Acute Respiratory Distress Syndrome (ARDS) from Endemic Influenza A/H1N1: Prehospital Management.

Acute respiratory distress syndrome (ARDS) is a form of acute life threatening respiratory failure. In daily practice there is difficulty in diagnostic and therapeutic management of Acute respiratory distress syndrome (ARDS). We observed delay in diagnostic and therapeutic procedures in patients with clinical signs for the presence of severe respiratory disorders. Finding timely evidence of the presence the clinical signs of threatening ARDS and underlying diseases like influenza A/H1N1 during prehospital period in early stage of disease it is possible introduce early adequate treatment: high flow oxygen, fluid replacement and pharmacological and antiviral therapy. This measure can reduce high mortality in patients who develop ARDS. It is important to improve diagnostic criteria for a precise definition of ARDS and transfer it in practice of emergency and family medicine, microbiology, intensive care units, hospital departments of infectious and respiratory diseases. In this article we underlined the key elements of the new definition of ARDS, diagnostic criteria and the importance of early diagnosis in prehospital period following clinical feature and course (a presence of severe dyspnea) by adding chest x-ray and laboratory investigations.

Epidemiological monitoring of nosocomial infections caused by acinetobacter baumannii.

INTRODUCTION: Acinetobacter baumannii is a frequent cause of infections in hospitals around the world, which is very difficult to control and treat. It is particularly prevalent in intensive care wards. AIM: The main objective of the research was to establish the application of epidemiological monitoring of nosocomial infections (NIs) caused by A. baumannii in order to determine: the type and distribution of NIs, and to investigate antimicrobial drug resistance of A. baumannii. MATERIAL AND METHODS: 855 patients treated at the Clinic of Anesthesiology and Reanimation, University Clinical Center Tuzla during 2013 were followed prospectively for the development of NIs. Infections caused by A. baumannii were characterized by the anatomical site and antibiotics resistance profile. RESULTS: NIs were registered in 105 patients (12.3%; 855/105). The predominant cause of infection was A. baumannii with an incidence of 51.4% (54/105), followed by ESBL-producing Klebsiella pneumoniae with 15.2% (16/105) of cases, methicillin-resistant Staphylococcus aureus with 8.6% (9/105), and ESBL-producing Proteus mirabilis with 7.6% (8/105). According to the anatomical site, and type of NIs caused by A. baumannii, the most frequent were respiratory infections (74.1%; 40/54). Infections of surgical sites were registered in 11.1% (6/54) of cases, while bloodstream infections in 9.2% (5/54). A. baumannii isolates tested resistant against most antibiotics examined, but showed a high degree of susceptibility to tobramycin (87%; 47/54) and colistin (100%; 54/54). CONCLUSION: The increasing incidence of multi- and extensively drug-resistant Acinetobacter spp. emphasizes the importance of administration of an adequate antibiotic strategy and the implementation of strict monitoring of the measures for controlling nosocomial infections.

Etiology of bacterial meningitis in children in Tuzla Canton.

INTRODUCTION: Bacterial meningitis is one of the most serious infectious diseases in childhood. AIM: To identify the most common causes of bacterial meningitis in children in Tuzla Canton. PATIENTS AND METHODS: This is a retrospective study which included 140 children, aged from 1 month to 14 years, treated at the Clinic for Infectious Diseases Tuzla, in the period 1999-2009, who had clinical and laboratory parameters of bacterial meningitis. RESULTS: In Tuzla Canton in ten year period were registered 140 cases of bacterial meningitis in children aged 1 month to 14 years. Prevalence was 1.53/1000. The average age of patients was 3.6 +/- 3.8 years. Male to female ratio was 1.3:1. April, May and November were the months with the most reported cases of bacterial meningitis (p = 0.02). Most affected were children 1-12 months of age (p < 0.001). The most common pathogens of bacterial meningitis were Haemophilus influenzae (13.6%), Neisseria meningitides (8.6%) and Streptococcus pneumoniae (5.7%) (p < 0.001). Mortality was 2.14%. CONCLUSION: Bacterial meningitis is present in Tuzla Canton, and three major pathogens are Haemophilus influenzae, Neisseria meningitis and Streptococcus pneumoniae. The most affected were children 1-12 months of age, and most cases of bacterial meningitis occurred in spring.

