Phenotypic and genotypic antibiotic resistance patterns in Salmonella Typhimurium and its monophasic variant from pigs in southern Spain.

The high incidence of human salmonellosis and multi-drug resistant (MDR) strains of Salmonella Typhimurium (ST) is of concern to global public and animal health. Our research, by means of the broth microdilution method, evaluated the Minimum Inhibitory Concentration (MIC) distribution of 12 antimicrobials against a collection of 73 ST and mST and S. typhimurium monophasic variant 4,[5],12:i:- (mST) isolates from slaughtered pigs reared in extensive systems in southern Spain, and also 12 resistance-associated genes or antimicrobial resistance (AMR) determinants using qPCR. Our data revealed that 98.6% of strains were MDR, with resistance to cephalothin/tetracycline/sulfamethoxazole-trimethoprim/ampicillin/chloramphenicol being the most common pattern (55.6%). Regarding AMR determinants, the most significantly (p < 0.05) genes detected by qPCR were sul1 and aadA2 (89% of strains positive), aadA1 and dfrA12 (87.7%), and blaTEM and tet(B) (86.3% and 84.9%, respectively). Up to date information on ST antimicrobial resistance patterns is essential for epidemiological surveillance programs to support animal and public health. The high number of MDR isolates and variability regarding resistance determinants revealed in this study highlights the role of animals reared in extensive systems as a source of resistant Salmonella strains.

[Importance of genetics in osteoartrosis]. / Importancia de la genética en la osteoartrosis.

INTRODUCTION: The study of our genome has played an important role in the field of personalized medicine and clinical practice becoming a useful tool to assist the medical community in the early diagnosis and treatment of countless diseases; osteoarthritis (OA) is a complex chronic degenerative joint disease, despite the high prevalence of this disease and its great impact on public health, little is currently known about its etiology and risk of progression. The purpose of this review is to show the advances in genetics in the study of osteoartrosis. METHODS: The present is a review of the literature of the different aspects in which genetics has developed in the study of osteoartrosis, its scopes and its possible impact on prevention and treatment. CONCLUSION: The identification of a high number of candidate genes confirms the complex nature of the disease, it seems clear that the degree of expression of different genes is altered between an arthrosic patient and a healthy one. A deeper understanding of the link between the entire genome sequence and the association with well-characterized OA phenotypes will enable the development of biomarkers, report the risk of disease progression and allow better guidance of treatments.

INTRODUCCIÓN: El estudio de nuestro genoma ha jugado un papel importante en el campo de la medicina personalizada y la práctica clínica, lo que la convierte en una herramienta útil para ayudar a la comunidad médica en el diagnóstico y tratamiento temprano de innumerables enfermedades. La osteoartrosis (OA) es una enfermedad articular degenerativa crónica compleja; a pesar de su alta prevalencia y gran impacto en la salud pública, actualmente se sabe poco sobre su etiología y riesgo de progresión. El objeto de la presente revisión es mostrar los avances de la genética en el estudio de la osteoartrosis. MÉTODOS: Revisión de la literatura sobre los diferentes aspectos en donde la genética se ha desarrollado en el estudio de la osteoartrosis, sus alcances y sus posibles repercusiones en la prevención y tratamiento. CONCLUSIÓN: La identificación de un elevado número de genes candidatos nos confirma la compleja naturaleza de la enfermedad, parece claro que el grado de expresión de diferentes genes está alterado entre un paciente artrósico y uno sano. Una comprensión más profunda del vínculo entre la secuencia de todo el genoma y la asociación con fenotipos bien caracterizados de la OA, permitirá el desarrollo de biomarcadores, informar el riesgo de progresión de la enfermedad y permitir una mejor orientación de los tratamientos.

An alternative methodology to determine 210Pb activity soil profiles.

Unsupported 210Pb (Pbexc) is generated in air and is subsequently deposited on soil surface. The Pbexc can be used for sediment dating, soil erosion/sedimentation and air mass studies. In many cases, 210Pb activity determination (gamma ray 46.5 keV) cannot be performed due to the lack of efficiency calibration curve, especially when radioactive patron source is not available. This work presents an alternative methodology to obtain the 210Pb activity values, based on the activity definition and the attenuation coefficient determinations and assuming that soil samples coming from depth higher than 25 cm only contain 210Pb generated in the soil (Pbexc free, i.e., for those soil layers the 210Pb activity is equal to the 226Ra activity, at secular equilibrium). The proposed methodology was evaluated using soils from La Plata region, Argentina. The same soil samples were also analyzed in a second laboratory by the conventional methodology. The obtained results indicated that the proposed procedure can be used as a good alternative in cases where a calibration sample is not available.

