Prevalence of chronic HCV infection in EU/EEA countries in 2019 using multiparameter evidence synthesis.

Background: Epidemiological data are crucial to monitoring progress towards the 2030 Hepatitis C Virus (HCV) elimination targets. Our aim was to estimate the prevalence of chronic HCV infection (cHCV) in the European Union (EU)/European Economic Area (EEA) countries in 2019. Methods: Multi-parameter evidence synthesis (MPES) was used to produce national estimates of cHCV defined as: π = πrecρrec + πexρex + πnonρnon; πrec, πex, and πnon represent cHCV prevalence among recent people who inject drugs (PWID), ex-PWID, and non-PWID, respectively, while ρrec, ρex, and ρnon represent the proportions of these groups in the population. Information sources included the European Centre for Disease Prevention and Control (ECDC) national operational contact points (NCPs) and prevalence database, the European Monitoring Centre for Drugs and Drug Addiction databases, and the published literature. Findings: The cHCV prevalence in 29 of 30 EU/EEA countries in 2019 was 0.50% [95% Credible Interval (CrI): 0.46%, 0.55%]. The highest cHCV prevalence was observed in the eastern EU/EEA (0.88%; 95% CrI: 0.81%, 0.94%). At least 35.76% (95% CrI: 33.07%, 38.60%) of the overall cHCV prevalence in EU/EEA countries was associated with injecting drugs. Interpretation: Using MPES and collaborating with ECDC NCPs, we estimated the prevalence of cHCV in the EU/EEA to be low. Some areas experience higher cHCV prevalence while a third of prevalent cHCV infections was attributed to PWID. Further efforts are needed to scale up prevention measures and the diagnosis and treatment of infected individuals, especially in the east of the EU/EEA and among PWID. Funding: ECDC.

Hepatitis B in Healthcare Personnel: An Update on the Global Landscape.

Despite the outstanding progress that has been made in the prevention, detection, and management of hepatitis B during the past decades, hepatitis B remains a problem among healthcare personnel (HCP) in many countries. We reviewed studies on all aspects of hepatitis B in HCP published from 2017 through April 2023. They revealed wide variations on the prevalence of infection among HCP, ranging from 0.6% in Europe to >8.7% in Africa, almost always in association with very low vaccination rates. Many studies found a significant association between HCP's knowledge about hepatitis B and hepatitis B vaccines, their vaccination status, and practices. This research also discloses global inequities regarding vaccination policies against hepatitis B, free-of-charge vaccinations, and access to post-exposure prophylaxis (PEP). Strategies to prevent and manage accidental exposures are needed in order to reduce the burden of hepatitis B on HCP, while written policies for all aspects of infection prevention, protective equipment, and PEP should be available. Lastly, HCP should be accordingly educated. These are all imperative given the decline of routine vaccinations in the COVID-19 era, particularly in countries with fragile vaccination programs, and the disruptions of interventions for hepatitis B that are expected to provide a pool of virus transmission to future generations.

Cerebrospinal Fluid Anti-Neuronal Autoantibodies in COVID-19-Associated Limbic Encephalitis with Acute Cerebellar Ataxia and Myoclonus Syndrome: Case Report and Literature Review.

Since the outbreak of coronavirus (COVID-19) in 2019, various rare movement disorders and cognitive changes have been recognized as potential neurological complications. The early treatment of some of these allows rapid recovery; therefore, we must diagnose these manifestations in a timely way. We describe the case of a 76-year-old man infected with severe acute respiratory syndrome coronavirus-2 who presented with confusion and hallucinations and was admitted to our hospital 14 days after the onset of symptoms. One day later, he developed generalized myoclonus, dysarthria and ataxia, and tonic clonic seizures and was admitted to the intensive care unit. A diagnosis of COVID-19-associated autoimmune encephalitis with characteristics of limbic encephalitis and immune-mediated acute cerebellar ataxia and myoclonus syndrome was supported by alterations in the limbic system shown in magnetic resonance imaging, lateralized discharges shown in electroencephalography, a slightly elevated protein level in the cerebrospinal fluid (CSF), and indirect immunofluorescence in the CSF with autoantibody binding to anatomical structures of the cerebellum and hippocampus. The patient improved with 2 weeks of corticosteroid treatment and four sessions of plasmapheresis. Our current case study describes a rare case of COVID-19-related limbic encephalitis with immune-mediated acute cerebellar ataxia and myoclonus syndrome (ACAM syndrome) and strengthens the need for tissue-based assays (TBAs) to screen the serum and/or CSF of patients highly suspected to have autoimmune encephalitis. We believe that the timely diagnosis and targeted aggressive immunotherapy were mainly responsible for the patient's total recovery.

