RESUMEN
Tick-borne encephalitis virus (TBEV) is an important central nervous system (CNS) infection in Europe and Asia. It is a flavivirus in the tick-borne group. Effective vaccines against TBE are available in the affected countries. However, diagnosing TBE is challenging due to cross-reactive antibodies between different viruses of the genus Flavivirus, family Flaviviridae. Differentiation between infection-induced and vaccine-induced antibodies can be difficult and in many cases impossible, due to the increasing vaccination rate against TBEV. We present a new approach to detect antibodies against the TBEV nonstructural protein 1 (NS1) as a diagnostic marker, which is exclusively indicative for virus replication in natural infection, on the basis of an enzyme-linked immunosorbent assay (ELISA). A total of 188 anonymous serum samples from the National Consultant Laboratory for TBEV were included in our study. The assay was validated according to the European Laboratory Norm DIN EN ISO 15189 for diagnostic use. The ELISA for the detection of TBEV NS1 specific IgG class antibodies has demonstrated a sensitivity of >94% and a specificity of >93% in broadly cross-reacting sera from patients with vaccinations against flaviviral diseases and single or multiple flavivirus infections, respectively. The detection of anti-NS1 antibodies is feasible and facilitates reliable differentiation between different flavivirus infections, TBEV infection, and TBE vaccination.
Asunto(s)
Virus de la Encefalitis Transmitidos por Garrapatas , Encefalitis Transmitida por Garrapatas , Anticuerpos Antivirales , Formación de Anticuerpos , Asia , Encefalitis Transmitida por Garrapatas/diagnóstico , Encefalitis Transmitida por Garrapatas/prevención & control , Ensayo de Inmunoadsorción Enzimática , Europa (Continente) , Humanos , Inmunoglobulina G , VacunaciónRESUMEN
OBJECTIVES: There are few data available regarding the clinical course of tick-borne encephalitis virus (TBEV) vaccination breakthrough infections. The published studies suggest that vaccination breakthrough infections may have a more severe course than native TBEV infection in unvaccinated individuals-potentially due to antibody-dependent enhancement. Here we report a large analysis of vaccination breakthrough infections. METHODS: This retrospective analysis was based on a national surveillance dataset spanning the years 2001-2018. Variables reflecting disease severity, such as 'CNS symptoms', 'myelitis', 'fatal outcome' and 'hospitalization' were analysed as well as general epidemiological variables. Cases were categorized as 'unvaccinated' or 'ever vaccinated', the latter category including cases with at least one dose of a TBEV vaccine. RESULTS: A total of 6073 notified TBEV infection cases were included in our analysis. Sufficient data on vaccination status were available for 95.1% of patients (5777/6073); of these, 5298 presented with a native infection. A total of (334/5777) cases developed an infection despite having been vaccinated at least once. Comparing unvaccinated patients with those with at least one vaccination, we find an odds ratio (OR) 2.73, (95% confidence interval (CI) 0.79-9.50) regarding the variable fatal outcome that did not reach statistical significance. Analysing the clinical variables 'CNS symptoms' and 'myelitis', there is no difference between these groups (OR 0.86, 95% CI 0.68-1.08; and OR 1.30, 95% CI 0.74-2.27 respectively). Patients who were vaccinated and had an assumed protection at symptom onset (n = 100) had a higher risk for the development of myelitic symptoms (OR 2.21, 95% CI 1.01-4.86]) than unvaccinated patients. CONCLUSION: Our findings could neither verify that vaccination breakthrough infections might cause a more severe disease than native infections nor prove a clear antibody-dependent enhancement phenomenon. It remains unclear whether the increased myelitis risk in a subgroup of vaccinated patients is a true effect or confounded.
