Positive Viral Serology Research Articles

Predictors of Remission in Severe Childhood Immune Thrombocytopenia.

Childhood immune thrombocytopenia (ITP; platelet count < 100 × 109/L) is the most common bleeding disorder in children. A total of 3-5% of children with ITP face a greater risk of bleeding, resulting in significant morbidity and mortality. Childhood ITP is often benign and self-limited; however, children with severe ITP (platelet count < 30 × 109/L) require investigation and monitoring. In addition, 20% of ITP patients may not go into remission (platelet counts < 100 × 109/L by 12 months after diagnosis) and may develop chronic ITP. The early identifying predictors associated with the resolution of severe ITP at the time of diagnosis may be helpful for family guidance. However, there is still controversy about the associations between the clinical factors at the time of initial diagnosis and the definitions of disease remission assessed at different timepoints after diagnosis. This retrospective study aimed to analyze the shared clinical factors among the disease remission definitions at three arbitrarily set timepoints-3, 6, and 12 months after diagnosis. This study retrieved records for hospitalized children aged under 18 years and diagnosed with ITP from the hospital registry in a tertiary university hospital. Clinical variables were recorded by reviewing the medical records with structured data entry for ITP admission. The serial follow-up platelet counts within 12 months after diagnosis were recorded. The times of ITP remission were identified by experienced pediatric hematologists. Patients with mild-form ITP (platelet counts ≥ 30 × 109/L) at diagnosis or who were lost to follow-up within 3 months were excluded. From 1988 to 2019, 546 children were enrolled, and a total of 497 children with severe ITP were included in the further analysis. In total, one (0.2%) died of an intracranial hemorrhage, 363 (73.2%) children went into remission at 3 months, 40 (8.1%) went into remission between 6 and 12 months, and 104 (20.9%) developed chronic ITP. The shared significant predictors for remission by the third, sixth, and twelfth months included pre-adolescent age (<10 years) at diagnosis, abrupt onset (duration of symptoms prior to admission ≤ 2 weeks), and speedy recovery (platelet count > 100 × 109/L at 1 month post diagnosis). ITP patients with positive viral serology tests or vaccination within 4 weeks had trends of delayed remission. In conclusion, diagnosis before preadolescent age, abrupt onset, and speedy recovery may share favorable factors for the remission of childhood ITP assessed at different timepoints.

S3248 A Case of Drug-Induced Liver Injury Secondary to Clobenzorex Use

Introduction: Drug-induced liver injury (DILI) is a cause of both acute and chronic liver disease and is often a challenging condition for clinicians. It is a diagnosis of exclusion that requires a detailed history and workup to ensure other potential causes have been ruled out before affirming the diagnosis. There are numerous offending agents with varied presentations, often idiosyncratic in nature, with the additional challenge being a lack of specific testing or biomarkers to aid diagnosis. Case Description/Methods: We present a case of a 25-year-old male who immigrated from Mexico 4 months ago, with no reported past medical history, who presented to the emergency department for a two-day history of postprandial non-radiating right upper quadrant and epigastric pain. Associated symptoms include subjective fevers, chills, decreased appetite, nausea, one episode of blood-tinged emesis, night sweats and dyspnea. The patient worked as a driver in Mexico and was taking two different formulations of 30mg Clobenzorex, an amphetamine pro-drug, daily for two years to help him stay awake for work. These medications were available over the counter. He had not taken it since he moved to the US. He denies the use of illicit drugs, contact with any inmates or Tuberculosis patients. At the time of his presentation, he works in a wooden floor-making company. Labs revealed a markedly elevated total bilirubin of 4.4 mg/dL, INR 1.1, AST 1325 IU/L, ALT 3151 IU/L, LDH 745 IU/L and a mildly elevated ALP 220 IU/L. Acute hepatitis and autoimmune panels were not reactive. Serum acetaminophen level was also within normal limits. Ultrasound of the abdomen and MRCP noted gallbladder wall thickening but no biliary dilatation or pathology. The patient subsequently underwent a core-needle liver biopsy that displayed lobular infiltrates of inflammatory cells of predominantly lymphocytes (Figure 1). Given the absence of positive viral serology, a diagnosis of drug-induced hepatitis was concluded. Discussion: This case report documents a unique instance of drug-induced liver injury secondary to Clobenzorex use. This case highlights the importance of a detailed social history and should encourage clinicians not to neglect to ask about over-the-counter medications to help elucidate potential causes of liver injury. This is an important consideration, especially in the subset of patients from countries outside the United States who have access to a variety of OTC medications that are potentially hepatotoxic.Figure 1.: Core needle liver biopsy showing lobular infiltrates of inflammatory cells consisting of predominantly lymphocytes.