COVID-19 and Respiratory Virus Co-Infections: A Systematic Review of the Literature.

Τhe COVID-19 pandemic highly impacted the circulation, seasonality, and morbidity burden of several respiratory viruses. We reviewed published cases of SARS-CoV-2 and respiratory virus co-infections as of 12 April 2022. SARS-CoV-2 and influenza co-infections were reported almost exclusively during the first pandemic wave. It is possible that the overall incidence of SARS-CoV-2 co-infections is higher because of the paucity of co-testing for respiratory viruses during the first pandemic waves when mild cases might have been missed. Animal models indicate severe lung pathology and high fatality; nevertheless, the available literature is largely inconclusive regarding the clinical course and prognosis of co-infected patients. Animal models also indicate the importance of considering the sequence timing of each respiratory virus infection; however, there is no such information in reported human cases. Given the differences between 2020 and 2023 in terms of epidemiology and availability of vaccines and specific treatment against COVID-19, it is rational not to extrapolate these early findings to present times. It is expected that the characteristics of SARS-CoV-2 and respiratory virus co-infections will evolve in the upcoming seasons. Multiplex real-time PCR-based assays have been developed in the past two years and should be used to increase diagnostic and infection control capacity, and also for surveillance purposes. Given that COVID-19 and influenza share the same high-risk groups, it is essential that the latter get vaccinated against both viruses. Further studies are needed to elucidate how SARS-CoV-2 and respiratory virus co-infections will be shaped in the upcoming years, in terms of impact and prognosis.

Hepatitis of unknown aetiology in children - epidemiological overview of cases reported in Europe, 1 January to 16 June 2022.

Following the report of an excess in paediatric cases of severe acute hepatitis of unknown aetiology by the United Kingdom (UK) on 5 April 2022, 427 cases were reported from 20 countries in the World Health Organization European Region to the European Surveillance System TESSy from 1 January 2022 to 16 June 2022. Here, we analysed demographic, epidemiological, clinical and microbiological data available in TESSy. Of the reported cases, 77.3% were 5 years or younger and 53.5% had a positive test for adenovirus, 10.4% had a positive RT-PCR for SARS-CoV-2 and 10.3% were coinfected with both pathogens. Cases with adenovirus infections were significantly more likely to be admitted to intensive care or high-dependency units (OR = 2.11; 95% CI: 1.18-3.74) and transplanted (OR = 3.36; 95% CI: 1.19-9.55) than cases with a negative test result for adenovirus, but this was no longer observed when looking at this association separately between the UK and other countries. Aetiological studies are needed to ascertain if adenovirus plays a role in this possible emergence of hepatitis cases in children and, if confirmed, the mechanisms that could be involved.

A double-hit in vivo model of GBA viral microRNA-mediated downregulation and human alpha-synuclein overexpression demonstrates nigrostriatal degeneration.

