Volume 27, Issue 3, 2019
Review
Diabetic calcaneal osteomyelitis
Waibel Felix W.A.,
Uçkay Ilker,
Sairanen Kati,
Waibel Lorenz,
Berli Martin C.,
Böni Thomas,
Gariani Karim,
Lipsky Benjamin A.
Diabetic foot infection (DFI), a multi-facetted disease requiring a multidisciplinary approach for successful treatment, mostly affects the forefoot. Calcaneal osteomyelitis (CO) is an uncommon presentation of DFI with a somewhat different epidemiology, clinical features, and approach to management. These patients, compared to those with non-calcaneal DFI, more often require special surgical techniques and off-loading approaches. In this narrative review targeted to non-surgical clinicians, we explore how CO differs from other types of DFI affecting other anatomical locations. Based on our review of the literature and personal experience, we also highlight important issues regarding the management of CO osteomyelitis, including the need for specialized surgical approaches.
Drug-drug interactions in anti-HCV therapy: a comparison among options available in Italy
Di Perri Giovanni,
Cariti Giuseppe
After a long period of interferon-and ribavirin-based therapy (IFN/RBV), a very fast evolution in the development of directly acting antivirals (DAAs) has now established a totally new paradigm for the treatment chronic HCV infection. An efficacy rate within the 95-100% interval, safer and more tolerable drugs, much shorter treatment duration and a quicker establishment of the sustained virological response (SVR) are among the most relevant properties of new DAAs as compared to former IFN/RBV therapies. The last wave of DAAs is also characterized by a lesser tendency to generate or being victim of drug-drug interactions.
Nevertheless, since the circumstances in which patients are also recipients of other medications are rather frequent, individualization of treatment is advised in order to minimize the risk of drug-drug interactions of clinical relevance. Three two-drug regimens are available in Italy for the treatment of chronic HCV infection: sofosbuvir/velpatasvir (SOF/VEL), glecaprevir/pibrentasvir (GLE/PIB) and grazoprevir/elbasvir (GZP/RLB). Based on the officially released summary of product characteristics (SmPC) of these three co-formulated dual regimens, we performed a comparative analysis concerning the drug-drug interactions possibly affecting the DAA regimens. According to specific individual conditions, including co-morbidities, the choice of the most appropriate regimen must carefully take into account, among the different variables, the metabolic profile of both DAAs and concurrent medications.
Original article
Educational ICU Antimicrobial Stewardship model: the daily activities of the AMS team over a 10-month period
Cappanera Stefano,
Tiri Beatrice,
Priante Giulia,
Sensi Emanuela,
Scarcella Marialaura,
Bolli Lorenzina,
Costantini Monya,
Andreani Paolo,
Sodo Susanna,
Martella Lucia Assunta,
Francisci Daniela
The emergence of antibiotic resistance as a consequence of inappropriate use results in higher mortality rates and has become a major public health challenge worldwide. Antimicrobial stewardship programs (ASPs) aim to ensure proper use of antimicrobials and reduce health care costs. We assessed the impact of using a behavioral approach during a persuasive ASP on antibiotic appropriateness, consumption and costs. We conducted a prospective interventional cohort before-and-after study in the intensive care unit (ICU) of a 554-bed, university teaching hospital in Terni, Italy, 14 of which are located in the ICU. We describe a 10-month persuasive ASP intervention model used in a referral ICU with daily rounds. The aim of the study was to improve medication appropriateness through educational action and reduce the consumption of carbapenems and echinocandins by conducting post-prescription reviews, prescribing reviews and holding daily discussions with the ICU team. We analyzed the prescribing appropriateness of the ICU team in accordance with the decisions made by the Antimicrobial Stewardship (AMS) team to improve the quality of antibiotic prescribing during the first five months and the last five months of the surveillance period. The results were expressed as the defined daily dose (DDD) per 100 occupied bed-days and costs. The data were compared with those previously obtained during the pre-educational period (the year before ASP implementation). Comparisons were made between the decisions taken to improve antimicrobial treatments administered during the first half of the surveillance period (March-July) and those administered during the second half (August-December). In all, 116 decisions were made from March to July while only 65 were made from August to December (p-value 0.00001). A significant reduction was observed in the consumption of carbapenems and echinocandins (11.15% and 25.62%, respectively). Total antibiotic cost savings amounted to 57,541.16 euros. The persuasive ASP strategy positively influenced the prescribing behavior of physicians, thus improving the appropriateness of antibiotic therapy and reducing antimicrobial consumption.
