Volume 32, Issue 1, 2024
Review
COVID-19 vaccines-associated Takotsubo cardiomyopathy: A narrative review
Hassanzadeh Shakiba,
Suleiman Addi,
Correia Joaquim J.,
Memar Montazerin Sahar
Takotsubo cardiomyopathy (TTC) is a severe, acute, reversible, and self-limited cardiac dysfunction. It usually affects postmenopausal women and is mostly triggered by physical or emotional stressors. Following the COVID-19 pandemic, millions of doses of different types of COVID-19 vaccines are being administered globally. There have been reports of different cardiac complications after receiving COVID-19 vaccines. To our knowledge, there have been 16 reported cases of COVID-19 vaccination-associated TTC. In this study, we first provide a brief overview of TTC and then an overview of selected reported TTC cases following COVID-19 vaccinations. It is crucial to highlight that the occurrence of TTC after vaccination does not establish a direct cause-and-effect relationship between immunization and TTC. Further investigations are necessary to examine any potential association between COVID-19 vaccines and the incidence of TTC. Additionally, the benefits of receiving COVID-19 vaccines significantly outweigh the potential risks of developing adverse events.
Monkeypox virus infections in low-risk groups during the 2022–23 global outbreak: An analysis of the WHO global report
Ramírez-Soto Max Carlos,
Arroyo-Hernández Hugo
Introduction. In the 2022-23 Mpox outbreak, cases also occurred in children, adolescents, and adults aged 50 years and older, for whom the risk of transmission is low and whose epidemiological characteristics are less known, compared to high-risk groups such as young adults. Here we describe the epidemiological characteristics of Mpox in children, adolescents and adults aged 50 years and older in the global Mpox outbreak.
Methods. A retrospective study on laboratory-confirmed surveillance data of Mpox cases reported to World Health Organization (WHO) was conducted. Case data from WHO's 2022-23 Mpox Outbreak: Global Trends from 1 January 2022 to 1 September 2023 was used for our analysis. We included cases reported by WHO with data on age (children [range, 0 to 9 years], adolescents [range, 10 to 17 years], adults 50 to 59 years, and adults 60 years and older), gender, WHO region, hospital admission, and intensive care unit admission.
Results. Until September 01, 2023, data from 89,752 cases of Mpox have been reported to WHO. Of all the reported cases, 1124 (1.3%), 6296 (7.0%) and 1501 (1.6%) were children and adolescents, adults aged 50-59 years, and adults aged 60 years or older, respectively, and the proportion varied among WHO regions. There was a high proportion of cases among population aged 0-17 years, adolescents (256 [66.3%]) from the region of the Americas and girls aged 0-9 years [127 (46.7%)] from the African region. Men aged 50–59 years [3495 (57.2%)] vs. 2553 (41.8%) cases from the region of the Americas and the European region, respectively) and men aged 60-69 years [639 (60.0%) vs. 607 (48.4%)]) from the region of the Americas and the European region) were most affected, compared to other age groups and women. Among children, adolescents, and adults aged 50 years or older, a low proportion of cases developed some complications and required hospital admission, and some cases were admitted to the intensive care unit.
Conclusions. Epidemiological evidence of Mpox in these low-risk groups highlights the risk of wider community transmission. Therefore, while efforts continue to control the global outbreak of Mpox in high-risk groups, it is also necessary to ensure that these low-risk groups have access to timely health care and vaccination.
On the use of intravenous metronidazole for severe and complicated Clostridioides difficile infection: a review and meta-analysis
Pipitone Giuseppe,
Granata Guido,
Sartelli Massimo,
Gizzi Andrea,
Imburgia Claudia,
Marsala Laura,
Cascio Antonio,
Iaria Chiara
The European Society of Clinical Microbiology and Infectious Disease (ESCMID) has advised against the use of metronidazole for fulminant Clostridioides difficile (C. difficile) infection (CDI) in their latest guidelines. They suggest using oral vancomycin alone instead. This recommendation is based on a few retrospective studies, which have multiple biases. We evaluated the three studies that led ESCMID to advise against intravenous metronidazole for fulminant CDI and performed a meta-analysis.
The meta-analysis revealed a mild (2.7%), not statistically significant (p=0.8) difference in mortality between the two groups. The high heterogeneity (I2= 89%) should also be noted. The decision to add or remove metronidazole should be discussed in the near future. In the meantime, combination therapy could be a cautious treatment for fulminant CDI.