SARS-CoV-2 in saliva, viremia and seroprevalence for COVID-19 surveillance at a single hematopoietic stem cell transplantation center: a prospective cohort study.

ABSTRACTThis prospective cohort study aims to analyze the surveillance of COVID-19 at a single hematopoietic stem cell transplantation (HSCT) center in Brazil, in 29 patients undergoing allogeneic HSCT and 57 healthcare workers (nurses and dentists), through viral shedding of SARS-CoV-2 in saliva and plasma and seroprevalence of anti-SARS-CoV-2 IgG. In addition, we report two cases with prolonged persistent detection of SARS-CoV-2 without seroconversion. The sample collection was performed seven times for patients and five times for healthcare workers. Only two patients tested positive for SARS-CoV-2 in their saliva and plasma samples (6.9%) without seroconversion. All healthcare workers were asymptomatic and none tested positive. Two patients (6.9%) and four nurses (8%) had positive serology. No dentists had positive viral detection or positive serology. Our results reflect a low prevalence of positive RT-PCR and seroprevalence of SARS-CoV-2 in patients and healthcare workers at a single HSCT center. Results have also corroborated how the rigorous protocols adopted in transplant centers were even more strengthened in this pandemic scenario.

Hospital-wide antigen screening for coronavirus disease in a tertiary reference center in Sapporo, Japan: A single-center observational study.

Hospital-wide screenings for coronavirus disease (COVID-19) are important to identify healthcare workers at risk of exposure. However, the currently available diagnostic tests are expensive or only identify past infection. Therefore, this single-center observational study aimed to assess the positivity rate of hospital-wide antigen screening tests for COVID-19 and evaluate clinical factors associated with antigen positivity during a COVID-19 institutional outbreak in Sapporo, Japan.We analyzed the data of 1615 employees who underwent salivary or nasal swab antigen tests on November 18, 2020, to detect severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Laboratory confirmation using reverse transcriptase polymerase chain reaction was performed for those with positive viral serology. The demographic characteristics, job titles, and risk of contact with COVID-19 patients were compared between employees with and without COVID-19.A total of 19 employees (1.2%) tested positive for the SARS-CoV-2 antigen. The positivity rate was high among rehabilitation therapists (2.1%) and employees in the low-risk contact group (6.1%). Although there was no association between the job titles and the seropositivity rate, those in the low-risk contact group had an increased risk of testing positive for the viral antigen (odds ratio, 8.67; 95% confidence interval, 3.30–22.8).The antigen positivity rate was low during the hospital outbreak, suggesting that risk assessment of exposure to COVID-19 patients may provide more useful information than using job titles to identify infected health care providers.

Risk factors for blood loss in liver resection surgery: An Institutional Review.

Background: Surgical resection of the primary or metastatic liver lesions is the treatment of choice for patients with resectable tumors. Identifying and managing preoperative and intraoperative risk factors responsible for increased blood loss during liver resection is extremely important. Therefore, the present study aims to identify preoperative and intraoperative risk factors associated with blood loss during liver resection.&#x0D; Methodology: A retrospective cross-sectional study was conducted on 72 patients who underwent liver resection for resectable primary and metastatic liver lesions at the Department of Surgical Oncology Hepatobiliary Unit, Shaukat Khanum Memorial Cancer Hospital, and Research Center Lahore. The study continued from October 2014 to July 2017, and data were collected from hospital records, including demographic, biochemical, and perioperative variables.&#x0D; Results: Out of the total 38 patients, 52.8% were female, with a mean age of 40.59 ± 21.66 years at the time of surgery. The results after multivariate analysis conclude two independent risk factors responsible for significant blood loss of more than 1000 milliliters during liver resection. These factors include liver cirrhosis, where the odds ratio is 7.96 with 95% CI (1.00-63.31) and P-value of 0.05 and operative time of 390 minutes where odds ratio is 8.94 with 95% CI (2.28-36.48) and P-value of 0.02.&#x0D; Conclusion: The risk factors associated with increased intraoperative blood loss during liver resections in our population are mainly associated with preoperative parameters, including positive viral serology and radiologically proven liver cirrhosis. In contrast, intraoperative factors were intravenous fluid administration and operative time.