Risk factors for central venous catheter-related bloodstream infections
Bekçibaşi Muhammed,
Dayan Saim,
Aslan Emel,
Kortak Mehmet Zeki,
Hoşoğlu Salih
Our study aimed to identify the risk factors playing a role in central venous catheter-related bloodstream infections (CR-BSI) in a tertiary large volume university hospital. The current prospective clinical trial was conducted in a university hospital with 1400 beds. All demographic data, length of hospital stay, coexisting diseases, features of catheters used, invasive diagnostic and therapeutic procedures and all antibiotics used in patients with CVCs were recorded. A total of 356 CVCs inserted in 281 patients were followed up for 5667 catheter days. The mean duration of catheterization was recorded as 15.9±12.7days. CR-BSI was detected in 46 (12.9%) patients. The incidence of CR-BSI was found to be 8.12 in 1000 catheter days. Advanced age and longer duration of catheterization were found to be independent risk factors for the development of CR-BSI in multivariate analysis. Coagulase-negative staphylococci (15.2%), Candida spp (13%) and Klebsiella pneumoniae (13%) were the agents most frequently isolated.
Trends in the antibiotic resistance of S. aureus clinical isolates: a 4 years retrospective study in a teaching hospital in South Italy
Ronga Luigi,
Abbasciano Angela,
Calia Carla,
Mosca Adriana,
Battista Michelina,
Sparapano Eleonora,
De Carlo Carmela,
Miragliotta Giuseppe,
Del Prete Raffaele
Staphylococcus aureus is responsible for life-threatening conditions, while in the meantime it has rapidly acquired resistance to several antibiotic classes. In the context of an effective empirical antibiotic therapy, an accurate evaluation of the resistance rates of S. aureus may be critical. The aim of this study was to determine the resistance rates of S. aureus in the years 2015-2018 and to assess the impact of specimen stratification on the resistance rates.
We have retrospectively analysed S. aureus strains isolated from blood, bronchial aspirate, pus, sputum and urine collected from hospitalized and ambulatory care patients. The comparison between resistance rates from 2015 to 2018 and among different specimens was assessed by Fisher's exact test followed by Benjamini and Hochberg’s correction of the p-values.
Higher resistance rates were detected for penicillin followed by oxacillin, levofloxacin, erythromycin and clindamycin. Differences in the annual resistance rates were not statistically significant after the BH's correction. The comparison between cumulative S. aureus resistance rates stratified by specimens showed some statistically relevant differences among the five specimen types. In particular, p-values were statistically significant for clindamycin, erythromycin, gentamicin, levofloxacin, oxacillin, penicillin and vancomycin.
Annual resistance rates of S. aureus clinical isolates remained constant over the course of time. Moreover, the stratification of the data by specimen may significantly impact on the evaluation of the resistance rates, at least for some antibiotics. Therefore, if the number of data is high, stratification by specimens may be recommendable to better approach an empirical antibiotic therapy.
Cognitive impairment and cardiovascular disease related to alexithymia in a well-controlled HIV-infected population
Ciccarelli Nicoletta,
Baldonero Eleonora,
Milanini Benedetta,
Fabbiani Massimiliano,
Cauda Roberto,
Di Giambenedetto Simona,
Silveri Maria Caterina
Both cognitive diseases and alexithymia may be associated with HIV. Moreover, alexithymia has been linked to cardiovascular (CV) diseases. Our aim was to explore the prevalence of alexithymia and its associations with neurocognitive disorders (HAND) and CV risk factors in a well-controlled HIV-positive population. We consecutively enrolled 140 HIV-positive individuals on antiretroviral therapy and 35 healthy subjects matched for age, education and gender. In all participants alexithymia was explored by the 20-item Toronto Alexithymia Scale. For HIV-positive subjects also data about CV risk factors were collected, and a comprehensive neuropsychological examination was administered; HAND was defined according to Frascati criteria.