Preclinical and clinical studies support a strong association between mutations in the GBA1 gene that encodes beta-glucocerebrosidase (GCase) (EC 3.2.1.45; glucosylceramidase beta) and Parkinson's disease (PD). Alpha-synuclein (AS), a key player in PD pathogenesis, and GBA1 mutations may independently and synergistically cause lysosomal dysfunction and thus, embody clinically well-validated targets of the neurodegenerative disease process in PD. However, in vivo models, recapitulating pathological features of PD that can be used to dissect the nature of the complex relationship between GCase and AS on the nigrostriatal axis, the region particularly vulnerable in PD, are direly needed. To address this, we implemented a bidirectional approach in mice to examine the effects of: 1) GCase overexpression (wild-type and mutant N370S GBA) on endogenous AS levels and 2) downregulation of endogenous GCase (Gba) combined with AS overexpression. Striatal delivery of viral-mediated GCase overexpression revealed minimal effects on cortical and nigrostriatal AS tissue levels and no significant effect on dopaminergic system integrity. On the other hand, microRNA (miR)-mediated Gba1 downregulation (miR Gba), combined with virus-mediated human AS overexpression (+AS), yields decreased GCase activity in the cortex, mimicking levels seen in GBA1 heterozygous carriers (30-40%), increased astrogliosis and microgliosis, decreased striatal dopamine levels (50% compared to controls) and loss of nigral dopaminergic neurons (~33%)- effects that were all reversible with miR rescue. Most importantly, the synergistic neurodegeneration of miR Gba + AS correlated with augmented AS accumulation and extracellular release in the striatum. Collectively, our results suggest that GCase downregulation alone is not sufficient to recapitulate key pathological features of PD in vivo, but its synergistic interplay with AS, via increased AS levels and extracellular release, drives nigrostriatal neurodegeneration. Furthermore, we report a novel double-hit GBA-AS model that can be used to identify putative mechanisms driving PD pathophysiology and can be subsequently used to test novel therapeutic approaches.

COVID-19 in Children: Where do we Stand?

From the beginning of the coronavirus disease 2019 (COVID-19) pandemic it became evident that children infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remain mostly asymptomatic or mildly symptomatic. We reviewed the epidemiologic and clinical features of children with SARS-CoV-2 infection. The true prevalence of asymptomatic SARS-CoV-2 infection is most likely underestimated, as asymptomatic children are less frequently tested. Serologic surveys indicate that half of children tested positive for SARS-CoV-2 report no symptoms. Anosmia/ageusia is not frequent in children but it is the strongest predictor of a positive SARS-CoV-2 test. In general, children with COVID-19 are at lower risk of hospitalization and life-threatening complications. Nevertheless, cases of severe disease or a post-infectious multisystem hyperinflammatory syndrome named multisystem inflammatory syndrome in children (MIS-C) have been described. Rarely children with severe COVID-19 develop neurologic complications. In addition, studies indicate that school closures have a limited impact on SARS-CoV-2 transmission, much less than other social distancing measures. The past months new SARS-CoV-2 variants emerged with higher transmissibility and an increased impact on morbidity and deaths. The role of children in the transmission dynamics of these variants must be elucidated. Lastly, preliminary results from COVID-19 vaccine trials indicate very good efficacy and tolerability in children. Very recently the United States Centers for Disease Control and Prevention and other public health authorities recommend vaccination of children 12 years or older to protect them but mostly to contribute to the achievement of herd immunity.

Modulation of ß-glucocerebrosidase increases α-synuclein secretion and exosome release in mouse models of Parkinson's disease.

Glucocerebrosidase gene (GBA) mutations are the most common genetic contributor to Parkinson's disease (PD) and are associated with decreased glucocerebrosidase (GCase) enzymatic activity in PD. PD patients without GBA mutations also exhibit lower levels of GCase activity in the central nervous system suggesting a potential contribution of the enzyme activity in disease pathogenesis, possibly by alteration of lysosomal function. α-synuclein (ASYN), a protein with a central role in PD pathogenesis, has been shown to be secreted partly in association with exosomes. It is possible that a dysfunction of the endocytic pathway through GCase may result in altered exosome release of ASYN. The aim of this study was to examine whether manipulating GCase activity in vivo and in vitro could affect ASYN accumulation and secretion. GCase overexpression in vitro resulted in a significant decrease of exosome secretion. Chronic inhibition of GCase activity in vivo, by administration of the covalent inhibitor conduritol-B epoxide in A53T-synuclein alpha gene Tg mice significantly elevated intracellular oligomeric ASYN species. Importantly, GCase inhibition, induced a profound increase in the number of brain exosomes released, as well as exosome-associated ASYN oligomers. Finally, virus-mediated expression of mutant GBA in the mouse striatum increased ASYN secretion in the same region. Together, these results provide for the first time evidence that a decrease of GCase or overexpression of mutant GCase in a chronic in vivo setting can affect ASYN secretion. Such effects may mediate enhanced propagation of ASYN, driving pathology in GBA-associated PD.

