Prenatal antibiotic exposure increases the risk of infant atopic dermatitis: data from a Greek cohort.

Summary: Background. The human microbiome is important due to the impact it has on host immunologic development and allergy-associated diseases. This study aimed to investigate the impact of prenatal exposure to antibiotics on the incidence of atopic dermatitis (AD) in children at 18 months of age. Methods. Mothers were interviewed at baseline, in the maternity ward and by phone questionnaire after 18 months. Demographic data, mode of delivery, yoghurt consumption, antibiotic and other drug use during pregnancy, atopic history, diagnosis of AD and history of infections in the offspring were noted. Results. 385 mothers were interviewed at baseline. 231 (60%) mothers with 236 children responded at follow up. Cesarean section was reported in 116 (50.2%) deliveries while antibiotic use during pregnancy in 55/231 (23.8%) women. 43/236 (18.22%) infants were diagnosed with AD. Intravenous antibiotic use was associated with a 7.7 increased risk of AD diagnosis in the offspring (95%CI 1.23-48.27, p = 0.029). An increased odd for AD was recorded for mothers 30-40 years of age (OR 4.50, 95%CI 1.08-18.7, p = 0.039). No significant association between cesarean section and AD (p = 0.70) was recorded. In multivariate analysis, reported food allergy (OR 8.03, 95%CI 2.30-27.97, p = 0.001) and otitis media episodes in children (OR 3.76, 95%CI 1.60-8.83, p = 0.002) were significantly associated with AD diagnosis. Conclusions. An increased risk of AD was recorded only when antibiotics were given prenatally by intravenous route and in women between 30-40 years of age. Children with food allergy had an increased risk for AD. The relatively high percentage of cesarean sections was not a risk factor for AD.

Vaccination coverage of general practitioners: a cross-sectional study from Greece.

OBJECTIVES: Vaccination coverage of general practitioners (GPs) is important for their own and for their colleagues' and patients' protection and has been associated with the coverage of the general population. Our study aims to evaluate the vaccination practices of GPs in Crete, Greece. STUDY DESIGN: Cross-sectional, questionnaire-based survey. METHODS: All practicing GPs in Crete (n = 294) were surveyed either by questionnaires or by phone call. We assessed the vaccination coverage and practices for influenza, measles, hepatitis B, and pertussis (booster Tdap dose) and the reasons for nonvaccination for influenza. RESULTS: A total of 260 (88% response rate) GPs participated. Vaccination rates were 56% for influenza (current season), 26% for measles (two doses), 68% for hepatitis B (three doses), and 18% for the booster dose with Tdap. Negligence (47%) and perceived low risk (29.6%) were the most common reasons for nonvaccination for influenza. History of natural measles infection was reported by 169 (65%) GPs, but none of the interviewed 31 provided laboratory confirmation. GPs with self-reported natural measles infection were less vaccinated than their peers (10% vs 55%, P < 0.001). Finally, 23 of 130 (18%) GPs contacted by phone falsely reported vaccination with Tdap in their childhood, when Tdap was not yet available. CONCLUSION: This study revealed insufficient vaccination rates and misconceptions among GPs that should be the focus of future evidence-based interventions with potential to significantly improve vaccination coverage of GPs and indirectly of their patients.

Evaluating a 24-year tuberculosis screening in first-grade elementary schoolers in a low-burden area.

AIM: Early diagnosis of tuberculosis infection can significantly contribute to the control of the disease. The aim of the present study was to describe the tuberculin skin test (TST) trends over a 24-year period (1990-2013) and explore the value of universal tuberculosis screening in a low-burden area. METHODS: All first graders that underwent TST during the 24-year study period (1990-2013) on the island of Crete, Greece, were retrospectively included in the study. RESULTS: A total of 82 402 children (92.3% of Greek nationality; 51.0% male) underwent TST, of whom 335 (0.41%, 95% CI 0.37-0.46) were found to have positive TST while 0.27% of the study population had a TST between 5 and 9 mm. The tuberculin index declined significantly between 1990-1994 and 2010-2013 (0.67 vs 0.26; RR 2.73, 95% CI 1.82-4.09; p < 0.0001). Positive TST result was significantly higher in the immigrant than the native group (0.66% vs 0.24%; RR 3.76 95%, CI 2.89-4.84; p < 0.0001). In the last study years, 386 children (488 native; 153 immigrant) should be tested for one to be found TST positive. CONCLUSION: Our findings question the massive tuberculin testing in low-burden areas and point to selective screening of high-risk groups.

