European Journal of Cardiovascular Medicine

Abstract   Introduction: Throughout ancient times, tuberculosis has posed a serious threat to humankind. Around 150 million years ago is when the Mycobacterium genus was first recognised. Egyptian mummies have been used to show the skeletal malformations caused by TB. Yet, the infectious agent behind this terrible sickness was not identified for quite some time. Material and Methods: Between January 2022 and October 2022, the epartment of Microbiology at the Ayaan Institute of Medical Sciences in Moinabad, Telangana conducted a prospective study. A total of one hundred people were included as part of this study's sample.  Results: Children who had expressed concerns were asked for and given permission to have a sample taken by their parents or legal guardians. Gastric aspirates, broncho-alveolar lavage, induced sputum, sputum, tracheal aspirate, ascitic fluid, lymph node aspirates, pleural fluid, and a synovial biopsy were all included in the collection of specimens. There was complete processing and analysis of all samples. Conclusion: This research was conducted to identify the most efficacious techniques for detecting TB in young people. CBNAAT has an advantage over other methods used to diagnose paediatric TB because it picked up more instances that were overlooked by those other approaches

Purpose: Acute undifferentiated febrile illness (AUFI) is a great challenge and burdenin the tropics with respect to diagnosis and clinical practice.Patients presenting with fever alone in Covid-19positive cases is very difficult to distinguish them from other AUFIs in the tropics like Malaria, Scrub Typhus, Dengue and Typhoid. Rapid sero-diagnostic tests of these infectionshad frequently shown sero-positivity for two or more infections leading to difficulty in clinical diagnosis and treatment in endemic zones. This study was performed to determine the false-positive serological test in Covid-19 patients for Typhoid Materials and Methods: The present study was observational prospective study conducted from April 2020 to November 2020. A total of 574 febrile patients which were positive in Real time PCR for Covid-19, were included in the study. Results: Widal test was found positive in 263samples (45.8%). Conclusion: Our experience suggests that cross reactivity in the serological test should be interpreted with caution andcontinuous follow-up of these patients along with surveillance should be done during Covid-19 pandemic in the resource-constrained tropical settings

Introduction: In recent years, scrub typhus has rapidly emerged to become the major cause of acute febrile illness (AFI) in India. The commonest tests used for diagnosis are serology and PCR. Therefore, the present study was planned to compare these two techniques in the diagnosis of scrub typhus. Aim of the study: To compare IgM ELISA and PCR for diagnosis of scrub typhus as a causative agent of AFI. Material and Methods: Patients with acute undiagnosed febrile illness presenting to the outpatient (OPD) or inpatient services of PGIMER Chandigarh between August 2013 and March 2014 were included in this study. Blood was collected for further analysis by IgM ELISA and nested PCR followed by Sanger sequencing. Result: Of 176 patients, 29 (16.4%) were positive for scrub typhus by nested PCR while 162 (92%) were positive by IgM ELISA. There was 59 % concordance between the two tests. Conclusion: This study report shows that the concordance between PCR and ELISA for the diagnosis of scrub typhus is less than 60%. Ideally, both tests should be performed to diagnose scrub typhus depending on the day of presentation to hospital

Introduction: The diagnosis of pure neural leprosy (PNL) remains difficult due to absence of characteristic skin lesions. Prior to the advent of invasive nerve biopsy, patients with pure neural leprosy were mainly diagnosed based on clinical judgement. Nerve biopsy and polymerase chain reaction (PCR) based tests are increasingly being done to diagnose PNL. Aim: To assess and compare the diagnostic value of nerve biopsy and RLEP3 gene detection using polymerase chain reaction tests in suspected cases of pure neural leprosy. Material and methodology: The study is a prospective non-randomised analytical study done for a period of 12 months in a tertiary care hospital in Chennai. Clinically suspected patients having pure neural leprosy with a sample size of 30 patients were included in the study. After clinical evaluation, basic investigations, nerve conduction study and slit skin smear for AFB, nerve biopsy and polymerase chain reaction assay were performed. Results: Specific histopathological findings were obtained in 3 out of 30 cases with 66.67% sensitivity, 40.74% specificity and 53.7% accuracy rate. PCR was positive in 7 out of 30 cases with 100% sensitivity, 52.17% specificity and 76.08% accuracy rate. In this study PCR was positive in additional 4 cases in which nerve biopsy was negative. This affirms PCR as an indispensable tool & necessity of using PCR in AFB negative cases. Conclusion: PCR based assay is more sensitive than nerve histopathology in the diagnosis of pure neural leprosy. A multimodal approach comprising clinical evaluation, nerve biopsy and PCR based assay gives the maximal diagnostic yield in suspected cases of pure neural leprosy.