Combined effect of conventional antimicrobials with essential oils and their main components against resistant Streptococcus suis strains.

Streptococcus suis is a major swine pathogen. Different strategies to reduce the antimicrobial resistance to conventional antimicrobials (AMBs) have been proposed, including the combined use with essential oils (EOs). The objective of this work was to evaluate the effectiveness of the combination of cinnamon, oregano, common thyme and red thyme EOs and their main components (cinnamaldehyde, carvacrol and thymol) with conventional AMBs (oxytetracycline, trimethoprim-sulfamethoxazole, gentamicin and penicillin) against field resistant S. suis strains. The checkerboard method was used to assess the interaction, by the fractional inhibitory concentration index (FICindex ) determination. All the AMBs showed synergistic (FICindex  ≤ 0·5) or additive (0·5 < FICindex  ≤ 1) effect with at least one of the four essential oils. In general, the combination of the AMBs with the EOs showed better results than combination the AMBs with the main components, although no antagonist effects were detected in any case. The results obtained would support the combined use of AMBs agents with EOs for the treatment of S. suis. SIGNIFICANCE AND IMPACT OF THE STUDY: Streptococcus suis is an important pig pathogen and a zoonosis. Control is based on antimicrobials; however, there is pressure to reduce the use of antimicrobials and new products or combination therapies are of considerable interest. We have evaluated the combined interaction of four essential oils or their main components with conventional antimicrobials against resistant S. suis strains. A positive interaction between gentamicin and oxytetracycline with cinnamon, oregano or thyme was observed, suggesting that a combination of conventional antimicrobials with EOs is a promising alternative for the control of S. suis infections.

Adapting the Caesium-137 technique to document soil redistribution rates associated with traditional cultivation practices in Haiti.

Large-scale deforestation, intensive land use and unfavourable rainfall conditions are responsible for significant continuous degradation of the Haitian uplands. To develop soil conservation strategies, simple and cost-effective methods are needed to assess rates of soil loss from farmland in Haiti. The fallout radionuclide caesium-137 (137Cs) provides one such means of documenting medium-term soil redistribution rates. In this contribution, the authors report the first use in Haiti of 137Cs measurements to document soil redistribution rates and the associated pattern of erosion/sedimentation rates along typical hillslopes within a traditional upland Haitian farming area. The local 137Cs reference inventory, measured at an adjacent undisturbed flat area, was 670 Bq m-2 (SD = 100 Bq m-2, CV = 15%, n = 7). Within the study area, where cultivation commenced in 1992 after deforestation, three representative downslope transects were sampled. These were characterized by 137Cs inventories ranging from 190 to 2200 Bq m-2. Although, the study area was cultivated by the local farmers, the 137Cs depth distributions obtained from the area differed markedly from those expected from a cultivated area. They showed little evidence of tillage mixing within the upper part of the soil or, more particularly, of the near-uniform activities normally associated with the plough layer or cultivation horizon. They were very similar to that found at the reference site and were characterized by high 137Cs activities at the surface and much lower activities at greater depths. This situation is thought to reflect the traditional manual tillage practices which cause limited disturbance and mixing of the upper part of the soil. It precluded the use of the conversion models normally used to estimate soil redistribution rates from 137Cs measurements on cultivated soils and the Diffusion and Migration conversion model frequently used for uncultivated soils was modified for application to the cultivated soils of the study area, in order to take account of the unusual local conditions. The model was also modified to take account of the fact that cultivation in the study area commenced in 1992, rather than predating the period of weapons test fallout which extended from the mid 1950s to the 1970s. Erosion rates on the upper parts of the hillside involved in the study were found to be relatively high and ca. -23 t ha-1 y-1 with low spatial variability. In the lower, flatter areas at the bottom of the slope, deposition occurred. Deposition rates were characterized by high spatial variability, ranging from 6.0 to 71 t ha-1 y-1. Soil redistribution rates of this magnitude are a cause for concern and there is an urgent need to implement soil conservation measures to ensure the longer-term sustainability of the local agricultural practices.

