine screening test in non-toilet-trained children suspected of febrile urinary tract infection. A previous study conducted by our group raised the hypothesis that the absence of direct contact between urine and the perinea during urine collection could limit urine contamination by perineal flora. The aim of this study was to evaluate the impact of the patient's position during urine collection (upright standing position versus free position) on the rate of contaminated urine samples in non-toilet-trained children with suspected febrile urinary tract infection.

METHODS

This prospective, randomized, controlled study took place in seven pediatric emergency departments. Two groups were compared: the intervention group (infants held in an upright standing position during urination) and the control group (free position during urination).

RESULTS

Among the 800 pediatric patients randomized to the study, 124 had a urine culture, 60 in the intervention group and 64 in the control group. Among the 124 urine cultures, 12 (9.7%) were contaminated: eight (13.3%) in the intervention group and four (6.3%) in the control group (p = 0.1824).

CONCLUSION

The results show that the patient's position does not have a significant impact on the quality of urine samples collected by bag.

Staphylococcus aureus Community-acquired Pneumonia in Children After 13-Valent Pneumococcal Vaccination (2008-2018): Epidemiology, Clinical Characteristics and Outcomes

BACKGROUND

The epidemiology of community-acquired pneumonia (CAP) has changed, influenced by sociosanitary conditions and vaccination status. We aimed to analyze the recent epidemiology of bacterial CAP in hospitalized children in a setting with high pneumococcal vaccination coverage and to describe the clinical characteristics of pediatric Staphylococcus aureus CAP.

METHODS

Children <17 years old hospitalized from 2008 to 2018 with bacterial CAP in 5 tertiary hospitals in Spain were included. Cases with pneumococcal CAP were randomly selected as comparative group following a case-control ratio of 2:1 with S. aureus CAP.

RESULTS

A total of 313 bacterial CAP were diagnosed: Streptococcus pneumoniae CAP (n = 236, 75.4%), Streptococcus pyogenes CAP (n = 43, 13.7%) and S. aureus CAP (n = 34, 10.9%). Throughout the study period, the prevalence of S. pyogenes increased (annual percentage change: +16.1% [95% CI: 1.7-32.4], P = 0.031), S. pneumoniae decreased (annual percentage change: -4.4% [95 CI: -8.8 to 0.2], P = 0.057) and S. aureus remained stable. Nine isolates of S. aureus (26.5%) were methicillin-resistant. Seventeen cases (50%) with S. aureus CAP had some pulmonary complication and 21 (61.7%) required intensive care. S. pneumoniae CAP showed a trend toward higher prevalence of pulmonary complications compared with S. aureus CAP (69.1% vs. 50.0%, P = 0.060), including higher frequency of pulmonary necrosis (32.4% vs. 5.9%, P = 0.003).

CONCLUSIONS

The incidence of S. aureus CAP in children remained stable, whereas the prevalence of pneumococcal CAP decreased and S. pyogenes CAP increased. Patients with S. aureus presented a high frequency of severe outcomes, but a lower risk of pulmonary complications than patients with S. pneumoniae.

Multi-inflammatory Syndrome in Children Related to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Spain

Some clusters of children with a multisystem inflammatory syndrome (MIS-C) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported. We describe the epidemiological and clinical features of children with MIS-C in Spain. MIS-C is a potentially severe condition that presents in children with recent SARS-CoV-2 infection.

The association of prepartum urine pH, plasma total calcium concentration at calving and postpartum diseases in Holstein dairy cattle