Incidence of childhood Type 1 diabetes mellitus in Crete.

AIM: To investigate the epidemiology of childhood Type 1 diabetes mellitus in Crete over the last 25 years and to evaluate incidence trends over time. METHODS: The study included all children aged 0-14 years who live in Crete and were diagnosed during the 25-year period from 1 January 1992 to 31 December 2016. RESULTS: A total of 271 children were diagnosed with Type 1 diabetes during the 25-year period: 148 boys and 123 girls (boy:girl ratio 1.2). The median (interquartile range) age at diagnosis was 8.3 (5.0-12.0) years for boys and 8.0 (5.3-11.3) years for girls. The standardized annual incidence rate was 10.5 per 100 000 children (95% CI 9.2 to 11.8). Incidence rates were higher in children aged 5-9 years. During the 25-year study period an average 4.4% annual increase in incidence was documented and was most prominent in the age group 5-14 years. Incidence seemed to remain relatively stable for the age group 0-4 years in the last decade. No seasonality of the clinical onset of Type 1 diabetes was observed. CONCLUSIONS: The recent increase in Type 1 diabetes incidence places Crete among regions with high incidence as per the World Health Organization DiaMond project classification. The rising trends in incidence confirmed by this study are in accordance with the reported global trends in Type 1 diabetes incidence.

Ethics of mandatory vaccination for healthcare workers.

Healthcare workers (HCWs) are at increased risk of contracting infections at work and further transmitting them to colleagues and patients. Immune HCWs would be protected themselves and act as a barrier against the spread of infections and maintain healthcare delivery during outbreaks, but vaccine uptake rates in HCWs have often been low. In order to achieve adequate immunisation rates in HCWs, mandatory vaccination policies are occasionally implemented by healthcare authorities, but such policies have raised considerable controversy. Here we review the background of this debate, analyse arguments for and against mandatory vaccination policies, and consider the principles and virtues of clinical, professional, institutional and public health ethics. We conclude that there is a moral imperative for HCWs to be immune and for healthcare institutions to ensure HCW vaccination, in particular for those working in settings with high-risk groups of patients. If voluntary uptake of vaccination by HCWs is not optimal, patients' welfare, public health and also the HCW's own health interests should outweigh concerns about individual autonomy: fair mandatory vaccination policies for HCWs might be acceptable. Differences in diseases, patient and HCW groups at risk and available vaccines should be taken into consideration when adopting the optimal policy.

Pseudomonas aeruginosa urinary tract infection in children: risk factors and outcomes.

PURPOSE: Pseudomonas aeruginosa is an unusual uropathogen that is mostly responsible for nosocomial or catheter associated urinary tract infections in adults. Data about P. aeruginosa urinary tract infections in children are scarce. We investigated P. aeruginosa urinary tract infections in children in a well-defined area. MATERIALS AND METHODS: Clinical, laboratory and radiological characteristics of all children with P. aeruginosa urinary tract infections were compared to those of gender matched children with community acquired Escherichia coli urinary tract infections during a 12-year period. RESULTS: A total of 35 children with 43 P. aeruginosa urinary tract infection episodes representing 6.7% of total urinary tract infection cases during the study period were compared to 70 children with E. coli urinary tract infections. Children with P. aeruginosa more often presented with a history of at least 1 previous urinary tract infection episode (p <0.0001), hospitalization (p = 0.0001), use of antibiotics (p = 0.0001), malformations predisposing to urinary tract infections (p = 0.004), vesicoureteral reflux (p <0.0001), abnormal dimercapto-succinic acid scan (p = 0.0003), longer hospitalization and surgery. Use of antibiotics either as prophylaxis or as treatment within the preceding 2 months was demonstrated by multivariate logistic regression analysis as the single independent risk factor for P. aeruginosa urinary tract infections (odds ratio 21.6, 95% CI 4.65-100, p = 0.0001). P. aeruginosa isolates were often resistant to gentamicin (27.9%) and ceftazidime (13.9%) but remained sensitive to carbapenems and ciprofloxacin. CONCLUSIONS: P. aeruginosa urinary tract infection is associated with distinct risk factors and outcomes, and should be considered in predisposed children with symptoms of urinary tract infection who are on prophylaxis or have a history of a recent course of antibiotics.