Seroprevalence and risk factors of exposure to caprine arthritis-encephalitis virus in southern Spain.

The aim of the present transversal descriptive study was to determine the exposure and risk factors associated with caprine arthritis-encephalitis virus (CAEV) in southern Spain. A total of 3,312 serum samples were collected from goat belonging to three different breeds coming from 48 flocks located in different geographic areas from southern Spain. In addition, health and productive parameters were surveyed during the visit to the herds. Serum samples were analysed by INgezim Maedi Screening (Ingenasa®) ELISA kit. The total percentage of herds exposed to CAEV was 87.71% (CI95 78.42-97.00). A total of 733 goats were seropositive with overall seroprevalence of 23.22% (CI95 21.78-24.65). The intraherd seroprevalence was 20.82%±24.07. Multivariate logistic regression showed significant association between CAEV and the next variables: (i) herd size (P<0.0001; OR: 2.07; CI95: 1.73-2.50), (ii) kidding area (P<0.0020; OR: 1.38; CI95: 1.13-1.69), (iii) cleaning and disinfection program (P<0.0067; OR: 1.90; CI95: 1.43-2.53), (iv) natural mating (P<0.0026; OR: 2.22; CI95: 1.73-2.86) and (v) multiparous (P<0.0001; OR: 2.90; CI95: 2.17-3.87). The results indicate a widespread of CAEV infection in goat herds in southern Spain, being herd size, existence of kidding area, absence of cleaning and disinfection program, natural mating and multiparous goats risk factors for the exposure to CAEV.

Serosurvey on schmallenberg virus and selected ovine reproductive pathogens in culled ewes from southern Spain.

After the first case of Schmallenberg virus (SBV) was reported in southern Spain (March 2012), a retrospective serological study was carried out in extensive sheep flocks from nearby areas to assess the history of exposure to SBV and other selected ovine reproductive pathogens (Chlamydophila abortus, Coxiella burnetii, Border Disease virus 'BDV', Toxoplasma gondii and Neospora caninum). Secondly, the presence of antibodies was investigated in meat juice samples against selected pathogens to validate their use in serosurveys in sheep. A total of 209 Merina and cross-bred culled ewes belonging to 12 outdoor flocks managed in extensive breeding systems were sampled. Serum and meat juice samples were collected at the slaughterhouse and analysed using commercial ELISA kits. Chlamydophila abortus (62.68%, CI95 56.13-69.23) and Toxoplasma gondii (57.42%, CI95 50.72-64.12) were the most prevalent pathogens. The seroprevalence of BDV (16.27%, CI95 11.27-21.27) and Coxiella burnetii (13.88%, CI95 9.2-18.56) was moderate, and only 4 of 209 animals (1.91%, CI95 1.82-2.96) presented specific antibodies against Neospora caninum or SBV. All the examined ovine flocks were seropositive to three or more pathogens. The highest percentage of seropositive animals was detected for T. gondii-C. abortus coseropositive (25.36%) culled ewes. The concordance between serum and meat juice samples was moderate for T. gondii (κ = 0.419) and BDV (κ = 0.568), and fair for C. abortus (κ = 0.311). Our results show evidence of circulation of SBV from summer 2011 in southern Spain. Furthermore, C. abortus and T. gondii were the most prevalent pathogens associated with sheep in outdoor rearing systems. Finally, these preliminary results point to meat juice samples as a potential biological sample for serosurveys studies on sheep.

A serological survey of Brucella spp., Salmonella spp., Toxoplasma gondii and Trichinella spp. in Iberian fattening pigs reared in free-range systems.

Zoonotic agents such as Brucella spp., Salmonella spp., Toxoplasma gondii and Trichinella spp., all considered high-risk zoonotic pathogens by the European Food Safety Agency (EFSA), may cause no symptoms of infection in free-range pigs yet still have a significant public health impact. A serological survey was therefore performed to determine the history of occurrence of these pathogens in such pigs in southern Spain. A total of 709 serum samples were collected at abattoir from pigs from 79 farms and analysed for specific antibodies against the above pathogens using commercially available ELISA kits. Encysted Trichinella spp. larvae were also sought following the artificial digestion method of diaphragm pillar muscle. The results showed Salmonella spp. to be widely distributed among the sampled herds [73.42%, 95% confidence interval (CI95 ) 65.6-81.78] and Toxoplasma gondii to be present in over half (58.23%, CI95 47.33-69.07). The seroprevalence of Brucella spp. was very low (3.8%, CI95 0.18-7.42), and antibodies against Trichinella spp. were not detected. No encysted Trichinella spp. larvae were microscopically detected.

