2j9g9_Ciobanca rezuzsrat

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CUPRINS

LISTA DE PUBLICATII ....................................................................................................................2INTRODUCERE ................................................................................................................................7PARTEA I STADIUL ACTUAL AL CUNOATERII ...................................................................10Capitolul 1. GENUL ECHINOCOCCUS .......................................................................................11

1.1. Istoric .....................................................................................................................................11

1.2. Taxonomie i clasificare.......................................................................................................121.3. Morfologie ............................................................................................................................121.4 Diferene morfologice i genetice ntre specii .......................................................................151.5. Epidemiologie ........................................................................................................................171.6. Ciclul biologic .......................................................................................................................19

1.6.1. Echinococcus granulosus ...............................................................................................191.6.2. Echinococcus multilocularis ...........................................................................................21

1.7. Contaminarea uman ..........................................................................................................22CAPITOLUL 2: CHISTUL HIDATIC ...........................................................................................23

2.1. Patogenia chistului hidatic .....................................................................................................23

2.2. Evoluia chistului hidatic ......................................................................................................23

2.3. Manifestri clinice ale hidatidozei umane............................................................................242.4. Diagnosticul bolii hidatice .....................................................................................................27

2.4.1. Diagnosticul clinic ..........................................................................................................282.4.2. Diagnosticul imagistic ....................................................................................................282.4.3. Diagnostic parazitologic .................................................................................................312.4.4. Diagnosticul imunologic .................................................................................................322.4.5. Diagnosticul diferenial al chistului hidatic....................................................................34

2.5. Tratamentul chistului hidatic ................................................................................................352.6. Profilaxia chistului hidatic .....................................................................................................38

PARTEA II CERCETARI PERSONALE ........................................................................................40

STUDIUL 1: Aplicabilitatea metodelor serologice n diagnosticul, terapia i profilaxia bolii hidaticeumane. ...............................................................................................................................................411.1. Introducere .............................................................................................................................411.2. Scopul i obiectivele studiului ...............................................................................................411.3. Material i metod..................................................................................................................42

1.3.1. Material ...........................................................................................................................421.3.2. Metoda ............................................................................................................................43

1.4. Rezultate ...............................................................................................................................471.4.1. Depistarea persoanelor seropozitive investigate prin teste imunoenzimatice ELISA IgGantiechinococcus n judeele Cluj i Slaj................................................................................471.4.2. Frecvena n funcie de mediul de provenien a persoanelor seropozitiven judeele Cluji Slaj.......................................................................................................................................481.4.3. Frecvena persoanelor seropozitive n judeul Cluj i Slaj n funcie de sex.............501.4.4. Aspecte epidemiologice privind persoanele seropozitive n judeul Cluj (inciden,mediul de provenien i repartizarea pe sexe) .........................................................................511.4.5. Frecvena persoanelor seropozitive n funcie de sex n judeul Cluj............................521.4.6. Aspecte epidemiologice privind persoanele seropozitive, n judeul Slaj(inciden, mediul de provenien i repartizarea pe sexe) .......................................................531.4.7. Frecvena persoanelor seropozitive n funcie desex n judeul Salaj...........................54


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1.5. Confirmarea rezultatelor obinute la testrile serologice prin metode imagistice utilizate ndiagnosticul echinococozei chistice umane .................................................................................55

1.5.1. Rezultatele examenului imagistic (ecografic, RX toracic, CT) ......................................561.6. DISCUII ..............................................................................................................................581.7. DESCRIERE CAZURI .........................................................................................................61

CONCLUZII .....................................................................................................................................68STUDIUL II: Evaluarea i optimizarea metodelor de diagnostic n boala hidatic.........................69

2.1. Introducere .............................................................................................................................692.2 Scopul i obiectivele studiului................................................................................................692.3 Material i metod...................................................................................................................70

2.3.1 Material ............................................................................................................................702.3.2 Metode paraclinice i clinice utilizate..............................................................................712.3.3 Metode statistice de analiz a datelor .............................................................................77

2.4. Rezultate ................................................................................................................................802.4.1 Rezultate epidemiologice (luand ca icriteriu sexul, mediul de provenien, varsta) ....802.4.2 Rezultate clinice si paraclinice privind diagnosticul bolii hidatice ...............................83

2.4.2.1 Valoarea examenului clinic n diagnosticul chistului hidatic ...................................832.4.2.2.Confirmarea chirurgical a diagnosticului prezumtiv de chist hidatic.....................85

2.4.2.3 Evaluarea analizelor de laborator uzuale (hemoleucograma, analize biochimice)folosite pentru depistarea chistului hidatic ..........................................................................862.4.2.4. Metode imagistice folosite pentru identificarea chistului hidatic ...........................892.4.2.5. Rezultatele obinute prin metode imunoserologice..................................................97

2.4.3. Rezultate comparative ...................................................................................................1062.5. DISCUII ............................................................................................................................1222.6. DESCRIERE CAZURI ......................................................................................................131

CONCLUZII: ..................................................................................................................................139CONCLUZII GENERALE ............................................................................................................140REFERINE ..................................................................................................................................142


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INTRODUCERE

Echinococoza/hidatidoza (boala hidaticsau chistul hidatic) este o boal parazitar, cauzatde genul Echinococcus, care poate evolua cu cele mai severe i variate implicaii. In ciudaprogreselor din domeniile de supraveghere i control aceast parazitoz continu s reprezinte oproblem important de sntate public n cele mai multe pri ale lumii [2].

Conform clasificrii OMS, boala este o zoonoz, care ridic numeroase probleme desntate, att n ceea ce privete omul ct i animalele, deoarece paraziii cauzali, pentru ancheiaciclul lor biologic, trec prin mai multe gazde animale vertebrate (de exemplu, cini pentru oameni).

