The impact of IL-6 and IL-28B gene polymorphisms on treatment outcome of chronic hepatitis C infection among intravenous drug users in Croatia.

BACKGROUND: Several genes and their single nucleotide polymorphisms (SNPs) are associated with either spontaneous resolution of hepatitis C infection or better treatment-induced viral clearance. We tested a cohort of intravenous drug users (IVDU) diagnosed with chronic hepatitis C virus (HCV) for treatment response and its association with the SNPs in the interleukin-6 (rs1800795-IL6) and the interleukin-28B (rs12979860-IL28B) genes. METHODS: The study included 110 Croatian IVDU positive for anti-HCV antibody. Genotyping was performed by polymerase chain reaction (PCR) based approach. Patients were treated by standard pegylated-interferon/ribavirin and followed throughout a period of four years, during which sustained virological response (SVR) was determined. All data were analysed with statistical package SPSS 19.0 (IBM Corp, Armonk, NY, USA) and PLINK v1.07 software. RESULTS: Patients showed a significantly better response to treatment according to the number of copies of the C allele carried at rs1800795-IL6 (P = 0.034). All but one of the patients with CC genotype achieved SVR (93%), whereas the response rate of patients with GG genotype was 64%. The association of rs1800795-IL6 with SVR status remained significant after further adjustment for patients' age, fibrosis staging, and viral genotype (OR 2.15, 95% CI 1.16-4.68, P = 0.019). Distributions of allele frequencies at the locus rs12979860-IL28B among the study cohort and the underlying general population were suggestive of a protective effect of CC genotype in acquiring chronic hepatitis C in the Croatian IVDU population. DISCUSSION: The rs1800795-IL6 polymorphism is associated with positive response to treatment in IVDU patients positive for HCV infection. A protective role of rs12979860-IL28B CC genotype in acquiring chronic hepatitis C is suggested for Croatian IVDU population.

Bus water storage tank as a reservoir of Legionella pneumophila.

Health concerns associated with Legionnaires' disease have been identified as an area of the increasing public and professional interest. Any natural water or man-made water systems worldwide might be reservoirs of Legionellae. We presented a sporadic, community-acquired case of Legionnaires' disease caused by Legionellapneumophila serogroup 1 in a bus driver who used water for hand and face washing from a bus water storage tank. The history of any other usual place of exposure to Legionellae was negative. The water from the tank was dirty, filled with sediment and leaves, at the temperature of 22 degrees C. The water was heavily contaminated with Legionella pneumophila serogroup 1 isolated from each sample with the concentration of 66,000, 16,000, 42,000, 56,000 and 34,000 CFU/L. The disinfection of the bus water storage tank was made using hyperclorination with 50 mg/L of free residual chlorine. The control sampling one week after the disinfection yielded negative results. So far, there are no recommendations on regular management or disinfection of water in bus storage tanks, but it seems to be reasonable to assume that passengers as well as bus drivers may be exposed to Legionella and therefore at risk of acquiring the infection. These recommendations should include regular empting, rinsing and filling the tank with fresh tap water, at least once a week. Finally, we have to be aware that Legionella bacteria are ubiquitous and any potential mode of producing contaminated aerosol should not be overlooked during an epidemiological field investigation and proposed appropriate measures.

[Viralhepatitis. Croatian Consensus Statement 2013]. / Virusni hepatitis. Hrvatska konsenzus konferencija 2013.

Croatian Consensus Conferences on Viral Hepatitis took place in 2005 and 2009. Considering the numerous novel concepts on the epidemiology, diagnosis and management of viral hepatitis (chronic hepatitis C genotype 1 in particular) that have emerged in the past four years, a new Croatian Consensus Conference on Viral Hepatitis was held in Zagreb on February 28, 2013. The abridged text of the Croatian Consensus Conference on Viral Hepatitis 2013 presents the new concepts on the epidemiology of viral hepatitis, serologic and molecular diagnosis of viral hepatitis, determination of the IL-28 gene promoter polymorphism, fibrosis grading, algorithm for patient diagnostic follow up, treatment of chronic hepatitis C (genotypes 1-6) and hepatitis B, treatment of special populations (children, dialysis patients, transplanted patients, individuals with HIV/HCV co-infection), and therapy side effects.