Original article
Investigating the diagnostic and prognostic value of anti-SARS-CoV-2 Spike IgG/IgM ELISA tests in patients infected with coronavirus Delta variant
Pouladzadeh Mandana,
Hosseinzadeh Mofid,
Khedri Reza,
Moradi Choghakabodi Parastoo,
Amini Payam,
Ghorbani Bavani Alireza,
Bahrami Moghaddam Hossein,
Behmanesh Babak,
Delirrooyfard Ali,
Sokooti Alireza,
Sheibani Behnam
Aim: This study aimed to investigate the diagnostic and prognostic value of anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Spike IgG/IgM antibodies in patients infected with coronavirus Delta variant. Methods: This analytical observational study included 270 unvaccinated patients (aged ≥18 years) diagnosed with coronavirus disease 2019 (Covid-19) Delta variant who referred to Emergency Department of our hospital. The serum levels of anti-SARS-CoV-2 Spike IgG and IgM were measured by indirect ELISA. Main measured outcomes included anti-SARS-CoV-2 Spike IgG and IgM, chest computed tomography (CT) severity score, clinical and laboratory findings which were prospectively evaluated throughout the study period. Results: The IgM levels in critical patients were significantly higher than non-critical patients (p>0.05). But the mean level of IgG in critical patients was not significantly different from its level in non-critical patients (p<0.05). However, a significant positive correlation was observed between the levels of both antibodies and chest CT severity score (p<0.0001); this implies that their levels may reflect the degree of lung involvement. The IgM level on 15th-16th days after symptoms onset was significantly associated with the hazard of death even after adjusting for all other factors (adjusted HR (95%CI):1.28(1.014_1.63), p=0.03), whereas IgG was not (p>0.05). The survival probability among patients with IgM level ≥8.67 RU/ml (34.2%) was significantly lower than those with IgM level <8.67 RU/ml (99.5%, p=0.0001). Conclusions: Anti-SARS-CoV-2 Spike IgM antibody was significantly associated with the disease severity and risk of death in unvaccinated patients infected with coronavirus Delta variant. However, further large-scale investigations on diverse infected populations are required to precisely determine the diagnostic/prognostic value of these antibodies.
Clinical and microbiological profile of Viridans group streptococcal bacteraemia; experience from South India
Arjun Rajalakshmi,
Niyas Vettakkara Kandy Muhammed,
Hussain Febeena,
Surendran Sandeep,
Mohan Viji
Background: Viridans Group Streptococci (VGS) are a group of distinct species that can cause bacteraemia and other invasive infections. They are also among the common organisms causing infective endocarditis. Data on the epidemiology and clinical profile of VGS is limited, especially from India.
Methods: We conducted an electronic medical record-based retrospective analysis of patients with VGS bacteraemia admitted to our hospital between January 2012 to December 2021. Blood cultures were incubated by BacT/ALERT system and bacterial identification and susceptibility testing were done by using the VITEK 2 microbial identification system. Susceptibility test reporting was as per Clinical and Laboratory Standards Institute (CLSI) guidelines. The incidence, clinical profile, source of bacteraemia, co-morbidities and antimicrobial resistance among VGS bacteraemia were analyzed.
Results: VGS were isolated in 219 patients, accounting for 3.2% of positive blood cultures during the period studied. The median age of the patients was 58 years and 69% were males. Diabetes mellitus was the most common co-morbidity (55%) followed by chronic kidney disease and chronic liver disease. Patients with haematological malignancy and neutropenia were few. Intra-abdominal infections were the most common source of infection and was noted in 26%. Infective endocarditis was diagnosed in only 10% of the cases. Streptococcus mitis was the most common species isolated followed by S. gallolyticus and S. sanguinis. 9.58% of the isolates could not be identified up to the species level. Overall penicillin susceptibility was 71% and ceftriaxone susceptibility was 92%, with individual species variation. In-hospital mortality was 19%.
Conclusions: VGS are an important cause of bacteraemia and was associated with 19% mortality in our study. High rates of penicillin and ceftriaxone resistance are a reason of concern. Molecular diagnostics like matrix assisted laser desorption ionization-time of flight (MALDI-TOF) identification must be increasingly applied for species identification considering that a substantial number of isolates were not identified to species level.