Etiology of peritonitis.

AIM: To determine the etiology of peritonitis, as well as the sensitivity of isolated bacteria to antibiotics. METHODS: Study was performed at the Surgical Clinic, Department of Anesthesiology and Reanimation, Department of Microbiology, Department of Clinical Pharmacology of University Clinical Centre (UCC) Tuzla. In a prospective study, starting from 1.6.2009. to 30.6.2010., was 60 patients analyzed who underwent surgery for acute peritonitis in the Surgical Clinic, UCC Tuzla. RESULTS: After microbiological processing of the content of the operative field, wound swabs and smears of drainage, we isolated Gram positive coccid bacteria: Coagulase-negative Staphylococcus in 18.36%, Staphylococcus aureus in 12.6%, while Enterococcus faecalis and Enterococcus faecum were found in 3.44% isolates. In the group of Gram-negative bacteria we isolated: Escherichia coli in 15.51%, and Pseudomonas aeruginosa and Klebsiella pneumoniae in 10.34% of the cases. The sensitivity of coagulase-negative Staphylococcus was largest to vancomycin (100%), and lowest to penicillin (10%) and Staphylococcus aureus sensitivity was largest to vancomycin and amoxicillin-clavulanate (100%) and lowest to penicillins (3.7%). Sensitivity of the facultative anaerobic Gram-negative bacilli was highest to carbapenems 95-100%, and lowest to penicillin preparations 0-56%. CONCLUSION: Based on the results of microbiological findings of 83.33% patients empirical antibiotic therapy was appropriately involved, and in 16.67% was inadequate and later changed, following the results of microbiological findings. This study indicates the importance and validity of microbiological diagnostics to determine the etiology of peritonitis and appropriate selection of antibiotics to treat these infections, with the required surgical treatment.

Human brucellosis in Tuzla Canton.

INTRODUCTION: The prevalence of human brucellosis in Bosnia and Herzegovina and the Tuzla Canton reached its peak in 2008, with a reported total of 994 cases within country, and with 104 cases within the Tuzla Canton. AIM: to analyze the clinical and epidemiological features of human brucellosis in patients hospitalized at the University Clinical Center Tuzla during the period from 01/01/2000 till the 31/12/2010. METHODS: We retrospectively analyzed the clinical symptoms, the laboratory and X-ray findings, the treatments, and the course and outcome of the disease. The diagnosis of brucellosis was based on anamnesis, clinical presentation, in correlation with a positive blood-culture, and/or serological tests. RESULTS: The majority of patients (93.18%) were from rural regions. There were more males (79.54%) than females. Most of the patients were aged between 30 to 39 years (21% cases). Contact with infected animals was registered for 83.40% of the patients. The main symptoms and signs were fever, joint-pains, night sweating, anorexia, headaches, and hepatosplenomegaly. The important laboratory findings were increased erythrocyte sedimentation rates, increased values of C-reactive protein, and anemia. Adult patients were treated with a combination of gentamicin or streptomycin with doxycycline, and the children with a combination of gentamicin, and trimethoprim-sulfametaxasol, over at least 6 weeks. Complications were documented in 20.45% of the patients. Relapses were observed in 14.20%, and a chronic form of brucellosis in 5.11% of patients. There were no cases with lethal outcomes. CONCLUSION: Brucellosis is a growing public health problem, not only within the Tuzla Canton, but throughout Bosnia and Herzegovina.

Diagnosis and treatment of chronic viral hepatitis B and C: doctrinary approach.