[Hepatitis B: who should be treated?]. / Hepatitis B: koga lijeciti?

Currently, therapy for hepatitis B has a limited effect and can rarely eradicate infection (ALT normalization, undetectable HBV DNA, HBsAg/anti-HBs seroconversion). Minimal progress in terms of treatment success has been achieved in the past four years. Changes from the previous Croatian Consensus Conferences in 2005 and 2009 are based on standings of the Consensus Conference of the American Association for the Study of Liver Disease (AASLD) 2009, Consensus Conference of the European Association for the Study of Liver (EASL) 2012, and Asia-Pacific Association Guidelines for the Study of Liver (APASL) 2012. In this paper, we will mention only differences in relation to the before mentioned Croatian guidelines from 2005 and 2009. New developments relating to the application of noninvasive methods for assessing fibrosis, quantification of HBsAg to predict treatment outcome, registration of new drugs, and some new recommendations for more efficient and rational treatment will be reviewed. New findings as well as recommendations for the treatment of patients in special circumstances including treatment of pregnant women, patients with drug resistance, patients with co-infection, hepatic decompensation, patients on immune and chemotherapy, patients after liver transplantation, and patients with HCC will also be included.

[Hepatitis C: who should be treated?]. / Hepatitis C: koga lijeciti?

Therapy is strongly recommended in patients with acute infection, patients with elevated ALT levels, patients with normal ALT level and F > or = 2 METAVIR score, in genotype 1 nonresponders and relapsers to antiviral therapy with triple therapy (pegylated interferon, ribavirin, bocaprevir or telaprevir), in patients with compensated cirrhosis and patients on hemodialysis. It is possible to treat patients with HBV and HIV co-infection, patients with severe HCV extrahepatic manifestations and patients with transplanted liver. Drug users and alcoholics can be treated after 6-month abstinence, but also with supportive therapy. This therapy is not recommended in patients with fulminant hepatitis, patients with persistent normal ALT levels and without fibrosis, in kidney transplant recipients and in pregnant women.

Evidence of an autochthonous Toscana virus strain in Croatia.

BACKGROUND: Phleboviruses are large and widespread group of viruses that are transmitted by arthropods and they have been reported to circulate in endemic regions of Mediterranean Basin, including Croatia. OBJECTIVES: To investigate the role of Toscana virus, as a cause of the aseptic meningitis, in summer months in Croatia. STUDY DESIGN: Samples from 30 patients with aseptic meningitis were retrospectively tested by serology and RT-PCR for TOSV. RESULTS: TOSV RNA was detected in 2/30 and TOSV IgM antibodies were found in 4/30 of patients. Phylogenetic analysis of partial L and S segments suggests that TOSV from Croatia represents an autochthonous strain. CONCLUSIONS: The study has confirmed the role of TOSV as an agent that causes aseptic meningitis in Croatia, therefore it should be considered by physicians when encountering meningitis or febrile illness among indigenous population or travellers during the summer months.

Cystic echinococcosis of lung and heart coupled with repeated echinococcosis of brain--a case report.

Echinococcosis is rarely encountered as a cystic brain disease. In this article we are presenting a case of a young woman repeatedly operated due to echinococcosis of lung, heart and brain. Recurrent brain ecchinococcosis developed despite preoperative and postoperative albendazol therapy after first and combined therapy with albendazol and praziquantel after the second brain surgery. The mechanism of recurrence remains unclear (primary infestation, dissemination after spontaneous or intraoperative cyst rupture or new infestation).

In search of a Croatian model of nursing education.