Datorit prevalenei ridicate, formelor clinico-evolutive severe, complicaiilor morfo-funcionale cu mortalitate primar sau secundar ridicat,boala este frecvent ntlnit atat n mediulrural cat i in mediul urban, la toate grupele de vrst, prevalen alarmant la tineri i la grupe derisc profesional [1]

In zona rii noastre patologia hidatic are o frecven destul de ridicat, zona denord-vest aTransilvaniei fiind descris ca zon endemic, cu o cazuistic important [ 3], medicina clujeanavand o important experien n diagnosticul i tratamentul chistului hidatic.

n pofida realizrilor nregistrate n ultimul timp n diagnosticul i terapia echinococozei

umane, aceasta deine nc un loc important n structura morbiditii i mortalitii n serviciilechirurgicale.Cea ce face util prezentarea unor date succinte asupra aspectelor variate pe care boala hidatic lepoate lua n evoluie din punct de vedere clinic, imagistic, serologic i evaluarea importaneiacestora n recunoaterea i diagnosticarea precoce a bolii.

PARTEA I: STADIUL ACTUAL AL CUNOATERII

Capitolul 1. Genul EchinococcusParazitul responsabil de producerea hidatidozei umane, este un plathelmint, care face parte

din clasa cestode (Eucestode), familia Teniidae, GenulEchinococcus. Speciile din genulEchinoccocusconsiderate ageni etiologici ai echinococozei/hidatidozei, dup experii OMS, sunturmatoarele:

- Echinococcus granulosus(Batsch, 1786) - echinococoza chistic- Echinococcus multilocularis (Leuckart, 1863)echinococoza alveolar- Echinococcus oligarthus (Diesing, 1863)- Echinococcus vogeli (Rausch, Bernstein, 1972) - echinococoza polichistic

S-a mai pus problema existenei celei de-a cincea specii, E.cruzi (Rausch i col. 1978;Kumaratilake i Thompson 1982), dar, Rausch i col. (1984), comparnd caracterele acesteia cuE.vogeliiE.oligarthus, au observat c de faptE. cruzieste sinonim cuE. oligarthus.

Distribuia geografic a hidatidozei urmeaz fidel curba dezvoltrii cresctorilor de oi i estedeterminat de promiscuitatea pastoral, fapt ce l-a determinat pe Deve s afirme c boala hidatic

este una din bolile minilor murdare.Larga varietate de specii de animale care pot fi gazde intermediare i deplasarea acestora din

Europa n alte pri ale lumii a fcut caEchinococcus s fie rspndit pe ntreg globul.In anul 2009 ECDC a raportat 790 de cazuri de echinococoz uman, cu 11% mai puine

dect n 2008 (n= 891). Printre cazurile declarate, n care se cunoate specia infestant, apredominat infestaia cuE.granulosus (72%) n timp ce infestaia cuE.multilocularisa fost raportatca avnd o frecven de 3 ori mai mic [4].


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CAPITOLUL 2: CHISTUL HIDATICChistul hidatic este o boal adesea invalidizant, cu complicaii posibile i adesea severe

(oc anafilactic), cu o terapie chirurgical de multe ori dificil, cu recidive postoperatorii frecvente.Manifestrile clinice datorate complicaiilor instalate prin mecanismele menionate apar, cnddimensiunile chistului hidatic devin apreciabile.

Tabloul clinic al chistului hidatic este puin caracteristic. Foarte adesea el este completasimptomatic, fiind descoperit ntmpltor. Alteori pacienii acuz jen n hipocondrul drept sauchiar durere intens. Reaciile alergice sunt destul de frecvente, mergnd de la o reacie urticarianpn la alergodermie sau chiar oc anafilactic (n general n caz de fisurare sau chiar rupereachistului hidatic).

Evidenierea morfologic a chisturilor hidatice se poate face prin radiografie toracic,ecografie, tomografie computerizat (CT) i rezonant magnetic (MR).

Pentru diagnosticul hidatidozei umane, metodele imagistice se completeaz cu reaciilede imunodiagnostic care au drept scop confirmarea etiologiei parazitare a formaiunilor decelate prinrspunsul imun indus. n ultimii ani exist o tendin de stadializare a dignosticului imunologic ; findfolosite mai intai teste primare care urmeaza sa fie confirmate prin alte metode care prezinta ospecificitate deosebit de ridicata(teste secundare) [5].

Managementul modern al chistului hidatic solicit participarea tuturor modalitilorterapeutice: medicala, percutana i chirurgicala. Chirurgia nu mai este tratamentul de prim eleciepentru orice chist hidatic hepatic. La pacienii cu chist univezicular mai mic de 4 cm, terapia deelecie este monoterapia cu albendazol.

PAIR este indicat cnd durerea este netratabil, sau albendazolul nu d rezultate.Tratamentul percutan combin alcool i polidocanol, dar nu poate fi utilizat n cazurile cu fistulchistobiliar.

Chirurgia este utilizat n cazurile n care nu exist experi n terapia percutan sitratamentul percutan nu poate fi efectuat n deplin siguran datorita unei extensii extrahepaticesemnificativ cu risc de perforaie a chistului sau/si n cazul rupturii chistului n cavitateaperitoneal[6].

PARTEA II: CERCETARI PERSONALE

STUDIUL 1: Aplicabilitatea metodelor serologice n diagnosticul, terapia i profilaxia boliihidatice umane.

Scopul acestui studiu a fost efectuarea i evaluarea unor teste serologice (metoda ELISA) cametode screening i de diagnostic a echinococozei chistice. Testele au fost efectuate la persoanelesimptomatice i asimptomatice din judeele Cluj i Slaj, pentru aprecierea frecvenei afeciunii naceste judee. Persoanelor crora li s-au detectat anticorpi IgG antiechinococcus, li s-au efectuatexaminri imagistice pentru confirmarea diagnosticului clinic i serologic de chist hidatic.

Aceste examinri au permis elucidarea aspectelor epidemiologice, diagnostice, terapeutice si

prognostice privind echinococoza chistic.Material i metodStudiul a fost efectuat n perioada ianuarie 2007 decembrie 2009 i a inclus 279 de

persoane simptomatice i asimptomatice din judeele Cluj i Slaj, cu scopul de a stabili prezena inivelul anticorpilor antiechinococcus n populaia celor dou zone i implicit a infecieiasimptomatice, folosind metoda imunoenzimatic ELISA.


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mai fost luate n studiu persoane care au suferit intervenie chirurgical pentru boala hidatic ipersoane care prezentau rezultate de laborator nespecifice dar cu suspiciune de boal parazitar.