Background: Bloodstream infections (BSIs) are a major global health issue, leading to significant morbidity and mortality, especially in healthcare settings. They are associated with prolonged hospital stays, increased healthcare costs, and high mortality rates, with a substantial incidence reported globally and particularly in pediatric intensive care units (PICUs). Objective: This study aims to assess the antimicrobial resistance patterns among Gram-negative isolates and evaluate the distribution of genetic markers of drug resistance in a tertiary care hospital in Cuttack, Odisha. Methods: A prospective study was conducted from November 2023 to July 2024 in the Department of Microbiology at SCBMCH, Cuttack, Odisha. The study included 558 pediatric patients with suspected BSIs from the PICUs. Blood cultures were processed using the BacT/ALERT 3D system. Isolates were identified using standard microbiological methods, and antimicrobial susceptibility was tested using the broth microdilution method. Genetic analysis for resistance markers was performed using PCR targeting TEM, SHV, CTX, NDM-1, and AmpC genes. Results: Out of 558 suspected cases, 192 (34.4%) were culture positive. Among these, 97 (50.5%) were Gram-negative bacteria, with 75 (77.3%) being multidrug-resistant (MDR). Genotypic analysis revealed that all Gram-negative isolates carried the TEM gene, with 18 (24%) containing both SHV and CTX genes. None of the isolates were carbapenemase producers by phenotypic methods, but 29 (38.6%) were detected by genotypic methods targeting the NDM-1 gene. Additionally, 4 isolates (5.3%) were identified as AmpC producers phenotypically, while 9 (12%) were detected genotypically. Conclusion: The high prevalence of MDR Gram-negative bacteria, particularly with significant genetic markers for drug resistance, highlights the urgent need for continuous surveillance and judicious use of antibiotics to manage BSIs effectively. Genotypic methods proved more sensitive than phenotypic methods in detecting resistance, emphasizing the importance of advanced diagnostic tools in clinical settings.

Introduction: Viral keratoconjunctivitis (VKC) is a common ocular condition characterized by inflammation of the conjunctiva and cornea, often caused by adenoviruses. It is highly contagious and can lead to significant morbidity, including blurred vision and discomfort. This study investigates an epidemic of VKC in a tertiary care hospital, focusing on its clinical presentation, epidemiological factors, and outcomes. Materials and Methods: A prospective observational study was conducted on 300 patients presenting with symptoms of VKC over six months. Inclusion criteria included clinical signs of VKC, such as redness, watering, and photophobia, while exclusion criteria involved bacterial or allergic conjunctivitis. Diagnostic tests included PCR for adenovirus and slit-lamp examination. Results: Of the 300 patients, 85% tested positive for adenovirus. The mean age was 32.5 years, with a male predominance (60%). Common symptoms included redness (95%), watering (90%), and photophobia (85%). Age >50 years and delayed presentation were significant risk factors for severe disease. Immunocompromised Status (25% of Severe Cases). Most patients experienced symptoms for 1–2 weeks, consistent with the natural course of adenoviral conjunctivitis. More than 2 Weeks (20%) are Prolonged symptoms were observed in a subset of patients, likely due to corneal involvement or delayed treatment. Persistent Blurred Vision (15%) are complication underscores the potential long-term impact of VKC on visual function. Conclusion: The epidemic was predominantly caused by adenovirus, with significant morbidity. Early diagnosis and strict infection control measures are essential to prevent outbreaks