AIM: To analyze the present status and ongoing reforms of nursing education in Europe, to compare it with the situation in Croatia, and to propose a new educational model that corresponds to the needs of the Croatian health care system. METHODS: The literature on contemporary nursing education in Europe and North America was reviewed, together with European Commission directives and regulations, as well as pertinent World Health Organization documents. In addition, 20 recent annual reports from 2003-2009, submitted by national nursing associations to the Workgroup of European Nurse Researchers (WERN), were studied. RESULTS: After appraisal of current trends, the Working Group on Reform of Nursing Education drafted The Croatian Model for Education in Nursing and developed a three-cycle curriculum with syllabus. The proposed curriculum is radically different from traditional ones. Responding to modern demands, it focuses on outcomes (developing competencies) and is evidence-based. CONCLUSIONS: A new, Croatian concept of nursing education is presented that is concordant with reforms in nursing education in other European countries. It holds promise for making nursing education an integral part of a unified European system of higher education.

Rickettsia hoogstraalii sp. nov., isolated from hard- and soft-bodied ticks.

A novel spotted fever group Rickettsia was found in Haemaphysalis sulcata ticks collected from sheep and goats in Croatia in 2006. At the same time, a genetically identical organism was co-isolated with the embryonic cell line CCE3 obtained from the soft tick Carios capensis in Georgia, USA. In this study, further phenotypic and genotypic characteristics of the novel rickettsial strain present in H. sulcata ticks were investigated. Based on the cultivation of bacteria in mosquito and Vero cell cultures, the presence of rickettsiae in tick tissues and cell cultures [confirmed by transmission electron microscopy (TEM)] and the amplification and sequencing of five rickettsial genes, it was demonstrated that the novel Rickettsia strain fulfils the criteria to be classified as a novel species. The name Rickettsia hoogstraalii sp. nov. is proposed for the new strain. Rickettsia hoogstraalii sp. nov., an obligately intracellular bacterium, was grown in Vero cells and arthropod CCE3, ISE6 and C6/36 cell lines. The morphology of the cells of the novel species was typical of SFG rickettsiae. The small coccobacillary appearance of the bacteria was apparent with light microscopy. A Gram-negative bacterial cell wall and a cytoplasmic membrane separated by a narrow periplasmic space were visible by TEM. To date, Rickettsia hoogstraalii sp. nov. has been isolated from two species of ticks, H. sulcata and C. capensis. The novel species appears to be geographically widely distributed, having been detected in Croatia, Spain and Georgia, USA. Although no information is available regarding the possible pathogenicity of the novel species for vertebrate hosts, R. hoogstraalii sp. nov. has a cytopathic effect in Vero, CCE3 and ISE6 cells. Sequence analyses of the 16S rRNA, 17 kDa, gltA, ompA and ompB genes indicated that even though R. hoogstraalii sp. nov. was closely related to Rickettsia felis, it represents a separate species within the spotted fever group. The type strain of R. hoogstraalii sp. nov. is strain Croatica(T) (=DSM 22243(T)=UTMB 00003(T)).

[Viral hepatitis. Croatian consensus conference--2009]. / Virusni hepatitis. Hrvatska konsenzus konferencija 2009.

Summarized text of Croatian Consensus Conference on Viral Hepatitis of 2009 comprises the following chapters: 1) Epidemiology, 2) Clinical Picture, 3) Diagnostic Procedure, 4) Aims of Treatment of Viral Hepatitis, 5) Terminology, 6) Medicaments (6.1. Interferon, 6.2. Analogues of Nucleozides and Nucleotides), 7) Hepatitis B (7.1. Serologic and Molecular HBV Diagnostics, 7.2. Terminology, 7.3.Whom to Treat? 7.4. Therapy), 8) Hepatitis C (8.1. Serologic and Molecular HCV Diagnostics, 8.2. Terminology, 8.3. Whom to Treat? 8.4. Therapy). Clinical, laboratory and histologic assessment of patients with chronic viral hepatitis (algorythm of pretherapeutic treatment; histologic evaluation) and notions related to therapy of viral hepatitis (category of the patient and category of the response to treatment) are presented in related tables.

