Follow-up Serology Research Articles

Infection control during GI endoscopy

This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, a search of the medical literature was performed by using PubMed, supplemented by accessing the "related articles" feature of PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations were based on reviewed studies and were graded on the strength of the supporting evidence (Table 1). This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient's condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.

The outcome of treatment of early latent syphilis and syphilis with undetermined duration in HIV-infected and HIV-uninfected patients

The aim of the study was to compare the outcome of syphilis treatment in HIV-infected and -uninfected patients. An observational study on patients diagnosed with early syphilis in three genitourinary clinics in the UK between January 2003 and June 2005 was conducted. Failure of the initial Venereal Disease Research Laboratory (test) (VDRL) titre to decrease four-fold within 12 months in the absence of history of re-infection was considered as treatment failure. During the study period, 190 HIV-uninfected and 129 HIV-infected patients were diagnosed, and 161 (84%) HIV-uninfected and 100 (77.5%) HIV-positive patients with diagnosis of syphilis who had 24 months follow-up syphilis serology results were included in the study (P = 0.10). There were 381 and 508 follow-up episodes for HIV-infected and -uninfected patients, respectively, within 24 months. One HIV-infected patient was diagnosed with neuro-syphilis. After 12 months, 102 (63%) HIV-uninfected and 76 (70%) HIV-infected patients were treated (P = 0.04). On Cox proportional hazard model, successful treatment after 12 months was associated with having VDRL titre more than 1:6 (hazard ratio [HR] 1.011; 95% confidence interval [CI], 1.004-1.019; P = 0.002). Those with negative immunoglobulin M enzyme immunoassay were less likely to have been successfully treated after 12 months (HR 0.676 [95% CI 0.518-0.883]; P = 0.004). HIV sero-status, age, sex group and treatment regimen were not associated with success of treatment. In conclusion, HIV sero-status did not play a role in the outcome of syphilis treatment. Treatment failure in a proportion of HIV-infected patients is due to a slower decline in VDRL titre rather than lack of response to treatment.

Outcomes from a Canadian public health prenatal screening program for hepatitis B: 1997-2004.

Without appropriate prophylaxis, the rate of vertical transmission of hepatitis B virus (HBV) can be as high as 95%. Alberta's provincial prenatal program screens all pregnant women for HBV, and provides prophylaxis to infants born to HBV-infected women. Canadian data on the outcomes of such programs are limited. We conducted a retrospective review of data from pregnant Albertan women who were Hepatitis B Surface Antigen (HBsAg) positive from 1997-2004. We describe the frequency of hepatitis B immunoglobulin (HBIG) and vaccine administration, follow-up serology and pregnancy outcomes. In total, 1,485 HBsAg-positive pregnant women were identified; an average of 186 women annually (range: 125-216). Of the 980 infants eligible to have completed prophylaxis and serological follow-up, 82.0% were appropriately immunized and serologically tested, 11.3% had complete immunization but no serology testing and 6.6% were incompletely immunized. Of infants with complete immunization and follow-up, 3.7% failed to mount an immune response and 2.1% were infected. A high proportion of infants born to carrier mothers are receiving appropriate post-natal prophylaxis in Alberta. Future research should examine maternal factors that may increase the vertical transmission of HBV.