The use of anionic salts to prevent milk fever in dairy cattle has been an effective nutritional strategy; however, the degree of acidification that determines the most acceptable productive responses and well-being of the cow is still a controversial topic. The objective of this study was to assess urine pH in prepartum Holstein cows fed anionic diets and determine its association with plasma total Ca, Mg, P, β-hydroxyl-butyrate (BHB) concentrations at parturition and the occurrence of peripartum disorders. This investigation consisted of 2 studies. Study 1 was conducted on a grazing dairy. Between February and May 2019, 60 prepartum multiparous cows were tested for urine pH and plasma metabolite concentration at parturition. Total Ca, P, Mg and BHB at day 1 in milk (DIM) were assessed and statistically analyzed by ANOVA (models for polynomial regression). Study 2 was conducted on a drylot dairy farm. Between July 2018 and January 2019, 203 cows were evaluated for urine pH and followed-up for 30 DIM to obtain the incidence of dystocia, stillbirths, milk fever, retained fetal membranes, metritis, clinical mastitis and ketosis. Cows were categorized based on their last urine pH as group 1: pH > 7.0 (n = 135); group 2: pH between 6.0 and 7.0 (n = 46) and group 3: pH < 6.0 (n = 22). A logistic regression model for each health event was conducted considering urine pH group as the main effect. Urine sample was collected at 2.71 ± 2.84 days before parturition. In study 1, there was a quadratic effect of urine pH on total Ca. Total Ca concentration was higher between urine pH 6.0 and 7.0, while decreasing below pH 6.0 and above pH 7.0. There was a trend (P = 0.11) for a quadratic effect of urine pH on the concentration of plasma BHB at parturition. β-Hydroxyl-butyrate was lower approximately between urine pH 6.5 and 7.5. In study 2, the odds for a stillborn in cows with urine pH < 6.0 was 2.39 (95% CI = 1.06-5.40) times the odds for a stillborn in cows with urine pH ≥ 7.0. There was no association between urine pH and the other diseases. In conclusion, cows with prepartum urine pH < 6.0 and >7.0 had lower concentration of plasma total Ca and tended to have a higher concentration of BHB. Cows with urine pH < 6.0 had a higher incidence of stillbirths than cows with urine pH > 7.0.

Application of transit data analysis and artificial neural network in the prediction of discharge of Lor River, NW Spain

Transit data analysis and artificial neural networks (ANNs) have proven to be a useful tool for characterizing and modelling non-linear hydrological processes. In this paper, these methods have been used to characterize and to predict the discharge of Lor River (North Western Spain), 1, 2 and 3 days ahead. Transit data analyses show a coefficient of correlation of 0.53 for a lag between precipitation and discharge of 1 day. On the other hand, temperature and discharge has a negative coefficient of correlation (-0.43) for a delay of 19 days. The ANNs developed provide a good result for the validation period, with R(2) between 0.92 and 0.80. Furthermore, these prediction models have been tested with discharge data from a period 16 years later. Results of this testing period also show a good correlation, with R(2) between 0.91 and 0.64. Overall, results indicate that ANNs are a good tool to predict river discharge with a small number of input variables.

Birth defects in a cohort of infants born to HIV-infected women in Spain, 2000-2009

BACKGROUND

Antiretroviral therapy (ART) in pregnancy has resulted in a marked impact on reducing the risk of mother-to-child transmission (MCT) of HIV. However the safety of in utero ART exposure in newborns remains a concern.

METHODS

A multicenter prospective observational study of HIV-infected mother and their infants was performed in Madrid, Spain, from 2000 to 2009. Children had regular visits with clinical examination according to protocol until the age of 24 months. An abdominal ultrasound and an echocardiogram were scheduled during follow up. Birth defects (BDs) were registered according to European Surveillance of Congenital Anomalies (EUROCAT).

RESULTS

A total of 897 live births from 872 mothers were included. Overall the birth defects prevalence observed was 6.9% (95% CI 5.4-9.1).The most commonly reported birth defects types were in genital organs and urinary system (19 cases, 30.6%) and cardiovascular system (17 cases, 27.4%). There was no increased risk for infants exposed in the first trimester to ARVs compared with unexposed infants. No significant associations were observed between exposure to any individual antiretroviral agent during pregnancy and birth defects

CONCLUSION

A higher prevalence of BDs was observed, higher than previously reported. In utero exposure to ART was not proved to be a major risk factor of birth defects in infants. However the relatively small number of patients is a major limitation of this study.