[Hepatitis B: who should be treated?]. / Hepatitis B: koga lijeciti?

Current therapy for hepatitis B has a limited effect and can rarely eradicate viral infection (normalization of ALT, nullification of HBV DNA, or seroconversion of HBsAg to anti-HBs). Progress in hepatitis B therapy over the last 5 years did not have much influence in this segment. Modifications in therapeutic indications for both acute and chronic hepatitis B presented below are based on standings of the Consensus Conference of the American National Institutes of Health (NIH) from 2008, Canadian Consensus Conference from 2007, and Consensus Conference of the European Association for the Study of the Liver (EASL) from 2009. It seemed appropriate to retain the division of treatable patients in 3 groups: 1) patients in whom therapy is indicated; 2) patients in whom therapy may be indicated; and 3) patients in whom immediate therapy is not routinely indicated, as stated in the guidelines of the 2002 EASL Consensus Conference, 2004 Croatian Consensus Conference and 2008 NIH Consensus Conference.

[Hepatitis C--who should be treated?]. / Hepatitis C--koga lijeciti?

All patients with hepatitis C virus (HCV) infection should be considered as candidates for antiviral therapy. In order to make decision whom to treat, it is necessary to evaluate the following parameters: stage of disease, comorbidity, patient age, contraindications and therapy risks. Therapy is strongly recommended in patients with acute infection, with elevated ALT levels, with normal ALT level and F > or = 2 METAVIR score, in non-responders to standard interferon monotherapy, in relapsers to antiviral therapy, in patients with compensated cirrhosis, and in hemodialysis patients. It is possible to treat patients with persistent normal ALT levels and without fibrosis, patients with HBV and HIV co-infection, patients with severe extrahepatic manifestations of HCV infection, and patients with liver transplant. Drug addicts and alcoholics can be treated after 6 months of abstinence, but also with supportive therapy. Therapy is not recommended in patients with fulminant hepatitis, kidney transplant recipients and pregnant women.

Snakebites in Mostar region, Bosnia and Herzegovina.

The aim of this study was to provide an overview of the snakebites in patients hospitalized at the Mostar Clinical Hospital, admitted between 1983 and 2006. A total of 341 patients were recorded, with moderate men predominance (52.8%). Majority of patients were bitten for the first time (99.1%). In 98.8% of patients snakebite occurred to the bare skin, most commonly during June to September period (64.2%). Snakebites were the commonest in agricultural workers (48.1%). Until 2003 all admitted patients were treated according to Russel's scheme (3-anti). As of 2003 new treatment scheme was applied, resulting in the reduction of antidote and supportive treatment use, causing a reduction in the number of clinically apparent allergic reactions. Serum sickness was recorded in only 2 patients, while lethal outcome was recorded in one (0.3%). Overall results indicate that lethality of snakebite is low, and that patients were often administered treatment without medical indication. High number of tourists as well as the presence of the peace keeping troops and other visiting personnel in this region make the snakebites and awareness on snakes not only a local issue, but also more general concern.

Hla-Cw7 allele as predictor of favorable therapeutic response to interferon-alpha in patients with chronic hepatitis C.

AIM: To evaluate the association between human leukocyte antigens (HLA) class I and therapeutic response to interferon-alpha in Croatian patients with chronic hepatitis C. METHODS: HLA-A, -B, and -C genotyping was performed in 55 patients with sustained virological response and in 57 patients without sustained virological response to interferon-alpha therapy. Patients were treated in the period from 1998-2001 with interferon-alpha at a dose of 3 million units three times a week. Patients who became negative for hepatitis C virus RNA after 12 weeks of therapy completed 48 weeks of therapy. RESULTS: There was no association between therapeutic outcome and frequency of HLA-A, as well as of HLA-B alleles. HLA-Cw7 was significantly more frequent in patients with than those without sustained virological response (27.0% vs 6.7%; P=0.011). CONCLUSION: In Croatian patients with chronic hepatitis C, HLA-Cw7 is the predictor of sustained virological response to interferon-alpha therapy.