MO088CLINICOPATHOLOGICAL FEATURES OF THROMBOTIC MICROANGIOPATHY

Abstract Background and Aims TMA is a rare and severe endothelial lesion with thrombus formation and vascular occlusion with organ damage. It can be a complication of several clinical conditions. The aim of this study was to characterize clinical and pathological findings of patients with confirmed kidney TMA. Method We performed a retrospective observational descriptive study that analyzed all patients with TMA diagnosed by kidney biopsy, in two hospital centers, from January 2015 until December 2020. Clinical, laboratorial, pathologic characteristics were analyzed as also therapeutic performed and kidney and patient outcomes. Results Our sample had 14 patients, the majority female (n=11, 78%) with a mean age of 45±10 years-old and 12 (80%) were Caucasian. Six (40%) had past medical history of HTA, 2 (13%) had Multiple Myeloma, 4 (26%) transplant (3 kidney, 1 lung) and none had positive viral serology’s. Prodromal symptoms included diarrhea in 2 (13%) patients, neurological in 3 (20%) and previous infection in 3 (20%). Mean laboratorial values were: Hemoglobin 7.8 g/dL, platelets 161.000/uL; LDH 586 UL; bilirubin 1.38 mg/dL, haptoglobin 1,55 g/L. Only 5 had schistocytes. ADAMTS13 activity was &amp;gt;10% in all performed and in all, Coombs test were negative. C3 was consumed in 3 (20%) patients and C4 in 2 (13%) but complement phenotypic study was normal in all performed patients. Auto-immune study revealed: 1 positive ANA, dsDNA negative in all but one with positive c1q antibody. One had positive antiphospholipid syndrome (AFS) antibodies and one scleroderma antibodies. Main kidney presentation was acute kidney injury in 8 (53%) patients, with mean eGFR 14ml/min/1,73m2. Mean proteinuria was 2,5 g/24h and half (50%) had hematuria. Kidney biopsies had a mean of 11,85 glomerulus, of which 14% sclerotic, mean interstitial fibrosis and tubular atrophy score 1,7. Acute tubular necrosis was present in 7 (46%) and inflammatory infiltrate in all, endotheliosis in 13 (86%), mesangiolysis in 3 (20%), arteriolar thrombus in 10 (66%), glomerular thrombus in 6 (40%), ischemic glomerulus in 12 (80%) and double-contour appearance in 7 (46%). TMA etiologies were the following: 2 malignant hypertension, 2 proteasome inhibitor (PI), 1 scleroderma, 1 lupus, 1 AFS, 2 calcineurin and mammalian target of rapamycin inhibitors, 2 antibody mediated rejection (AMR), 1 methylmalonic acidemia and 2 undetermined. Treatment performed encompassed: hypertension management, withdrawal od PI, changing immunosuppression, AMR treatment, cyanocobalamin, lupus induction treatment and eculizumab. Kidney recovery was observed in 8 patients (53%). Patient survival at 6 months was 73%. Conclusion These study results highlight the vast context of conditions that TMA can appear. Most of them had only with mild or even absent clinical and laboratory features. Therefore, a high index of suspicion is required to diagnose TMA, allowing targeted treatment to preserve of kidney function.

Influenza Viral Infections Surveillance and Clinical Presentations in Hospitalized Children: A Cross-sectional Study

Background: Influenza virus and other respiratory viruses have been identified as an essential cause of acute respiratory infections (ARIs) in children worldwide. However, there are few data on its frequency and clinical presentation in Jordan. Objectives: We aimed to identify the viral etiology of acute respiratory infections and the various clinical presentations in hospitalized children, especially those with influenza viruses compared to other respiratory viruses. Methods: A retrospective study was conducted at the Jordan University Hospital. All the positive nasopharyngeal aspirates that were collected from hospitalized children aged 0-19 years from January 2017 to January 2019 were reviewed. Results: A total of 338 nasopharyngeal aspirates (NPAs) with positive viral serology results were reviewed. Among the patients younger than four years, the RSV virus was the most frequently detected. However, the Influenza B virus was the most commonly seen in patients older than 5 years, H1N1 was more frequent in autumn (29.5%), and RSV was the most frequent virus in winter. Bronchopneumonia was the most frequent diagnosis among all hospitalized patients, followed by bronchiolitis. Out of 338 patients, 50.3% had tachypnea, 70.7% of patients were admitted to the pediatric floor, while 18.6% presented with a severe illness and required admission to the pediatric intensive care unit (PICU). Infants under the age of one were more likely to have higher co-infection rates with other viruses compared to children over five years that had influenza. Conclusion: Presentations of influenza and other respiratory viruses vary between different age groups, such as sepsis in children younger than one year.