Asunto(s)
Encefalitis Transmitida por Garrapatas/epidemiología , Mielitis/epidemiología , Vacunación/estadística & datos numéricos , Vacunas Virales/administración & dosificación , Adulto , Anciano , Virus de la Encefalitis Transmitidos por Garrapatas/inmunología , Encefalitis Transmitida por Garrapatas/inmunología , Femenino , Alemania/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Mielitis/microbiología , Vigilancia de la Población , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Vacunas Virales/inmunologíaRESUMEN
BACKGROUND: Prosthetic valve endocarditis (PVE) has the highest in-hospital mortality among all cases of infective endocarditis (IE), it is estimated at about 40 %. Orthotopic heart transplantation (OHT) as a measure of last resort, may be considered in selected cases where repeated surgical procedures and conservative efforts have failed to eradicate persistent or recurrent IE. Only few clinical data are available regarding this rare indication for OHT, since active IE has traditionally been considered as a contraindication for OHT. CASE PRESENTATION: We report on a 55 year old male patient who underwent prosthetic valve replacement with a mechanical valved conduit ten years ago and developed now persistent PVE with severe complications due to methicillin-resistant Staphylococcus epidermidis (MRSE). Repeated surgical procedures and conservative efforts have failed to eradicate the pathogen. Regarding the lack of curative options, salvage OHT was discussed as a measure of last resort. 28 months after the first diagnosis of PVE, the patient was successfully transplanted and is now doing well under close follow-up (6 months post-OHT). CONCLUSIONS: PVE remains a challenging condition regarding diagnosis and treatment. The presented case underscores the urgent need for an integrated and multidisciplinary approach to patients with suspected and definitive IE - especially in PVE. OHT might be a feasible measure of last resort in selected patients with IE. Our case report adds published clinical experience to this rarely performed procedure and consolidates previous findings.
Asunto(s)
Endocarditis Bacteriana/cirugía , Trasplante de Corazón , Resistencia a la Meticilina , Infecciones Relacionadas con Prótesis/cirugía , Infecciones Estafilocócicas/microbiología , Staphylococcus epidermidis/aislamiento & purificación , Estenosis de la Válvula Aórtica/cirugía , Endocarditis Bacteriana/microbiología , Endocarditis Bacteriana/mortalidad , Prótesis Valvulares Cardíacas/microbiología , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Infecciones Relacionadas con Prótesis/microbiología , Infecciones Relacionadas con Prótesis/mortalidad , Reoperación , Terapia RecuperativaRESUMEN
BACKGROUND: Prescription of third-generation cephalosporins and fluoroquinolones has been linked to an increasing incidence of gram-negative bacteria producing extended-spectrum beta-lactamases, methicillin-resistant Staphylococcus aureus and nosocomial infection with Clostridium difficile. Antibiotic stewardship (ABS) programmes offer evidence-based tools to control antibiotic prescription rates and thereby influence the incidence of nosocomial infection and contain the development of multidrug-resistant bacteria, but there is limited experience with such programmes at community hospitals. METHODS: We implemented an ABS programme at a 200-bed community hospital and aimed at a > 30 % reduction of cephalosporin and fluoroquinolone consumption within 1 year. Pharmacy data were obtained to estimate hospital-wide drug use density expressed in WHO-ATC-defined daily doses (DDD) or hospital-adapted recommended daily doses (RDD) per 1,000 patient days. The effect of the ABS intervention on drug use density was analysed using interrupted time-series analysis for the periods between January 2011 and March 2013 as pre-intervention, and between April 2013 and March 2014 as post-intervention period. The CDI incidence was calculated based on microbiology laboratory data. RESULTS: Cephalosporin use (measured in RDD/1,000 patient days) decreased by 33 %, and fluoroquinolone use decreased by 31 %, respectively. Interrupted time-series analysis confirmed significant changes in the drug use density trends for both cephalosporins and fluoroquinolones after the intervention as well as for total antibiotic use that decreased by 11 % while no significant effect was noted for CDI incidence rates. CONCLUSION: ABS programmes can be effective in community hospitals and may help establish ecologically advantageous antibiotic strategies when needed.
