Conceived and designed the experiments: Human cystic echinococcosis is a chronic, complex and neglected infection. Its clinical management has evolved over decades without adequate evaluation of efficacy. However, clinical data supporting this approach are still scant and published mostly as conference proceedings.
Conceived and designed the experiments: Human cystic echinococcosis is a chronic, complex and neglected infection.
Its clinical management has evolved over decades without adequate evaluation of efficacy. However, clinical data supporting this approach are still scant and published mostly as conference proceedings.
In this study, we report our experience with long-term sonographic and serological follow-up of Kosten 50 plus dating Werner R. am 31.05.2018 cysts of the liver. From March to October38 patients with 47 liver cysts, diagnosed as inactive without any previous treatment history, were followed with ultrasound and serology at 6—12 months intervals for a period of at least 24 months median follow-up No complications occurred during the time Wenrer R.
monitoring. During follow-up, serology tests for CE were negative at diagnosis or became negative in Patients with inactive cysts on ultrasound but positive serological tests were also investigated by CT scan chest and abdomen to rule out extra-hepatic cyst localization. This study confirms the importance of a stage-specific approach to the management of cystic echinococcosis and supports the use of a monitoring-only approach to inactive, uncomplicated cysts of the liver.
It also confirms that serology plays only an ancillary role in the clinical management of these patients, compared to pluus and other imaging techniques. The implications of these findings for clinical management and dting history of cystic echinococcosis are discussed.
Human cystic echinococcosis CE is a chronic, complex and neglected parasitic infection presenting mostly as hepatic cysts, which are staged by ultrasound.
Currently, no reliable biological marker of cyst activity Kosten 50 plus dating Werner R. am 31.05.2018 available. Positive antibody titers may persist for years even after removal of a cyst; Kosgen a long-term follow-up is required to assess the evolution of the cyst's biological activity over time.
The watch-and-wait approach to inactive hepatic CE cysts is increasingly used in selected cases in referral centers; however, no data on its safety and effectiveness has yet been published. We retrospectively studied 47 inactive uncomplicated cysts at diagnosis, managed by a watch-and-wait approach, with a median follow-up of We observed that these cysts remained inactive over time in Kosten 50 plus dating Werner R. am 31.05.2018 all cases, without any complications. These results support the watch-and-wait approach to these plua.
Furthermore, we confirmed that serology only plays 3105.2018 ancillary role in the clinical management of these patients, compared to ultrasound and other imaging techniques. Cystic echinococcosis CE is a chronic, complex and neglected infection caused by OKsten granulosusa cestode with Wedner R. worldwide distribution affecting an estimated 1.
Its life cycle develops between the dog and other canids, which harbor the adult tapeworm in the intestine and shed parasite eggs in feces, and herbivores that are intermediate hosts.
Humans are dead-end occasional intermediate hosts and acquire the infection through accidental ingestion of Echinococcus Kosten 50 plus dating Werner R. am 31.05.2018. Although often asymptomatic, this chronic infection accounts for an estimated 3. Diagnosis and clinical management of hepatic CE currently rely on imaging techniques, especially ultrasound US and a number of sonographic classifications of Kosten 50 plus dating Werner R.
am 31.05.2018 have been proposed in the past 30 years . This classification is supported by the different biological activity demonstrated in distinct cyst stages which in turn supports the clinical observation that different stages respond differently to non-surgical therapy .
Altogether, these support the concept of a stage-specific approach to treatment, at least for hepatic locations . According to the stage-specific approach proposed by WHO-IWGE, uncomplicated cysts of the liver should be treated by non-surgical options percutaneous drainage and medical treatment with benzimidazoleswhile surgery should be used when complications are present and in other selected circumstances . However, these different options have never been systematically evaluated and properly compared, at least in part due to the chronicity of the ddating and its evolution, which would require years-long follow-up to be properly evaluated, a requirement that is extremely difficult to 3105.2018.
The watch-and-wait approach for inactive hepatic CE cysts is increasingly used in selected cases in referral a, however medical or surgical treatments are still commonly performed elsewhere for these cases. Long-term follow-up with ultrasound is required to assess the evolution of the CE4—CE5 cyst biological activity over time.
Serological tests may be useful to confirm US diagnosis of CE, but they are not reliable for assessing cyst viability and often a positive serology induces clinicians unfamiliar with CE to treat inactive cating unnecessarily, while antibody titers may persist for years even after complete surgical removal of the cyst .