İnfluenza veya diğer solunum yolu virüsleri: kritik hastalarda akut solunum yetmezliğinin sebebi olarak önemli midir?

Respiratory virus infections may cause serious respiratory failure requiring intensive care unit (ICU) admission. The objective of this study was to evaluate the clinical features and the outcome in patients with acute respiratory failure (ARF) due to viral infections comparing etiological agents.ARF patients with positive viral serology were retrospectively recruited. Cohort was evaluated with regard to subgroups as influenza and other respiratory viruses (ORV), as well as survivors and nonsurvivors.Out of 938 admitted patients, 319 were followed as ARF and only 149 patients had viral respiratory panel results. In 49 patients with ARF, 52 positive viral results were detected and 47 patients with single positive viral isolates of either influenza or ORV were included. Among them, 62% had ORV with quite similar characteristics with influenza group apart from diabetes mellitus which was encountered more in influenza group (p= 0.02). Overall ICU mortality was 32% and there was no difference between the two groups (p= 0.42). Acute Physiology and Chronic Health Evaluation (APACHE) II score was independently associated with ICU mortality (OR: 1.25; 95% CI: 1.04-1.51; p= 0.02).This study emphasizes to consider the possibility of other respiratory viruses for the cause of ARF with similar characteristics and mortality as influenza species.

Update on liver transplantation-newer aspects

Liver transplantation (LT) remains the only therapeutic option offering gold standard treatment for end-stage liver disease (ESLD) and acute liver failure (ALF), as well as for certain early-stage liver tumors. Currently, the greatest challenge facing LT is the simple fact that there are not enough adequate livers for all the potential patients that could benefit from LT. Despite efforts to expand the donor pool to include living and deceased donors, organ shortage is still a major problem in many countries. To solve this problem, the use of marginal liver grafts has become an inevitable choice. Although the definition of marginal grafts or criteria for expanded donor selection has not been clarified yet, they are usually defined as grafts that may potentially cause primary nonfunction, impaired function, or late loss of function. These include steatotic livers, older donors, donors with positive viral serology, split livers, and donation after cardiac death (DCD). Therefore, to get the best outcome from these liver grafts, donor-recipient selection should be vigilant. Alcohol-related liver disease (ALD) is one of the most common indications for LT in Europe and North America. Traditionally, LT for alcoholic liver disease was kept limited for patients who have achieved 6 months of abstinence, in part due to social and ethical concerns regarding the use of a limited resource. However, the majority of patients with severe alcoholic hepatitis who fail medical therapy will not live long enough to meet this requirement. Besides, the initial results of early liver transplantation (ELT) without waiting for 6 months of abstinence period are satisfactory in severe alcoholic hepatitis (SAH). It will be important to take care of these patients from a newer perspective.

Incidence of Viral Infections as a Cause of Acute Decompensation of Heart Failure and the Prevalence of Viral Testing in a Tertiary Referral Centre

Background: In patients with heart failure (HF), viral infection is postulated to cause acute exacerbations, resulting in more frequent hospitalisations and longer hospital stays. Early diagnosis of a viral cause for decompensation could streamline HF treatment and reduce unnecessary investigations, potentially reducing length of admission. However, the prevalence of viral testing is unclear. Objectives: Our aims were to determine viral testing uptake in patients with acute decompensated HF, and the impact of viral infection on length of admission. Methods: We retrospectively examined all admissions categorised as acute decompensated HF (based on DRG coding) in a tertiary hospital from 2014–2018. Demographic information, comorbidities and evidence of viral infection (defined by positive viral swabs or serology) were obtained from medical records. Length of admission was compared between patients with positive viral testing and those without. Results: We examined 470 admissions for acute HF exacerbation, in a cohort of 248 HF patients (age 66.1 ± 15.6 years; 34% female). Investigations for viral cause of decompensation only occurred in 172 (37%) admissions. A respiratory virus was identified in 43 cases (24%). Compared to those who experienced a non-infective exacerbation of HF, patients who tested positive for a viral pathogen had significantly longer length of stay (13.4 days vs 9.1 days, p = 0.04). Conclusions: Our results suggest that there is significant under-testing and under-diagnosis of viral infection in patients presenting with acute decompensated HF. The uptake of viral screening in these patients should be further encouraged to better streamline management of HF exacerbations and optimise preventative strategies.