Am folosit ca material de lucru cazuistica medical i chirurgical din Clinicile Medicale iChirurgicale din Cluj-Napoca i Slaj (Clinica Chirurgie III, Clinica Chirurgie V i ambulatorul uneipoliclinici private). Tipurile de date colectate folosite n acest studiu au fost: genul, vrsta, mediul deprovenien, diagnosticul clinic; complicaiile chistului hidatic; antecedente de chist hidatic;metodele de diagnostic imagistic efectuate (ecografie abdominal, Rx pulmonar, CT, RM,tratamentul chirurgical, examenul piesei operatorii, histopatologic); analize de laborator; localizareaformaiunilor chistice n funcie de segmentaia hepatic i n funcie de organul afectat; metodelede diagnostic serologic efectuate (metoda imunoenzimatica IgG antiechinococcus ELISA, respectivmetoda IgG echinococcus Western- blot).

2.4. RezultateDin rezultatele obtinute rezult c nu exist o asociere semnificativ ntre eozinofilie i

diagnosticul bolii hidatice (p>0.05); Totui, atunci cnd eozinofilia este prezent se constat ocoinciden relativ ridicat, de 71% (IC=52% - 85%), cu diagnosticul de chist hidatic.

Analiza statistic a corelaiei dintre rezultatele examenului imagistic cu rezultatele obinutepe baza confirmrii chirurgicale i paraclinice a evidentiat o sensibilitate de 96,89% a examenului

imagistic, specificitatea fiind 100%; din punct de vedere statistic ele nu difer semnificativ. Valoareadiagnostic a examenului imagistic este dat ns de valoarea predictiv pozitiv (VPP) i respectivnegativ (VPN), ambele fiind peste 84%, cu toate c VPN este semnificativ statistic mai mic dectVPP.

Evaluarea rezultatelor examenului IgG antiechinococcus ELISA n raport cu confirmareachirurgical, histopatologic i paraclinic a diagnosticului de chist hidatic evidentiaza oSpecificitate de 96,43% i VPP de 99,19% ; Acestea fiind foarte ridicate se poate considera cmetoda ELISA este un bun test de screening.

Comparativ cu examenele imagistic, ecografic sau CT, IgG antiechinococcus ELISA are unindice Youden mai mic. Prin urmare, din acest punct de vedere IgG antiechinococcus ELISA pare a fiun test diagnostic mai puin concludent, dect examenele imagistice menionate. Pe de alt parte,

comparnd intervalele de ncredere la indicatorii Specificitate, VPP la examenele imagistice (global,ecografic, CT) i IgG antiechinococcus ELISA se constat c nu difer semnificativ statistic.

Rezultatele examenului imagistic i cele ale IgG antiechinococcus ELISA se asociazsemnificativ. Este de remarcat c odat cu ceilali coeficieni de asociere (coeficientul decontingen, Kendal tau), coeficientul de concordan dintre rezultatele examenului imagistic i celeale IgG antiechinococcus ELISA este semnificativ statistic (p


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concordan Kappa = 0,861 indic faptul c ntre cele dou examinri exist o concordan foartebun.

2.5. DiscutiiEvaluarea eozinofiliei ca marker diagnostic n echinococoza chistic a permis unor autorii

s afirme c eozinofilia nu este un indicator suficient pentru stabilirea diagnosticului deechinococoz chistic, fiind necesar i un diagnostic complementar clinic [9].

Sensibilitatea i specificitatea ecografiei a fost raportat n mai multe studii din literatur cafiind ntre 8898% i respectiv 95100% pentru echinococoza chistic i echinococoza alveolaruman. Autorii o considera golden standard dei recunosc imperfeciunea acestei tehnici.Examenul clinic, examenul de laborator i datele epidemiologice sunt considerate deasemeneaimportante pentru diagnosticul echinococozei chistice i echinococozei alveolare [10].

Testele serologice contribuie la diagnostic, detecia anticorpilor IgG a avut o sensibilitatede 95% i o specificitate de 94% ntr-un studiu efectuat de Shambesh MA i colaboratorii [11].Sensibilitatea obinut de Shambesh este semnificativ mai ridicat dect cea determinat n studiulnostru, care raporteaz o sensibilitate de 76,4% cu IC= 69,07%-82,72%. n schimb specificitateanu difer semnificativ statistic de cea obinut n studiul nostru (96,43%, IC=81,65%-99,91%).

Infeciile echinococice sunt considerate unele dintre cele mai periculoase boli helmintice

umane. Deosebirea ntre echinococoza chistic i alveolar este important din punct de vedere alprognosticului i tratamentului.

In diferite stadii ale echinococozei chistice i echinococozei alveolare testul cel mai relevants-a apreciat a fi testul Western blot IgG echinococus care a confirmat rezultatele pozitive [ 12].

Cercetrile efectuate cu scopul de a evidenia prezena IgG echinococcus prin metodaWestern blot raportat la metoda de aur considerat (confirmarea chirurgical, histopatologic idiagnostic paraclinic) au demonstrat o sensibilitate de 92,11% (IC = 78,62% - 98,34%),specificitatea fiind de 100% (IC = 83,89% - 100%), date care sunt asemntoare celor ntlnite nliteratura de specialitate.

n majoritatea rilor echinococoza alveolar a cptat deja un caracter endemic i este ncurs de extindere continu cu o rapiditate alarmant, devenind o boal emergent.

Parazitul adult E.multilocularisnu a fost depistat n Romnia pn n prezent la nici o gazddefinitiv[13].

Studiul efectuat a relevat prin metoda Western blot, pentru prima dat n ara noastrexistena probabilitii infeciei cu Echinococcus multilocularis la om. Sunt necesare studiiulterioare pentru depistarea persoanelor cu echinococoz alveolar existente n Romania, ncondiiile existenei acesteia n numeroase ri din Europa, inclusiv cele vecine Romniei (Ungaria,Ucraina); Centraliznd cercetrile recente privind situaia epidemiologic, problemele clinice iopiunile terapeutice, autorii au descris primul caz de echinococoz alveolar n Ungaria. Pentruconfirmarea acestei infecii rare trebuie s fie luat n considerare diagnosticul diferenial cu alteleziuni hepatice infiltrative [14].