Prevalence and clinical course of hepatitis delta infection in Greece: a 13-year prospective study.

BACKGROUND & AIMS: Hepatitis D virus (HDV) has decreased in Europe, but recent reports indicate a rising trend. We report the epidemiological changes, clinical progress, and effect of treatment on the natural course of HDV infection in Greece during the last 13 years. METHODS: Prospective data were extracted from the HepNet.Greece Cohort-Study. RESULTS: Since 1997, 4673 chronic HBV (CHB) cases (4527 adults, 146 children) have been followed prospectively. Two thousand one hundred thirty-seven patients were tested for anti-HDV [101 (4.7%) positive]. Anti-HDV testing in Greece decreased significantly (57.0% before 2003, 35.3% thereafter; p<0.001). Anti-HDV prevalence among HBsAg-positives was 4.2%; lower in native Greeks (2.8%) than in immigrants (7.5%) or in children (15.3%; p<0.001). Within 2.3 years of follow-up, HDV occurred in 11/2047 HBsAg-positive patients (2.2 new delta-infected adults and 8.7 children per 1000 HBsAg-positive annually). HDV-positive compared to CHB adults were younger (p=0.035) and had more active and advanced disease at baseline, as indicated by laboratory indices and the higher prevalence of cirrhosis at younger age. During a 4.2-year median observation, significantly more anti-HDV-positive than CHB adults developed a liver-related first event (20.0% vs. 8.5%, p Log-rank=0.014).Treatment was received by 46/90 (51.1%) patients, 40 of them interferon-based. In multivariable analysis, interferon significantly decreased disease progression in HDV-positive patients [HR=0.14 (95% CI: 0.02-0.86; p=0.033)]. CONCLUSIONS: In Greece, HDV serology is currently tested in only one-third of HBsAg-positive patients. HDV prevalence is lower in native Greeks compared to immigrants, who may contribute >50% of the HDV infection burden in Greece. Data show that HDV infection is a rapidly progressive disease, but interferon-based treatment may alter its course.

Macrolide resistance in Streptococcus pyogenes: prevalence, resistance determinants, and emm types.

To investigate the antimicrobial resistance trends and the distribution of emm types of group A streptococci (GAS), we examined 1160 clinical isolates of GAS collected between 2003 and 2006. Susceptibilities to commonly used antimicrobial agents were determined by Etest, and macrolide resistance genes were detected by polymerase chain reaction (PCR). GAS isolates were typed by polymerase chain reaction PCR and sequencing of emm gene. The rates of resistance to erythromycin (ERY), clindamycin, azithromycin, tetracycline, and chloramphenicol were 14.9%, 1.4%, 14.9%, 18.9%, 0.6%, respectively. None of the isolates exhibited resistance to penicillin, ceftriaxone, linezolid, moxifloxacin, rifampicin, or vancomycin. Macrolide resistance increased from 12.1% in 2003 to 18.8% in 2006 (P = 0.02). Of 173 ERY-resistant GAS isolates, 93 (53.7%) harbored the mefA gene, 70 (40.4%) the ermA, and 10 (5.8%) the ermB. Eighty percent of the observed emm types are covered by the proposed 26-valent GAS vaccine. Among 173 ERY-resistant isolates, the predominant emm types were 12 (19.5%), 77 (17.9%), and 4 (16.8%), and among 770 ERY-susceptible isolates, the predominant types were 1 (18.8%), 12 (17.5%), 28 (13.8%). The observed antimicrobial resistance trends and the distribution of specific emm types have implications in guiding empiric therapy and in developing vaccine strategies to prevent GAS infections.

Wilson disease in children: analysis of 57 cases.