A 14-Year Audit and Analysis of Human Skin Allograft Discards.

The objective of this study was to review the incidence of skin allograft discard and bacterial contamination due to donor bioburden at the Ontario Professional Firefighters Skin Bank over a 14-year period. We sought to determine whether modifications to our prerecovery donor preparation process have been effective in reducing skin bioburden and identify other potential risk factors of allograft contamination. A retrospective review of all skin donors (n = 259) processed from 2002 to 2015 was performed. Multivariate logistic regression was used to determine whether donor-related factors and procurement-related factors were significantly associated with microbial contamination predisinfection and discard secondary to contamination. Eighty-one donor recoveries were discarded (81/259; 31%) or 694 grafts (694/2636; 26%), with bacterial contamination being the most common reason for discard (29/81; 36%) followed by positive viral serology (21/81; 26%) primarily for hepatitis B core antibodies. Bacterial contamination predisinfection was detected in 46% of donors (49% of grafts). Analysis of risk factors showed that only donor preparation using a 70% alcohol spray significantly reduced odds of both bacterial contamination predisinfection (P < .0001) and discard secondary to bacterial contamination (P = .0233). Our results suggest that selective screening of donors to reduce risk of microbial contamination is unlikely to alter the rate of allograft contamination. However, use of a 70% alcohol spray during donor preparation may minimize bacterial contamination and subsequent bacterial-related discards. Given that detailed guidelines for donor preparation do not exist, use of an alcohol spray may be of value for tissue banks experiencing allograft loss due to bacterial contamination.

Profile of hepatic involvement in dengue infections in adult Pakistani population.

Objectives:To estimate the range of hepatic involvement in dengue infections by assessing clinical and biochemical profile of adult dengue infected patients.Methods:Serologically confirmed 220 adult cases of dengue infections admitted to Mayo hospital from June 2013 to November 2013 were classified as having dengue fever, dengue haemorragic fever and dengue shock syndrome. The frequency and range of bilirubin, liver enzymes derangement and presence of liver enlargement in each group was calculated and further stratified according to age and gender. Patients with positive viral serology, chronic liver disease, malaria and typhoid were excluded from the study.Results:About 60% of DHF patients had hepatomegaly compared to 40% of DF patients. Liver dysfunction was more common in DF compared to DHF (38.15 vs 18.6%). Hyperbilirubinemia was noted in 40 (18.2%) patients, 28 (12.7%) in DF and 12(5.5%) in DHF. The mean serum bilirubin was higher in DHF [0.87+0.33] compared to DF [0.74+0.27]. Bilirubin was higher in male patients and in younger (<20 years) age group. ALT was elevated more frequently in male patients in age group of 31-40 years and in DF patients as compared to DHF [72(32.7% vs 40(18.2%)]. The mean serum ALT level was 103.7 U/l in DHF and 69.2U/l in DF. AST was raised in all DHF patients as compared to DF in which 40% patients had normal AST levels. Alkaline Phosphate was high in all DHF patients with a mean of 278.7. It was raised in most of the DF patients as well and majority of patients were in age group of 31-40 years.Conclusion:Liver involvement is very common in dengue infections and is not limited to elevation of transaminases only. Bilirubin and Alkaline phosphatase are also raised in considerable number of patients. Therefore in adults with fever, jaundice, hepatomegaly and altered liver function tests, the diagnosis of dengue infection should be strongly considered in areas where dengue infection is endemic.List of abbreviations:DF: Dengue FeverDHF: Dengue Hemorrhagic FeverDSS: Dengue Shock SyndromeDIC: Disseminated intravascular coagulationALT: Alanine transaminaseAST: Aspartate aminotransferase

Why Should Viral Markers Be Mandatory in Ocular Surgeries: A Hospital Based Retrospective Study.