Risk factors for therapeutic failure in adults with methicillin-resistant Staphylococcus aureus (MRSA) infection treated with vancomycin in a high-complexity hospital in Cali, Colombia
Muriel Carlos Mauricio,
García-Goez Jose Fernando,
Ortega Delia,
Martínez Diana,
Rosselli Diego
Objective: To determine the risk factors associated with therapeutic failure of vancomycin in hospitalized adult patients with methicillin-resistant Staphylococcus aureus (MRSA) infections.
Design: Case-control study.
Setting: Conducted in a high complexity hospital in Cali, Colombia.
Participants: Adult hospitalized from January 1, 2015, to December 31, 2021, with MRSA infections with confirmed microbiological isolation.
Methods: Cases were patients with therapeutic failure of vancomycin (mortality, poor clinical improvement, change of antibiotic used, early relapse, or persistence of positive blood cultures) and control patients were those who did not present failure. Significant variables from the bivariate analysis were included in a multiple analysis with an asymmetric logistic regression model.
Results: A total of 105 patients were included in the study, 28 in the treatment group and 77 in the control group. The median age was 49 years and 59 (56%) of participants were men. The following variables: age (OR 1.034; 95% CI 1.007-1.061, p = 0.011), osteomyelitis/septic arthritis (OR 6.035; 95% CI 2.282-15.956, p = 0.000) and minimum inhibitory concentration (MIC) (OR 5.971; 95% CI 1.321-26.979, p = 0.020) were found to be independent risk factors associated with therapeutic failure of vancomycin. Vancomycin trough levels were not different between cases and controls (OR 0.976; 95% CI 0.911- 1.044, p = 0.478).
Conclusions: When a multiple analysis was performed to control for confounding factors, only 3 variables were found to be significant and were considered risk factors for therapeutic failure of vancomycin in adult patients with MRSA infection: age, MIC, and osteomyelitis/septic arthritis.
Seroprevalence of Chlamydia trachomatis and associated risk factors among HIV positive women in North Central Nigeria
Omosigho Pius Omoruyi,
Ajide Tope Elizabeth,
Izevbuwa Osazee Ekundayo,
Okesanya Olalekan John,
Oladejo Janet Mosunmola,
Uyigue Paulinus Osarodion
Introduction: Chlamydia trachomatis infection is among the STDs that are known to increase the risk of HIV infection. The present study aims to determine the seroprevalence of C. trachomatis among HIV positive women in Ilorin and Offa, Kwara State, North Central Nigeria.
Methods: Serum samples from 400 HIV positive women attending the HAART Clinic in Offa and the Ilorin General Hospital in Kwara State, Nigeria, were screened using Enzyme Linked Immunosorbent Assay (ELISA), utilizing the immunocomb Chlamydia IgG test kit (Calbiotech, El Cajon, CA, USA) to check for the existence of anti-C. trachomatis antibodies.
Result: Anti-C. trachomatis antibodies were present in 92 (23.0%) of the 400 HIV positive women samples. There was a higher prevalence among the age group 36–40 years. Hence, age groupings were statistically and significantly associated (p=0.001) with the seroprevalence of C. trachomatis among HIV positive women. Married HIV positive women (60.9%) had the highest prevalence of C. trachomatis, with a statistically significant association (p=0.001). There was a statistically significant association between the number of sexual partner(s) (p=0.001) and the seroprevalence of C. trachomatis among HIV positive women.
Conclusions: The high frequency confirms the necessity for comprehensive sexual education among young adults and routine testing for anti-C. trachomatis. It reflects the endemicity of the infection in Ilorin and Offa Kwara State, Nigeria.
Development of a clinical scoring system to make a presumptive diagnosis of Kyasanur Forest Disease: a case-control study from South India
Gupta Nitin,
Boodman Carl,
Saravu Kavitha
Introduction. Kyasanur Forest Disease (KFD) is a viral haemorrhagic fever endemic in South India. Based on clinical presentation alone, it is challenging to distinguish KFD from other febrile illnesses in the region. The study aimed to develop a clinical scoring system for early presumptive diagnosis of KFD.
Patients and methods. This retrospective case-control study included microbiologically diagnosed KFD patients (n=186) with other undifferentiated febrile illnesses as controls (n=203). The clinical and laboratory features between cases and controls were compared. A logistic regression analysis included those variables found to be significantly associated with KFD on univariate analysis. The adjusted odds ratio for the significant variables was calculated and converted into logarithmic scales. These numbers were rounded off to the nearest integer to find the score assigned to each variable. A receiver operating characteristics curve was created to find the best cut-off for the scoring system that predicted the diagnosis of KFD.