Association of Gastroenterologists and Hepatologists of Bosnia and Herzegovina based on the experiences of domestic and foreign centers operating in the field of hepatology and accepted guidelines of the European and the U.S. Association for Liver Diseases adopted the consensus for the diagnosis and treatment of chronic viral hepatitis B and C. The guidelines are intended for specialists in gastroenterology and hepatology, and infectious diseases physicians working in primary health care and family medicine, but also other physicians who are confronted with this disease in their practice, with the aim of facilitating and shortening the diagnostic and treatment protocols of patients with chronic viral hepatitis B and C. This ensures faster, more efficient, more rational and cost-effective care of patients with hepatitis, with an emphasis on stopping the deterioration of liver disease to liver cirrhosis and eventually hepatocellular carcinoma. Key words: Chronic hepatitis B and

Antimicrobial resistance profiles of human Brucella melitensis isolates in three different microdilution broths: the first multicentre study in Bosnia and Herzegovina.

OBJECTIVES: Brucellosis is a ubiquitous emergent bacterial zoonotic disease causing significant human morbidity in Bosnia and Herzegovina. So far, a high rate of resistant Brucella has been found worldwide. This study prospectively analysed the rates of resistance among human Brucella melitensis strains isolated in Bosnia and Herzegovina. METHODS: This study included 108 B. melitensis isolates from 209 patients diagnosed at five medical centres in Bosnia and Herzegovina. The resistance profiles of the B. melitensis isolates for the 13 most commonly used antimicrobials were studied in standard Brucella broth (BB) and cation-adjusted Mueller-Hinton broth (CAMHB) supplemented with 4% lysed horse blood or 5% defibrinated sheep blood. RESULTS: Of the 209 patients, B. melitensis blood cultures were positive for 111 (53.1%). Among the 108 isolates investigated, 91 (84.3%) were resistant to trimethoprim-sulfamethoxazole on BB, but not on either CAMHB. Nearly all isolates (>90%) were resistant to azithromycin on BB and both CAMHBs. CONCLUSION: We observed a high rate of B. melitensis resistance to azithromycin. The high rate of resistance to trimethoprim-sulfamethoxazole that we observed was related to BB, so an alternative broth should be used, such as the enriched CAMHBs in this study, for evaluating resistance to trimethoprim-sulfamethoxazole. Whole-genome sequencing studies are needed to understand the development of antimicrobial resistance in B. melitensis strains isolated from humans.

Intrafamilial Spread of COVID-19 Infection Within Population in Bosnia and Herzegovina.

BACKGROUND: The corona virus is transmitted in three ways: by direct contact with an infected person, by droplets, and by air. Transmission control according to official guidelines can be prevented by keeping a distance, wearing a mask and washing hands. Sharing a space with several members of the immediate or extended family increases the risk of transmission in all three ways. In Traditional Bosnian families two or three generations live in one household. The family doctor is informed with living conditions of the residents and has the opportunity to monitor the rate of secondary transmission from the index case, and then recommend additional preventative and treatment measures. OBJECTIVE: The aim of the study was to determine the first occurrence of the symptoms and to monitor possible intrafamilial transmission of the disease through clinical examinations and microbiological-serological tests. METHODS: The study was conducted in a family medicine clinic in the region of northeastern Bosnia and Herzegovina from March to December 2020. Patients with symptoms that could indicate the presence of COVID-19 disease were registered. If COVID-19 was proven, the patient became an index case. The other members of the family would be monitored for the secondary transmission via laboratory (PCA SARS-CoV-2 and IgM and IgG antibodies) and clinical parameters. RESULTS: Characteristics of 25 index cases were analyzed. All 25 of them were middle-aged men that worked outside the home. In 25 households, there was a total of 123 members that shared a home with the index patient. Secondary transmission developed in 76 out of 123 family members (61.8%). Only one patient had a severe form of the disease and was hospitalized. 2 patients died. CONCLUSION: Intrafamiliar transmission of Covid-19 in households of Bosnia and Herzegovina is high. The secondary attack rate of SARS- CoV-2 in households is 61,8%. In the surveyed households, family members use common rooms with an infected patient, and the customs of family gatherings are maintained, without the implementation of protective measures. The family medicine team has the opportunity to apply appropriate preventive action, education and early prehospital treatment as well as adequate selection for the hospital admission.