Hepatitis B Virus (HBV), Hepatitis C Virus (HCV) and Human Immunodeficiency Virus I, II (HIV-I,II) are serious global and public health problem. Knowledge of the seroprevalence would enable early diagnosis, treatment of patients and also help in prevention of horizontal spread of infection by application of universal infection control measures. To determine the seroprevalence of HBV, HCV and HIV I, II infection in patients undergoing ocular surgery. A retrospective review of 560 patients who had undergone ocular surgery between Dec 2014 to June 2015 at Regional Institute of Ophthalmology, Patna, India, was done. Blood samples of patients were tested for the presence of Hepatitis B Surface Antigen (HBsAg) and anti-HCV antibodies by Enzyme Linked Immunosorbent Assay (ELISA) method, while HIV I, II was tested by ELISA and Western Blot as per National AIDS Control Organization (NACO), India guidelines. The number of patients with positive viral serology, age, sex ratio and nature of surgery were analysed. Out of 560 patients, 27 (4.8%) patients were found to be positive for viral serology. HBsAg was positive in 22 patients (3.92%). Out of these 14 patients (2.5%) were male while 8(1.4%) were females. Anti- HCV was positive in 3 (0.53%) patients. Out of these 2(.35%) were male and 1 (.17%) was female. HIV was positive in 2 patients (0.35%), both of whom were males. Keeping in view the number of cases of seropositivity in our study and various studies showing the presence of these viruses in aqueous and tears, we suggest that screening for viral markers should be made mandatory before ocular surgery so that early detection and treatment of patients can be done and risk of horizontal spread is minimized.

Association of aplastic anaemia with positive viral hepatitis serology, and its outcome after immunosuppressive therapy

s / Journal of Clinical Virology 69 (2015) 223–246 241 advocacy by comparison with other infectious diseases. TheWorld Health Organization supports the development of national strategic approaches. The aim of this study was to provide evidence for developing coordinated policy responses by investigating the elements of the public policy response to chronic viral hepatitis in Taiwan to inform best practice. Methods: The policy assessment reviewed literature and conducted semi-structured qualitative interviews with key participants and interested partners in the national response to chronic viral hepatitis in Taiwan. These participants (n=26) included clinicians, government officials, advocates, representatives from non-governmental organisations, and pharmaceutical companies and were conducted in Taiwan in June, 2013. Findings: Taiwan implemented a public policy response to viral hepatitis through a series of 5-year plans commencing from 1982. Initially, this response provided the framework for the world’s first comprehensive hepatitis B vaccination programme, and over time incorporated interventions to improve access to clinical services and to reduce the burden related to hepatitis C infection. Interpretation: Critical factors in Taiwan’s response are an effective health-service delivery architecture, an acceptance of the need for disease prevention, government promotion and funding of science and technology, and a rigorous evidence base with sustained advocacy. http://dx.doi.org/10.1016/j.jcv.2015.06.055

P1286 : Low prevalence of positive viral serology for HBV and HCV among a general dutch elderly population: Results from the rotterdam study

P1286 : Low prevalence of positive viral serology for HBV and HCV among a general dutch elderly population: Results from the rotterdam study

Hepatitis B virus-related post-infectious glomerulonephritis: a case report

Hepatitis B virus infection is an uncommon cause of acute glomerulonephritis. We present a case of acute glomerulonephritis revealing a chronic viral hepatitis B. A 45 year-old man was admitted in the nephrology department of Hassan II university hospital (Fez, Morocco) for nephritic syndrome with advanced acute kidney injury. The investigations have revealed viral hepatitis B with a positive HBV-DNA and Others viral serology tests were negative. Renal biopsy showed a diffuse and global endocapillary proliferation without extra-capillary proliferation; and global deposits of C3 and Ig G On immunofluorescence. There wasn't any other infectious cause. We thus retained the diagnosis of hepatitis B virus-associated acute glomerulonephritis. He was given entecavir and corticosteroids. Three months later, the evolution was marked by the normalization of renal function, negativity of proteinuria and HBV DNA became undetectable. There was no relapse of glomerulonephritis and HBV viral load was still negative after one year follow-up.