Nu a fost raportat nici un caz la nivelul Romniei, prin alte studii. Recomandm

introducerea acestei metode n screeningul i diagnosticul acestei boli grave.n ncercarea de a compara metodele folosite pentru diagnosticarea chistului hidatic i a

rezultatelor obinute prin aceste metode, putem afirma c testul Western blot IgG echinococcus estecel mai sensibil pentru a preciza un diagnostic etiologic.


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REFERINTE

1. Junie, Monica, Zoe Coroiu, Carmen Costache, 2002, The consequences ofEchinococcusgranulosus infection n the human population,Rev. Scienia Parasitologica 3:2, 86-91

2. Seres tefania, Monica Junie, V. Cozma, 2009, Prevalence of Echinococcus granulosus inCluj county, Romania, revealed by PCR,Rev. Scienia Parasitologica, 1o:1-2, 68-71

3. Coroiu, Zoe, Judith Bele, Cornelia Munteanu, Rodica Radu, 2007, Aspecte epidemiologiceprivind hidatidoza uman n judeul Cluj pe o perioada de 20 de ani (1981-2000), Rev.Scientia Parasitologica, 8:1, 32-38.

4. A. Lahuerta, T. Westrell, J. Takkinen, F. Boelaert, V. Rizzi, B. Helwigh, B. Borck, H.Korsgaard, A. Ammon, P. Mkel: Zoonoses n the European Union: origin, distribution anddynamicsthe EFSA - ECDC summary report, 2009

5. Craig, P.S., 1997, Immunodiagnosis of Echinococcus granulosus and a comparison oftechniques for diagnosis of canine echinococcosis. In: Compendium on cystic echinococcosisn Africa and Middle Eastern countries with special reference to Morocco, Brigham YoungUniversity Pris Services, Provo.

6. Schipper H.G. Modern management of echinococcosis. World Gastroenterology News vol. 9,nr. 2, 2004

7. Arda, B., H. Puluku, T. Yamazhan, O.R. Sipahi, S. Tamsel, G. Demirpolat, M. Korkmaz, 2009, Prevalence of Echinococcus granulosus detected using enzyme immunoassay andabdominal ultrasonography n a group of students staying n a state dormitory n Turkey,Turk. J. Med. Sci., 39:1, 1-4.

8. Liance, M., V. Janin, S. Bresson-Hadni, D.A. Vuitton, R. Houin, R. Piarroux, 2000,Immunodiagnosis of Echinococcus infections: confirmatory testing and speciesdifferentiation by a new comercial Western blot,J. Clin. Microbiol., 38, 3718-3721.

9. Karadam SY, Ertabaklar H, Sari C, Dayanir Y, Ertu S. Should cystic echinococcosis beinvestigated n patients having high eosinophil counts?. Turkiye Parazitol Derg.2009;33(3):203-6.

10.Macpherson CN, Milner R. Performance characteristics and quality control of communitybased ultrasound surveys for cystic and alveolar echinococcosis. Acta Trop. 2003Feb;85(2):203-9

11.Shambesh MA, Craig PS, Macpherson CN, Rogan MT, Gusbi AM, Echtuish EF. Anextensive ultrasound and serologic study to investigate the prevalence of human cysticechinococcosis n northern Libya.Am J Trop Med Hyg. 1999 Mar; 60(3):462-8.

12.Reiter-Owona I,Grner B,Frosch M,Hoerauf A,Kern P,Tappe D.Serological confirmatorytesting of alveolar and cystic echinococcosis in clinical practice: results of a comparativestudy with commercialized and in-house assays.Clin Lab. 2009;55(1-2):41-8.

13.Sik Barabsi S. i Cozma V. ,2008 , Echinococoza alveolar. O posibil zoonoz emergentn Romnia (Sintez).Rev.Scientia Parasitologica. 9, 1, 48-60;

14.Horvth Andrea, Patonay Attila, Bnhegyi Dnes, Szlvik Jnos, Balzs Gyrgy, GrgDnes s Werling Klra,. A humnEchinococcus multilocularis infectio els hazai esete.Berkezett: 2007. november 16.; elfogadva: 2008. mrcius 7
http://www.ncbi.nlm.nih.gov/pubmed?term=%22Karadam%20SY%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Ertabaklar%20H%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Sari%20C%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Dayanir%20Y%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Ertu%C4%9F%20S%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Ertu%C4%9F%20S%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/19851964http://www.ncbi.nlm.nih.gov/pubmed?term=%22Macpherson%20CN%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Macpherson%20CN%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Milner%20R%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/12606098http://www.ncbi.nlm.nih.gov/pubmed?term=%22Shambesh%20MA%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Shambesh%20MA%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Craig%20PS%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Macpherson%20CN%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Rogan%20MT%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Gusbi%20AM%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Echtuish%20EF%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/10466978##http://www.ncbi.nlm.nih.gov/pubmed?term=%22Reiter-Owona%20I%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Reiter-Owona%20I%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Gr%C3%BCner%20B%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Frosch%20M%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Hoerauf%20A%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Kern%20P%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Tappe%20D%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/19350848http://www.ncbi.nlm.nih.gov/pubmed/19350848http://www.ncbi.nlm.nih.gov/pubmed?term=%22Tappe%20D%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Kern%20P%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Hoerauf%20A%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Frosch%20M%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Gr%C3%BCner%20B%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Reiter-Owona%20I%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/10466978##http://www.ncbi.nlm.nih.gov/pubmed?term=%22Echtuish%20EF%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Gusbi%20AM%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Rogan%20MT%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Macpherson%20CN%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Craig%20PS%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Shambesh%20MA%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/12606098http://www.ncbi.nlm.nih.gov/pubmed?term=%22Milner%20R%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Macpherson%20CN%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/19851964http://www.ncbi.nlm.nih.gov/pubmed?term=%22Ertu%C4%9F%20S%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Dayanir%20Y%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Sari%20C%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Ertabaklar%20H%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Karadam%20SY%22%5BAuthor%5D


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10

CURRICULUM VITAE

1. Nume: Ciobanca2. Prenume: Petrica Teofil3. Data i locul naterii: 25.11.1979; Localitatea Zalau, judetul Salaj4. Cetenie: Romana5. Stare civil: Casatorit