Clinical and laboratory characteristics of acute community-acquired urinary tract infections in adult hospitalised patients.

Urinary tract infections (UTI) cause a great number of morbidity and mortality. These infections are serious complications in pregnancy, patients with diabetes, polycystic kidneys disease, sickle cell anaemia, kidney transplant and in patients with functional or structural anomalies of the urinary tract. The aim of this investigation was to determine a dominant causative agents of UTI and some of the clinical and laboratory characteristics of acute community-acquired UTI in adult hospitalised patients. We studied 200 adult patients with acute community-acquired UTI hospitalised in the Clinic for Infectious Diseases Tuzla from January 2006 to December 2007. The patients were divided into two groups: a group of patients with E. coli UTI (147) and a group of patients with non-E. coli UTI (53). In these two groups, the symptoms and signs of illness, blood test and urine analysis results were analysed. Our results have shown that the patients with E. coli UTI frequently had fever higher than 38,5 degrees C (p<0,0001), chills (p=0,0349), headache (p=0,0499), cloudy urine (p<0,0001), proteinuria (p=0,0011) and positive nitrite-test (p=0,0002). The patients with non-E. coli UTI frequently had fever lower than 38,5 degrees C (p<0,0001) and urine specific gravity <1015 (p=0,0012). There was no significant difference in blood test results between patients with E. coli and non-E. coli UTI. These clinical and laboratory findings can lead us to early etiological diagnosis of these UTI before urine culture detection of causative agents, which takes several days. Early etiological diagnosis of the E. coli and non-E. coli UTI is necessary for an urgent administration of appropriate empirical antibiotic treatment. This is very important in prevention of irreversible kidney damage, prolonged treatment, complications, as well as recidives and chronicity of the illness.

Risk factors for intrafamilial spread of hepatitis B in northeastern Bosnia and Herzegovina.

BACKGROUND: Accurate estimations of hepatitis B virus transmission risk for any region in Bosnia and Herzegovina are not clearly established. We aimed to determine levels of risk associated with intrafamilial transmission of hepatitis B infection within families in our region. PATIENTS AND METHODS: Family members of 81 chronic carriers of hepatitis B surface antigen (>6 months positive and considered as index case) were tested for hepatitis B markers. For family members, we recorded their age, sex, and family relationship to the index case, and vaccination status. RESULTS: The proportion of HBsAg positive family members was 25/207 (12.1%), while the proportion of family members with evidence of exposure to HBV was 80/207 (38.6%). Only 17/207 (8.2%) family members had evidence of past HBV vaccination. Age was found to be a significant predictor of HBV exposure of family members (odds ratio 1.05, 95% CI 1.03-1.07, P<.001). In a multivariate analysis, HBsAg positivity was associated with a female index case (odds ratio 11.31, 95% CI 3.73-34.32, P<.001), HBeAg positivity in the index case (odds ratio 5.56, 95% CI 1.80-17.23, P<.005) and being a mother of the index case (odds ratio 9.82, 95% CI 2.43-39.68, P<.005). A female index case (odds ratio 4.87, 95% CI 2.21-10.72, P<.001), HBeAg positivity in the index case (odds ratio 3.22, 95% CI 1.15-9.00, P<.05) and being a mother of the index case (odds ratio 3.72, 95% CI 1.19-11.64, P<.05) were also risk factors for HBV exposure among family members. The combination of HBeAg positivity and female index case was a significant predictor for HBsAg positivity of family members (odds ratio 70.39, 95% CI 8.20-604.61, P<.001). CONCLUSIONS: Children of HBeAg positive mothers are at highest risk for becoming chronic carriers themselves and generally, the combination of female sex and HBeAg positivity dramatically increases the chances of HBV transmission within the family.

Hepatitis C virus genotypes in chronic hepatitis C patients and in first time blood donors in northeastern Bosnia and Herzegovina.