Trends of rural tropospheric ozone at the northwest of the Iberian Peninsula

Tropospheric ozone levels around urban and suburban areas at Europe and North America had increased during 80's–90's, until the application of NO_x reduction strategies. However, as it was expected, this ozone depletion was not proportional to the emissions reduction. On the other hand, rural ozone levels show different trends, with peaks reduction and average increments; this different evolution could be explained by either emission changes or climate variability in a region. In this work, trends of tropospheric ozone episodes at rural sites in the northwest of the Iberian Peninsula were analyzed and compared to others observed in different regions of the Atlantic European coast. Special interest was focused on the air quality sites characterization, in order to guarantee their rural character in terms of air quality. Both episodic local meteorological and air quality measurements along five years were considered, in order to study possible meteorological influences in ozone levels, different to other European Atlantic regions.

Adsorption and desorption of copper and zinc in the surface layer of acid soils

The environmental and health effects of the contamination of soils by heavy metals depend on the ability of the soils to immobilize these contaminants. In this work, the adsorption and desorption of Cu and Zn in the surface layers of 27 acid soils were studied. Adsorption of Cu(II) from 157-3148 mumol L(-1) solutions was much greater than adsorption of Zn(II) from solutions at the same concentration. For both Cu and Zn, the adsorption data were fitted better by the Freundlich equation than by the Langmuir equation. Multiple regression analyses suggest that Cu and Zn adsorption depends to a significant extent on pH and CEC: for both metals these variables accounted for more than 80% of the variance in the Freundlich pre-exponential parameter K(F), and pH also accounted for 57% of the variance in 1/n for Zn and, together with carbon content, for 41% of the variance in 1/n for Cu. The percentage of adsorbed metal susceptible to desorption into 0.01 M NaNO3 was greater for Zn than for Cu, but in both cases depended significantly on pH, decreasing as pH increased. In turn, both pH(H2O) and pH(KCl) are significantly correlated with cation exchange capacity. Desorption of metal adsorbed from solutions at relatively low concentration (787 mumol L(-1)) exhibited power-law dependence on Kd, the quotient expressing distribution between soil and soil solution in the corresponding adsorption experiment, decreasing as increasing Kd reflected increasing affinity of the soil for the metal. The absence of a similarly clear relationship when metal had been adsorbed from solutions at relatively high concentration (2361 mumol L(-1)) is attributed to the scant between-soil variability of Kd at these higher concentrations. In general, adsorption was greater and subsequent desorption less in cultivated soils than in woodland soils.

Adsorption-desorption dynamics of cyprodinil and fludioxonil in vineyard soils

Cyprodinil and fludioxonil are new-generation fungicides that are employed to protect grapevines from botrytis and various rots. In this work, their adsorption and desorption dynamics in eight vineyard soils from Galicia (northwestern Spain) were examined in batch and column experiments. Both fungicides exhibited linear adsorption isotherms, with more ready adsorption (greater Kd) of fludioxonil. Kd values for cyprodinil were significantly correlated with soil organic matter content (r 2= 0.675, p < 0.01). Both pesticides exhibited adsorption-desorption hysteresis, but desorption was easier and more variable for cyprodinil (12-21%, RSD = 17%) than for fludioxonil (3-5%, RSD = 13%) and appeared to depend on the formation of irreversible bonds in the former case and on poor solubility in the latter. A linear adsorption model involving nonequilibrium conditions and an irreversible adsorption term was found to reproduce transport behavior accurately.