Results. A total of 186 anonymised cases and 203 anonymised controls were recruited from the records for this study. Myalgia, headache, lymphadenopathy, bleeding manifestations, Central Nervous System (CNS) involvement, raised haematocrit, leukopenia, and raised transaminases were more common in patients with KFD. Except for lymphadenopathy and raised transaminases, all the other variables were independent predictors of making a diagnosis of KFD. Since raised transaminases tended towards significance, it was included in the scoring system with other independent predictors. A scoring system was created with a maximum score of 12. The receiver operating characteristic curve showed an Area Under Curve of 0.912 (95%CI: 0.88-0.94). A score of 4 or more was found to have a sensitivity and specificity of 83% and 87%, respectively.
Conclusion. The presence of specific features should alert primary care physicians working in endemic areas about the possibility of KFD. This diagnostic scoring system can be used to make a presumptive diagnosis of KFD after undergoing a prospective validation study.
Prevalence of Rotavirus antigen in children with gastroenteritis in Auchi Etsako West Local Government Area, Edo State, Nigeria
Omosigho Pius Omoruyi,
Osayekewmen Ugiagbe Victory,
Oghogho Guobadia Precious,
Okesanya Olalekan John,
Oladejo Janet Mosunmola,
Osarodion Uyigue Paulinus
Introduction: This study aimed to determine the prevalence of rotavirus infection among children in Auchi, Edo State, Nigeria, and its association with selected demographic factors. Rotavirus infections are a major cause of viral gastroenteritis in children globally, and despite the availability of vaccines, they continue to pose a significant health burden.
Methods: The study population consisted of 200 children aged 2-15 years, with data collected through a questionnaire and stool samples analysed using Enzyme Linked Immunosorbent Assay (ELISA) kits (Abbexa, UK) following the manufacturer’s instructions.
Results: The overall prevalence of rotavirus infection was found to be 6%, which was relatively low compared to previous studies in Nigeria and other countries. The study revealed that children in the age group of 6-10 years had the highest prevalence of rotavirus infection, while the prevalence was lower among nursery and secondary school children. There was no significant association between any of the participant's demographic factors and rotavirus infection. However, living in rural areas was associated with a higher risk of rotavirus infection compared to semi-urban and urban areas.
Conclusions: The study emphasizes the importance of rotavirus vaccination, promoting good hygiene practices, and raising awareness among parents, caregivers, and healthcare professionals. Further investigation is needed to explore additional risk factors and improve understanding of rotavirus infection in this population.
Histopathologic and transmission electron microscopic findings in monkeypox cutaneous lesions
Venturi Consuelo,
Guadagno Antonio,
Varesano Serena,
Ricucci Valentina,
Nigro Nicola,
Di Biagio Antonio,
Bassetti Matteo,
Nozza Paolo,
Drago Francesco,
Parodi Aurora,
Ciccarese Giulia
Background: a few pathologic and ultrastructural findings of monkeypox skin lesions are available in the literature. To integrate such evidence, we aimed to describe the pathologic features of monkeypox skin lesions and to show monkeypox virions by transmission electron microscopy (TEM). Methods: we studied the cutaneous biopsies of three patients affected by monkeypox during the 2022 monkeypox outbreak. Skin biopsies have been collected only from body sites with a recent laboratory‐confirmed mpox virus infection, defined by a polymerase chain reaction (PCR) positive result in specimens taken through skin swabs. Results: in all the samples the epidermis showed keratinocytes ballooning degeneration; perivascular/peri-adnexal infiltrates composed of neutrophils and lymphocytes were observed in the deep dermis. Immunohistochemistry showed that the infiltrate was mostly composed of CD3+ T-cells. TEM revealed monkeypox virus-like particles in various stages of morphogenesis in the dermis and epidermis; virions were interspersed among keratinocytes and within their cytoplasm. At the intracellular level, virions showed a biconcave-shaped central core, surrounded by lateral bodies and an external membrane; they also appeared as rectangular, brick-shaped, or oval particles with eccentric nucleoids. The histologic features of our skin samples confirmed the few other studies on this topic, except for the eosinophilic inclusions of the cytoplasm of keratinocytes (Guarnieri’s bodies). Conclusion: the role of molecular biology is crucial for monkeypox diagnosis but when it is not disposable and/or in doubtful cases, skin biopsy and TEM may be helpful to establish the diagnosis.