Prevalence of hepatitis C virus (HCV) genotypes in Bosnia and Herzegovina (B&H) is an issue that is not sufficiently researched and there is a need for studies that would explore this in detail.The aim of this study was to determine the distribution of HCV genotypes in the group of patients with chronic hepatitis C and also in the group of first time blood donors that tested positive for anti HCV antibodies during the blood screening process. Our secondary goal was to compare the proportions of HCV genotypes between these two groups.We analyzed 75 blood samples of patients with confirmed chronic hepatitis C. We also analyzed 13/16082 blood samples of first time blood donors found to be HCV positive during the blood screening process. We also determined HCV genotype in HCV RNA positive samples.We have found that genotype 1b was more prevalent in chronic hepatitis C patients (52/75; 69,3%) than in first time blood donors (6/13; 46,1%), however this difference was not statistically significant (c2=1,721; df=1; p=0,19). Genotype 1a was more prevalent in the group of first time blood donors (3/13; 23,1%) than in the group of chronic hepatitis C patients (3/75; 4%), but this was also with limited statistical significance (c2=3,71; df=1; p=0,054). We have not found any significant difference in prevalence of genotypes 1a (p=0,2) and genotypes 3 (p=0,70) when compared between chronic patients (3/75 and 16/75; respectively) and first time blood donors (3/13 and 4/13; respectively). Our study confirmed domination of genotype 1b in the region of northeastern B&H which is in accordance with HCV genotype prevalence in other countries in our part of Europe.

Cytomegalovirus Infection in Pregnancy - Our Experiences.

INTRODUCTION: Cytomegalovirus (CMV) infection is ubiquitous. It affects all age groups, and its clinical picture ranges from mild to severe, especially as a congenital infection in neonates. AIM: To determine frequency of CMV infection in pregnant women in Tuzla Canton (TC) and the risk factors that lead to the infection. METHODS: This prospective study included 300 pregnant women from TC aged 18 to 42 years. CMV serology was performed on all participants, and in case of acute infection additionally IgG avidity test. Participants also completed the questionnaire on the risk factors for CMV infection. RESULTS: The median age of the 300 women was 28 ±4.97 years. There were 161participants (53.6%) who classified their environment as urban and 295 (98.33%) were married. More than half of the women had completed secondary school 168 (56%). Positive IgG antibodies to CMV had 280 (93.0%) women. Positive IgM and IgG antibodies had 9 (3.0%) participants, but all of them had high IgG avidity, which indicates reinfection or recurrent CMV infection. There was a statistically significant higher number of seropositive participants living in rural areas than those living in urban areas (p= 0.048). Also, there was significantly higher percentage of positive anti-CMV IgG in pregnant women with lower education (p=0.04). CONCLUSION: In our region there is high seropositivity rates of IgG antibodies to CMV in pregnant women. No case of primary CMV infection was proven. The risk factors for CMV infection have been proven to be rural environment and lower level of education.

Clinical Characteristics and Treatment Efficasy of Chronic HCV Infection Among Intravenous Drug Users in Tuzla Canton.