6. Contact: Tel: 0040-740052584; E-mail :[email protected]. Studii:Instituia Universitatea

de Vest VasileGoldis Arad

Universitatea deMedicina siFarmacieIuliuHatieganu ClujNapoca

Universitatede MedicinaCarolDavilaBucuresti

Universitateade medicina siFarmacieIuliuHatieganuCluj Napoca

Liceul TeoreticZalau -SectiaMatematica-Fizica

Perioada: Octombrie2004 -Iunie 2005

Ianuarie2005-februarie2005

Ianuarie 2005-Martie 2005

Octombrie1998-Septembrie

2004

Septembrie1994 -

Iulie 1998

Grade saudiplomeobinute

Diploma deMaster inManagementulFinanciarContabil siJuridic alFirmelor

Certificat deAbsolvire: curspostuniversitarde ecografiegenerala modul I

Certificat deAbsolvire :curspostuniversitarde ecografiegeneralamodulul II

Diploma deLicentaMedicinaGenerala

Diploma deBacalaureat

8. Titlul tiinific: Medic, Asistent Universitar, Doctorand cu frecventa9. Experiena profesional:

Perioada: Functia Responsabilitati01. 11. 2005 -prezent

-Asistent Universitar-Medic Rezident Medicina deLaborator-Doctorand cu frecventa

U.M. F Iuliu Hatieganu CLUJ- Activitate didactica in Microbiologie(Bacteriologie, Parazitologie,Virusologie, Micologie) cu studentiianului II, III, Medicina Generala,Farmacie, Colegii Medicale, in cadrulUMF Iuliu Hatieganu-Stagii in activitatea de rezidentiat-activitate de cercetare

01.01.2006

prezent

-Medic generalist SALVO- SAN

-practica medicala in medicina generala01.06. 200920.11. 2009

SHORMO RMO INTERNATIONAL-Practica medicala, examinari clinice presi post operatorii;-managerul echipei de resuscitare in cazde urgenta

15.01.200714.11.2007

Medic Rezident Medicina defamilie

Spitalul Clinic Judetean de UrgentaCluj Napoca


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11

-examinari clinice, EKG, diagnostic sitratament, stagii de Obstetrica siGinecologie, Psihiatrie, Boli Infectioase

29.08.200510.09.2005

Medic Stagiar Spitalul Kantonal FlawilElvetia-stagii de Medicina Interna, prezentari siexplorari diagnostice

01.01.200501.01.2006

Medic Stagiar Spitalul Clinic Municipal Cluj Napoca-stagii de Medicina Interna 6 luni,-stagii de Chirurgie 6 luni

14.03.200501.04.2005

Medic Stagiar Spitalul Clinic de Pediatrie MariaSklodowska Curie-am asistat la explorarile endoscopiceefectuate

Cursuri post-universitare Ecografie generala, modulul unu: Ianuarie 2005februarie 2005Ecografie generala, modulul doi: Ianuarie 2005martie 2005Medicina ocupationala

Urgente chirurgicale la copiiCurs de resuscitare adulti

ALS - London Ambulance Service

EPLS - Royal Brompton Hospital London

Ultrasonografie de urgenta

EKG

Ecografie Doppler

10. Locul de munc actual i funcia: Asistent Universitar, Doctorand cu frecventa, U.M.F.

Iuliu Hatieganu Cluj Napoca11 . Vechime la locul de munc actual: 6 ani

12. Lucrri elaborate i / sau publicate Monica Junie, Petrica Ciobanca: (B-783). 2005, Comparison of Antibiotic Resistance of Pseudomonas

Aeruginosa Strains Isolated from Different Types of Infections, Abstracts of the XIth InternationalCongress of Bacteriology and Applied Microbiology July 23-28, San Francisco, California, U.S.A -ISBN:1-555-81-353-4

Monica Junie, Petrica Ciobanca(M-722). 2005, Evolution of Resistance Phenomenon to AntimycoticDrugs of Candida Species and Dermatophytes, Abstracts of the XIth International Congress of MycologyJuly 23-28, San Francisco, California, U.S.A ISBN:1-555-81-354-2

Lia Monica Junie,Doina Matinca, Doina Tulescu, AN Ferke, Petrica Ciobanca, 2006, Evolution ofAntibiotic Resistance of Pseudomonas aeruginosa strains isolated from Hospital Infectious, InternationalJournal of Infectious Diseases, vol.10, suppl 1, ISSN 1201 9712, pag, S 78 Lisabon, Portugal, ISSN1201-9712, IJID, indexed in MEDLINE EMCASE /Escerpta Media and Urlichs; Elsevier Publishing,Presented at the International Congress of Infectious Diseases, sesiunea Antibiotic Resistance Gramnegatives (poster nr. 13003), iunie 15-18,

Lia Monica Junie, Zoe Coroiu i col. AN Ferke, Petrica Ciobanca, 2006, The significance ofAntiToxoplasma IgG and IgM Antibodies Detection in Toxoplasmosis Diagnosis, Abstract books the 12thISID , pag. 80, Presented at the 12th ISID 15-18 iunie, 2006 Lisbon, Portugal, Sectiunea ParasiticInfectious,


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12

Junie, Monica,Petrica Ciobanca,2006, Species Distribution and Antifungal Susceptibility Of CandidaIsolates Colected From Hospitalised Patients. Abstracts of 16 th European Congress Of ClinicalMicrobiology And Infectious Diseases. Nice France 1- 4 aprilie 2006

Constantea N.i Petrica Ciobanca, 2007, Studiul clinic pentru mbuntirea metodelor de diagnostic delaborator i profilaxia chistului hidatic,Rev.Rom.de Parasitol. 17, 48-49.