Patients and controls did not differ in the proportion of alexithymic status (10% vs. 11%; p=0.761). Among HIV-positive patients, alexithymic participants presented a higher prevalence of diabetes (21% vs. 3%, p=0.035) and hypertension (36% vs. 13%, p= 0.037) compared to non-alexithymic. About 30% (n=41) of HIV-positive patients met criteria for asymptomatic HAND. Alexithymia was not independently associated with a higher risk of HAND (p=0.189). Analyzing each cognitive domain, alexithymia showed an independent association with an abnormal performance (OR 1.08; p=0.037) only in psychomotor speed. In conclusion, in the context of a well-controlled HIV infection, we found a low prevalence of alexithymia comparable to healthy controls. Alexithymia was linked to higher risk of CV disease in the HIV-positive population, but with a rate similar to that previously estimated in the HIV-negative alexithymic. Finally, alexithymia was clearly associated to cognitive impairment only in the psychomotor speed domain, suggesting a common fronto-striatal system dysregulation.
Microbiology of Elizabethkingia spp. isolates in hospitalized patients
Bazzi Ali M.,
Rabaan Ali A.,
Al-Tawfiq Jaffar A
An increasing number of infections due to Elisabethkingia spp. have been observed and reported in recent years. Here we report the microbiological aspects of 13 cases with positive cultures for Elizabethkingia spp. from 1998 to 2017. Elizabethkingia isolates were identified using the Vitek 2 Compact 60 (AES software) Gram-Negative Identification test (GNI) card (bioMérieux. Marcy-l’Etoile, France). The MICs were determined using Vitek 2 and interpreted according to CLSI guidelines based on the interpretive MIC breakpoints for Acinetobacter spp. Vitek 2 susceptibility results were confirmed using the manual E-test and the colistin result was confirmed using the broth dilution method. Twelve cases were observed between 2010 and 2017 with four cases in 2017. Of the 2017 samples, three out of four isolates were obtained outside the intensive care units compared to one out of eight samples between 2010 and 2016. There was variable susceptibility to trimethoprim/sulfamethoxazole (58.3%), ciprofloxacin (41.7%), piperacillin/tazobactam and gentamicin (16.6% each), and all were resistant to colistin. There is a high rate of drug resistance and further studies to identify the source of the infection are needed to build up a profile of Elizabethkingia spp. to inform public health policy in this context.
Evaluation of the possible involvement of Ad-36-induced adipogenesis and coronary artery disease development in mediastinal adipose tissue samples
Ergin Sevgi,
Turan Nuri,
Gode Safa,
Yilmaz Huseyin,
Saribas Suat,
Dinc Oyku,
Cizmecigil Utku,
Bakir Ihsan,
Keskin Melike,
Sirekbasan Serhat,
Atalık Kevser,
Yeniterzi Mehmet,
Demirci Mehmet,
Gurcan Mert,
Erdogan Sarper,
Gareayaghi Nesrin,
Kocazeybek Bekir S.
Mediastinal fat has been suggested to be associated with cardiovascular diseases such as carotid stiffness, atherosclerosis and coronary artery calcification. We investigated the possible role of Ad-36-induced obesity in the pathogenesis of the coronary artery disease (CAD). Ad-36 DNA was investigated in the anterior mediastinal fat tissue samples of obese adults with CAD. Seventy-five obese adults with left main coronary artery (LMCA) disease, 28 non-obese adults with valvular heart diseases, and 48 healthy individuals without cardiovascular problems were included as the obese patient group (OPG), non-obese patient group (NOG) and healthy control group (HCG), respectively. We also simultaneously investigated Ad-36 antibodies by serum neutralization test (SNA), and measured leptin and adinopectin levels. Ad-36 antibodies were detected only in 10 patients (13.3%) within the 75 OPG. A statistically significant difference was detected between OPG, NOG and HCG in terms of Ad-36 antibody positivity (p<0.05). Ad-36 DNA was not detected in mediastinal tissue samples of OPG and NOP without PCR inhibitors. We suggest that Ad-36 may not have an affinity for mediastinal adipose tissue in obese patients with left main CAD and valvular heart diseases. Ad-36 antibody positivity results are not sufficient to reach a causal relationship.
Overuse of prophylaxis in HBsAg and/or anti-HBc positive patients after increasing awareness to prevent reactivation in patients receiving immunosuppressive therapies: How rational are our prophylaxis decisions according to the literature?