Spectrum of hearts with one underdeveloped and one dominant ventricle

Hearts with one underdeveloped and one dominant ventricle form a spectrum of anomalies extending from the heart with two clearly adequate chambers to those with a true single ventricle. An angiographic concept of grouping such hearts is presented. 129 patients with unequal ventricles underwent catheterization and cineangiography between 1974 and 1983. The age at first catheterization ranged from one day to 24 years (mean 3.9 years). Male-female ratio was 2:1. Five groups of hearts (with their relative frequencies in the spectrum) were established: dominant left ventricle (53%); dominant right ventricle (20%), each with normally related chambers; dominant left ventricle (20%); dominant right ventricle (3%), each with ventricular inversion; true single ventricle (5%). The incidence of atrial anatomy, venous return, intracardiac connections and associated lesions within each group was assessed. From the standpoint of deranged physiology as well as surgical implications there are more similarities than differences among these hearts. The fact that one ventricle will not generate an adequate stroke volume after repair is overwhelmingly more important than most other considerations. For the diagnostic and surgical approach, we believe that the system offers many advantages.

[Lyell syndrome and Stevens-Johnson syndrome caused by lamotrigine]

BACKGROUND

Lamotrigine is a new anticonvulsant belonging to the triazine family. Several cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) have been described in patients taking this drug. We report 2 cases in children attending the same hospital.

CASE REPORTS

Two children, aged 9 and 13 years, developed SJS and TEN respectively, 3 and 28 days after lamotrigine was added to their usual anticonvulsant regimen. In both cases, outcome was favorable despite major decline in psychomotor capacity in one. In the first case, chronological attributability was plausible for lamotrigine and doubtful for sodium valproate, clonazepam and hydrocortisone. In the second case, chronological attributability was probable for amoxicillin, plausible for lamotrigine and doubtful for sodium valproate, but the numerous previous absorptions of amoxicillin made lamotrigine more suspect.

DISCUSSION

The risk of Steven-Johnson syndrome and toxic epidermal necrolysis is high with lamotrigine with an estimated frequency of 1/1000. This risk is probably higher than with other anticonvulsants. Associating lamotrigine with sodium valproate increases the frequency of adverse skin reactions.

Human complement factor H deficiency associated with hemolytic uremic syndrome

This study reports on six cases of deficiency in the human complement regulatory protein Factor H (FH) in the context of an acute renal disease. Five of the cases were observed in children presenting with idiopathic hemolytic uremic syndrome (HUS). Two of the children exhibited a homozygous deficiency characterized by the absence of the 150-kD form of Factor H and the presence, upon immunoblotting, of the 42-kD Factor H-like protein 1 (FHL-1) and other FH-related protein (FHR) bands. Southern blot and PCR analysis of DNA of one patient with homozygous deficiency ruled out the presence of a large deletion of the FH gene as the underlying defect for the deficiency. The other four children presented with heterozygous deficiency and exhibited a normal immunoblotting pattern of proteins of the FH family. Factor H deficiency is the only complement deficiency associated with HUS. These observations suggest a role for FH and/or FH receptors in the pathogenesis of idiopathic HUS.

Percutaneous transluminal angioplasty of renal artery stenosis in children

Twenty percutaneous transluminal renal angioplasties were performed on 16 children (mean age 8.7 years) with hypertension secondary to renal artery stenosis (RAS). The aetiologies were neurofibromatosis (n = 1), Williams syndrome (n = 2), Takayasu arteritis (n = 1) and fibromuscular dysplasia (n = 12). The stenosis was isolated proximal or distal in 13 cases and multiple in 3 cases. Angioplasty resulted in a complete cure without medical treatment in 9 cases. Angioplasty allowed a reduction of medical treatment in two single stenoses, but was ineffective in all cases of multiple stenoses. Our findings show that angioplasty of RAS in children is an effective treatment when the stenosis is isolated, with a 69 % success rate. It seems ineffective in case of multiple stenoses (three cases).

Human immunodeficiency virus infection modifies the natural history of chronic parenterally-acquired hepatitis C with an unusually rapid progression to cirrhosis

BACKGROUND/AIMS

To investigate the possible role of HIV infection in the natural history of chronic parenterally-acquired hepatitis C.

METHODS

A multicenter cross-sectional study was performed in 547 patients with chronic parenterally-acquired hepatitis C with or without HIV infection (116 HIV-positive and 431 HIV-negative). Approximate duration of HCV infection was estimated in all patients included, and histologic diagnoses made at different time intervals following HCV infection were analyzed in both groups. Factors related to serum HCV-RNA levels were also investigated.