Long-term trends in the epidemiology and resistance of childhood bacterial enteropathogens in Crete.

In this study, we investigated the long-term trends in the epidemiology and susceptibility of bacterial enteropathogens among children in a well-defined area of adequate health standards. The study included all children younger than 14 years of age treated for enteritis at Heraklion University General Hospital on the island of Crete during the 18-year period from January 1993 to December 2010. Stool specimens were tested for Salmonella, Shigella, Campylobacter, enteropathogenic Escherichia coli (EPEC), Yersinia, and Aeromonas species. Of the 33,032 stool samples from patients of any age, 2,912 (8.82%) were positive for bacterial enteropathogens. The 1,597 isolates from children were identified as S. enterica (42.3%), Campylobacter spp. (33.6%), EPEC (17.4%), Y. enterocolitica (5.82%), A. hydrophila (0.44%), and Shigella spp. (0.38%). A decline in prevalence was observed for all bacterial enteropathogens. Taken as a total, enteropathogens were susceptible to gentamicin, ceftriaxone, ciprofloxacin, co-trimoxazole, and amoxicillin in 98.8%, 88.0%, 83.0%, 67.1%, and 59.6%, respectively. During the study period, the susceptibility rates decreased for co-trimoxazole (p<0.0001) and ciprofloxacin (p<0.001), and increased for amoxicillin (p<0.0001). Our findings suggest declining long-term trends in the prevalence of bacterial enteropathogens and changes in susceptibility rates to first-line antibacterial agents. These changing trends in the long-term morbidity and susceptibility call for ongoing surveillance and tailored management.

Infant colonization by Staphylococcus aureus: role of maternal carriage.

Infant colonization by Staphylococcus aureus has not been adequately investigated. In this study, we aimed to define determinants associated with the carriage of S. aureus in early infancy. Serial nasal swabs were collected from 128 infants and their mothers at months 0, 6, and 12 postpartum. S. aureus isolates were characterized by pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), spa typing, and the presence of chromosomal mecA and of Panton-Valentine leukocidin (PVL) genes. S. aureus was isolated in 17.7% and 15.7% of swabs from infants and mothers, respectively. Carriage rates were higher in infants with carrier mothers, non-smoking mothers, and many siblings. Persistent carriage rates were higher in infants with carrier or non-smoking mothers. S. aureus typing revealed identical strains in 10/15 investigated infant-mother pairs. Among 19 investigated S. aureus isolates from infants, ten harbored mecA and two harbored PVL genes, and these determinants were concomitantly present in isolates from mothers. Resistance to methicillin was 43.6% among all isolates from infants. In conclusion, isolates from infants were commonly identical to isolates from their mothers, pointing to a principal role of maternal carriage in S. aureus colonization in infants.

Hepatitis B virus acquisition and pathogenesis in childhood: host genetic determinants.

The clinical course of hepatitis B virus (HBV) infection varies from spontaneous recovery to chronic persistent infection leading to severe liver injury. Mounting evidence has recently highlighted the influence of host genotype in the complex interplay between viral and host factors. Studies in adults have suggested the existence of a genetic predisposition to HBV infection secondary to certain defects in the host response. These defects include opsonic deficiency, compromised antigen processing and presentation by human leucocyte antigen variations, attenuated T- and B-cell response, impaired cytokine and chemokine release, and production of receptors for several pertinent factors such as vitamin D and estrogen. By contrast, little is known about the genetic factors involved in the susceptibility to HBV transmission in early childhood. Herein, we review the literature regarding the association between host genetics and susceptibility to primary HBV infection, and we discuss the prospects of investigation in this field. A better understanding of HBV infection immunopathogenesis in the critical period of infancy may allow the development of optimal and innovative prevention and treatment.