Epidural catheter with integrated light guides for spectroscopic tissue characterization.

Epidural catheters are used to deliver anesthetics and opioids for managing pain in many clinical scenarios. Currently, epidural catheter insertion is performed without information about the tissues that are directly ahead of the catheter. As a result, the catheter can be incorrectly positioned within a blood vessel, which can cause toxicity. Recent studies have shown that optical reflectance spectroscopy could be beneficial for guiding needles that are used to insert catheters. In this study, we investigate the whether this technique could benefit the placement of catheters within the epidural space. We present a novel optical epidural catheter with integrated polymer light guides that allows for optical spectra to be acquired from tissues at the distal tip. To obtain an initial indication of the information that could be obtained, reflectance values and photon penetration depth were estimated using Monte Carlo simulations, and optical reflectance spectra were acquired during a laminectomy of a swine ex vivo. Large differences between the spectra acquired from epidural adipose tissue and from venous blood were observed. The optical catheter has the potential to provide real-time detection of intravascular catheter placement that could reduce the risk of complications.

Salmonella Indiana as a cause of abortion in ewes: Genetic diversity and resistance patterns.

Salmonella enterica subspecies enterica Indiana, a food-borne serovar uncommon in most countries, was responsible for an outbreak of abortion in a flock of Lacaune dairy ewes in southern Spain. Drinking water and feedstuff samples were analysed in an attempt to determine the source of the infection. Pigeons (Columba livia) and turtledoves (Streptopelia turtur) in close contact with the ewes were captured and examined for the bacterium. Seventeen S. Indiana strains were isolated from the ewes and wild birds and the genetic similarity among them analysed by Pulsed Field Gel Electrophoresis (PFGE) after the digestion of their genomic DNA with the restriction enzyme XbaI. The results suggest the wild birds might be responsible for the outbreak in the ewes. The strains recovered were fully susceptible to 15 out of the 16 antimicrobial agents tested: ampicillin, amoxycillin clavulanate, cephalothin, ceftriaxone, gentamicin, neomycin, streptomycin, tetracycline, ciprofloxacin, enrofloxacin, sulphonamides, trimethoprim-sulphamethoxazole, apramycin, colistin and chloramphenicol. Differences in the resistance pattern to nalidixic acid were observed; 11 strains (64.7%) were nalidixic acid resistant (R-Nx) and 6 (35.3%) sensitive (S-Nx). Among the R-Nx strains, a substitution of Gly to Cys at position 81 (Gly81àCys) of the gyrA gene in 10 strains isolated from wild birds and ovine foetuses, and of Asp to Tyr at position 87 (Asp87àTyr) in one strain isolated from ewe faeces, were revealed by sequencing the gene. To control the outbreak, enrofloxacin treatment was administered for 5 days. The same therapy was used to prevent infection during following gestation cycles, administering the antimicrobial agent at presentation and over 4 weeks before birth. Anti-bird meshes and closed drinking and feeding troughs were also installed to prevent further contact of the ewes with wild birds.

Epidemiological tracing of Salmonella enterica serotype Abortusovis from Spanish ovine flocks by PFGE fingerprinting.

Salmonella enterica serotype Abortusovis, an ovine host-specific serotype, rare in most countries, is responsible for epidemic abortion episodes in Spain. With the aim of surveillance and detection of the spread of specific clones, 55 Abortusovis isolates collected during 1996-2001 from flocks in 11 provinces, were studied using XbaI-PFGE. Despite the fact that the strains were geographically and spatially related, PFGE demonstrated an epidemiologically acceptable discriminating power, identifying 20 clones (similarity, 52-96%). Clones Sabv6, 1, 5 were disseminated in seven, five and two areas respectively, while another 17 clones appeared in single places. Clones from nearby geographic regions showed a high relatedness (one band of difference in the PFGE profile) Sabv1-2-3, Sabv5-6, Sabv7-8, and Sabv13-14, suggesting a common ancestor. Co-isolation in the same flock (Sabv5-6, Sabv1-3, Sabv1-6) was detected. PFGE surveillance detected the predominance and widespread distribution of clone Sabv6 in 21 out of the 55 Abortusovis serotype episodes studied in Spain.