Background: Congenital Heart Diseases (CHDs) are the most common congenital anomalies, contributing significantly to neonatal morbidity and mortality. Early detection of CHDs is crucial for timely intervention and improved clinical outcomes. Genetic markers have emerged as potential diagnostic tools for early identification of CHDs in neonates. This study aimed to evaluate the efficacy of specific genetic markers in the early detection of CHDs among neonates. Materials and Methods: A prospective case-control study was conducted over 24 months in a tertiary care hospital. A total of 150 neonates were enrolled, comprising 75 diagnosed with CHDs (case group) and 75 healthy neonates (control group). Blood samples were collected from all participants within 24 hours of birth. Genetic analysis focused on detecting mutations and polymorphisms in genes commonly associated with CHDs, including GATA4, NKX2-5, and TBX5, using Polymerase Chain Reaction (PCR) and sequencing techniques. Statistical analysis was performed using SPSS software, with a p-value of <0.05 considered significant. Results: The frequency of mutations in GATA4, NKX2-5, and TBX5 genes was significantly higher in the case group (45%, 40%, and 35%, respectively) compared to the control group (5%, 7%, and 4%, respectively) (p < 0.001). Sensitivity and specificity of GATA4 mutations in detecting CHDs were 90% and 85%, respectively. Combined analysis of all three genetic markers improved diagnostic accuracy to 92%. Conclusion: The findings suggest that genetic markers such as GATA4, NKX2-5, and TBX5 are effective in the early detection of congenital heart diseases in neonates. Incorporating genetic screening into neonatal screening protocols could enhance early diagnosis and facilitate timely interventions, potentially improving clinical outcomes. Further studies with larger sample sizes are warranted to validate these findings.

Background: Pseudomonas aeruginosa is a major contributor to hospital-acquired infections (HAIs), with metallo-beta-lactamase (MBL) production driving resistance to carbapenems, a critical therapeutic class. In Western India, where healthcare systems face resource constraints and high patient loads, the epidemiology of MBL-producing P. aeruginosa remains underexplored. This study investigates the prevalence and mechanisms of MBL production in P. aeruginosa isolates from HAIs in this region. Methods: Between January 2023 and March 2025, 200 non-duplicate P. aeruginosa isolates were collected from HAIs across five tertiary care hospitals in Western India (Silvassa, Mumbai, Pune, Ahmedabad, and Jaipur). Isolates were identified using VITEK 2 and subjected to antibiotic susceptibility testing via Kirby-Bauer disk diffusion and E-test for carbapenems. MBL production was detected phenotypically using the imipenem-EDTA combined disk test and genotypically via PCR targeting blaNDM, blaVIM, blaIMP, and blaSPM genes. Plasmid analysis and conjugation experiments assessed resistance transferability. Results: MBL production was confirmed in 128 isolates (64%, 95% CI: 57.2–70.8%), with the highest prevalence in ventilator-associated pneumonia (72%) and bloodstream infections (62.5%). Resistance to meropenem (89.8%) and imipenem (84.4%) was predominant among MBL producers, alongside significant resistance to ceftazidime (78.1%) and piperacillin-tazobactam (68.8%). blaNDM-1 was the most common MBL gene (60.9%), followed by blaVIM (29.7%), with 94.4% of MBL genes located on conjugative plasmids transferable to Escherichia coli J53 in 86.4% of cases. MBL production correlated with prolonged ICU stays (66.4%) and higher mortality (21.9%). Conclusion: The 64% prevalence of MBL-producing P. aeruginosa in Western India, driven by plasmid-mediated blaNDM-1 and blaVIM, signals a critical resistance burden in HAIs. These findings highlight the urgent need for enhanced infection control, molecular surveillance, and antibiotic stewardship to curb the spread of MDR pathogens in this region.

Background: Hepatitis C virus (HCV) is a bloodborne virus and is the primary agent of posttransfusion hepatitis. Hepatitis C is a virally mediated liver inflammation and is a major health care burden in India and worldwide.  Government of India launched a National Viral Hepatitis Control Program (NVHCP) to eliminate Hepatitis C by 2030. Aim: To qualitatively and quantitatively estimate the HCVRNA in seropositive Hepatitis C patients attending tertiary center in Central Kerala and to describe their clinico- epidemiologic profile. Materials and Method: This descriptive cross-sectional study conducted at GMC; Ernakulam included 55 Hepatitis C seropositive patients. After obtaining consent from seropositive Hepatitis C patients, clinical details were collected according to the proforma. The samples were collected as per the NVHCP guidelines for qualitative detection and quantitative estimation of HCV RNA by real time PCR. It was analyzed using Statistical Package for Social Sciences (SPSS) software 20.0. Qualitative variables were summarized using frequency or percentage. Chi square test was used in the analysis of study variables. Quantitative variables (viral load) were analyzed using mean ± SD. Independent t test was used in the analysis of viral load. The level of significance was taken as P value <0.05. Results and Discussion: In the study 90.9% of the seropositive Hepatitis C patients were HCV RNA positive. Among HCVRNA positive cases 52.7% had a viral load of >1lakh IU/ml who required aggressive therapy. In our study it was observed that history of alcohol consumption and high-risk behavior such as MSM character and multiple sexual partners were the major risk factors associated with the seropositive Hepatitis C patients as we could prove the association statistically significant. We could not find any statistically significant association between Hepatitis C seropositive patients and other risk factors such as IV drug abuse, history of blood transfusion and percutaneous injury which may be because of lesser number of study sample. Conclusion: Males were predominant in our study and the common age group was 31- 45 years. 90.9% of HCV seropositive patients in our institution were HCV RNA positive who were having active infection requiring treatment. More than 1 lakh IU/ml of viral load was obtained in 52.7% warranting aggressive therapy. We could prove statistically significant association only for alcoholism and high-risk behavior such as MSM character, multiple sexual partners