Prevalence of Helicobacter pylori infection in advanced gastric carcinoma

[corrected] There is substantial evidence that infection with Helicobacter pylori plays a role in the development of gastric cancer and that it is rarely found in gastric biopsy of atrophic gastritis and gastric cancer. On advanced gastric tumors, the bacteria can be lost from the stomach. To analyze the hypothesis that the prevalence of H.pylori in operated advanced gastric carcinomas and adjacent non-tumor tissues is high, comparing intestinal and diffuse tumors according to Lauren's classification A prospective controlled study enrolled 56 patients from "Hospital Universitário", Federal University of Rio Grande do Norte, Natal, RN, Brazil, with advanced gastric cancer, treated from February 2000 to March 2003. Immediately after partial gastrectomy, the resected stomach was opened and several mucosal biopsy samples were taken from the gastric tumor and from the adjacent mucosa within 4 cm distance from the tumor margin. Tissue sections were stained with hematoxylin and eosin. Lauren's classification for gastric cancer was used, to analyse the prevalence of H. pylori in intestinal or diffuse carcinomas assessed by the urease rapid test, IgG by ELISA and Giemsa staining. H. pylori infected patients were treated with omeprazole, clarithromycin and amoxicillin for 7 days. Follow-up endoscopy and serology were performed 6 months after treatment to determine successful eradication of H. pylori in non-tumor tissue. Thereafter, follow-up endoscopies were scheduled annually. Chi-square and MacNemar tests with 0.05 significance were used. Thirty-four tumors (60.7%) were intestinal-type and 22 (39.3%) diffuse type carcinomas. In adjacent non-tumor gastric mucosa, chronic gastritis were found in 53 cases (94.6%) and atrophic mucosa in 36 patients (64.3%). All the patients with atrophic mucosa were H. pylori positive. When examined by Giemsa and urease test, H. pylori positive rate in tumor tissue of intestinal type carcinomas was higher than that in diffuse carcinomas. In tumor tissues, 34 (60.7%) H. pylori-positive in gastric carcinomas were detected by Giemsa method. H. pylori was observed in 30 of 56 cases (53.5%) in tissues 4 cm adjacent to tumors. This difference was not significant. Eradication of H. pylori in non-tumor tissue of gastric remnant led to a complete negativity on the 12th postoperative month The data confirmed the hypothesis of a high prevalence of H. pylori in tumor tissue of gastric advanced carcinomas and in adjacent non-tumor mucosa of operated stomachs. The presence of H. pylori was predominant in the intestinal-type carcinoma.

Intradermal pre-exposure rabies immunisation in New Zealand

Rabies is a fatal infection and immunisation is important to consider in those travellers going to rabies endemic areas. In those at high risk, a course of three immunisations may be given by the intramuscular (IM) or intradermal (ID) route, both of which are approved by the World Health Organization (WHO) and the Centers for Disease Control (CDC). Little is known in the New Zealand context regarding the effectiveness of pre-exposure ID rabies immunisation. The data was collected prospectively on all travellers requiring the immunisation from July 2001 to September 2003 in Auckland. The standard WHO rabies immunisation protocol was used with three ID injections of 0.1 ml, given on days 0, 7, and 21 or 28 with a booster after 12 months. The vaccine used was the Pasteur Merieux human diploid cell vaccine (HDCV) or the Rabipur Purified chick embryo cell (PCEC) vaccine. Both vaccines are approved by the WHO and the CDC, and are interchangeable. Serology was performed approximately 2 weeks after completion of the primary immunisation course or after a booster, wherever possible. Antibody levels were measured using EIA, and levels of >0.5 IU/ml were considered protective. Of the 263 travellers assessed in this study, 125 were males and 138 were females. The mean age of the cohort was 34.8 years (SD=11.7). There were not found to be any statistically significant correlations between age and antibody levels neither was there any significant association between gender and antibody levels. In addition to the sample group, a further 12 travellers had rabies serology performed but were excluded from the study because they had IM vaccines as part of their primary course. Whilst rabies serology ranged from 0.2 to 27.9 IU/ml in the study cohort, the mean antibody level for the group was 4.7 IU/ml (SD=4.1 IU/ml). The mean antibody level for males was 4.3 IU/ml (SD=3.3), and for females, 5.2 IU/ml (SD=4.6). Of the 263 travellers, all had some level of detectable antibodies. The overall seroconversion rate was 95.1%. ID rabies immunisation appears effective, when given according to the standard WHO protocol, in New Zealand. ID rabies immunisation is also more affordable for travellers, especially those on a restrictive budget. ID rabies immunisation can continue to be recommended, particularly where follow-up serology can be done before travel and where there are staff who are experienced in ID immunisation.

Determinants of human papillomavirus 16 serological conversion and persistence in a population-based cohort of 10 000 women in Costa Rica.

Determinants of human papillomavirus (HPV)-16 serological conversion and persistence were assessed in a population-based cohort of 10 049 women in Guanacaste, Costa Rica. Serologic responses to HPV-16 were measured in 7986 women by VLP-based enzyme-linked immunosorbent assay at both study enrolment (1993/94) and at 5–7 years of follow-up. Seropositive women were defined as ⩾5 standard deviations above the mean optical density obtained for studied virgins at enrolment (n=573). Seroconnversion (n=409), persistence (n=675), and clearance (n=541) were defined based on enrolment and follow-up serology measurements. Age-specific distributions revealed that HPV-16 seroconversion was highest among 18- to 24-year-old women, steadily declining with age; HPV-16 seropersistence was lowest in women 65+ years. In age-adjusted multivariate logistic regression models, a 10-fold risk increase for HPV-16 seroconversion was associated with HPV-16 DNA detection at enrolment and follow-up; two-fold risk of seroconversion to HPV-16 was associated with increased numbers of lifetime and recent sexual partners and smoking status. Determinants of HPV-16 seropersistence included a 1.5-fold risk increase associated with having one sexual partner during follow-up, former oral contraceptive use, and a 3-fold risk increase associated with HPV-16 DNA detection at both enrolment and follow-up. Higher HPV-16 viral load at enrolment was associated with seroconversion, and higher antibody titres at enrolment were associated with seropersistence.