The Utility of Tissue Immunohistochemistry and Viral Culture in Immunocompromised Patients Based on Endoscopic Findings

Purpose: Immunosuppressed patients presenting with gastrointestinal signs and symptoms are often assessed for opportunistic infections with endoscopic mucosal biopsy for tissue immunohistochemistry and viral cultures. However, the utility of this practice is unclear. Methods: Using laboratory and pathology databases we retrospectively identified all patients >18 years old undergoing tissue viral cultures or viral immunohistochemistry (IHC) between January 2005 and November 2011. The results of IHC staining, viral culture results, and endoscopic findings were independently reviewed by different physicians who were not aware of the other results. The primary end point was the diagnostic yield of IHC staining and viral cultures in patients with endoscopically normal and abnormal GI mucosa. Results: A total of 154 patients, age 18 to 80, who underwent a total of 209 procedures (102 upper and 107 lower GI endoscopy) were reviewed. 77% of patients had documented use of an immunosuppressive medication at the time of endoscopy. Endoscopic exam showed 62/209(30%) with ulcerations, 97/209(46%) with non-ulcer abnormal mucosa, and 50/209(24%) with normal mucosa. Of all the specimens, 14/209(7%) were positive for viral cultures and 10/209(5%) had positive IHC staining consistent with viral infection. Of the 14 specimens with positive viral cultures, the endoscopic findings included 12 with ulcers, 2 with erosions, and 2 normal findings. Also, 7/14 of these specimens had positive IHC and 6/14 patients had documented positive viral serology prior to endoscopy. The yield of viral cultures in association with endoscopic findings were 12/62(19%) for ulcers, 2/97(2%) for non-ulcer abnormal mucosa and 2/50 (4%) for normal mucosa. Thus, the yield of positive viral culture in non-ulcerated mucosa biopsies was 4/147 (3%), and 2 out of 4 patients had documented positive viral DNA PCR prior to endoscopy. The yield of positive IHC staining in association with endoscopic findings were 9/62(10%) for ulcers, 1/97(1%) for non-ulcer abnormal mucosa, and 0/50 (0%) for normal mucosa. Thus, the yield of positive IHC staining in non-ulcerated mucosa biopsy was 1/147 (0.7%). Although this patient did not have positive viral culture result, the patient had documented positive serology study, prior to endoscopy. Therefore, the additional yield for IHC was zero. Conclusion: Endoscopic biopsies for IHC and viral cultures often yielded positive results in immunocompromised patients with ulcerated mucosa. However, the yield in the setting of non-ulcerated mucosa is very low and not likely to alter patient management.

Predictors of outcome in children with acute viral hepatitis and coagulopathy

The presence of coagulopathy in acute viral hepatitis (AVH) in children raises issues about prognosis and need for liver transplantation. We evaluated factors predicting outcome in such patients and determined the applicability of the paediatric acute liver failure study group (PALFSG) definition of acute liver failure (ALF) of coagulopathy alone in comparison with coagulopathy and encephalopathy. Children with AVH (clinical features, raised transaminases and positive viral serology) with uncorrectable coagulopathy [prothrombin time (PT) > 15 s] with or without hepatic encephalopathy (HE) were enrolled. Comparative analysis was based on (i) outcome: survivors/nonsurvivors and (ii) ALF criteria: group A coagulopathy (PT > 15 s) and encephalopathy and group B coagulopathy (PT > 20 s). We studied 130 children (86 boys, mean age 7.5 ± 4.5 years): 86 recovered and 44 died. Single virus infection was present in 96 (74%), hepatitis A being the commonest (n-69). On multiple stepwise logistic regression analysis, age <3.5 years, serum bilirubin ≥ 16.7 mg/dL, PT ≥ 40.5 s and clinical signs of cerebral oedema were independent predictors of mortality. Mortality increased from 0% with single to 100% with four risk factors. Ninety-seven cases met the PALFSG criteria: group A-79 and group B-18. Group A subjects had higher mortality (55.6%vs 0%) and poorer liver functions (bilirubin 18.1 ± 8.9 vs 13.8 ± 6.9 mg/dL, PT 63.9 ± 35.1 vs 27.2 ± 5.2 s) than group B. PT deteriorated significantly with the appearance and progression of HE. One-third of children with AVH with coagulopathy die without transplantation. Age <3.5 years, bilirubin ≥ 16.7 mg/dL, PT ≥ 40.5 s and signs of cerebral oedema are predictors of poor outcome. Children with encephalopathy and coagulopathy have a poorer outcome than those with coagulopathy alone.