Junie, Monica, N. Constantea,Petrica Ciobanca, 2007, Surveillance programme in echinococcosis andimportance in the prophylaxis and therapy of human infection, Clinical Microbiology and Infection,

13:2., Christofidou M, Spiliopoulou A, Vamvacopoulou S, Stamoulis V, Dimitracopoulos G, Anastassiou E.D,

Monica Junie, Costache C, Colosi I, Ciobanca P T., 2008, Species distribution and antifungalsusceptibility of Candida isolates collected from hospitalized patients in Romania and Greece, ScientiaParasitologica;1:61-7. ISSN 1582 - 1366,

L M Junie, Vasile Cozma, Zoe Coroiu, Petrica Ciobanca, 2009, Epidemiology of humanechinococcosis in Europe", pg. 109-127

Junie Monica, S. Rpuntean, N. Fi, Cosmina Cuc, F. Puiu, Gh. Rpuntean, L. Deac Simion, P. T.Ciobanca, 2009, Alternative therapies for combating antimicrobial resistence and reduction of severenosocomial infections, Abstract Book of IMED (International Meeting on Emerging Diseases andSurveillance), Vienna, Austria, Februarie 13-16, 2009; Abstract 10152, pg.86,

V. Cosma,PT Ciobanca, R. Blaga, C. Gherman, Lia Monica Junie,2009; Hydatidosis Epidemiology atHumans and Animals in the Area of the Center and North-Vest, Romania, Abstract book of IMEDInternational Meeting on Emerging Diseasesand Surveillance, Vienna, Austria, Februarie, pg.86

Ciobanca Petrica, Monica Junie,2011, Serological diagnosis and its applicability to the prophylaxis andtherapy of hydatid cyst in human patients,Rev. Scienia Parasitologica, 12:1, 39-46.

Ciobanca Petrica Teofil, Junie Lia Monica, 2011,Diagnosis confirmation of human cysticechinococcosis by imagistic methods and immunoserological determinations,Scientia

Parasitologica,12(3):151-161

13. Limbi strainecunoscute: Engleza-fluent, Francezaincepator, Germana - incepator14.Specializri i calificri: Ecografie, Operare PC15. Experiena acumulat n programe naionale/internaionale:

Programul/Proiectul Funcia Perioada:

Constituirea unei reele naionale privindstudiul unor zoonozeparazitare iimplicaiile lor n siguranaalomentelor,CEEX 178/2005 cu o durat de24 luni

realizat in colaborare cu Universitatea deStiine Agricole i Medicin VeterinarDoctorand, Responsabil economic

20062007

Evaluarea i optimizarea interdisciplinar ametodelor de screening, diagnostic itratament n trichineloza i echinococozachistic uman i animal n centrul i nord-vestul Romniei - TRICHID, ProgramCEEX 199/2006.

realizat ntre Universitatea de StiineAgricole i Medicin Veterinar(conductor al proiectului) i U.M.F. ClujNapoca (partener ).Doctorand, Responsabil economic

2006 -2008

Constituirea unei reele naionale decercetare a dermatofitozelor la om ianimale,Program CEEX 151/2006

realizat ntre USAMV (conductor alproiectului) i U.M.F. Cluj Napoca(partener).Doctorand, Responsabil economic

2006-2008

Declar pe propria rspundere c datele prezentate sunt n conformitate cu realitatea.


13/24

"IULIU HAIEGANU" UNIVERSITY OF MEDICINE AND PHARMACY

OF CLUJ-NAPOCA

STRATEGIES IN HYDATID CYST DIAGNOSIS AND

THERAPEUTICAL MONITORING

ABSTRACT OF DOCTOR'S THESIS


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TABLE OF CONTENTS

LIST OF PUBLICATIONS ................................................................................................................2INTRODUCTION ..............................................................................................................................7PART I CURRENT KNOWLEDGE STATUS ...............................................................................10Chapter 1. ECHINOCOCCUS GENUS ..........................................................................................111.1. Background ............................................................................................................................11

1.2. Taxonomy and classification .................................................................................................121.3. Morphology...........................................................................................................................121.4 Genetic and morphologic differences between species .........................................................151.5. Epidemiology ........................................................................................................................171.6. Biological lyfe cycle .............................................................................................................19

1.6.1. Echinococcus granulosus ...............................................................................................191.6.2. Echinococcus multilocularis ...........................................................................................21

1.7. Human contamination ..........................................................................................................22CHAPTER 2: HYDATID CYST ....................................................................................................23

2.1. The pathogeny of the hydatid cyst .........................................................................................232.2. The evolution of the hydatid cyst .........................................................................................232.3. Clinical occurrence of human hydatidosis ............................................................................242.4. Diagnosis of hydatid diseases ...............................................................................................27

2.4.1. Clinical diagnosis ............................................................................................................282.4.2. Medical imaging diagnosis ............................................................................................282.4.3. Parasitologic diagnosis....................................................................................................312.4.4. Immunologic diagnosis ...................................................................................................322.4.5. Differential diagnosis in hydatid cyst ............................................................................34

2.5. Treating the hydatid cyst .......................................................................................................352.6. The prophylaxis of the hydatid cyst ......................................................................................38

PART II PERSONAL RESEARCHES ............................................................................................40STUDY 1: The applicability of the serological methods for the diagnosis, therapy and prophylaxis ofthe human hydatid disease ................................................................................................................41

1.1. Introduction ............................................................................................................................411.2. Study aim and objectives ......................................................................................................411.3. Material and method ..............................................................................................................42

1.3.1. Material ...........................................................................................................................421.3.2. Method ............................................................................................................................43

1.4. Results ...................................................................................................................................471.4.1. Detecting the seropositive persons investigated by ELISA IgG Antiechinococcus in Clujand Slaj Counties.....................................................................................................................471.4.2. Frequency depending on the environment the seropositive persons belong to in Cluj andSlajCounties ...........................................................................................................................481.4.3. Seropositve persons frequency in Cluj and SlajCounties depending on gender ..........501.4.4. Epidemiological aspects on seropositive persons in Cluj County (incidence, environmentthey belong to and distribution on genders) ..............................................................................511.4.5. The seropositive persons frequency depending on sex in Cluj County .........................521.4.6. Epidemiological aspects on seropositive persons in SlajCounty (incidence, environmentthey belong to and distribution on genders) ..............................................................................53
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1.4.7. The frequency of seropositive persons dependending on sex in Salaj Couty ................541.5. Confirming the determinations following the serological tests through imagistic methods inhuman cystic echinococcosis ........................................................................................................55

1.5.1. The results of imagistic determinations (ultrasound scan, thoracic RX, CT) 561.6. DEBATES..............................................................................................................................581.7. CASE DESCRIPTION ..........................................................................................................61

CONCLUIONS .................................................................................................................................68STUDY II: Evaluation and optimization of diagnosis methods in hydatid disease ........................69