Seroprevalence of Crimean-Congo hemorrhagic fever virus in the population of Turkestan region
Abuova Gulzhan Narkenovna,
Berdaliyeva Farida Abdullayevna,
Polukchi Tatyana Vasiliyevna,
Aliyev Daulet Sabyrovich,
Raymkulov Gulamzhan Sattarkulovich,
Kulemin Maksim Vladimirovich,
Saylaubekuly Ratbek
Purpose. To determine the level of seroprevalence to the virus of Crimean-Congo Hemorrhagic Fever (CCHF) in population of rural area of the particular districts of Turkestan region, Kazakhstan and its connection with epidemiological alerts.
Materials and methods. For determining the real Crimean-Congo hemorrhagic fever virus (CCHFV) circulation in Turkestan region, Kazakhstan, massive sero-epidemiologic studies were conducted. Healthy residents of Turkestan Region aged from 10 to 75 years were examined without having been previously registered with CCHF. After receiving an informed consent, 5 ml of venous blood was collected for ELISA assay using the following test kits: VectoCrimea-CHF-IgG and VectoCrimea-CHF-IgM by the Vector-Best JSC. Findings on CCHF morbidity rate along with prevalence of ticks were received from the reports of the Committee of Sanitary and Epidemiological Control of the Ministry of Healthcare of the Republic of Kazakhstan.
Results. Blood serum samples were collected prospectively from 4259 residents in all 16 districts of rural areas of Turkestan region. CCHF seroprevalence was detected in 2.39 % of cases. Anamnesis of a tick-bite along with livestock contact in 18-30 years and 41-50 years age groups were considered as risk factors. The highest rate of CCHF seroprevalence was determined in the following recognized endemic regions and districts, namely Sozak District (4.04%), Turkestan Region (3.85 %), Jetisu Region (3.6 %). Reactivity probes were detected in residents of all 16 districts of Turkestan Region. The research statistics displayed that CHHF pathogen considerably increased its circulation in the endemic regions and the disease communicated into a number of new districts.
Conclusion. IgG ELISA was performed to screen CCHFV in 4259 village inhabitants of Turkestan Region and revealed the presence of antibodies in 2.39 % of its population. Weak linear correlation relationship was established between CCHFV seroprevalence rate and CCHFV morbidity rate in the particular districts of Turkestan Region. As people grow older, CCHFV IgG detection rate increases. Living on CHHF endemic territories is a serious risk factor to become CHHF positive which is characterized by manifestation of the subclinical forms of this disease.
Prevalence of vaccine-derived poliovirus in sewage waters in Maiduguri, Borno State, Nigeria
Bislava Sakinatu Buba,
Daja Aliyu,
Oderinde Bamidele Soji,
Uzairu Sani Muhammad
After a long global battle with wild poliovirus, the virus has been defeated through researches and vaccination using the oral polio vaccine and inactivated polio vaccine as well as sensitization. The issue that is now of global concern is that of vaccine-derived poliovirus which emerged from the unstable oral polio vaccine. Ninety sewage water samples were collected from slums in Maiduguri using grab method, concentrated using two phase separation method and subjected to intratypic differentiation and vaccine-derived poliovirus screening. The result revealed the presence of Sabin 1in 17 samples (61,0%) and Sabin 3 in 22 samples (79,0%), all of which were positive after vaccine-derived poliovirus screening. The presence of strains of Sabin 1 and Sabin 3 in the sewage water samples collected is an indication of virus shedding in individuals which could be as a result of vaccination or contact with the faeces infected or vaccinated individuals
Case report
An unusual case of Brucella melitensis-related wound infection
Alkan Bilik Ozge,
Ince Fatma Meral,
Ozcan Nida,
Ayaydin Zeynep
Background: Brucellosis is an anthropo-zoonotic infectious disease caused by various Brucella species. It is usually transmitted through contact with infected animals or consumption of contaminated animal products. Brucellosis most commonly affects the musculoskeletal and reticuloendothelial system with additional involvement observed in gastrointestinal system, urinary tract, reproductive system, central nervous system, and cardiovascular system. Skin involvement is extremely rare in brucellosis. Here, we report a rare case of Brucella melitensis infection developing in a back wound following a lumbar disc herniation surgery over 14 years ago.