OBJECTIVES: Wilson disease (WD) has a wide spectrum of clinical manifestations. Affected children may be entirely asymptomatic and the diagnosis problematic. Herein we present the clinical and laboratory characteristics of 57 children with WD and point out the diagnostic difficulties in a pediatric population. PATIENTS AND METHODS: Clinical and laboratory data were collected from 57 consecutive children with WD. Evaluation included detailed physical examination, conventional laboratory testing, genetic analysis, and liver biopsy. RESULTS: The mean age at diagnosis was 9.27 +/- 3.62 years (range 4 months-18 years). Twenty patients were symptomatic, 19 were referred because of abnormal liver function test results and/or hepatomegaly, and 18 received their diagnoses after family screening. Twenty-two patients had both Kayser-Fleischer ring and decreased serum ceruloplasmin levels, 13 had urinary copper excretion after penicillamine challenge >1600 microg/24 hours, and 3 had liver copper content >250 microg/g dry weight. Of the remaining 19 patients, 17 had both low serum ceruloplasmin 75 microg/24 hours before, or >1000 microg/24 hours after penicillamine challenge. In 2 patients with equivocal cases who had serum ceruloplasmin 26 mg/dL, the diagnosis was confirmed by genetic analysis. No correlation was found between specific mutations and the disease phenotypic expression. Chelating therapy was well tolerated, and the outcome was satisfactory. CONCLUSIONS: WD in children may be obscure and requires extensive investigation to establish the diagnosis. Genetic analysis is needed in equivocal cases.

Presence of hepatitis C virus (HCV) RNA in the genital tracts of HCV/HIV-1-coinfected women.

BACKGROUND: Hepatitis C virus (HCV)-infected women--in particular, those coinfected with human immunodeficiency virus type 1 (HIV-1)--can transmit infection to their children and sex partners. METHODS: The present study was conducted to analyze the presence of HCV RNA in cervicovaginal lavage (CVL) fluid from 71 women (58 HCV/HIV-1-coinfected women and 13 HCV-infected, HIV-1-uninfected women) enrolled in the Women's Interagency HIV Study. RESULTS: HCV RNA was detected (by a commercial polymerase chain reaction assay) in CVL fluid from 18 (29%) of the HIV-1-infected women and from none of the HIV-1-uninfected women (P<.05). Multivariate analysis revealed that risk factors for the presence of HCV RNA in CVL fluid were HCV viremia (odds ratio [OR], 16.81; P=.02) and HIV-1 RNA in CVL fluid (OR, 19.87; P=.02). This observation suggests local interactions between HIV-1 and HCV in the genital tract compartment. There was no correlation between HCV RNA in CVL fluid and CD4, CD8, or CD3 cell counts, HIV-1 RNA viremia, the number of leukocytes in CVL fluid, or HIV-1 therapy. Furthermore, in 3 of 5 analyzed patients who had a detectable CVL HCV RNA load, we found viral variants differing in the 5' untranslated region that were present neither in plasma nor in peripheral-blood mononuclear cells. CONCLUSIONS: Our observations point to the importance of the genital tract compartment, in which local HCV replication could be facilitated by local HIV-1 replication.

Mother to child transmission of hepatitis C virus: rate of infection and risk factors.

To determine the rate of mother-to-child transmission of hepatitis C virus (HCV) and identify risk factors associated with HCV transmission we prospectively studied 86 infants born to anti-HCV positive mothers. HCV infection was verified in all mothers before delivery and their HCV viral load was measured at or near delivery using reverse transcription polymerase reaction. For HCV genotyping the INNO-LiPA II probe assay was used. All mothers were tested for HIV infection. Possible risk factors for vertical transmission were recorded. The children were followed up for a minimum of 18 months for evidence of HCV infection, as determined by persistent HCV antibodies, or detection of HCV-RNA. Vertical transmission was restricted to infants born to viraemic mothers and the rate was 3.6% (95% CI 0.004-0.123). The HIV-infected mothers and those using drugs intravenously were more likely to transmit HCV to their children. The infected children had the same genotype as their mothers. Although the HCV RNA titre was higher in mothers who transmitted the virus than in those who did not, the viral load had borderline significance (p=0.08). Viral transmission was not influenced by mother's age, mode of delivery, genotype or type of feeding. Mother-to-child transmission of hepatitis C virus is uncommon and restricted to infants born to HCV viraemic mothers. Active drug use and HIV coinfection increase the risk for HCV vertical transmission.