Que penser de la vidéocapsule endoscopique en 2004 ?

The purpose of this clinical practice update is to define key modalities in the diagnosis and monitoring of celiac disease (CD) in adults as well as in children and adolescents.The recommendations outlined in this expert review are based on available published evidence, including cohort and case-control studies of the diagnostic process as well as controlled and descriptive studies of disease management.Best Practice Advice 1: Serology is a crucial component of the detection and diagnosis of CD, particularly tissue transglutaminase–immunoglobulin A (TG2-IgA), IgA testing, and less frequently, endomysial IgA testing.Best Practice Advice 2: Thorough histological analysis of duodenal biopsies with Marsh classification, counting of lymphocytes per high-power field, and morphometry is important for diagnosis as well as for differential diagnosis.Best Practice Advice 2a: TG2-IgA, at high levels (> ×10 upper normal limit) is a reliable and accurate test for diagnosing active CD. When such a strongly positive TG2-IgA is combined with a positive endomysial antibody in a second blood sample, the positive predictive value for CD is virtually 100%. In adults, esophagogastroduodenoscopy (EGD) and duodenal biopsies may then be performed for purposes of differential diagnosis.Best Practice Advice 3: IgA deficiency is an infrequent but important explanation for why patients with CD may be negative on IgA isotype testing despite strong suspicion. Measuring total IgA levels, IgG deamidated gliadin antibody tests, and TG2-IgG testing in that circumstance is recommended.Best Practice Advice 4: IgG isotype testing for TG2 antibody is not specific in the absence of IgA deficiency.Best Practice Advice 5: In patients found to have CD first by intestinal biopsies, celiac-specific serology should be undertaken as a confirmatory test before initiation of a gluten-free diet (GFD).Best Practice Advice 6: In patients in whom CD is strongly suspected in the face of negative biopsies, TG2-IgA should still be performed and, if positive, repeat biopsies might be considered either at that time or sometime in the future.Best Practice Advice 7: Reduction or avoidance of gluten before diagnostic testing is discouraged, as it may reduce the sensitivity of both serology and biopsy testing.Best Practice Advice 8: When patients have already started on a GFD before diagnosis, we suggest that the patient go back on a normal diet with 3 slices of wheat bread daily preferably for 1 to 3 months before repeat determination of TG2-IgA.Best Practice Advice 9: Determination of HLA-DQ2/DQ8 has a limited role in the diagnosis of CD. Its value is largely related to its negative predictive value to rule out CD in patients who are seronegative in the face of histologic changes, in patients who did not have serologic confirmation at the time of diagnosis, and in those patients with a historic diagnosis of CD; especially as very young children before the introduction of celiac-specific serology.Best Practice Advice 10: Celiac serology has a guarded role in the detection of continued intestinal injury, in particular as to sensitivity, as negative serology in a treated patient does not guarantee that the intestinal mucosa has healed. Persistently positive serology usually indicates ongoing intestinal damage and gluten exposure. Follow-up serology should be performed 6 and 12 months after diagnosis, and yearly thereafter.Best Practice Advice 11: Patients with persistent or relapsing symptoms, without other obvious explanations for those symptoms, should undergo endoscopic biopsies to determine healing even in the presence of negative TG2-IgA.

P0799 PROSPECTIVE STUDY TO EVALUATE THE EFFICACY OF QUADRUPLE THERAPY IN THE TREATMENT OF HELICOBACTER PYLORI GASTRITIS IN CHILDREN IN WHOM TRIPLE THERAPY HAS FAILED