2.1. Introduction ............................................................................................................................692.2 Study aim and objective ..........................................................................................................692.3 Material and method ...............................................................................................................70

2.3.1 Material ............................................................................................................................702.3.2 Paraclinic and clinical methods involved ........................................................................712.3.3 Statistical methods of data analysis ................................................................................77

2.4. Results ...................................................................................................................................802.4.1 Epidemiological results (considering the sex, origins, age) ............................................802.4.2 Clinical and paraclinical results regarding the hydatid cyst diagnosis ...........................832.4.2.1. The clinical examination value in hydatid cyst diagnosis .......................................83

2.4.2.2. Surgical confirmation in hydatid cyst presumtive diagnosis ..................................852.4.2.3. Assessing the usual laboratory analysis (haemoleucogram, biochemical analysis usedto determine hydatid cyst) ....................................................................................................862.4.2.4. Imagistic methods involved to determine the hydatid cyst .....................................892.4.2.5. Results obtained through immunoserological methods ..........................................97

2.4.3. Comparative results ......................................................................................................1062.5. DEBATES............................................................................................................................1222.6. CASE DESCRIPTION .......................................................................................................131

CONCLUSIONS: ...........................................................................................................................139GENERAL CONCLUSIONS ........................................................................................................140REFERENCES ..............................................................................................................................142
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INTRODUCTION

The Echinococcosis / hydatidosis (the hydatid disease or the hydatid cyst) is a parasiticdisease determined by genus Echinococcus, which may evolve with the most severe and differentimplications. Despite progresses in control and monitoring fields this parasitosis keeps representing

an important issue of the public health in the most parts of the world [1

].According to WHO classification the disease is a zoonosis which brings a lot of health issues,both in humans and animals because the causing parasites in order to end their biological cycle passthrough more vertebrate animal hosts (as for example, dogs for the humans).

Due to its high prevalence, the severe clinical developing forms, the morphofunctionalcomplications with high primary or secondary mortality, the disease if frequently met both in ruraland urban environment, at all age groups, alarming prevalence in youngsters and occupational riskgroups [2].

In our country area the hydatid pathology has a quite high frequency, the northwestern partof Transylvania being described an endemic area with important cases [3], the medicine of Clujhaving a significant experience in hydatid cyst diagnosis and treatment.

Despite the lately achievements in human echinococcosis diagnosis and therapy, it still hasan important place in morbidity and mortality structure within surgical services. So in this waypresenting some briefly data over the different aspects the hydatid disease may adopt in itsdevelopment from clinical, imagistic, serological point of view and their importance evaluation inearly recognition and diagnosis of the disease.

PART I: CURRENT STATUS OF KNOWLEDGE

Chapter 1. Genus Echinococcus

The parasite responsible for causing human hydatidosis is a Platyhelminthe belonging toCestoda class (Eucestoda), Taeniidae family, Genus Echinococcus. The species of genus

Echinococcus considered as etiologic agents of echinococcosis / hydatidosis according to WHOexperts are as follows:- Echinococcus granulosus(Batsch, 1786) - cystic echinococcosis- Echinococcus multilocularis (Leuckart, 1863)alveolar echinococcosis- Echinococcus oligarthus (Diesing, 1863)- Echinococcus vogeli (Rausch, Bernstein, 1972)polycystic echinococcosis

The issue of the 5th species existence arose, E.cruzi (Rausch and co. 1978; Kumaratilakeand Thompson 1982), but Rausch and co. (1984) comparing its features with E.vogeli andE.oligarthus remarked that in factE. cruziis similar toE. oligarthus.

The geographical distribution of hydatidosis loyally follows the sheep breeders developing

curve and it is determined by pastoral promiscuity fact that determined Deve assert that "the hydatiddisease is one of the dirty hands diseases".The wide range of animal species which may be intermediary hosts and their circulation from

Europe in other parts of the world made thatEchinococcusbe spread on the entire globe.In 2009 ECDC reported 790 cases of human echinococcosis, with 11% lower than in 2008

(n= 891). Among the reported cases where the infecting species is known predominated the infectionwith E.granulosus (72%) while E.multilocularis infection was reported as having a frequency 3times lower [4].


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CHAPTER 2: HYDATID CYST

The hydatid cyst is often an invaliding disease with possible and often severe complications(anaphylactic shock), with often difficult surgical therapy and frequent post-surgery recidivations.The clinical behaviours due to the complications settled through the aforementioned mechanisms

appear when the hydatid cyst sizes become considerable.The clinical framework of the hydatid cyst is little characteristic. Quite often it is completelyasymptomatically and discovered purely by chance. Other times the patients accused discomfort inthe right hypochondrium or even intense pain. The allergic reactions are quite frequently fromurticaria reaction up to alergodermy or even anaphylactic shock (generally in case of fissure or eventhe hydatid cyst rupture).

The morphological determination of the hydatid cysts may be done through thoracicultrasound scan, computer tomography (CT) and magnetic resonance (MR).

The imagistic methods for human hydatidosis diagnosis are completed with immunodiagnosisreactions aiming the parasitic aetiology confirmation of the determined formations through immuneinduced response. In the last years exists a tendency of immunologic diagnosis staging; firstly

primary tests are used following to be confirmed through other methods having a significantlyspecificity (secondary tests) [5].The hydatid cyst modern management require involving all therapeutic methods: medical,

percutaneous and surgical. The surgery is not anymore the first election for treating any hepatichydatid cyst. In patients with univesicular cyst smaller that 4 cm the chosen therapy is themonotherapy with albendazole.

PAIR is indicated when the pain in not treatable or the albendazole is ineffective. Thepercutaneous treatment combines the alcohol and polidocanol but cannot be used in case of cysto-billiary fistula.

The surgery is used in cases when in percutaneous therapy no experts exist and thepercutaneous treatment cannot safely performed due to a significant extra-hepatic extension withperforation risk of the cyst or/and in case of cyst rupture in the peritoneal cavity [6].