Molecular typing and anti-microbial susceptibility of clinical isolates of Streptococcus equi ssp. zooepidemicus from equine bacterial endometritis.

The anti-microbial susceptibility and genetic diversity of 65 strains of Streptococcus equi ssp. zooepidemicus (Sez) isolated from mares presenting clinical signs of endometritis was determined by disk agar diffusion and pulsed field gel electrophoresis (PFGE) methods, respectively. Overall, Sez isolates were susceptible to beta-lactams, enrofloxacin, trimethoprim-sulfamethoxazole and gentamicin. These anti-microbials could be recommended as empiric anti-microbial therapy in cases of endometritis caused by Sez. Pulsed field gel electrophoresis typing revealed a great genetic diversity (56 different PFGE macrorestriction profiles) and a low level of genetic relatedness amongst the isolates.

Efficacy of lanreotide Autogel administered every 4-8 weeks in patients with acromegaly previously responsive to lanreotide microparticles 30 mg: a phase III trial.

OBJECTIVE AND DESIGN: Depot somatostatin analogues are well accepted as either adjuvant or primary therapy for acromegaly, and their long dosage intervals facilitate adherence to treatment. Our objective was to evaluate whether lanreotide Autogel 120 mg, every 4-8 weeks, was as effective in controlling acromegaly as lanreotide microparticles 30 mg, every 1-2 weeks. PATIENTS DESIGN AND MEASUREMENTS: Patients who had used lanreotide microparticles 30 mg, >or= 2 months prestudy, and had responded to treatment were recruited to this open, prospective, multicentre phase III trial. Three to five injections of lanreotide Autogel 120 mg were administered. Lanreotide Autogel 120 mg was injected every 4, 6 or 8 weeks in patients previously receiving lanreotide microparticles every 7, 10 or 14 days, respectively. GH and insulin-like growth factor (IGF)-1 levels were assessed one dosing interval after the final injections. RESULTS: Ninety-eight patients were enrolled and 93 completed. Steady-state GH concentrations demonstrated similar efficacy between the formulations (upper 95% confidence interval of the quotient, 77.7%). Mean (SE) GH levels were lower with lanreotide Autogel than with lanreotide microparticles (3.8 (0.5) vs 4.3 (0.5) ng/ml; P < 0.001). GH levels < 2.5 ng/ml were observed in 54% and 46% of patients; 40% and 35% having GH < 2.5 ng/ml and normalized IGF-1 with lanreotide Autogel and microparticles, respectively. Symptoms were controlled better with lanreotide Autogel and treatment was well accepted. CONCLUSIONS: Lanreotide Autogel 120 mg every 4-8 weeks, is at least as effective and as well tolerated in acromegaly as lanreotide microparticles 30 mg injected every 7-14 days.

Minimal model analysis in nondiabetic renal transplant recipients with hepatitis C.

INTRODUCTION: Epidemiological data suggest that hepatitis C virus (HCV) infection may contribute to the development of posttransplantation diabetes mellitus (PTDM). METHODS: We investigated the glucose metabolism in 19 renal transplant recipients with antiHCV antibodies and without DM according to World Health Organization criteria before or after transplantation. We measured insulin sensitivity (SI), glucose effectiveness (SG), and pancreatic insulin response using the frequently sampled intravenous glucose tolerance test (FSIGTT). SI and SG were estimated using the Bergman minimal model method and pancreatic insulin response was expressed as the area under insulin curve (AUIC) between 0 and 19 minutes. RESULTS: Impaired glucose tolerance was shown in 42% of patients, some (31.5%) in the range of glucose intolerance (KG: 1-1.5) and others (10.5%) in the diabetes range (KG < 1). SI and SG were decreased in 39% and 63% of patients, respectively. Pancreatic insulin response revealed high variation among patients although showing a tendency to be enhanced. CONCLUSIONS: A high number of HCV-positive renal transplant recipients without clinically manifest PTDM have impaired glucose tolerance, which suggests the future development of diabetes in these patients.