Serotypes and susceptibilities of paediatric clinical isolates of Streptococcus pneumoniae in Crete, Greece, before and after the heptavalent pneumococcal conjugate vaccine.

All Streptococcus pneumoniae strains isolated from paediatric clinical samples at Heraklion University General Hospital in the 10-year period 2000-2009 were tested for serotype and susceptibility to antimicrobials. Among a total of 258 strains, 159 were isolated in the 5-year period 2000-2004, before the introduction of the heptavalent pneumococcal conjugate vaccine (PCV7), and 99 in the post-PCV7 5-year period 2005-2009. The prevalence of PCV7-included serotypes decreased in the post-PCV7 period (p = 0.0002), but an increase was observed for serotypes 7F (p = 0.002) and 19A (p = 0.004). Pan-susceptibility rates and susceptibility to cotrimoxazole increased in the post-PCV7 period (p = 0.01 and p = 0.008, respectively), but serotype 19A emerged as a contributor to multi-resistance (p = 0.007). PCV7 was followed by decreased S. pneumoniae resistance and prevalence of vaccine-related serotypes but increased prevalence of serotypes 7F and 19A. Continuing surveillance is required after the recent introduction of PCV10 and PCV13.

Polymorphisms of the TNF-alpha and ACE genes, and renal scarring in infants with urinary tract infection.

PURPOSE: Susceptibility to renal scarring is increasingly investigated through polymorphisms of genes regulating inflammation and fibrosis. TNF-alpha and ACE gene polymorphisms have been studied in chronic renal conditions but their role in urinary tract infection and vesicoureteral reflux associated renal scarring is unclear. We investigated the relationship between TNF-alpha A/G and ACE I/D polymorphisms, and renal scarring after urinary tract infection in infants. MATERIALS AND METHODS: ACE I/D and TNF-alpha -308 A/G polymorphisms were investigated with restriction fragment length polymorphism analysis in 39 boys and 25 girls with a first urinary tract infection before age 2 years and in 77 controls. Genotype and allele frequencies were compared among children with urinary tract infection with and without renal scarring, and controls. RESULTS: ACE I/D genotype frequencies were similar among infants with urinary tract infection with and without renal scarring, and controls. However, all 6 children with severe renal scarring and impaired renal function bore a D allele, 5 of which were DD homozygotes. D allele was more common in these severely affected children than in their peers with urinary tract infection and mild or no renal scarring (OR 9.92, 95% CI 1.24-79, p = 0.012), and controls (OR 8.03, 95% CI 1.01-64, p = 0.029). No differences were observed in TNF-alpha A/G genotype frequencies among the 3 groups. Presence of vesicoureteral reflux was not related to phenotypes or allele frequencies. CONCLUSIONS: Our findings suggest that D allele polymorphism of the ACE gene is associated with urinary tract infection related severe renal scarring in young children.

A Chryseobacterium meningosepticum colonization outbreak in a neonatal intensive care unit.

PURPOSE: To report the epidemiologic, bacteriologic, and clinical features of a Chryseobacterium meningosepticum outbreak in a neonatal intensive care unit (NICU) of a referral teaching hospital. PATIENTS AND METHODS: From April to October 2002, a strain of C. meningosepticum was isolated from four neonates in the NICU. All neonates were colonized in the endotracheal tubes and respiratory secretions, but none of them progressed to clinical infection. Multiple samples were obtained for cultures. RESULTS: Pulsed-field gel electrophoresis (PFGE) of isolates showed them to be representatives of a single strain. Environmental surveillance did not reveal the C. meningosepticum source. None of the neonates received specific treatment. The outbreak was only controlled by reinforcement of the usual measures and no additional colonization/infection was confirmed for more than a year after the last case. CONCLUSION: This study suggests that C. meningosepticum colonization in neonates does not necessarily lead to infection and that such colonization outbreaks may be controlled with emphasis on the standard precautions.