Case: A 34-year-old male patient, who had a herniated disc surgery 14 years ago, was admitted to the hospital with complaints of joint pain, sweating and discharge at the surgery site. Wound culture revealed the presence of Gram negative cocobacilli which was identified as Brucella melitensis. The subsequent diagnostic tests, including the Rose-Bengal and Brucella Capture test positivity at a titer of 1/320 confirmed the diagnosis.
The patient received six weeks of doxycycline (200 mg/day, orally) and rifampin (600 mg/day orally) treatment, accompanied by wound care procedures. Daily cleaning, sterile dressing, and wound debridement were employed. Following treatment, the patient's condition improved, and wound discharge ceased. Continuous monitoring showed no signs of relapse, achieving complete remission.
Conclusion: Brucella spp. should be considered as a potential cause of wound infections developing after surgery or trauma in brucellosis-endemic areas. This report also emphasizes the importance of promptly determining the cause of infection before initiating antibiotic treatment
Presumptive pulmonary toxocariasis in a patient affected by acute myeloid leukemia and Hodgkin lymphoma: case report and review of the literature in immunocompromised hosts
Lupia Tommaso,
Crisà Elena,
Sangiorgio Valentina,
Bosio Roberta,
Stroffolini Giacomo,
Staffilano Elena,
Gregorc Vanesa,
Corcione Silvia,
De Rosa Francesco Giuseppe
Toxocariasis is a zoonosis transmitted by the nematode Toxocara spp. Immunocompromised hosts are more susceptible than general population to bacterial, viral, fungal and parasitic infections. In this population toxocariasis may present as exacerbation or reactivation and could have severe or atypical manifestations being a diagnostic challenge for healthcare providers. We report a case of a presumptive pulmonary toxocariasis during chemotherapy in a patient affected by acute myeloid leukaemia (AML) and Hodgkin lymphoma and we summarize current evidence of pulmonary involvement in immunocompromised population with Toxocara spp infection in a narrative review. The aim of this work is also to revise the current literature on pulmonary involvement during Toxocara spp infection in immunocompromised hosts to improve knowledge on clinical presentation, treatment and outcome. A 66 years old man who had undergone to a cytarabine and idarubicin chemotherapy induction scheme for AML, complained of febrile neutropenia and dry cought. At the chest computed tomography (CT) there were multiple nodular pulmonary lesions with subpleural consolidations. The lung biopsy revealed inflammatory infiltration with diffuse small granulomas with minor eosinophil component. The laboratory analysis showed high immunoglobulin E (IgE) count with normal peripherical eosinophils, among the extended parasitological analysis, Toxocara immunoblot assay resulted positive. In the most accepted hypothesis of a polmunary toxocariasis infection, the patient was treated with a combination of albendazole plus corticosteroids for four weeks, with a positive outcome. Infection complications during chemotherapy are not uncommon, however, this is the first reported case of pulmonary toxocariasis during cytarabine and idarubicin treatment in AML. The revised literature shows male gender and younger age as possible risk factors, nevertheless the majority of cases of seropositivity for Toxocara was reported in solid organ malignancies. In this case, the suspect was mainly based on laboratory total elevated IgE, confirmed by serological, anatomo-pathological and radiological findings. Hypereosinophilia is often not present in chronic infection. In conclusion, pulmonary toxocariasis should be ruled out in patients with pulmonary involvement and high IgE titre, with or without peripheral eosinophilia, especially in those with known immunocompromised status.
The Infections in the History of Medicine
Asclepieia in ancient Greece: pilgrimage and healing destinations, the forerunner of medical tourism
Pavli Androula,
Maltezou Helena C.
Asclepios, the first physician-demigod in Greek mythology, was born in Thessaly of the God Apollo and Coronis, a mortal mother. Asclepieia were healing sanctuaries dedicated to Asclepios. Asclepieia were located throughout the Eastern Mediterranean area, in ancient Greece and the Roman world. Travelers from all over the Mediterranean area seeking healing made pilgrimages to the Asclepieia, the early forerunner of “medical tourism”.
Letters to the editor
HCV screening in hospitalized patients: new challenges and opportunities for the target of microelimination
Garlatti Costa Elena,
Moratto Anna,
Villalta Danilo,
Da Re Mirella,
Basaglia Giancarlo,
Tonizzo Maurizio,
Grazioli Silvia
Not available