Asociación entre diabetes mellitus y hepatitis C en trasplante renal / Association between diabetes mellitus and hepatitis C in kidney transplant patients

Introducción: La diabetes mellitus de aparición postrasplante (DMPT) ha sido generalmente atribuida al tratamiento inmunosupresor; sin embargo, diversos estudios sugieren una posible asociación entre el virus de la hepatitis C (VHC) y la diabetes mellitus, tanto en la población general como en pacientes trasplantados hepáticos y renales. Material y métodos: Estudiamos retrospectivamente a 325 pacientes trasplantados renales que no padecían diabetes antes del trasplante y que recibieron tratamiento con ciclosporina A en el postoperatorio. Estudiamos en ellos si distintos factores como edad, sexo, peso, enfermedad renal, inmunosupresión, rechazos o VHC constituyen factores de riesgo independientes de DMPT. Resultados: De los 325 pacientes, 94 eran VHC positivo y 231 VHC negativo. La DMPT se observó en el 22,3 por ciento de los pacientes VHC positivo comparado con el 6,5 por ciento de los pacientes VHC negativo (p < 0,001). En el análisis multivariable las variables que aparecen como factor predictivo independiente de DMPT son: VHC positivo (OR: 5,65, IC 95 por ciento: 2,6-12), índice de masa corporal (OR: 1,10, IC 95 por ciento: 1,02-1,2) y edad (OR: 1,07, IC 95 por ciento: 1,03-1,12). Conclusión: Nuestros datos apoyan la hipótesis de una asociación entre el VHC y la DMPT (AU)

Variability in the presence of the metabolic syndrome in Type 2 diabetic patients attending a diabetes clinic. Influences of age and gender.

In this study, we have assessed age and gender-related influences on the presence of the metabolic syndrome (MS) and closely related variables in Type 2 diabetic patients attending a diabetes clinic. For this purpose, we have taken retrospective clinical and biochemical data from consecutive Type 2 diabetic patients (n = 291) and we have classified them by gender, age (with 55 and 70 years as cut-off levels) and having or not having the MS (using both the WHO and NCEP-ATP III MS definitions). A higher prevalence of adiposity and hypertension was present in the females. Males were characterized by higher uric acid and lower HDL-cholesterol and apoA(1) levels (two-way ANOVA considering jointly age and gender as main effects, P < 0.05 in every case). Overall the prevalence of NCEP-ATP III-defined MS was less frequent than WHO-defined MS (63.2% versus 81.1%, respectively). This difference was greater for males (42.1% versus 77.6%, respectively) than for females (75.5% versus 83.2% respectively). The kappa-coefficient for the concordance between both MS definitions was 0.46 for males and 0.72 for females in the first age band, 0.29 for males and 0.48 for females in the second age band and 0.24 for males and 0.51 for females in the third age band. Thus, this study reveals relevant differences in the application of WHO and NCEP-ATP III MS definitions in a clinic-based Type 2 diabetic population from Southern Spain. In addition, the data suggest that gender confers a specific influence upon some MS-associated features in Type 2 diabetic patients attending a diabetes clinic irrespective of age band.

[Association between diabetes mellitus and hepatitis C in kidney transplant patients]. / Asociación entre diabetes mellitus y hepatitis C en trasplante renal.

BACKGROUND: Diabetes mellitus appearing after transplant (PTDM) has generally been attributed to immunosuppressive treatment. However, the findings of several studies suggest a possible relationship between hepatitis C virus (HCV) infection and diabetes mellitus, both in the general population and in liver or kidney transplant patients. METHODS: We reviewed data corresponding to 325 kidney transplant patients who did not have diabetes before transplant and were treated with ciclosporin A posttransplant. We explored whether factors such as age, gender, weight, renal disease, immunosuppression, rejection episodes or HCV could be independent risk factors for PTDM. RESULTS: Ninety four of the 325 patients were HCV positive and 231 were HCV negative. PTDM was observed in 22.3% of the HCV positive patients versus 6.5% of the HCV negative patients (p < 0.001). The independent factors found by multivariate analysis to be predictive of PTDM were: HCV positivity (OR: 5.65, IC 95%: 2.6-12), body mass index (OR: 1,10, IC 95%: 1.02-1.2) and age (OR: 1.07, IC 95%: 1.03-1.12). CONCLUSIONS: Our findings support a link between HCV and PTDM.