Intron 4 polymorphism of the endothelial nitric oxide synthase eNOS gene and early microangiopathy in type 1 diabetes.

Nitric oxide (NO) is an endogenous vasodilator involved in inflammatory and autoimmune response, and in the pathophysiology of diabetic vascular disease. Endothelium-derived NO is formed from L-arginine by endothelial NO synthase (eNOS), and earlier studies have provided evidence for altered NO metabolism and impaired endothelial function in diabetes, probably due to polymorphisms in eNOS gene. In the present study we investigated the association of the eNOS gene intron 4 a/b VNTR polymorphism with diabetic microangiopathy in 61 young individuals with type 1 diabetes (T1D), 35 male and 26 female, aged 5.0-29.1 (mean 15.6) years, and followed up for 3.24-11.4 (mean 7.44) years. Ten patients (16.4%) had developed microalbuminuria, three hypertension and two retinopathy. Wild-type b/b homozygosity for eNOS gene intron 4 VNTR was found in 37 (60.7%) and a/b polymorphism in 24 (39.3%). No significant relationship was demonstrated between eNOS gene intron 4 polymorphisms and microalbuminuria, hypertension or retinopathy in these young individuals. Our findings suggest that a/b polymorphism of the intron 4 eNOS gene is not associated with early onset diabetic microangiopathy.

Environmental tobacco smoke exposure as a risk factor for infections in infancy.

AIM: This prospective observational study investigated the effect of environmental tobacco smoke (ETS) on frequency and severity of common infantile infections. METHODS: In a representative sample of 926 infants, parental smoking was recorded at months 1 and 9 postpartum, and all infantile infectious episodes were recorded at 1, 3, 6, 9 and 12 months postpartum. RESULTS: Both parents were regular smokers all through the first year in 107 (11.6%), at least one smoked regularly or occasionally in 492 (53.1%), and parents did not smoke at all in 327 (35.3%) families. Among mothers, 168 (18.1%) smoked perinatally. Infantile ETS exposure was associated with increased frequency of total infectious episodes (p = 0.025) and hospitalizations for infection (p = 0.007). In ETS exposed infants, birth in autumn and presence of siblings contributed to increased frequency of most infections and of hospital admissions for infection. By contrast, exclusive breastfeeding protected against the effect of ETS on total infantile infections (OR 0.982, 95% CI 0.965-0.999; p = 0.036), hospital admissions for infection (OR 0.980, 95% CI 0.961-0.999; p = 0.036) and thrush (OR 0.973, 95% CI 0.951-0.996; p = 0.022). CONCLUSION: Our findings point to harmful effect of ETS on infantile health and further suggest that this effect may be enhanced or diminished by other factors. ETS should be regarded as a preventable risk factor for infections in infancy.

Familial Mediterranean Fever in Crete: a genetic and structural biological approach in a population of 'intermediate risk'.

Familial Mediterranean Fever (FMF) is an autosomal, recessively inherited disease, characterized by recurrent and short attacks of fever with serosal inflammation that are caused by mutations in MEFV gene that encodes pyrin protein. To date, more than 70 disease-associated mutations have been identified, almost all of them representing missense nucleotide changes. FMF is very common among patients with Mediterranean ancestry, although the exact prevalence is not yet known, Greeks are considered to be at 'intermediate risk'. In the present study, we studied FMF patients in natives of Crete, a population sharing a common genetic and cultural background. The spectrum of MEFV gene mutations in 71 patients as well as 158 healthy controls was studied by performing a molecular analysis focused on the 12 most frequent FMF-associated mutations. We found that 59 of 71 (83.1%) FMF patients had at least one MEFV mutation, five patients were homozygotes and 54 heterozygotes for FMF-associated mutations. No mutations were detected in 12 patients (16.9%). As in high-risk populations, common MEFV mutations were found in Cretan FMF patients, with the M694V being the most penetrant. M694V and M694I mutations were associated with severe phenotypes, with many patients presenting with uncommon clinical manifestations such as erysipelas-like erythema or renal disturbances. Of interest, 20 (37%) of our heterozygous FMF patients presented with a severe phenotype. Population genetics analysis showed an FMF carrier frequency in healthy Cretan population of approximately 6% (1:17) and places Cretans closer to the Western rather than Eastern populations of the Mediterranean basin. Finally, we constructed a three-dimensional model showing the interaction of the PRYSPRY domain of pyrin with caspase-1 onto which we mapped MEFV mutations, classified according to disease severity. In this model, the 'flexible loops' of caspase-1 appear to have no access to some positions that have been previously associated with mild disease, suggesting that alternative pathogenic pathways leading to FMF need to be explored.