RESULTS

Histologic findings were similar in liver biopsies from both HIV-infected and noninfected patients. However, in the first 10 years, 13 out of 87 (14.9%) HIV-positive subjects developed cirrhosis, in comparison with 7 out of 272 (2.6%) in the HIV-negative group (p < 0.01). Similar results were found in the first 5 and 15 years, respectively, and most of the HIV-negative patients with cirrhosis (42 out of 56) developed cirrhosis in a time interval longer than 15 years. Consequently, mean interval from estimated time of HCV infection to cirrhosis was significantly longer in HIV-negative than HIV-positive patients (23.2 vs. 6.9 years; p < 0.001). Chronic active hepatitis (with and without cirrhosis) and long duration of HCV infection were significantly associated with higher HCV load (p < 0.05). Finally, HIV-positive patients with CD4+ cell counts > 500 cells/ml showed a lower HCV load than those with < 500 cells/ml (p < 0.05).

CONCLUSIONS

HIV infection modifies the natural history of chronic parenterally-acquired hepatitis C with an unusually rapid progression to cirrhosis. HIV-related immunodeficiency may be a determinant of higher hepatitis C viremia levels and more severe liver damage.

[Angiography of the aorta]

The aorta, the most important vessel of the body, starts at the aortic valve and ends at its bifurcation in the lower abdomen. It is the common supplier of all systemic arteries with the coronary arteries being the most proximal, and the common iliac arteries the terminal branches. In this article, the angiographic appearance of the normal aorta, aneurysms of the aorta, dissection of the aorta, Takayasu arteritis and acute traumatic aortic trans-section are reviewed.

Influence of human immunodeficiency virus type 1 infection on the natural course of chronic parenterally acquired hepatitis C

The aim of the present study was to investigate the possible role of human immunodeficiency virus (HIV) infection in the natural course of chronic hepatitis C. Seventy-six adult patients with chronic parenterally acquired hepatitis C virus (HCV) infection examined from 1989 to 1993 were enrolled; of these 32 (42.1%) were HIV positive and 44 (57.9%) were HIV negative. Serum HCV RNA quantitation was carried out by polymerase chain reaction in a well-characterized group (n = 20; 11 HIV positive and 9 HIV negative). Distribution of histological findings in liver biopsies from both HIV-infected and noninfected patients was similar. However, within 15 years after initial HCV infection, 8 of 32 (25%) HIV-positive patients developed cirrhosis, in comparison with only 2 of 31 (6.5%) patients in the HIV-negative group (p < 0.05); similar incidences of cirrhosis were found in both patient groups within 5 and 10 years after HCV infection. Most of the HIV-negative cirrhotic patients (9 of 11) developed cirrhosis in a time interval longer than 15 years. Finally, HCV load was almost ten times higher (1 10-fold dilution) in the HIV-positive group, but this difference did not reach statistical significance in this small study population. These results suggest that HIV infection can alter the natural course of chronic parenterally acquired hepatitis C, causing an unusually rapid progression to cirrhosis.

Results of a randomized study of early stage Hodgkin's disease using ABVD, EBVD, or MBVD

From January 1986 to December 1989, 157 previously untreated patients, with Hodgkin's disease stage I or II without bulky disease, were enrolled in a clinical comparative study. The objectives of the study were to compare the efficacy and safety of using epirubicine or mitoxantrone instead of adriamycin in the combination chemotherapy regimen ABVD (adriamycin, bleomycin, vinblastine, and dacarbazine). The complete response rate was better in the patients treated with the ABVD or EBVD regimens compared to the MBVD arm. Also, differences in overall survival and relapse-free survival were better in the patients who received ABVD or EBVD compared to the MBVD regimen. Hematological, gastrointestinal and cardiac toxicity were similar in the three groups. Dose intensity, delays and complications were also similar in the three groups. The mitoxantrone-containing regimen was found to have less efficacy in comparison to the other regimens tested in the present study in patients with favorable stage I or II Hodgkin's disease.