Background: Colistin serves as a last-line antibiotic for treating multidrug-resistant Gram-negative infections. The emergence of plasmid-mediated resistance genes, notably mcr-1 and mcr-2, among Enterobacteriaceae has raised significant clinical concern, especially in bloodstream infections where therapeutic options are limited. Objective:To determine the prevalence of phenotypic and genotypic colistin resistance among bloodstream Enterobacteriaceae isolates and assess the correlation between mcr gene presence and minimum inhibitory concentration (MIC) values. Methods: This cross-sectional study was conducted from June 2022 to May 2023 at IMS & SUM Hospital, Bhubaneswar, Odisha. A total of 110 non-duplicate Enterobacteriaceae isolates from blood cultures were included. Colistin susceptibility was determined using broth microdilution, and MICs were recorded. PCR assays targeting mcr-1 and mcr-2 were used for genotypic detection. Correlation between mcr gene presence and MIC values was assessed using descriptive statistics and visual analysis. Results: Colistin resistance was observed phenotypically in 21.8% of isolates. The mcr-1 gene was detected in 12.7% and mcr-2 in 2.7% of isolates. All mcr-positive isolates had MIC values exceeding 4 µg/mL, while mcr-negative isolates remained below the 2 µg/mL breakpoint. A perfect concordance was noted between mcr gene positivity and phenotypic resistance. Escherichia coli and Klebsiella pneumoniae were the most frequently identified mcr-positive species. Conclusion: The study demonstrates a significant burden of mcr-mediated colistin resistance in bloodstream infections, with strong phenotypic-genotypic concordance. Routine screening for mcr genes may enhance early detection and guide antimicrobial therapy in high-risk settings.

Introduction: Oropharyngeal candidiasis (OPC) is the most common opportunistic infection observed in HIV seropositive patients. It has been perceived that low CD4 counts and high plasma HIV RNA levels, both significantly correlate with oral candidiasis in HIV patients.  Aim: To determine the antifungal susceptibility testing of the Candida isolates by disc diffusion method. Materials and Methods: The present study is a cross-Sectional study that included 100 clinical samples processed for speciation of Candida isolates by using standard mycological techniques and antifungal susceptibility of the Candida isolates was done by using disc diffusion method and MICs was done by ‘E’ strip test for fluconazole resistant isolates. CD4 count was estimated by using Flow cytometry method & viral load was estimated by using Real time PCR, Abbott M2000SP and correlated with oral thrush.  Results: Out of 100 Candida isolates, Candida albicans 84 (84%) was the predominant species followed by Candida krusei 7 (7%), Candida glabrata6 (6%), Candida tropicalis3 (3%). Among the antifungals used in this study, the most sensitive agent was voriconazole 99(94.4%) and the least was Itraconazole 59 (19.6%). CD4 count was less than 200 cells/μl in 45(45%). Viral load varied from 1,62409 to 58 copies/ml of blood in the patients with oral thrush with significant association. Conclusions: To conclude, though Candida albicans was the common species, the emergence of non-albicans candida species and the increasing rate of azole resistance, emphasizes the need for speciation and determination of susceptibility pattern to provide appropriate treatment for HIV patients with oral candidiasis