PART II: PERSONAL RESEARCHES

STUDY 1: The applicability of the serological methods in the diagnosis, therapy and

prophylaxis of human hydatid disease

The aim of this study was serological tests (ELISA method) conducting and evaluation asscreening and diagnosis methods of cystic echinococcosis. The tests were conducted in symptomaticand asymptomatic persons from Cluj and Slaj Counties in order to estimate the disease frequency inthese counties. In the persons where anti-echinococcus IgG antibodies were determined imagisticinvestigations were performed in order to confirm the clinical and serological diagnosis of hydatidcyst.

The investigations allowed clarifying the epidemiological, diagnosis, therapeutic andprognostic aspect regarding cystic echinococcosis.

Material and methodThe study was conducted during January 2007 December 2009 and included 279

symptomatic and asymptomatic persons from Cluj and Slaj Counties in order to determine thepresence and the level of anti-echinococcus antibodies level in the population of the two regions andimplicitly the asymptomatic infection using ELISA immunoenzyme method.


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2.3 Material and methodThe study was performed during 2006 2010 and included a representative sample of 189

symptomatic persons, with suggestive symptoms and imagistic suspicion of hydatid disease. Otherstudied persons were those for whom surgical intervention was performed in hydatid cyst andpersons having non-specific laboratory results but with suspicions of parasitic disease.

The working material I used were the medical and surgical cases from the Medical andSurgical Clinics of Cluj-Napoca and Slaj (Clinica Chirurgie III, Clinica Chirurgie V i and theambulatory of a private policlinic). The types of data collected and used within this study were:gender, age, origin, clinical diagnosis; the hydatid cyst complications; hydatid cyst antecedents; theimagistic diagnosis methods performed (abdominal ultrasound scan, pulmonary Rx, CT, RM,surgical treatment, the examination of the surgical piece, hystopathological); laboratory analysis;finding the location of the cystic formation depending on the hepatic segmentation and depending onthe organ in question; the serological diagnosis methods performed (immunoenzyme IgG anti-echinococcus ELISA method, IgG echinococcus Western- blot method)

2.4. Results

The results obtained determined that there isnt a significant association between IgGechinococcus Western-blot and the hydatid disease diagnosis (p>0.05); notwithstanding wheneosinophilia is present results a relatively high coincidence of 71% (IC=52% - 85%) with the hydatidcyst diagnosis.

The statistic analysis of imagistic investigation results and surgical and paraclinicalconfirmation results correlation presented a sensibility of 96.89% for the imagistic investigation, thespecificity was of 100%; they don't differ significantly from statistical point of view. The diagnosisvalue of the imagistic examination is given by the positive predictive value (PPV) and the negativeone (NPP) both of them are over 84% although the NPP is statistical significantly lower than PPV.

The evaluation of IgG antiechinococcus ELISA results compared with the surgical,hystopathological and paraclinical confirmation of hydatid cyst diagnosis determines a Specificity of96.43% and a PPV of 99.19%; as these are very high it may be considered that ELISA method is agood screening test.

By comparison with imagistic, ultrasound scan or CT investigations, the IgGantiechinococcus ELISA has a lower Youden index. As a consequence from this point of view IgGantiechinococcus ELISA seems to be a less conclusive diagnosis test comparing with the mentionedimagistic investigations. On the other side, comparing the trust intervals of Specificity, PPV andimagistic investigations (globally, ultrasound scan, CT) and IgG antiechinococcus ELISA we observethat they dont differ statistically speaking.

The imagistic investigation results and those of IgG antiechinococcus ELISA associatesignificantly. It is noticeable that at the same time with the other association coefficients(contingency, Kendal tau coefficient) the concordance coefficient between the imagisticinvestigation results and those of the IgG antiechinococcus ELISA are significantly statistical(p


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Specificity of 100% an a positive predictive value of 100%; as these are very high you may considerthat the IgG echinococcus Western Blot detecting test is a good screening test.

It is noticeable that at the same time with the other association coefficients (contingency,Kendal tau coefficient) the concordance coefficient between the imagistic investigation results andthose of the IgG echinococcus Western blot are significantly statistical (p


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CURRICULUM VITAE

1. Surname: Ciobanca

2. Name: Petrica Teofil

3. Date and place of birth: 25.11.1979; Zalau, Salaj

4. Citizenship: Romanian

5. Marital status: married6. Contact: Tel: 0040-740052584; E-mail:[email protected]. Studies:

Institution

Vasile GoldisWest University

Arad

Iuliu HaieganuUniversity ofMedicine andPharmacy of Cluj-Napoca]

Carol DavilaUniversity ofMedicine ofBucharest]

IuliuHaieganuUniversity ofMedicine andPharmacy ofCluj-Napoca]

Theoretical HighSchool of Zalau;Physics -Mathematicsspecialty]

Period:October 2004 /

June 2005January 2005 /February 2005

January 2005/March 2005

October 1998 /September 2004

September 1994/July 1998

Skills ofdiplomasobtained:

Masters Degree

inFinancial,

Accounting andLegal

Management ofthe Companies

Certificate ofgraduation:general ultrasound

scan post-university course

module I

Certificate ofgraduation:

generalultrasound scanpost-universitycourse module

II

UniversityDegreeGeneral

Medicine

High SchoolDiploma

8. Scientific title: Medical doctor, University Assistant, Full-time doctoral student9. Professional experience:Period: Position Responsibilities01. 11. 2005up

now

- University Assistant

- Resident Physician inLaboratory Medicine- Full-time doctoralstudent

U.M. F Iuliu Hatieganu CLUJ

- Didactical activity in Microbiology (Bacteriology,Parasitology, Virology, Mycology) with the 2nd, 3rdyearstudents, General Medicine, Pharmacy, Medical Collegeswithin "Iuliu Hatieganu" University of Medicine andPharmacy- Stages within residency activity- Research activity

01.01.2006 upnow

- Physician SALVO - SAN- medical practice in general medicine

01.06. 200920.11. 2009

SHORMO RMO INTERNATIONAL-Medical practice, clinical investigations before and afteroperation;

-The manager of resuscitation team in emergency cases15.01.200714.11.2007

Resident physician inFamily Medicine

Spitalul Clinic Judetean de Urgenta Cluj Napoca- clinical examinations, EKG, diagnosis and treatment,stages in Obstetrics and Gynaecology, Psychiatry, InfectiousDiseases

2j9g9_Ciobanca rezuzsrat

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