Predictive value of IgM antibodies to hepatitis C virus in patients with chronic hepatitis C undergoing interferon-alpha therapy. Analysis by two different methods

To determine the predictive value of IgM anti-hepatitis C virus (HCV) testing in patients with chronic hepatitis C infections undergoing interferon-alpha (IFN-alpha) therapy, IgM anti-HCV reactivity was analysed by two different methods (non-commercial and commercial) in 19 patients and monitored at times 0 (pretreatment), 3, 6, 12, and 24 months during follow-up. Eight patients were non-responders, five remained in sustained response 1 year after stopping treatment, and six had a relapse. No correlation between alanine transaminase (ALT) levels and IgM anti-HCV reactivity was found by either method in baseline samples. In addition, neither the presence nor absence of IgM anti-HCV in baseline samples, nor the loss of specific IgM reactivity during treatment, had any predictive value. Finally, no other parameters analysed (age, sex, risk group and histological diagnosis), were significantly associated with IgM anti-HCV reactivity in our study. In summary, these results suggest that baseline detection and monitoring of IgM anti-HCV reactivity are not useful in predicting the sustained response to IFN-alpha therapy in chronic hepatitis C infection.

Heterosexual transmission of hepatitis C virus and the possible role of coexistent human immunodeficiency virus infection in the index case. A multicentre study of 423 pairings

OBJECTIVES

To define the role that sexual transmission plays in the spread of hepatitis C virus (HCV) infection, and to examine the influence of coexistent human immunodeficiency virus (HIV) infection on this mode of transmission.

DESIGN

A multicentre, seroprevalence study of anti-HCV performed in the stable heterosexual partners (SHP) of index cases reactive for anti-HCV.

SETTING

Department of Internal Medicine and Section of Gastroenterology of three University Hospitals, Spain.

SUBJECTS

A total of 423 stable heterosexual partners of index cases reactive for anti-HCV. This included a group of 142 intravenous drug users (IVDU), 120 of whom were coinfected with HIV. Additionally, 2886 first-time voluntary blood donors selected at random were included to compare the prevalence of anti-HCV.

MAIN OUTCOME MEASURES

Serum samples were screened for anti-HCV by a commercially available, second-generation enzyme-linked immunoassay. Tests repeatedly reactive for anti-HCV were analysed by a four-antigen, recombinant immunoblot assay. Anti-HIV was tested by enzyme immunoassay and Western blot was used for confirmation of positive cases.

RESULTS

The prevalence of anti-HCV, was 7.1% in SHP and 1.2% in random donors (P < 0.001). This prevalence was higher in SHP of index cases coinfected with HIV in comparison with that shown in the SHP of index cases only reactive for the anti-HCV (9.1 vs. 6.3%; P = 0.2), particularly when a younger and more homogeneous group such as the SHP of IVDU index cases was considered alone (9.2 vs. 0%; P = 0.1). However, the SHP of IVDU index cases coinfected with HIV were almost three times more likely to be infected with HIV than HCV (24.2 vs. 9.2%).

CONCLUSIONS

These data suggest that HCV infection may be sexually transmitted but with low efficiency, and this could be increased in the presence of coexistent HIV infection in the index case.

High rate of nonspecific anti-hepatitis C reactivity amongst homosexual men in comparison with that found in other sexually active groups and blood donors. Viral Hepatitis and AIDS Study Group

OBJECTIVES

To investigate the concordance of anti-hepatitis C virus (anti-HCV) reactivity by a second-generation enzyme immunoassay (EIA-2) and by a four-antigen recombinant immunoblot assay (4-RIBA) in homosexual men, in comparison with that found in other sexually active groups and blood donors.

DESIGN

Prospective study.

SETTING

Tertiary referral centre, Seville, Spain.