INTRODUCTION: Chronic HCV infection is chronic inflamatory liver disease caused by hepatitis C virus. Anti HCV prevalence among intravenous drug users (IVDU) is very high and it accounts 40% -90% (60%-90%) with the risk of 80% of developing the chronic infection. AIM: The aims of this study were: a) to compare clinical characteristics of chronic HCV infection among IVDU and non-users population and to detect their impact to treatment outcome; b) to investigate the treatment efficacy comparing sustained viral response (SVR) in these two populations in Tuzla Canton. PATIENTS AND METHODS: The study was retrospective-prospective and included 45 IVDU of both sexes from Tuzla Canton which were treated from chronic HCV infection with Pegilated interferon 2a/2b + ribavirin in the Clinic for Infectious Diseases and Clinic for Internal Disease of University Clinical Centre in Tuzla. The control group were presented by non-users who completed therapy in both Clinics. For statistical analyses it was used statistical package SPSS 20,0 (SPSS Inc, Chicago, IL, USA) with tests of descriptive statistics with measures of central tendency and dispersion. Quantitative variables were tested by t-test or by Mann-Whitney test. Qualitative variables were tested by hi-square test or by Fisher's test. The standard analyse of level's risk was used too. The analyse of predictive value of EVR for achieving the ETR and SVR was done by cross-tabulation. The impact of known factors for achieving the SVR was evaluated by logistic regression analyses. All tests were done with statistical level of significance of 95% (p=0,05). RESULTS: Men were more dominant in the test group (93,3% / 61,7%), also younger age (p<0,001) and lower BMI (p=0,019). The test group had significant higher basal values of Le, Hb, Plt and ALT and tendency to lower stages of fibrosis (p=0,08). The difference in genotype frequencies was statistically significant (p=0,001) with clearly dominance of G3 and G4 among IVDU. Treatment was not complited by two patients in both groups (4,4% /3,3%). EVR was significantly higher in test group (p=0,001) so did the ETR (p=0,002) and SVR (p<0,001). Predictive factors for SVR were: age (negative predictive factor), male sex, absence of reduction of pegilated interferon and ribavirin, Metavir stage of fibrosis and presence of EVR. CONCLUSION: Population of IVDU were adherent to treatment protocol and with excellent treatment response they justified the hope of health care workers for success treatment of this population.

Intrafamilial transmission of hepatitis B in Tuzla region of Bosnia and Herzegovina.

OBJECTIVE: To determine (i) the prevalence of HBV infection in families of confirmed chronic carriers, (ii) possible routes of transmission and risk factors for the intrafamilial transmission, (iii) vaccination rate among family members of chronic carriers and (iv) family members with highest risk for infection. METHODS: A total of 172 family members of 67 hepatitis B surface antigen chronic carriers were tested for hepatitis B markers; 716 first-time blood donors from the same area were used as controls. RESULTS: Prevalence of hepatitis B surface antigen was higher (P<0.001) among family members of index cases (12.2%; 21/172) than among controls (3.6%; 26/716) with relative risk of 3.3 (95% confidence Intervals=1.9-5.8; P<0.05). Rate of exposure among family members was 37.8% (65/172); only 8.7% (15/172) had been vaccinated for hepatitis B virus. Difference (P<0.001) in exposure existed among family members; exposure increased with age (rhos=0.34; P<0.001). Prevalences of hepatitis B surface antigen positivity and hepatitis B virus exposure were higher among parents of index cases (P<0.005) and among offspring of female index cases (P<0.001). There were more (P<0.001) hepatitis B surface antigen-positive family members among those with mother-children relationship with index case (13/31; 41.9%) than among those with father-children (19/85; 22.4%) and horizontal (siblings and spouses) relationship (2/56; 3.6%). Significantly more (P<0.001) hepatitis B surface antigen-positive and hepatitis B virus-exposed offspring were found in families where only mother was hepatitis B surface antigen positive. Among family members of HBeAg-positive cases more hepatitis B surface antigen-positive cases and hepatitis B virus-exposed cases have been found (P<0.001). Combination of HBeAg positivity and female sex of index case significantly increased risk for chronic carriage among family members (relative risk=24.06; 95% confidence interval=8.88-65.21; P<0.05). CONCLUSION: In the area studied, both horizontal and vertical transmission exists, but maternal route is predominant. Female sex, HBeAg positivity of index carrier and presence of hepatitis B surface antigen-positive mother inside family increased risk for hepatitis B surface antigen positivity and exposure among family members. Vaccination rate of family members of index cases is alarmingly low.

Hepatitis C infection in risk groups.