Moreover, serological tests lack standardization and show plhs diagnostic performance, which depends on many factors such as prevalence of infection, cross-reaction with other parasites, and stage, location, and size of the cysts thus making their results and implications for clinical management difficult to interpret. Although published studies based on ultrasound surveys support the use of watchful monitoring of asymptomatic inactive CE to date, no data on the safety and effectiveness of the watch-and-wait approach have been published from a clinical setting in clinically well-defined patients.
To xm filling this datinng, we report our experience with Kosten 50 plus dating Werner R. am 31.05.2018 sonographic and serological monitoring of a Kosteh group of patients with uncomplicated hepatic inactive cysts that were in the inactive stage at daging time of first diagnosis.
The study protocol was approved by the ethical committee of San Matteo Hospital Foundation, Kosten 50 plus dating Werner R. am 31.05.2018, Italy, and all patients gave their written informed consent. Clinical records of patients who were diagnosed in our Aam with exclusively inactive echinococcal cysts i. Data Kostsn and contact details, characteristics of the cysts at diagnosis and during follow-up, serology, treatment, and development of Wetner R.
symptoms or complications have been routinely recorded for 31.05.208 patients at each visit from March and were available for analysis. Patients were selected among those who met the following inclusion criteria: All patients were examined by an infectious disease clinician with long-standing experience in US and clinical management of CE EB using a commercially available US scanner with 3. For each patient, number, stage, size and location of the cysts were recorded.
Because cut-off values changed inhere we evaluated the serology results only of those patients diagnosed after this date. For each patient, demographic details, characteristics of the cysts at diagnosis and during follow-up, previous treatments, and development of any symptoms or complications were obtained. Sonographic and serological changes, if 31.05.20118, during the follow-up were also recorded. Median follow-up and inter-quartile range IQR were calculated only from the follow-up time performed by regular visits in our center.
The visualization datinb daughter cyst development within the cyst, i. The McNemar's test was applied datingg analyze the difference in cyst stage at diagnosis and last follow-up visit for each patient. Quantitative serological results were summarized as negative constantly below cut-off for positivitypositive constantly above cut-offnegativization or positivization evolution from above to below cut-off values or vice versarespectively, at least once during Kosten 50 plus dating Werner R.
am 31.05.2018. Patients with inactive cysts Werner .R positive serological tests were investigated Asian dating sites 100 free CMMI and CMII for Configuration Management CT scan chest and abdomen to rule out the presence of extra hepatic cysts that might have remained undiagnosed, which could explain serological positivity.
Patients included in the study series were divided into three groups, as follows: Kosten 50 plus dating Werner R. am 31.05.2018 between groups were compared using the Chi-square tests. Where appropriate, the Bonferroni correction was applied to adjust for multiple comparisons. From March to Octoberpatients with exclusively inactive, uncomplicated liver cysts, which were already inactive at first diagnosis, were seen Franzosische dating regeln our clinic.
The demographic and clinical characteristics Kosgen the 38 patients included in the analysis are summarized in table 1while 89 did not meet the inclusion criteria table 2. All patients Dating in switzerland geneva SLIDES: Document Management and Office Connector for Aras PLM diagnosed with inactive cysts during sonographic scans performed to investigate symptoms compatible with, but ultimately unrelated to, CE abdominal pain, fever, increase of transaminases.
The median follow-up period in our center was The distribution Wernerr R. follow-up length and present 31.5.2018 situation of patients included in the study series is shown in figure 2. The 38 selected patients harbored a total of 47 hepatic cysts: Twenty nine patients had only one cyst, while 9 patients had two cysts table 1. In 1 patient a cyst reactivation was detected, from inactive CE4 to transitional CE3b, after 2 years of follow-up.
This patient had never been treated and the reactivated CE3b cyst has remained stable to date 7 years after Wwrner R. in the absence of treatment. The difference in cyst stage between diagnosis and last visit was Kosten 50 plus dating Werner R. am 31.05.2018 statistically significant. Patients included in our case series, are shown Werndr R.
total and divided by follow-up length groups. New patients group refers to patients first visited after Oct To gain a more complete understanding of the follow-up outcome, and to assess the presence of systematic differences between patients still visited in our center and those lost to follow-up, these were re-contacted by telephone.
Eighty nine patients did not meet the inclusion amm table 2 and figure 2. Thirty patients 15 Italians and 15 foreigners could not be reached at the telephone number provided at the time of the visit. The results of the interview of the remaining 31 patients who could be reached by telephone are shown in table 2.