SUBJECTS

A total of 1203 subjects were studied. Eight hundred and three were sexually active individuals: 547 female prostitutes, 88 heterosexual men who had frequent sexual intercourse with prostitutes, and 168 homosexual men. All of them denied blood transfusion and parenteral drug use. In addition, 400 voluntary blood donors were selected at random.

MAIN OUTCOME MEASURES

All serum samples were screened for anti-HCV by EIA-2 and repeatedly reactive sera were tested by 4-RIBA. Homosexual men were also screened for anti-human immunodeficiency virus (anti-HIV), hepatitis B virus (HBV) markers and gammaglobulin concentration. Finally, serum samples from homosexual men reactive for anti-HCV by EIA-2 were analyzed for HCV-RNA by polymerase chain reaction (PCR).

RESULTS

Concordance between EIA-2 and 4-RIBA in female prostitutes (71.4%), clients of prostitutes (75.0%), and blood donors (83.3%) was significantly higher than in homosexual men (38.8%) (P < 0.04). In this collective the concordance between 4-RIBA and PCR was 85.7% for positive cases and 88.8% for negative ones, and EIA-2 ratios in reactive sera were significantly higher in 4-RIBA confirmed cases (P < 0.0001). No correlation between false positive EIA-2 results and presence of HIV infection, HBV markers or hypergammaglobulinaemia was found in homosexual men by univariate analysis.

CONCLUSIONS

There is a high level of non-specific anti-HCV reactivity by EIA-2 amongst homosexual men in comparison with that found in other sexually active groups and blood donors. The true prevalence of HCV infection amongst homosexual men could be even lower than previously described.

Anomalous origin of posterior descending artery from left anterior descending artery with unusual intraseptal course

The posterior descending artery (PDA) arises from the right coronary artery (RCA) in approximately 85% of people; only in from 10 to 15% does it arise from the circumflex artery. We report an unusual case of origin of the PDA from a branch of the left anterior descending artery (LAD). The PDA passed through the interventricular septum before it reached the posterior interventricular groove.

Selective injection of a left coronary artery arising anomalously from the posterior aortic sinus

Six cases of anomalous origin of the left main coronary artery arising from the posterior or noncoronary aortic sinus have been previously found at autopsy by nonselective aortic sinus injection and only once by selective injection. The seventh known case of this anomaly is demonstrated by selective injection that also reveals distal severe coronary artery disease.

[Anhidrotic ectodermal dysplasia]

The case of an hyperthermia-induced sudden death in an infant with anhidrotic dysplasia is reported. This disease, easily diagnosed, should now be better known and its early assessment, with thermal monitoring might improve the initial severe prognosis. A genetic counselling might be possible.

Two-dimensional echocardiography and Doppler color flow mapping in the diagnosis and prognosis of ventricular septal rupture

Doppler color flow mapping in conjunction with two-dimensional echocardiography was used to evaluate ventricular septal rupture after myocardial infarction (seven anterior and eight inferior) in 15 patients and to correlate these findings with cardiac catheterization and surgical or autopsy data. Ventricular septal rupture was diagnosed by turbulent flow traversing the ventricular septum. The direction and velocity of shunt flow was determined by color M-mode and conventional Doppler methods. In all patients, Doppler color flow mapping correctly defined the site of septal rupture, which occurred at areas of discordant septal wall motion or "hinge points" (six posterior inlet, three anterior inlet, and six apical trabecular septum). Each of three patients with moderate tricuspid regurgitation and three of four patients with right-to-left shunting during diastole died, and all had an elevated right ventricular end-diastolic pressure. Right ventricular wall motion index was significantly higher in the patients who died compared with those who survived (mean +/- SEM; 2.8 +/- 0.2 vs. 2.0 +/- 0.2, p = 0.012), but there was no difference in left ventricular wall motion index. The rupture size measured by Doppler color flow imaging (1.7 +/- 0.1 cm) correlated with the size determined during surgery or autopsy (1.8 +/- 0.2 cm, r = 0.68, p = 0.022) and the pulmonic-to-systemic shunt flow ratio by cardiac catheterization (2.4:1 +/- 0.3, r = 0.74, p = 0.004). Color-guided continuous-wave Doppler estimates of right ventricular systolic pressure (47 +/- 2 mm Hg) correlated with cardiac catheterization measurements (48 +/- 3 mm Hg, r = 0.90, p = 0.0002).(ABSTRACT TRUNCATED AT 250 WORDS)