HCV viremia is associated with drug use in young HIV-1 and HCV coinfected pregnant and non-pregnant women.

AIMS: Vertical transmission of HCV is increased among HIV-1/HCV coinfected women and is related to HCV viral load. In this study we assessed clinical and demographic factors associated with HCV viremia in a cohort of young pregnant and non-pregnant mothers coinfected with HIV-1. DESIGN: A cross-sectional clinic-based study nested within a prospective cohort study. METHODS: From 1988 to 2000, HIV-1 + pregnant and non-pregnant women with children followed in a large maternal, child and adolescent HIV-1 clinic were evaluated for HCV infection using EIA 3.0. HCV RNA levels were determined for HCV antibody + women using polymerase chain reaction. Demographic and clinical characteristics between HCV-RNA(+) and HCV-RNA(-) women and between pregnant and non-pregnant HIV-1/HCV coinfected women were compared using univariate and multivariate analyses. FINDINGS: Among 359 HIV-1(+) women, 84 (23%) were HCV-ab + and 49/84 (58%) had detectable HCV-RNA in plasma. Median age was 31. CD4 counts, HIV-1 RNA levels and demographic characteristics were similar for viremic and non-viremic women and pregnant and non-pregnant women. However, viremic women were more likely to report a history of (88% versus 43%; P < 0.001) or active injection drug use (AIDU) (83% versus 29%; P < 0.001). Logistic regression analysis showed that HCV viremia was associated significantly with AIDU (adjusted OR: 15.17; 95% CI: 3.56, 64.56) after adjusting for age, race, number of sexual partners, pregnancy status, CD4 counts and HIV-1 viral load. CONCLUSION: In this cohort of young HIV-1 and HCV coinfected women, HCV viremia was associated strongly with active injection drug use, perhaps due to reinfection or reactivation of HCV. Thus, careful evaluation for HCV infection and counseling related to drug use may be necessary.

Pediatric fractures during skateboarding, roller skating, and scooter riding.

BACKGROUND: Skateboarding, roller skating, and scooter riding are popular recreational and sporting activities for children and adolescents but can be associated with skeletal injury. The purpose of this study is to describe the frequency and characteristics of fractures resulting from these activities. PURPOSE: Fractures from skateboarding, roller skating, and scooter riding compose a considerable proportion of pediatric musculoskeletal injuries. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Demographic data and injury characteristics were analyzed for all patients who presented to the pediatric fracture clinic of the level I trauma center from January 2001 to May 2002 after sustaining fractures due to skateboarding, roller skating, and scooter riding. RESULTS: Among a total of 2371 fractures, the authors identified 325 fractures (13.7%) that occurred during one of these activities. There were 187 patients (mean age, 13 years; 95% male) who sustained 191 skateboard-related fractures, 64 patients (mean age, 10.8 years; 54% male) who sustained 65 fractures while roller skating, and 66 patients (mean age, 9.7 years; 64% male) who sustained 69 fractures while riding a scooter. The forearm was fractured most often, composing 48.2% of skate-boarding fractures, 63.1% of roller-skating fractures, and 50.7% of fractures due to scooter riding. Of the forearm fractures, 94% were located in the distal third. In the skateboarding group, 10 of 191 (5.2%) fractures were open injuries of the forearm, compared to 6 of 2046 (0.3%) fractures caused by other mechanisms of injury (significant odds ratio, 18.8). CONCLUSIONS: Skateboarding, roller-skating, and scooter-riding accidents result in a large proportion of pediatric fractures. An open fracture, especially of the forearm, was more likely to be caused by skateboarding than by other mechanisms of injury. Use of wrist and forearm protective equipment should be considered in all children who ride a skateboard.

Detection and analysis of hepatitis C virus sequences in cerebrospinal fluid.

Hepatitis C virus (HCV) sequences were detected in cerebrospinal fluid (CSF) in 8 of 13 HCV-positive patients. In four patients harboring different virus strains in serum and peripheral blood mononuclear cells (PBMC), CSF-derived virus was similar to that found in PBMC, which suggests that PBMC could carry HCV into the brain.