Hepatitis C infection is important global health problem with wide spectrum of health, social and economic consequences. The goal of this research was to estimate prevalence of hepatitis C virus infection in risk groups, and to determine association hepatitis C virus (HCV) infection and risk factors. Research included 4627 subjects divided in two groups. Test group included 2627 subjects divided in 4 subgroups with risk for HCV infection: those who received blood transfusion without screening on HCV (it was introduced in 1995) (700); intravenous drug users (60); patients on hemodialysis (168) and health care workers (1699). Control group included 2000 healthy volunteer blood donors. In all subjects anti-HCV antibodies were tested with third generation ELISA test. Positive serum samples were tested for presence of HCVRNA, using reaction of reverse transcription and polymerase chain reaction. In all anti-HCV positive subjects further epidemiological and clinical workup was performed. Prevalence of HCV infection in risk groups was: 4.6% in subjects who have received blood transfusions without HCV blood screening, 35% in intravenous drug users, 58.9% in patients on chronic dialysis, and 0.4% in health care workers. In control group prevalence was low (0.2%). In the group of 158 anti-HCV positive subjects, 73.4% had HCVRNA. The largest number of subjects with HCV infection was in the age group of 30-49 years (45.8%). This study showed that multiple blood transfusions before introducing the blood screening for HCV, longer duration of intravenous drug abuse, longer duration of hemodialysis treatment, larger number of accidental injuries in health care workers are independent and statistically significant risk factors for those groups examined. Results of this study confirm that general screening for HCV infection is recommended in risk groups for HCV infection in order to identify to prevent and to treat it.

Human West Nile virus infection in Bosnia and Herzegovina.

AIM: To describe the first two cases of West Nile virus (WNV) neuroinvasive infections in Bosnia and Herzegovina. METHODS: At the Clinic for Infectious Diseases of the University Clinical Centre Tuzla, Bosnia and Herzegovina (BiH), specific screening for WNV infection was performed on patients with neuroinvasive diseases from 1 August to 31 October 2013. Serum samples were tested for the presence of WNV IgM and IgG antibodies using enzyme-linked immunosorbent assay (ELISA); positive serum samples were further analyzed by detection of WNV nucleic acid of two distinct lineages (lineage 1 and lineage 2) in sera by RT-PCR. RESULTS: Three (out of nine) patients met clinical criteria, and two of them had high serum titre of WNV specific IgM antibodies (3.5 and 5.2). Serum RT-PCR testing was negative. Conformation by neutralization testing was not performed. Both cases represented with encephalitis. None of these cases had recent travel history in WNW endemic areas, or history of blood transfusion and organ transplantation, so they represented autochthonous cases. CONCLUSION: Although there were no previous reports of flavivirus infections in BiH, described cases had high titre of WNV specific antibodies in serum, and negative flavivirus-vaccination history, they were defined as probable cases because recommended testing for case confirmation was not performed. The West Nile virus should be considered a possible causative pathogen in this area, probably in patients with mild influenza-like disease of unknown origin and those with neuroinvasive disease during late summer and early autumn.

Clinical and Epidemiological Characteristics of HIV Infection/AIDS in Hospitalized Patients.

INTRODUCTION: More than three decades after recognition of acquired immunodeficiency syndrome (AIDS) in the United States, the pandemic of human immunodeficiency virus (HIV) infection has dramatically changed the global burden of disease. AIM: The main goal of this research is retrospective analysis of epidemiological and clinical characteristics of 28 HIV infected patients, who were diagnosed and treated at the Clinic for Infectious Diseases in University Clinical Center Tuzla in the period from 1996 until the end of 2013. SUBJECTS AND METHODS: Retrospective analysis was performed using the medical records of 28 HIV-infected persons. Two rapid tests were used for HIV testing: OraQuick Advance test, Vikia HIV1/2, Elisa combo test, HIV RNA test. AIDS disease was determined by using the criteria from WHO. RESULTS: Among a total of 28 HIV-infected persons, 23 (82.14%) were males and 5 (17.86%) were females, with the male: female ratio of 4,6:1. In terms of the transmission route, a large proportion of cases were infected through heterosexual contact 19 (67.86%). At the time of the first visit, 16 (57.15%) patients showed asymptomatic HIV infection, 4 (14.28%) HIV infection with symptoms other than the AIDS defining diseases, and 8 (28.57) had AIDS. At the time of first hospital visit, the CD4 + cells count ranged from 40 to 1795/µl (conducted in 19 patients), and mean value of CD4 + cells was 365,31/µl, and mean HIV RNA titer was 287 118 copies/ml³. Of 28 HIV-infected persons 39 cases of opportunistic diseases developed in 12 patients (42.9%). In terms of the frequency of opportunistic diseases, tuberculosis (12 cases, 42.9%). Among a total of 28 HIV-infected patients, 6 (21.4%) of them died. CONCLUSION: This study characterizes the epidemiological and clinical patterns of HIV-infected patients in Tuzla region of Bosnia and Herzegovina to accurately understand HIV infection/AIDS in our region, in the hope to contribute in the establishment of effective HIV guidelines in the Tuzla region of B&H in the future.