Asunto(s)
Antibacterianos , Cefalosporinas , Infección Hospitalaria , Fluoroquinolonas , Servicio de Farmacia en Hospital/organización & administración , Prescripciones/estadística & datos numéricos , Antibacterianos/administración & dosificación , Antibacterianos/uso terapéutico , Cefalosporinas/administración & dosificación , Cefalosporinas/uso terapéutico , Infección Hospitalaria/epidemiología , Infección Hospitalaria/prevención & control , Farmacorresistencia Bacteriana , Fluoroquinolonas/administración & dosificación , Fluoroquinolonas/uso terapéutico , Alemania/epidemiología , Hospitales Comunitarios , Humanos , Incidencia , Análisis de Series de Tiempo InterrumpidoAsunto(s)
Dermatosis del Pie/diagnóstico , Dermatosis de la Pierna/diagnóstico , Pancreatitis Alcohólica/diagnóstico , Paniculitis/diagnóstico , Tejido Adiposo/patología , Amputación Quirúrgica , Biopsia , Resultado Fatal , Femenino , Dermatosis del Pie/patología , Dermatosis del Pie/cirugía , Humanos , Dermatosis de la Pierna/patología , Dermatosis de la Pierna/cirugía , Persona de Mediana Edad , Necrosis , Pancreatitis Alcohólica/patología , Pancreatitis Alcohólica/cirugía , Paniculitis/patología , Paniculitis/cirugía , Piel/patologíaRESUMEN
The steady increase in antimicrobial resistance is of growing concern in healthcare. Antibiotic Stewardship [ABS] Strategies are important tools to control antibiotic use and -prevent antimicrobial resistance. An increasing number of institutions are developing ABS initiatives also in pediatrics. However, few data are available assessing the implementation and efficiency of these pediatric ABS programs.At the Dr. von Hauner Children's Hospital, Ludwig-Maximilian University, a tertiary care pediatric reference center, a pediatric ABS Team has been implemented. Key structural elements were the same as for adult patients, but antimicrobials agents selected for monitoring and appropriate clinical endpoints are different in pediatrics.Key features were: 1. prospective-audit with feedback and formulary restriction and 2. pre-authorization (also referred to as prior approval). The ABS team consisted of one pediatric infectious disease specialist, one clinical fellow in pediatric infectious diseases, and one clinical pharmacist with training in infectious diseases.With the implementation of a pediatric ABS strategy we could significantly influence antimicrobial consumption in our hospital. Cost-savings are estimated to be above 330 000 per year, and concomitantly the use of broad-spectrum antibiotics and antifungal compounds was significantly reduced.Antibiotic Stewardship [ABS] Strategies may be an effective tool to control antibiotic use in the setting of a large tertiary pediatric teaching hospital. A national guideline for ABS initiatives may help to further improve rational use of antibiotics in the hospital setting.
Asunto(s)
Antibacterianos/uso terapéutico , Infecciones Bacterianas/tratamiento farmacológico , Farmacorresistencia Bacteriana , Infecciones Bacterianas/diagnóstico , Niño , Preescolar , Conducta Cooperativa , Grupos Diagnósticos Relacionados , Utilización de Medicamentos/tendencias , Predicción , Alemania , Hospitales Pediátricos , Hospitales Universitarios , Humanos , Lactante , Recién Nacido , Comunicación Interdisciplinaria , Tiempo de Internación , Grupo de Atención al Paciente , Proyectos Piloto , Derivación y Consulta , Factores de Riesgo , Rondas de EnseñanzaAsunto(s)
Antibacterianos/uso terapéutico , Staphylococcus aureus Resistente a Meticilina , Infecciones Estafilocócicas/tratamiento farmacológico , Antibacterianos/efectos adversos , Artritis Infecciosa/tratamiento farmacológico , Artritis Infecciosa/microbiología , Bacteriemia/tratamiento farmacológico , Bacteriemia/microbiología , Relación Dosis-Respuesta a Droga , Esquema de Medicación , Quimioterapia Combinada , Endocarditis Bacteriana/tratamiento farmacológico , Endocarditis Bacteriana/microbiología , Humanos , Pruebas de Sensibilidad Microbiana , Osteomielitis/tratamiento farmacológico , Osteomielitis/microbiología , Neumonía Estafilocócica/tratamiento farmacológico , Neumonía Estafilocócica/microbiología , Infecciones Relacionadas con Prótesis/tratamiento farmacológico , Infecciones Relacionadas con Prótesis/microbiología , Infecciones de los Tejidos Blandos/tratamiento farmacológico , Infecciones de los Tejidos Blandos/microbiología , Infecciones Estafilocócicas/microbiología , Resistencia a la VancomicinaRESUMEN
BACKGROUND: Current guidelines of the "Centers for Disease Control and Prevention [CDC]" recommend routine screening for Hepatitis B before cytotoxic or immunosuppressive therapies are initiated. The national German guideline "Prophylaxis, diagnosis and therapy of hepatitis B virus infection" is in line with the CDC recommendations and underscores general HBV screening before immunosuppression is induced. However, screening adherence and acceptance of these guidelines vary in different oncological specialities. To assess the HBV screening adherence a retrospective study was performed. PATIENTS AND METHODS: Data of 140 patients were analyzed retrospectively. 37 case-records did not meet inclusion criteria. Patients diagnosed with breast-cancer (n = 43) and Hodgkin's disease (n = 14) requiring chemotherapy were included, as well as patients receiving allogenic stem cell transplantation (SCTx) therapy (n = 22) or transarterial chemoembolization (TACE) therapy of the liver (n = 24). All included case-records were reviewed regarding HBV and HCV serology. RESULTS: In the TACE group three patients were screened for HBsAg. Four patients with breast cancer and five patients in the Hodgkin disease group were screened for HBsAg. In contrast, screening adherence was 100 % in the group of patients receiving allogenic stem cell transplantation therapy (n = 22). CONCLUSION: Apart from patients with allogenic stem cell transplantation, only some patients receiving immunosuppressive therapies had been screened for HBV infection. Our data indicate that standardized checklists may improve HBV screening previous to immunosuppressive therapies. These clinical structures have led to an almost optimal screening adherence in the high-risk group of allogenic SCTx patients.
Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Neoplasias de la Mama/tratamiento farmacológico , Quimioembolización Terapéutica/efectos adversos , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Virus de la Hepatitis B/fisiología , Hepatitis B/diagnóstico , Hepatitis B/virología , Enfermedad de Hodgkin/tratamiento farmacológico , Inmunosupresores/efectos adversos , Tamizaje Masivo/estadística & datos numéricos , Cooperación del Paciente , Activación Viral/inmunología , Algoritmos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias de la Mama/inmunología , Lista de Verificación/normas , Emigrantes e Inmigrantes , Femenino , Alemania , Adhesión a Directriz , Hepatitis B/inmunología , Enfermedad de Hodgkin/inmunología , Humanos , Inmunosupresores/administración & dosificación , Masculino , Estudios Retrospectivos , Factores de RiesgoAsunto(s)
Antibacterianos/administración & dosificación , Infecciones Bacterianas/tratamiento farmacológico , Pautas de la Práctica en Medicina , Antibacterianos/efectos adversos , Antibacterianos/farmacocinética , Infecciones Bacterianas/sangre , Disponibilidad Biológica , Cefalosporinas/administración & dosificación , Cefalosporinas/efectos adversos , Cefalosporinas/farmacocinética , Colistina/administración & dosificación , Colistina/efectos adversos , Colistina/farmacocinética , Infección Hospitalaria/sangre , Infección Hospitalaria/tratamiento farmacológico , Relación Dosis-Respuesta a Droga , Farmacorresistencia Bacteriana Múltiple , Quimioterapia Combinada , Fluoroquinolonas/administración & dosificación , Fluoroquinolonas/efectos adversos , Fluoroquinolonas/farmacocinética , Semivida , Humanos , Infusiones Intravenosas , Pruebas de Sensibilidad Microbiana , beta-Lactamas/administración & dosificación , beta-Lactamas/efectos adversos , beta-Lactamas/farmacocinéticaAsunto(s)
Pneumocystis carinii , Neumonía por Pneumocystis/diagnóstico , Infecciones Oportunistas Relacionadas con el SIDA/diagnóstico , Infecciones Oportunistas Relacionadas con el SIDA/tratamiento farmacológico , Infecciones Oportunistas Relacionadas con el SIDA/patología , Antiinfecciosos/efectos adversos , Antiinfecciosos/uso terapéutico , Antifúngicos/efectos adversos , Antifúngicos/uso terapéutico , Atovacuona/efectos adversos , Atovacuona/uso terapéutico , Líquido del Lavado Bronquioalveolar/microbiología , Caspofungina , Diagnóstico Diferencial , Equinocandinas/efectos adversos , Equinocandinas/uso terapéutico , Humanos , Lipopéptidos , Pulmón/patología , Infecciones Oportunistas/diagnóstico , Infecciones Oportunistas/tratamiento farmacológico , Infecciones Oportunistas/patología , Pentamidina/efectos adversos , Pentamidina/uso terapéutico , Neumonía por Pneumocystis/tratamiento farmacológico , Neumonía por Pneumocystis/patología , Tomografía Computarizada por Rayos X , Combinación Trimetoprim y Sulfametoxazol/efectos adversos , Combinación Trimetoprim y Sulfametoxazol/uso terapéutico , Trimetrexato/efectos adversos , Trimetrexato/uso terapéuticoAsunto(s)
Antineoplásicos/efectos adversos , Bromodesoxiuridina/análogos & derivados , Herpes Zóster/diagnóstico , Vasculitis Leucocitoclástica Cutánea/diagnóstico , Aciclovir/uso terapéutico , Antineoplásicos/uso terapéutico , Antivirales/efectos adversos , Antivirales/uso terapéutico , Bromodesoxiuridina/efectos adversos , Bromodesoxiuridina/uso terapéutico , Diagnóstico Diferencial , Neoplasias Esofágicas/secundario , Exantema/diagnóstico , Exantema/etiología , Herpes Zóster/complicaciones , Herpes Zóster/tratamiento farmacológico , Humanos , Pierna , Linfoma de Células del Manto/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Síndromes Paraneoplásicos/diagnóstico , Vasculitis Leucocitoclástica Cutánea/tratamiento farmacológicoAsunto(s)