War-associated cases of typhoid fever imported to Split-Dalmatia County (Croatia).

OBJECTIVE: The goal was to investigate the number and origin of typhoid fever cases in Split-Dalmatia County, Croatia, during the period of 1970-2005. METHODS: Data from the medical records of typhoid fever cases treated at the University Hospital during the 35-year period were analyzed. Cases were defined as those in which Salmonella typhi was isolated from blood and/or stool. All isolates were tested for susceptibility to antimicrobial agents. RESULTS: A total of 45 cases were identified. Forty-four patients originated from Bosnia and Herzegovina, and all of their isolates were susceptible to all antimicrobial agents tested. One patient from Pakistan was infected with multidrug-resistant S. typhi. No autochthonous case of typhoid fever was identified. CONCLUSION: All cases of typhoid fever were acquired in countries where typhoid fever is endemic, and their importation to Croatia was the result of war-associated population movements. Increased awareness of health care workers regarding persons who originated from or have traveled to a typhoid-endemic area is needed. To avoid treatment failure, particular attention should be given to persons coming from regions with a known presence of multidrug-resistant S. typhi.

Chronic fatigue syndrome after Q fever.

BACKGROUND: Q fever is a common and acute but rare chronic zoonosis caused by Coxiella burnetii. Its acute form manifests as atypical pneumonia, flu-like syndrome, or hepatitis. Some authors observed symptoms of chronic fatigue in a small number of patients after the acute phase of Q fever; in many cases serological assay confirmed the activity of Coxiella burnetii infection. The effect of antibiotic therapy on post-Q-fever fatigue syndrome has not been studied in south-east Europe thus far. CASE REPORTS: Three patients are presented with post-Q-fever fatigue syndrome. All fulfilled the CDC criteria for chronic fatigue syndrome. IgA antibodies to phase I of the growth cycle of Coxiella burnetii were positive in two patients and negative in one. Two patients were treated with doxycycline for two weeks in the acute phase of illness and one with a combination of erythromycin and gentamycin. After 4-12 months they developed post-Q-fever fatigue syndrome and were treated with intracellular active antibiotics (fluoroquinolones and tetracycline) for 3-12 months. Efficacy of the treatment was observed in two patients, but in one patient the results were not encouraging. CONCLUSIONS: These results suggest the possibility of the involvement of Coxiella burnetii infection in the evolution of chronic fatigue syndrome. This is the first report on post-Q-fever fatigue syndrome in Mediterranean countries. Evidence of IgA antibodies to phase I of the growth cycle of Coxiella burnetii is not a prerequisite for establishing a diagnosis of CFS. The recommendation of antibiotic treatment in post-Q-fever fatigue syndrome requires further investigation.

Molecular identification of Rickettsia felis-like bacteria in Haemaphysalis sulcata ticks collected from domestic animals in southern Croatia.

Haemaphysalis sulcata ticks collected from sheep and goats in southern Croatia were found infected with rickettsiae. Molecular analysis of the complete gltA gene and portion of 17 kDa and ompB genes revealed the presence of Rickettsia felis-like bacteria in up to 26% of tested ticks.

Venomous snakebites in southern Croatia.