Yenilmez Ercan,
Cetinkaya Riza Aytac
Screening prior to initiation of immunosuppressive therapy, and decision making between the initiation of hepatitis B virus (HBV) prophylaxis and monitoring with the intent of on-demand anti-HBV therapy initiation are the key determinants to prevent reactivation of HBV. Patients over 18 years of age with HBsAg and/or anti-HBc positivity, who received HBV prophylaxis due to immunosuppressive treatments between 2013 and 2019, enrolled in this retrospective descriptive study. We tried to create awareness about the reactivation of hepatitis among clinicians in our hospital from the beginning of 2017, via warnings at the hospital data management system and via in-service training activities. Changes or differences between two-time period groups (first group between 2013 and 2016, the second between 2017 and 2018) and between four reactivation risk groups (low, moderate, high and very high) were analyzed. Of 125 patients who received immunosuppressive therapies and HBV prophylaxis, 52 (41.6%) were HBsAg positive while 73 (58.4%) were anti-HBc positive/HBsAg negative. Eighteen of the patients were in the 1st-period-years and 107 were in the second. The ratio of anti-HBc positive/HBsAg negative patients increased from 22.22% (n: 4) to 64.49% (n: 69) in the 2nd period (p: 0.001). In the 1st period, 16.67% of the patients had hepatitis B surface antibodies (anti-HBs), which increased to 46.73% during the 2nd period. The ratio of patients with HBV DNA positivity was found to be 55.56% in the first period and 33.87% in the second. Patients in the moderate (1-10%) and high (10-30%) reactivation risk groups were predominant, with rates of 38.89% and 33.33% of all the patients during the 1st period, respectively. However, the number of patients with a low reactivation risk increased 19-fold (from 2 to 38) and reached a proportion of 35.51% of all patients during the 2nd period. There was also a 6.33-fold increase (from 6 to 38) in the number of patients with high reactivation risk, reaching a rate of 35.51% during the 2nd period. None of the patients developed HBV reactivation when HBV prophylaxis was initiated before (n:11), concurrently (n:81) with or after (n:33) the immunosuppressive therapy. Awareness of HBV reactivation among clinicians has significantly increased in recent years mainly due to in-service training activities in our hospital. This rapid progress in awareness resulted in increased rates of screening for HBV and therefore increased the number of anti-HBc positive/HBsAg negative patients. However, it also led to the overuse of HBV prophylaxis even in low-risk patients.
Epidemiological trends in patients living with human immunodeficiency virus: a 13-year experience from a tertiary care center in India
Gupta Nitin,
Niyas Vettakkara Kandy Muhammed,
Nischal Neeraj,
Soneja Manish,
Vinod Kutty Sharada ,
Ranjan Sanjay,
Sethi Prayas,
Jorwal Pankaj,
Biswas Ashutosh,
Wig Naveet,
Sood Rita
With significant advancement in the tools and strategies available for diagnosis and management, there is an expected change in the epidemiological profile of patients living with HIV/AIDS (Human immunodeficiency syndrome/Acquired immune deficiency syndrome). We retrospectively analyzed the changing epidemiological pattern of HIV infection over a period of 13 years in the anti-retroviral (ART) center of a tertiary care hospital in India. The study included a total of 9419 patients (8811 adults and 608 children) who were registered at our ART center between 2005 and 2017. Among adult patients, 68.9% patients were males and the mean age of presentation was 35.6±9.9 years. Heterosexual route was the most common route of transmission (95.5%). A total of 97.4% of pediatric patients acquired HIV infection via vertical transmission from their mothers. Most of the adult patients (77.1%) were educated only to primary level. Despite the economic growth in the country over the years, the monthly income of these patients has not significantly changed. The median CD4 count at the time of eligibility for starting ART was 244/l of blood. An increasing trend in the baseline CD4 count was noticed from 2005 to 2017. Also, improved outcomes with less loss to follow up were noticed in the latter years. However, an increasing trend was also noted in the time gap between registration at the ART center and initiation of ART. Improvement in the baseline CD4 count and better treatment outcomes are indicators of a well-functioning national program. However, continued programmatic interventions are needed to further tackle the menace of HIV/AIDS in India.