Double outlet right ventricle with discordant atrioventricular connexion: an angiographic analysis of 19 cases

Nineteen patients with double outlet right ventricle and discordant atrioventricular connexion were studied in order to analyze their angiographic anatomy. The discordant atrioventricular connexion was parallel in 18 patients and criss-cross in one. A ventricular septal defect, present in all cases, was perimembranous in ten (50%), muscular in seven (37%), and was part of an atrioventricular septal defect in two. The defect was related spatially to the subaortic outflow in six (29%), to the subpulmonary outflow in 11 (52%), was doubly committed in one and non-committed in two. Long axial and four-chamber views of the ventriculograms were most useful for the angiographic delineation of the basic anatomy of this entity. In patients with abnormally located hearts, variations of the axial views were necessary for proper delineation of the anatomy. It is concluded that modified axial views of ventriculograms are useful for diagnosis of double outlet right ventricle and discordant atrioventricular connexions.

Ventricular septal defects: a surgical viewpoint

Seventy-six cardiac autopsy specimens with ventricular septal defects were studied from a surgical viewpoint. The defects were classified as being conoventricular (n = 25), in the right ventricular outlet (n = 21), in the inlet septum (n = 11) or in the trabecular septum (n = 19) with each category having several subcategories. The left ventricular outflow tract relations of the defects are emphasized. The borders of the ventricular septal defects are described in detail, with use of the prefix "juxta" to indicate the immediate adjacency of the defect to a structure such as the tricuspid valve.

Two-dimensional and color Doppler assessment of ventricular septal defect of congenital origin

Two-dimensional echocardiography and color Doppler examinations were performed in 53 patients with 58 ventricular septal defects (VSD) proven surgically or anatomically. All patients also had angiocardiograms. Two-dimensional echocardiography/color Doppler examination detected all VSDs and correctly categorized the site and extension of VSDs in 50 of 58 (86%). All 40 perimembranous VSDs were diagnosed in the left ventricular outflow tract short-axis plane as an area of discontinuity adjacent to septal tricuspid valve leaflet attachment. Fourteen of 16 VSDs with inlet extension showed initial color flow signals along the septal tricuspid leaflet and along the ventricular septum. Of 23 perimembranous VSDs with outlet extension, 19 had flow signals moving directly toward the right ventricular outflow tract. One perimembranous VSD with trabecular extension showed flow signals directed anterolaterally toward the right ventricular free wall. Eleven of 13 muscular VSDs were similarly categorized correctly by color Doppler as inlet, outlet and trabecular. All 5 doubly committed VSDs were correctly diagnosed as an area of discontinuity adjacent to the pulmonary valve in the short-axis view with flow signals directly moving through VSD into right ventricular outflow and pulmonary artery. Angiography correctly detected all VSDs and correctly classified their site and extension in 45 of 58 (77.5%). It misclassified 8 of 40 perimembranous, 3 of 13 muscular and 2 of 5 doubly committed VSDs. Color Doppler compares favorably with angiocardiography in the detection and localization of VSDs.

Dual connection of the left anterior descending coronary artery to the left and right coronary arteries

Origin of the left anterior descending coronary artery from the right coronary artery is a well-described but rare congenital coronary anomaly. In this report, we describe two cases in which the mid left anterior descending coronary artery is connected to the right coronary artery through an intraseptal connecting vessel, while the proximal left anterior descending coronary artery originates normally from the left main coronary artery. This previously unreported pattern suggests partial persistence of the peritruncal ring, which occurs during normal embryologic development of the coronary circulation. Even though it is classically described as an epicardial structure, the vascular pattern in our cases suggests that the peritruncal ring may have an intramural segment in some individuals.