Background: Myocarditis is an inflammatory disease of the myocardium with diverse histopathological patterns. Viral infections are the leading cause, yet the strength of association between histopathological subtypes and specific viral agents remains unclear. Objective: To systematically review and quantitatively synthesize available evidence on the relationship between histopathological patterns of myocarditis and viral etiologies detected in myocardial tissue. Methods: PubMed, Embase, Scopus, and Web of Science were searched up to March 2025 for studies reporting histopathological subtypes of myocarditis with concomitant viral testing of myocardial tissue by PCR, immunohistochemistry, or in situ hybridization. Eligible studies included cohorts, case-control studies, and case series (≥5 patients). Data were pooled using random-effects models to estimate odds ratios (OR) for associations between histological patterns (lymphocytic, eosinophilic, giant cell, granulomatous) and viral detection. Heterogeneity was quantified by I², and publication bias by Egger’s test. Results: Thirty-two studies comprising 4,256 patients (3,112 with endomyocardial biopsy, 1,144 with autopsy samples) were included. Lymphocytic myocarditis was the predominant pattern (61.8%), followed by eosinophilic (9.2%), granulomatous (6.5%), and giant cell myocarditis (3.8%). Viral genomes were detected in 53.4% of biopsies overall. Pooled analysis showed that lymphocytic myocarditis was strongly associated with viral detection (OR 3.12, 95% CI 2.25-4.32, I² = 28%). In contrast, eosinophilic (OR 0.54, 95% CI 0.33-0.88, I² = 12%) and giant cell myocarditis (OR 0.41, 95% CI 0.19-0.88, I² = 0%) were negatively associated with viral presence. Granulomatous myocarditis, often reflecting sarcoidosis or tuberculosis, showed no significant association with viral genomes (OR 0.92, 95% CI 0.55-1.56, I² = 35%). Subgroup analysis revealed parvovirus B19 and enteroviruses as the most frequently associated viruses with lymphocytic myocarditis. Conclusions: Histopathological patterns of myocarditis correlate strongly with underlying etiology. Lymphocytic myocarditis is significantly associated with viral detection, especially parvovirus B19 and enteroviruses, whereas eosinophilic and giant cell forms are typically non-viral. Recognition of these associations is essential for diagnostic interpretation and therapeutic decision-making

Introduction: Infertility is increasingly recognized as a multifactorial condition in which genital tract microbiota and antimicrobial resistance (AMR) may impair semen function. We evaluated semen parameters, culture/PCR-detected microorganisms, and resistance patterns among infertile men attending a tertiary center. Materials & Methods: In a prospective cohort of 246 males, semen analysis followed WHO laboratory standards. Semen was cultured for aerobic/fungal pathogens; STI PCR targeted Mycoplasma genitalium, M. hominis, Ureaplasma urealyticum, U. parvum, and Chlamydia trachomatis. Antibiotic susceptibility testing for Gram-positive and Gram-negative isolates used Kirby–Bauer per CLSI 2021. Outcomes included isolate spectrum, symptomatic status, and ESBL/MBL markers. Results: Culture positivity in males was 76.4% (188/246); asymptomatic carriage predominated (67%). The most frequent organisms were Escherichia coli (n=36), Staphylococcus aureus (n=24) and Candida albicans (n=22). STI-associated organisms were also detected (e.g., Mycoplasma genitalium n=15). Progressive motility averaged 32.1% and morphology 6.4% normal forms. Gram-positive isolates showed highest susceptibility to doxycycline and linezolid; Gram-negative isolates retained activity to gentamicin and amoxicillin–clavulanate, with notable resistance to meropenem and fluoroquinolones. ESBL/MBL phenotypes were present among Enterobacterales and non-fermenters. Conclusion: Male infertility in this cohort was strongly associated with microbial colonization and significant AMR. Routine, partner-inclusive screening and targeted therapy are warranted to mitigate subclinical colonization and improve fertility outcomes.