The Rate of Organ and Tissue Donation After Brain Death: Causes of Donation Failure in a Romanian University City

Aim To evaluate the rate of organ donation after brain death in 2 tertiary care medical centers of a Romanian city, the reasons for donation exclusion (donors or organs), and identification of potential strategies for improvement. Material and Methods The study retrospectively evaluated potential organ donors with brain death (BD) who were identified between January 2006 and June 2009 in an university city of Romania. The potential donors were considered patients with severe intracranial pathology and clinical signs of brain death who were reported to the regional transplant team. The BD declaration was completed according to the Law of Transplant Procurement and Management in Romania: clinical signs of brain stem death, apnea test, and flat EEG, criteria that must be fulfilled twice at a 6 hour interval. According to Romanian law, family consent is mandatory for organ harvesting. Results The study included 35 potential donors, of whom 22 had a declaration of BD. Failure of potential donors to be declared BD was caused by positive viral serology (n = 7), improvement in clinical status (n = 2), sudden cardiac arrest (n = 2), and refusal of physician in charge (n = 2). Among the 22 with a BD declaration, organ harvesting was performed in only 12 cases due to family refusal (n = 10). In 4 cases the planned organ harvesting was aborted owing to unexpected intraoperative findings. Discussion Factors that generate the low rate of organ procurement include local organizational particularities, a high rate of viral infections, poor education, (both of lay persons and of medical personnel), restrictive criteria for BD declaration and the mandatory need for family approval. Conclusion The rate of donation in this university city of Romania is still low. Several strategies have been identified to improve the rate: better identification of potential donors, better management, and education of the public and of health care personnel.

The effect of donor race on the survival of Black Americans undergoing liver transplantation for chronic hepatitis C: Is racial mismatch a predictor of graft survival?

Chronic liver diseases are the 12th leading cause of death in the United States, and the burden of disease has been projected to increase substantially in the next several decades. Hepatitis C virus (HCV) is the most common disorder leading to liver transplantation, and its late-stage complications are expected to result in increased hospitalizations and morbidity. The epidemiology of chronic hepatitis C, the natural history of the disease, and its response to therapy are greatly influenced by racial and ethnic differences. African Americans exhibit a higher prevalence of hepatitis C–positive viral serology, and in comparison with nonHispanic whites, they are twice as likely to get infected with genotype 1, which reduces the probability of sustained virological clearance when they are treated. The dissimilarity in viral clearance has been speculated to be a function of racial variation in immunological reactivity. A study of HCV-specific CD41 cell response indicated that even though African Americans have a significantly greater proliferative response to HCV NS3NS5 antigens than non-Hispanic whites, the HCV-specific CD41 T-cell proliferative response is dysfunctional, and the production of gamma interferon, a cytokine that inhibits protein synthesis and RNA replication of subgenomic and genomic HCV replicons, is reduced in this population. The speculated dysfunctional immunological reactivity would explain partially why African Americans progress more often to cirrhosis than nonHispanic whites. Nevertheless, more recently, the National Institutes of Health–sponsored Viral Resistance to Antiviral Therapy of Chronic Hepatitis C (VIRAHEP-C) study, with all of its substudies, has failed to show any racial difference in viral genetics or immunological variability to which the lack of response to antiviral treatment could be attributed. Race also seems to play an important role in access to liver transplantation and in graft survival post–orthotopic liver transplantation (OLT). Prior to the introduction of the Model for End-Stage Liver Disease (MELD), liver organ allocation was based on subjective parameters such as severity of ascites and grade of hepatic encephalopathy. Several studies performed during the pre-MELD era illustrated that African American were underrepresented on the transplant waiting list and among recipients of transplantation. African Americans were also more likely to be referred for liver transplantation at a later stage of their disease in comparison with white patients and had a higher probability of becoming too ill or dying while waiting for liver transplantation. The use of the MELD scoring system has provided a more objective method for the assessment of severity of liver disease and eliminated race as a predictor of organ allocation and as a risk factor for death on the waiting list. The effect of race and ethnicity on post–liver transplantation outcomes has also been extensively reviewed; the most common findings are the reduced 2and 5-year patient survival observed in African Americans after liver transplantation and the in-