HBsAg, anti-HCV and anti-HIV seroprevalence among blood donors in Southeastern Anatolia, Turkey, 2011-2015
Dayan Saim,
Özekinci Tuncer,
Bekçibaşı Muhammed,
Deveci Özcan
Transmission of infections through blood and blood product transfusion is a serious healthcare problem. There are insufficient up-to-date data about seroprevalence of HBsAg, anti-HCV and anti-HIV 1/2 among healthy blood donors in Turkey. We aimed to investigate the seroprevalence of HBsAg, anti-HCV and anti-HIV 1/2 in Southeastern Anatolia, Turkey. HBsAg, anti-HCV, and anti-HIV 1/2 analysis results among blood donors who applied to Dicle University Faculty of Medicine, Diyarbakir District Blood Centre, between January 1, 2011 and December 31, 2015 were retrospectively evaluated. HBsAg, anti-HCV, and anti-HIV 1/2 screenings were performed using a fully automated device with the microparticle enzyme immunoassay method (MEIA). The chi-square (χ²) test was applied to variables. Among the donors, 1607 (1.73%) were HBsAg-positive, 255 (0.27%) were anti-HCV-positive and two (0.0021%) were positive for anti-HIV 1/2. HBsAg positivity rates by years were 2.50% in 2011, 1.92% in 2012, 1.74% in 2013, 1.53% in 2014 and 1.27% in 2015 (p<0.001). HBsAg-positivity was 0.78% for the donors between 18-24 years of age, 1.90% for those between 25-49 years of age and 3.92% for donors over the age of 49 (p<0.001). Anti-HCV positivity rates were as follows: 0.35% in 2011, 0.34% in 2012, 0.29% in 2013, 0.23% in 2014 and 0.16% in 2015 (p<0.001). Verified anti-HIV 1/2 positivity was observed for only two donors (0.0021%) within five years. HBsAg and anti-HCV positivity were observed to decrease significantly over the years and were significantly lower among younger donors.
Low prevalence of Toxoplasma gondii infection among children in a rural community in Fars province, Southern Iran
Arefkhah Nasir,
Goodarzi Roghayeh,
Rezaei Zahra,
Layegh Gigloo Akram,
Sarkari Bahador
The current study aimed to determine the seroprevalence of Toxoplasma gondii infection and associated risk factors in children in a rural community in Fars province in southern Iran. Blood samples were collected from 671 children living in three rural areas, and sera and buffy coats were isolated from each sample. Anti-T. gondii antibodies were detected by ELISA, using a commercial kit. Also, buffy coats of seropositive children were examined by a PCR method, targeting a 529 bp gene of T. gondii. Of 671 children participating in the study, 319 (51.7%) were boys and 298 (48.3%) were girls. The mean age of the children was 9.7 (±10.7) years. Anti-Toxoplasma antibodies were detected in sera of 23 out of 671 children, corresponding to a seroprevalence rate of 3.8%. Gender and level of education had no significant influence on the risk of Toxoplasma infection (p>0.05). Toxoplasma DNA was not detected in buffy coats of any of the seropositive cases. Geographic location, as well as the low age of the participants, may contribute to the low rate of Toxoplasma infection in children of rural areas in southern Iran.
Case report
Acquisition of FKS2 mutation after echinocandin treatment of infective endocarditis by Candida glabrata
Corcione Silvia,
D’Avolio Antonio,
Pasero Daniela,
Trentalange Alice,
Pagani Nicole,
Sanguinetti Maurizio,
De Rosa Francesco Giuseppe
Bloodstream infections caused by non-albicans Candida species are increasing and echinocandins have been extensively used especially in patients with hemodynamic instability, previous antifungal treatment and hospital risk factors for intrinsic or acquired resistance to azoles. Candida glabrata resistance to echinocandins is reported and is generally associated with previous use of echinocandins; FKS gene mutations have been associated with a worse outcome. We report the case of a 65-year-old woman who developed candidemia and endocarditis by C. glabrata with a newly acquired FKS mutation 24 months after successful treatment of infective endocarditis by C. glabrata with a double dosage of anidulafungin (200 mg daily) followed by oral voriconazole. Driven by high echinocandin MICs the strain taken by intraoperative cultures was further analyzed in a referral microbiology laboratory, confirming the new onset of point mutation S633P of the FKS2 gene.