Bacteriemia/diagnóstico , Técnicas Bacteriológicas/instrumentación , Recolección de Muestras de Sangre/instrumentación , Medios de Cultivo , Fungemia/diagnóstico , Lesiones por Pinchazo de Aguja/prevención & control , Administración de la Seguridad , Bacteriemia/microbiología , Niño , Fungemia/microbiología , Humanos , Garantía de la Calidad de Atención de SaludAsunto(s)
Aneurisma de la Aorta/diagnóstico por imagen , Disnea/patología , Anciano de 80 o más Años , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/patología , Presión Sanguínea , Diagnóstico Diferencial , Progresión de la Enfermedad , Disnea/diagnóstico por imagen , Femenino , Frecuencia Cardíaca , Humanos , RadiografíaAsunto(s)
Bacteriemia/diagnóstico , Recolección de Muestras de Sangre/métodos , Sangre/microbiología , Fungemia/diagnóstico , Adulto , Antibacterianos/uso terapéutico , Bacteriemia/tratamiento farmacológico , Bacteriemia/microbiología , Técnicas Bacteriológicas , Recolección de Muestras de Sangre/instrumentación , Contraindicaciones , Infección Hospitalaria/diagnóstico , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/microbiología , Progresión de la Enfermedad , Fungemia/tratamiento farmacológico , Fungemia/microbiología , HumanosAsunto(s)
Hemorragia/diagnóstico por imagen , Triaje/métodos , Heridas y Lesiones/diagnóstico por imagen , Traumatismos Abdominales/diagnóstico por imagen , Urgencias Médicas , Humanos , Riñón/diagnóstico por imagen , Riñón/lesiones , Pericardio/diagnóstico por imagen , Bazo/diagnóstico por imagen , Bazo/lesiones , Traumatismos Torácicos/diagnóstico por imagen , Factores de Tiempo , UltrasonografíaRESUMEN
HISTORY AND ADMISSION FINDINGS: A 69-year-old man was admitted to the department of gastroenterology having for months had persistently elevated liver enzymes after discontinuing systemic antimycotic therapy. He reported loosing five kilogram of body weight in the past six months. No macroscopic or microscopic abnormalities had been found on esophago-gastroduodenoscopy. INVESTIGATIONS: Congo-red staining of the liver biopsy revealed massive sinusoidal amyloidosis of the liver. Immunoelectrophoresis of the urine and serum, as well as bone marrow biopsy, ruled out multiple myeloma or Waldenström's disease. Immunohistochemical staining identified the amyloid protein as a IgG kappa light chain (KLC). The free light chain (FLC) test confirmed KLC monoclonal gammopathy with an abnormal free kappa to lambda chain (KLLC) ratio. TREATMENT AND COURSE: Systemic KLC amyloidosis in this patient older than 65 years was given chemotherapy with melaphalan and dexamethasone (M-Dex). After three courses of M-Dex the renal clearance deteriorated and the serum N-terminal probrain natriuretic peptide (T-proBNP) had increased. COURSE: The patient was included in a phase II clinical trial which evaluates the use of bortezomib in patients with amyloidosis. Normalization of the free KLLC ratio and the NT-proBNP level will serve as important prognostic indicators. CONCLUSION: KLC amyloidosis is a rare cause of elevated liver enzymes. The nonspecific symptoms often delay the diagnosis. FLC testing is a helpful tool in identifying monoclonal gammopathies, even when immunoelectrophoretic tests are normals.