Toxoplasmosis in pregnant women in Crete.

In Greece there are no official recommendations concerning the management of pregnant women for the prevention of congenital toxoplasmosis. A protocol for monitoring pregnant women was designed in order to differentiate between acute and latent toxoplasmosis and was tested successfully for 7 years. The maternofetal transmission rate in Crete was assessed and a map showing seroprevalence of pregnant women in all prefectures of Greece was prepared. The high seroprevalence of Toxoplasma gondii in Greece (up to 46% in some areas) may be explained by: (a) the presence of a great number of stray cats; (b) the Greek diet consisting of large amounts of raw, wild vegetables and salads that could easily be contaminated with oocysts; (c) the high consumption of meat, smoked pork and sausages, well-documented sources of T. gondii infection. T. gondii genotypes were characterized, directly from clinical samples, after PCR-RFLP on the SAG2 gene and sequence analysis at the restriction sites. They belonged to all 3 clonal lineages.

Early European attitudes towards "good death": Eugenios Voulgaris, Treatise on euthanasia, St Petersburg, 1804.

Eugenios Voulgaris (Corfu, Greece, 1716; St Petersburg, Russia, 1806) was an eminent theologian and scholar, and bishop of Kherson, Ukraine. He copiously wrote treatises in theology, philosophy and sciences, greatly influenced the development of modern Greek thought, and contributed to the perception of Western thought throughout the Eastern Christian world. In his Treatise on euthanasia (1804), Voulgaris tried to moderate the fear of death by exalting the power of faith and trust in the divine providence, and by presenting death as a universal necessity, a curative physician and a safe harbour. Voulgaris presented his views in the form of a consoling sermon, abundantly enriched with references to classical texts, the Bible and the Church Fathers, as well as to secular sources, including vital statistics from his contemporary England and France. Besides euthanasia, he introduced terms such as dysthanasia, etoimothanasia and prothanasia. The Treatise on euthanasia is one of the first books, if not the very first, devoted to euthanasia in modern European thought and a remarkable text for the study of the very early European attitudes towards "good death". In the Treatise, euthanasia is clearly meant as a spiritual preparation and reconciliation with dying rather than a physician-related mercy killing, as the term progressed to mean during the 19th and the 20th centuries. This early text is worthy of study not only for the historian of medical ethics or of religious ethics, but for everybody who is trying to courageously confront death, either in private or in professional settings.

Comparative effects of ertapenem, imipenem, and meropenem on the colonization of the gastrointestinal tract of mice by Candida albicans.

We evaluated the effect of three carbapenems on gut colonization of mice by Candida albicans. A total of 150 Crl:CD1 (ICR) BR mice were fed chow containing C. albicans or regular chow. Both groups were subsequently treated either with one carbapenem or with normal saline for 10 days. Stool cultures to determine colonization by C. albicans were performed immediately before, at the end, and one week after the end of treatment. Candida-colonized mice that received carbapenems had substantially higher C. albicans concentrations than control animals fed C. albicans, especially if they received ertapenem. Mice fed regular chow and treated with the study antibiotics or saline did not have Candida in their stools. Candida was not detected in the internal organs of any group of mice.

Hypertrophic pyloric stenosis in twins: same genes or same environments?

The aetiology of infantile hypertrophic pyloric stenosis (IHPS) remains obscure. Cases in twins, usually monozygotic, have been sporadically reported as evidence for the genetic origin of the disease. We present a case of IHPS in a pair of dizygotic male twins together with a review of the literature, focusing on the question of whether the twin cases actually support a genetic or an acquired nature of IHPS.