Background: Individual variations in response to antihypertensive therapy are partly influenced by genetic factors affecting drug metabolism. The CYP3A5 enzyme plays a key role in the biotransformation of amlodipine, a commonly prescribed calcium channel blocker. This study aimed to evaluate the effect of CYP3A5 genetic polymorphism on the antihypertensive response to amlodipine in patients with essential hypertension. Material and Methods: A prospective observational study was conducted among 120 newly diagnosed hypertensive patients aged 30–65 years. All participants received amlodipine (5–10 mg daily) for eight weeks. Genomic DNA was extracted and CYP3A5 (6986A>G) polymorphism was determined by PCR-RFLP. Participants were categorized as expressors (*1/*1 or *1/3) and non-expressors (*3/3). Blood pressure was recorded at baseline and after eight weeks. Data were analyzed using SPSS version 25, with p < 0.05 considered statistically significant. Results: Of the 120 subjects, 48 (40%) were expressors and 72 (60%) were non-expressors. Baseline characteristics were comparable between the two groups. The mean reduction in systolic and diastolic blood pressures was significantly greater in expressors (17.2 ± 6.3 mmHg and 13.2 ± 4.5 mmHg, respectively) than in non-expressors (13.9 ± 6.8 mmHg and 10.8 ± 4.9 mmHg; p = 0.02 and p = 0.01). Overall, 70.8% of patients were responders, with a higher response rate among expressors (81.3%) compared to non-expressors (63.9%; p = 0.04). Adverse effects, including pedal edema and headache, were mild and comparable between groups. Conclusion: CYP3A5 polymorphism significantly influences the antihypertensive efficacy of amlodipine. Expressor genotypes exhibit better blood pressure control, indicating the potential value of pharmacogenetic profiling in optimizing hypertension management

Background: Multidrug-resistant (MDR) Gram-negative bacilli are increasingly prevalent in intensive care units (ICUs) and pose a major threat to patient care due to limited therapeutic options. Objectives: To characterize MDR Gram-negative bacilli isolated from ICU patients and to determine their antimicrobial resistance patterns and molecular mechanisms of resistance. Methods: A hospital-based cross-sectional study was conducted over one year (2024–2025) at Calcutta National Medical College and Hospital. A total of 100 non-duplicate Gram-negative bacilli isolates from ICU patients were identified using standard biochemical methods and automated systems. Antimicrobial susceptibility testing was performed by the Kirby–Bauer disk diffusion method and interpreted as per CLSI guidelines. Extended-spectrum β-lactamase (ESBL), AmpC, and carbapenemase production were phenotypically detected, and molecular characterization was carried out by PCR targeting resistance genes (bla_TEM, bla_SHV, bla_CTX-M, bla_NDM, bla_KPC, bla_OXA-48). Data were analyzed statistically. Results: The most common isolates were Klebsiella pneumoniae (35%), Escherichia coli (25%), Pseudomonas aeruginosa (20%), Acinetobacter baumannii (15%), and others (5%). High resistance rates were observed against third-generation cephalosporins (82%), fluoroquinolones (76%), and carbapenems (58%). ESBL production was detected in 45% of isolates, AmpC in 20%, and carbapenemase in 35%. Molecular analysis revealed bla_CTX-M (40%), bla_TEM (32%), bla_SHV (18%), bla_NDM (22%), bla_OXA-48 (12%), and bla_KPC (8%). Colistin retained the highest susceptibility (92%).\ Conclusion: MDR Gram-negative bacilli are highly prevalent in ICU patients, with carbapenemase-mediated resistance emerging as a major concern. The predominance of ESBL and carbapenemase genes underscores the urgent need for strict antimicrobial stewardship, continuous surveillance, and infection control practices to contain the spread of these pathogens

Quantification DNA from the hepatitis B virus (HBV) is essential for treating persistent HBV infections But because HBV is a DNA virus with a lot of genetic variety, using antiviral medications has led to the emergence of drug-resistant mutations.About 400 million individuals have a chronic infection with the hepatitis B virus, and between 500,000 an 1,200,000 people may away each year from illnesses linked to the virus. The objective of our research was to look at the HBV DNA results in patients who tested positive for HBsAg.ELISA was used to find HBsAg positive in individuals who were suspected of having hepatitis and admitted to our hospital. Real-time PCR was used to analyse HBV DNA. In this regard, a retrospective analysis was conducted to determine the HBV DNA in the serum samples of 128 HBsAg-positive patients who were sent to our laboratory. 102 (79.6%) of the patients had positive HBV DNA. HBV DNA was found to be positive in 29.4% of female patients and 69.6% of male patients. 96% of adult patients and 4% of children in the child age group were positive for HBV DNA. Therefore, in order to monitor the effectiveness of antiviral medication, we recommend that viral replication be shown in HBsAg-positive cases and that the quantity of HBV DNA be determined