Brucellosis in children in Bosnia and Herzegovina in the period 2000 - 2013.

AIM: To analyse clinical, laboratory and epidemiological characteristics of brucellosis in children in Bosnia and Herzegovina. METHODS: The study included 246 children aged 0-18 years, who were hospitalized in Clinics and Departments for Infectious Diseases in Tuzla, Sarajevo, Banja Luka, Zenica and Bihac in the period 2000-2013, in whom the diagnosis of brucellosis was established based on anamnestic data, clinical features and positive results from blood culture and/or positive results from one of the serological tests. RESULTS: In this period, a total of 2630 patients, 246 (9.35%) of whom were children, were treated from brucellosis at the Clinics and Departments in Bosnia and Herzegovina. In the majority of cases, the children were from rural parts of the country, 226 (91.87%);214 (87.04%) cases had direct contact with sick animals, sick family member or consumption of unpasteurized dairy products from farms where brucellosis had been already established. Male children predominated, 157 (63.82%). The most frequent clinical features in affected children were fever, 194 (78.86%) and joint pain, 158 (64.22%). The average duration of antimicrobial treatment was 42.85 ± 10.67 days. A total of 228 (92.68%) children were completely cured, while relapses occurred in 18 (7.32%) children. CONCLUSION: Since brucellosis is an endemic disease in Bosnia and Herzegovina, it is important that physicians in their daily practice consider brucellosis and establish proper diagnosis and therapy in children with prolonged fever, arthralgia, leukopenia and positive epidemiological data, especially in rural parts of the country.

Online combination algorithm for non-invasive assessment of chronic hepatitis B related liver fibrosis and cirrhosis in resource-limited settings.

OBJECTIVE: The use of commercially available noninvasive markers for chronic hepatitis B (CHB) related fibrosis is not widely available in developing countries so clinicians in those countries frequently use free alternatives. We aimed to create an optimized algorithm for selection of patients with the highest probability for presence/absence of significant liver fibrosis and cirrhosis based on the use of multiple free scores. METHODS: We evaluated six free noninvasive markers for CHB related fibrosis against liver biopsy and selected the best thresholds for prediction/exclusion of significant fibrosis and cirrhosis in CHB patients. Algorithm based on four scores and their corresponding thresholds was created. RESULTS: The calculator based on developed algorithm can be found at http://www.chb-lfc.com. We evaluated 211 patients in main group and 65 patients in external validation group. We selected four scores for creation of combination algorithm. The algorithm was able to classify 123/211 (58.3%) patients with a 93.5% accuracy of correct classification for prediction of presence/absence of significant fibrosis in main group. In validation group, the algorithm was able to classify 48/65 (73.8%) of patients with 93.8% (45/48) overall accuracy. When used to predict presence/absence of cirrhosis, the algorithm was able to correctly classify 181/211 (85.8%) and 59/65 (90.8%) of patients in main and validation group, respectively, with an overall accuracy of 97.8% and 98.3%, respectively. CONCLUSION: Developed algorithm based on routine laboratory tests is a usable, applicable and accurate tool for diagnosis of CHB related fibrosis and cirrhosis, suitable for resource-limited settings where more expensive modalities are unavailable.