Introduction: Treatment of Helicobacter pylori gastritis remains a challenge despite the availability of effective therapies, with eradication rates of 80 %. Our aim was to investigate the efficacy of quadruple therapy in children with H. pylori gastritis when two courses of primary triple anti- H. pylori therapy had failed. Methods: Charts of children with proven H. pylori gastritis as diagnosed with two of the following three criteria: namely positive CLO test, culture, and / or histology were reviewed. We selected only those who had received two courses of triple therapy with either Omeprazole or Lansoprazole and a combination of two of the following antibiotics: Amoxicillin 40 mg / kg / d, max 1g bid; Clarithromycin 250 mg bid in children <10 years, and 500 mg bid in children > 10 years; Metronidazole 20 mg / kg / d, max 500 mg bid; Tetracycline 50 mg / kg / d, max 1 g / d. Results: Eighteen patients met the criteria for quadruple therapy. Age range was 4–18 years, mean 12.8 years. 11 females / 7 males, 12 African American, 3 Caucasian, 3 Hispanic. This group received quadruple therapy of a PPI in addition to two of the above mentioned antibiotics based on antibiotic susceptibilities, as well as Pepto-Bismol bid for two weeks. Ten patients of these have been evaluated with follow-up endoscopies to assess eradication; 7/10 were cured with complete eradication of H. pylori based on follow-up endoscopy, CLO, and culture; and 3/10 showed persistence of infection on repeat endoscopy, (although these particular patients had more than two failures of triple therapy in the past despite the H. pylori strain being susceptible to the antibiotics chosen, therefore a question of compliance arises). Repeat endoscopy is pending in the rest 8 patients; however, follow-up serology has shown a trend for decreasing serum titers of H. pylori IgG levels. Conclusion: We conclude rescue therapy with four drugs can be effective in those who failed to eradicate with triple therapy; however, a multitude of factors play a role in the outcome of H. pylori eradication or persistence, as antimicrobial susceptibility, patient compliance, and inherent qualities in the H. pylori strain itself.

14 Pediatric Community-Acquired Needlestick Injuries: Description and Risk of Seroconversion

Community-acquired needlestick injuries (CA-NSI) are an emerging phenomenon. Although anxiety exists concerning the perceived risk of transmission of blood-borne viruses, seroconversion in this setting appears to be a rare event. To describe the circumstances surrounding pediatric CA-NSI and to document the rate of seroconversion of HIV, HBV and HCV in these children. We conducted a retrospective chart review of a cohort of children presenting with a CA-NSI to the Emergency Department of the Montreal Children's Hospital between January 1, 1988 and October 30, 2003. Patients were identified by review of the Infectious Disease Clinic records. The variables collected included demographics (date of birth, sex, postal code), circumstances of injury, prophylaxis offered (HIV, HBV), vaccination status and follow-up serology at 6 months post-injury. Data were analyzed using descriptive statistics. Ninety-two cases were identified over a period of 14 years and 10 months. Mean age was 8.2 years±3.4 years, ranging from 2.6 to 17.7 years of age. Sixty-three (68.5%) were boys. Most injuries occurred in streets (38.0%) and most children purposely picked up the needle (76.1%). Only 11 (12.0%) patients reported a syringe containing blood. Sixty-nine (75.0%) presented on the day of the injury. Among the 86 patients not known to have been previously vaccinated for HBV, 74 (86.0%) received HBIG and 83 (96.5%) received HBV vaccine. Seventy-two of the 83 (86.7%) who received HBV vaccine completed a 3-dose course in follow-up. Prophylactic antiretroviral therapy (ART) was offered as of 1998. Of the 51 patients who presented thereafter, 30 (58.8%) received ART, of whom 26 (86.7%) completed a four-week course of therapy. At 6 months, 62 were tested for HBV, 71 for HIV and 41 for HCV. There was no seroconversion. Fourteen patients were lost to our follow-up and testing is pending for 3 patients. The majority of pediatric NSI can be prevented. Therefore, children and parents need to be educated about the risks of discarded needles. Our study showed no infections in this setting.

Seroconversion rates in healthcare workers using a latex agglutination assay after varicella virus vaccination.

To determine the seroconversion rate after varicella immunization of healthcare workers (HCWs) and the effect of seroconversion rate on current cost-based recommendations for universal vaccination. A voluntary vaccination program for HCWs was performed at a tertiary-care cancer center in New York City. A commercial latex agglutination assay was used to test postvaccination antibody response. Costs for vaccination and postvaccination serological testing were compared to potential costs of postexposure employee furloughs. Of 263 seronegative HCWs, 96 (36.5%) began the vaccine program. Thirty-nine HCWs received only one dose of vaccine. Seven returned for follow-up antibody testing, of whom 4 were seropositive. Of the 57 HCWs who received two doses, 38 returned for follow-up serology. Thirty-one (81.6%) HCWs were seropositive for varicella-zoster virus antibodies, and seven HCWs (18.4%) remained seronegative. Total cost of vaccination for all 263 seronegative HCWs was estimated and compared to the cost of varicella-related furloughs at our institution. We found a considerably lower rate of vaccine-induced seroconversion at our hospital compared to that of the published literature. Despite this finding, universal varicella vaccination remained an extremely cost-effective alternative to the furloughing of exposed, seronegative HCWs. Projected hospital savings exceeded $53,000 in the first year after vaccination alone.