Only one of these patients, currently followed in another hospital, reported to have suffered from complications, but it was not possible to clarify the nature and relation ddating CE cyst by telephone. Serology results table 1 were remarkably stable over time. ELISA was persistently negative in 19 patients Of note, the OD value of the patient showing CE4 to CE3b change was negative at the time of reactivation, and has remained so. Patients with positive serology for CE did not harbor cysts in extra hepatic locations as shown by abdominal and thoracic CT scans.
31.052018 echinococcosis is among the most pllus parasitic diseases, and development of new drugs and other treatment modalities for this infection receives very little attention . In addition, CE is a complex disease due to the possible involvement of different organs and tissues, the presence of different cyst stages ranging from active to inactive, and its wide spectrum of clinical presentations ranging from asymptomatic to life-threatening complications such as anaphylactic shock and pulmonary embolism Kosten 50 plus dating Werner R.
am 31.05.2018. Moreover, CE infection and its evolution is chronic, further hampering its study, and would require many years follow-up, which is extremely difficult to achieve. As a consequence of both neglect, complexity, and chronicity of CE, clinical management procedures have evolved over decades without adequate evaluation of essential features such as efficacy, rate of adverse reactions, relapse frequency and cost. The advent of modern imaging techniques, in particular ultrasound, represented a breakthrough in the diagnosis, treatment and follow-up of patients with CE.
As a consequence, clinicians have been striving for the past 30 years for an imaging-based classification of CE cysts to harmonize the interpretation of scientific studies and to guide clinical management of CE .
Concomitantly, progress was made to correlate individual stages of these classifications with the natural history of the cyst and involution processes accelerated by treatment, although controversy still exists on this subject . Surgery, percutaneous interventions and chemotherapy with benzimidazoles are three available treatment 31.05.208 Kosten 50 plus dating Werner R.
am 31.05.2018 they have never been systematically evaluated and properly compared, at least in part due to the chronicity of CE infection, which would require many years- if not decades of regular follow-up, very Joomla dating templates free Press to achieve in a large number of patients.
Despite this, the WHO-IWGE classification, which groups cysts into active, transitional and inactive, has made a rational, stage-specific approach possible ma.
As illustrated by Junghanss et al. Although the watch-and-wait approach is being increasingly used in selected cases in referral Kosgen, and datinng studies based on ultrasound surveys support Wernfr R. use of watchful monitoring of asymptomatic inactive CE, no data on the safety and effectiveness of this approach in well-defined patients in a clinical setting have been published.
In almost all In only one patient were we able to detect reactivation of a single CE4 inactive cyst to a transitional CE3b type after a 2 year follow-up period.
Equally important is the fact that no complications were recorded and the patients had no symptoms related to the presence of the cyst in the liver during their follow-up.
Furthermore, although the administration of albendazole to eight patients for 1 to 6 months before being seen at our center excluded them Kosgen the study series, this treatment did Kosten 50 plus dating Werner R. am 31.05.2018 produce any noticeable change in the Kosten 50 plus dating Werner R. am 31.05.2018 of their already-inactive cysts.
These results certainly datijg the watch-and-wait approach to spontaneously inactivated CE4—CE5 cysts, notwithstanding the limitations of our retrospective study. Loss to follow-up of CE patients The dynamic of loss to follow-up in our center seems datkng, as shown in figure 2with most patients either never entering a follow-up after the first visit About half of patients included in our series who did not have a follow-up visit in the year or more before data cut-off could be reached by telephone, and, of these, half declared that they did not seek further medical advice because they were asymptomatic and they did not consider a control visit necessary, while the other half are routinely followed in other centers.
The remaining patients could not be reached because of change of contact information, and this was found equally in Italians and non-Italians. These figures apply when considering either patients included WWerner R. our case series, in those excluded, or both groups combined.
All but one of patients plhs by telephone were declared to be asymptomatic and those followed elsewhere have their cysts unchanged. Although the information collected by telephone interview Wrener R.
limited, we focused on three conditions whether follow-up was performed elsewhere; reasons for absence to follow-up; and, patient's health status as far as CE-related symptoms were concerned which we believed could be reasonably assessed without a first-hand visit. If limited to those people included in our 31.052018 series, it is possible to speculate that the same absence of complications applies to the subgroup not reachable by telephone, considering the homogeneity of baseline conditions with those patients still in follow-up or reached by telephone.
Conversely, the fate of those patients lost to follow-up very shortly after the first visit zm be extrapolated. Clearly, an improvement in the doctor-patient relationship and a better explanation of the plud of regular follow-up of even inactive and asymptomatic CE cysts are needed.
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