Asunto(s)
Amiloidosis , Cadenas kappa de Inmunoglobulina/análisis , Hepatopatías , Anciano , Amiloidosis/tratamiento farmacológico , Amiloidosis/enzimología , Amiloidosis/inmunología , Amiloidosis/patología , Antineoplásicos/uso terapéutico , Biopsia , Glucocorticoides/uso terapéutico , Humanos , Hepatopatías/tratamiento farmacológico , Hepatopatías/enzimología , Hepatopatías/inmunología , Hepatopatías/patología , Masculino , Paraproteinemias/inmunologíaRESUMEN
We report on the first case of acute renal failure related to obstructive urinary tract lithiasis involving sulfadiazine crystals in a kidney transplant recipient. This patient had disseminated toxoplasmosis which was treated by sulfadiazine (4 g/day) and pyrimethamine (50 mg/day). In the fourth week of anti-toxoplasmosis therapy, he presented with obstructive acute renal failure: the plasma creatinine level increased from 220 micromol/l to 547 micromol/l. Apercutaneous pyelography was conducted showing the presence of a lithiasis located at the junction between the graft ureter and the bladder. Six days later, he underwent surgery to retrieve an orange-colored, friable stone. Its spectrophotometric analysis confirmed that the stone consisted of N-acetyl sulfadiazine crystals.
Asunto(s)
Lesión Renal Aguda/inducido químicamente , Sulfadiazina/efectos adversos , Cálculos Urinarios/inducido químicamente , Cálculos Urinarios/terapia , Lesión Renal Aguda/fisiopatología , Adulto , Drenaje/métodos , Estudios de Seguimiento , Fungemia/diagnóstico , Fungemia/tratamiento farmacológico , Humanos , Pruebas de Función Renal , Trasplante de Riñón , Litotricia/métodos , Masculino , Medición de Riesgo , Índice de Severidad de la Enfermedad , Sulfadiazina/uso terapéutico , Toxoplasmosis/diagnóstico , Toxoplasmosis/tratamiento farmacológico , Resultado del Tratamiento , Cálculos Ureterales/inducido químicamente , Cálculos Ureterales/patología , Cálculos Ureterales/terapia , Cálculos de la Vejiga Urinaria/inducido químicamente , Cálculos de la Vejiga Urinaria/patología , Cálculos de la Vejiga Urinaria/terapia , Cálculos Urinarios/patologíaRESUMEN
PURPOSE OF THE STUDY: Primary management of developmental dislocation of the hip involves a series of events (clinical screening and detection, choice and interpretation of imaging studies, indication and proper execution of treatment). Each event has an important effect on outcome and failure may result from inadequate attention to any one. We analyzed the causes of failure observed over 31 years experience in our region. MATERIAL AND METHODS: We analyzed the files of children hospitalized in the Rouen Infantile Surgery Department from 1968 to 1998 for management of congenital dislocation of the hip diagnosed late (> 3 months) or for revision after inappropriate treatment. We identified 353 files. This series was retrospective from 1968 to 1985 (283 cases) and prospective from 1986 to 1998 (70 cases). RESULTS: Up through 1981, failed detection of developmental dislocation of the hip was identified in 10 to 27 children per year (mean 21.5). Since 1982, this rate has varied from 1 to 10 (mean 6.5). The number of children treated before the age of one year was 10.5 per year up through 1981 then 4.5 per year after 1982. The number of children treated after the age of one year was 11 per year through 1981 then 2 per year after 1982. Since 1986, treatment was undertaken for failure of primary management in 57 children after clinical diagnosis, in 3 children after radiological and ultrasonographic diagnosis, and in 11 children during the course of treatment. Standard x-ray studies systematically obtained at four months corrected the diagnosis in 24 children. The diagnosis was corrected after repeating the examination in 14 children before the age of one year. Correct diagnosis was established after the age of one year in 18 children. DISCUSSION: Although our University Department was the only referral center for pediatric surgery in our region during this period, these figures cannot be compared with the annual birth rate in the region (24,000 births/year) because the number of infants managed in other centers is unknown. Nevertheless, organizing regular follow-up by a pediatric orthopedic surgeon of all infants screened positive in the maternity ward enabled a 70% reduction in the number of failures since 1982. Systematic clinical screening, repeated regularly during the first year of life, has reduced the mean age of diagnosis. Neither ultrasonography nor radiography has replaced physical examination. Care must also be taken to avoid over reliance on ultrasound findings which do not correspond to clinical findings. Amongst the children treated late, 14% had undergone an inappropriate treatment for dislocation correctly identified during the neonatal period. Referring all children screened positive to a pediatric orthopedic surgeon should help reduce this rate.