Guidelines of care for dermatologic conditions in patients infected with HIV

Guidelines of care for dermatologic conditions in patients infected with HIV

Measles Immunity in a Population of Healthcare Workers

To evaluate measles seroprevalence among cohorts of new employees and to evaluate vaccine responses of susceptible adult healthcare workers. New employees were screened for measles susceptibility as part of employee evaluations. Anti-IgG measles antibody tests were completed on 2,473 workers. Demographic, measles history, and measles vaccination information was collected using a short questionnaire. Susceptible workers were vaccinated and screened for vaccine responses following vaccination. Ninety-three workers (4%) were seronegative, and 56 (2%) were equivocal. Individuals in the youngest cohort (born after 1956) were significantly more likely to be susceptible than those in the middle cohort (born 1951 to 1956) and those in the oldest cohort (born before 1951) (P < 0.01). The middle cohort included eight (5%) of the 149 seronegative or equivocal workers. Among the members of the youngest cohort, those from the United States were more likely to be susceptible (P < 0.01) than those from outside the United States. Of the 106 vaccinated susceptible workers whose follow-up serologies were determined, 90 (85%) developed positive IgG serologies, six had equivocal results, and 10 were seronegative. Eleven of the 16 non- or hyporesponders were revaccinated and re-evaluated; nine developed low positive IgG antimeasles levels, one exhibited an equivocal response, and one failed to respond. A small but important proportion of healthcare workers are susceptible to measles. Whenever feasible, measles immunity programs for healthcare workers should include workers born before 1957. Of workers born after 1956, those from outside the United States are more likely to be immune than workers from inside the United States. Using the currently available vaccine, revaccination of initial non- or hyporesponders appears to be effective.

Une épidémie de bilharziose à schistosoma mansoni 113 observations dans une collectivité militaire au retour d'Afrique centrale

The authors report on an outbreak of Schistosoma mansoni infestation involving 113 military men who had been contaminated together in a tributary of the Chari river in the Central African Republic. The patients were examined on their return to France 50 days after being contaminated and were compared with a control group of 25 subjects who had lived in Africa under the same conditions but were exempt of bilharziasis. All were subjected to a retrospective questionnaire, physical examination, examination of the faeces and serological test for bilharziasis by indirect haemoagglutination. All received two courses of praziquantel. Follow-up serology was performed after 1 year in 86 cases. The results of this study in both groups are presented and commented upon. With intestinal bilharziasis, prophylaxis against contamination is extremely difficult to carry out in endemic areas among people who visit and work "on the spot". Detection by routine serology must be performed upon return.

Incidence of cytomegalovirus disease in cyclosporine-treated renal transplant recipients based on donor/recipient pretransplant immunity.

We retrospectively reviewed the clinical data of all renal transplant patients treated with cyclosporine as their main chronic immunosuppressive agent between 12/83 and 11/85 to identify cytomegalovirus-negative patients at our institutions who received cytomegalovirus (CMV)-positive kidneys. Using a latex agglutination test, twenty-two such patients were identified, of whom 2 were excluded due to early death and lack of posttransplant follow-up serology. Of the remaining 20 patients, 12 developed CMV antibody in the first 4 months posttransplant, and of these, 11 were hospitalized with complications related to primary CMV disease. Two of these seroconverting patients eventually died, and one lost her kidney. Of the 8 persistantly CMV-negative patients, 1 lost his kidney soon after transplantation, and one had a febrile illness 4 months posttransplant caused by a bacterial pneumonia. Concomitantly, 145 renal transplants (CMV-negative recipient receiving a CMV-negative kidney or CMV-positive recipient receiving either positive or negative kidneys) given to 142 patients functioned for at least 4 weeks. Only 3 cases of CMV reactivation disease occurred in previously antibody-positive patients. We conclude that the transplantation of a cytomegalovirus-positive kidney into a CMV-negative recipient carries a high risk of mortality/morbidity from primary cytomegalovirus disease. On the other hand, reactivation of CMV disease was uncommon early in the posttransplant course of cyclosporine-treated patients.