This retrospective study is based on the analysis of 542 snakebite envenomation cases in southern Croatia, which were treated in the University Hospital Split over the period of 21 years. The aim of this study was to determine the incidence of venomous snakebite in southern Croatia, epidemiological and clinical features of snakebite and treatment in the region. The mean annual snakebite incidence in southern Croatia was 5.2 per 100,000 inhabitants. The nose- horned viper (Vipera ammodytes) was responsible for most bites, only a small proportion being inflicted by the adder (Vipera berus). People of all ages were affected (1 - 82 year old), but the bites were more frequent in individuals older than 50 (46% of the cases) and in children and adolescents 19 year old and younger (27% of the cases). Most snakebite accidents happened in warm spring and summer months, the highest number occurring in May (22%). A majority of the victims were rural people engaged in agricultural activities. Bites on the upper limbs were more frequent (57%) than bites on the lower limbs (42%). With regard to envenomation severity, there were 15.1% minor, 40.5% mild, 26% moderate and 18% severe cases. Two victims died (0.4%). The antivenom produced by the Institute of Immunology in Zagreb was given to virtually all patients, and complications following its administration were rare. The antivenom was used more often than it was suggested by the symptoms present.

Clinical and epidemiological features of hospitalized acute Q fever cases from Split-Dalmatia County (Croatia), 1985-2002.

BACKGROUND: Q fever shows a wide diversity of clinical manifestation. Q fever is endemic in northern Croatia, but the epidemiological and clinical characteristics of this disease in various ecological areas of southern Croatia are unclear. MATERIAL/METHODS: From January 1985 to December 2002, acute Q fever cases hospitalized at Split University Hospital were analyzed. Acute Q fever was defined as fever (>38 degrees C) with clinical findings in lung and/or liver verified by serologic testing with Coxiella burnetii phase II antigen. RESULTS: During the period of observation, 155 acute Q fever cases were hospitalized. The mean incidence of acute Q fever in the study region was 0.20/100,000/year (95%CI:0-0.78) in the coastal area and 4.64/100,000/year (95%CI:0.44-8.85) in the non-coastal areas, with a male predominance (chi2=60.0; p=0.0000) and a mean male to female ratio of 4.2:1. People of essentially all ages (4-76 years) were affected, the highest rate of infection being recorded in 20- to 49-year-old age groups. In contrast to adults, girls were more frequently affected than boys (2:1). No case of acute Q fever was recorded on any of the nearby islands. Clinically, acute Q fever most commonly presented with both pneumonia and hepatitis (60.0%), followed by pneumonia (25.8%), hepatitis (9.0%), and nonspecific febrile illnesses (5.2%). CONCLUSIONS: C. burnetii is endemic in rural, coastal, and non-coastal areas of southern Croatia and is associated with stock breeding. In these areas, Q fever occurs sporadically and epidemically. Males 20-49 years of age were the prevalent cases.

Distribution of hepatitis C virus genotypes in Croatia--a 10 year retrospective study of four geographic regions.

The aim of this 10-year retrospective study was to investigate the distribution of HCV genotypes in patients with chronic hepatitis C monitored in the largest center for molecular diagnostics of HCV infection in Croatia. The study enrolled 1163 anti-HCV positive adults with detectable HCV RNA in the plasma. The patients were classified in four regions: Zagreb and surrounding continental area, Split, Slavonija and Rijeka. HCV genotyping was performed by using VERSANT HCV Genotyping Assay (LIPA) (Bayer Diagnostics, Puteaux Cedex, France). Statistical analysis was performed by using Statistica for Windows V.5.1. The majority of HCV infections in the study population were caused by genotypes 1 (58.8% of infected patients) and 3 (35.6%). Percentages of patients infected with subtypes 1b and 1a were 37.4% and 13.1%, respectively. Genotypes 2 and 4 were present in a very low percentage of patients (2.2% and 3.4%, respectively) while genotypes 5 and 6 were not detected. Analysis of regional differences in the distribution of HCV genotypes revealed similar percentages of subtype 3a and 1b infections in the Split region while the majority of infections in other regions were caused by subtype 1b. Infections with genotypes 2 and 4 were present in less than 5% of patients in all geographic regions. Analysis of an association between risk factors for infection and distribution of genotypes and subtypes in a subset of patients from the Split region confirmed the association between IVDU and subtype 3a. We conclude that the prevalence of HCV genotypes and subtypes follows the pattern of other Southern and Eastern European Countries with the predominance of subtypes 1b, 3a and 1a.