Norwegian scabies presenting as erythroderma in HIV: A case report
Paparizos Vassilios,
Vasalou Varvara,
Velissariou Eirini,
Kourkounti Sofia,
Daskalakis Evangelos,
Rigopoulos Dimitrios
Crusted scabies is a rare and extreme manifestation of scabies that is observed mainly among immunosuppressed patients. We describe the case of a 55-year-old patient with a history of HIV infection and injection drug use. The patient was not on any antiretroviral therapy during the previous year, was malnourished and was living in unsanitary conditions. He had extensive, generalized, thick, hyperkeratotic, crusting, papular lesions, which had evolved over the previous month. Hyperkeratotic areas were fissured and linear excoriations were noted diffusely. The rash was distributed on the entire body from the scalp to the toes, with mild itching. Microscopic examination of the scale revealed numerous scabies mites and eggs. The patient was treated with topical scabicidal agents, which resulted in complete resolution. Because of the extremely contagious nature of crusted scabies, as well as its potential for complete cure with an appropriate therapy, there should be a high degree of suspicion for this disease in patients with AIDS, even when the lesions do not have the classical appearance. Nosocomial transmission of scabies from patients with AIDS is a risk, and protective measures, early diagnosis, and therapy are essential
Giardiasis: report of a case refractory to treatment
Iza José A.,
Iza Shirley N.,
Olivera Mario J.
Caused by the protozoan Giardia lamblia, giardiasis is one of the most common parasitic diarrheal infections affecting humans. Although a variety of antigiardial drugs are available to treat infections in humans, failure of conventional treatment with nitroimidazoles for giardiasis has been increasingly reported. We describe the follow-up of a patient with recurrent giardiasis refractory to nitroimidazoles. Despite the different therapies received, the symptomatology and parasitic forms of G. lamblia persisted in the patient. There is no standard treatment regimen for giardiasis refractory to nitroimidazoles. When treatment failure is confirmed, it is necessary to switch to second-line regimens.
Myiasis from Sarcophaga spp in a patient with cutaneous lymphoma
De Pasquale Rocco,
Pulvirenti Jessica,
Messina Agnese Maria Isabella,
Lombardo Francesco,
Stefani Stefania,
Scalia Guido,
Patamia Ildebrando
Human autochthonous myiasis is uncommonly reported in Europe. This report describes a case of myiasis of a wound caused by Sarcophaga spp. Suffering from cutaneous lymphoma, the patient showed, at the level of his scalp lesions, the presence of larvae that were removed during curettage surgery; they were subsequently identified as belonging to the genus Sarcophaga. Preservation of these larvae in 10% formalin did not allow identification at the species level using molecular methods
Cutaneous leishmaniasis associated with Systemic Lupus Erythematosus (SLE)
Asgari Qasem,
Gholizadeh Fatemeh,
Nohtani Mohammad,
Mirzaeipour Mehdi,
Zare Mehdi,
Bahreini Mohammad Saleh
Cutaneous Leishmaniasis (CL) is a protozoan disease caused by Leishmania spp. and is endemic in the Americas, the Mediterranean basin, Middle East, and Central Asia. There are reports regarding the co-infection of CL with other diseases, especially immune system disorders. Herein, we presented a patient with several leishmania lesions who suffered from Systemic Lupus Erythematosus (SLE). He was a 22-year-old man from Fars province, southern Iran who was treated with corticosteroid drugs to control the manifestations of SLE. The presence of leishmanial bodies was confirmed by microscopic and molecular methods. Treatment was performed based on sodium antimony gluconate (1.5 mg/5ml) for three weeks, resulting in acceptable outcomes. However, recurrence of the lesions was observed after two months when the medication was discontinued. This was the first report of Zoonotic Cutaneous Leishmaniasis (ZCL) in an SLE patient.
The Infections in the History of Medicine
De morbo gallico omnia quae extant apud omnes medicos cuiuscunque nationis: the sixteenth-century collection of Luigi Luigini
Martini Mariano,
Gazzaniga Valentina,
Barberis Ilaria,
Luigi Nicola,
Parodi Alessandra,
Armocida Emanuele,
In recent decades, a rising rate of syphilis infection, often in association with HIV, has been recorded in Europe. In the first years following their appearance, syphilis and HIV shared the character of “new”, challenging and serious diseases. The prime example of a “new disease”, syphilis appeared between the end of the Middle Ages and the beginning of the Renaissance period, a time in which medicine was changing from a dogmatic to an experimental discipline. Luigi Luigini’s collection of all the works on syphilis that had appeared to date (1566) offers a unique and significant insight into the discussion of the novelty of this disease, even after half a millennium.
Letters to the editor
Philippines hit by deadly Measles outbreak – a wakeup call?
Ochani Rohan Kumar,
Yasmin Farah,
Tariq Afreen,
Shaikh Asim
not available
