Endocarditis in the Mediterranean Basin.

Infective endocarditis is a severe disease with high mortality. Despite a global trend towards an increase in staphylococcal aetiologies, in older patients and a decrease in viridans streptococci, we have observed in recent studies great epidemiologic disparities between countries. In order to evaluate these differences among Mediterranean countries, we performed a PubMed search of infective endocarditis case series for each country. Data were available for 13 of the 18 Mediterranean countries. Despite great differences in diagnostic strategies, we could classify countries into three groups. In northern countries, patients are older (>50 years old), have a high rate of prosthetic valves or cardiac electronic implantable devices and the main causative agent is Staphylococcus aureus. In southern countries, patients are younger (<40 years old), rheumatic heart disease remains a major risk factor (45-93%), viridans streptococci are the main pathogens, zoonotic and arthropod-borne agents are frequent and blood culture-negative endocarditis remains highly prevalent. Eastern Mediterranean countries exhibit an intermediate situation: patients are 45 to 60 years old, the incidence of rheumatic heart disease ranges from 8% to 66%, viridans streptococci play a predominant role and zoonotic and arthropod-borne diseases, in particular brucellosis, are identified in up to 12% of cases.

Using MALDI-TOF MS typing method to decipher outbreak: the case of Staphylococcus saprophyticus causing urinary tract infections (UTIs) in Marseille, France.

Staphylococcus saprophyticus is one of the leading causes of urinary tract infections (UTI). In December 2014, our surveillance system identified an abnormal increase in S. saprophyticus causing UTIs in four university hospitals in Marseille, indicating a suspected community S. saprophyticus UTI outbreak. This was detected by our surveillance system BALYSES (Bacterial real-time Laboratory-based Surveillance System). S. saprophyticus/ Escherichia coli UTI ratio increased three-fold from 0.0084 in 2002 to 0.025 in December 2015 in Marseille with an abnormal peak in December 2014, and with an annual estimated ratio trend of 5.10-6 (p-value < 10-3). Matrix-Assisted Laser Desorption Ionisation-Time of Flight Mass Spectrometry (MALDI-TOF MS) spectral analysis of strains was used to analyse strains cluster expansion, comparing strains from Marseille to those from Nice during the same period. MALDI-TOF MS spectral analysis revealed a geographical restricted clonal expansion of the strains clusters in Marseille as compared to Nice. Our finding suggests (i) a geographically restricted expansion of a specific S. saprophyticus strain clusters circulating in Marseille, and (ii) MALDI-TOF MS can be used as a cost-effective tool to investigate an outbreak.

Increase in reported adverse events following seasonal influenza vaccination among the French armed forces, 2008-2009: possible role of stimulated reporting and background cases of influenza-like infection.

OBJECTIVES: In September 2009, an increase in seasonal influenza vaccine adverse events (VAE), compared with reports for previous years, was detected among the French armed forces in the setting of an extended immunization campaign. This work presents the results of this investigation. STUDY DESIGN: VAE were surveyed among all French military personnel from 2008 to 2009 by Epidemiological Departments of the French Military Health Service. For each case, a notification form was completed, providing patient and clinical information. METHODS: Case definitions were derived from the French drug vigilance guidelines. Three types of VAE were considered: non-serious, serious and unexpected. Incidence rates were calculated by relating VAE to the number of vaccine doses injected. RESULTS: Forty-seven seasonal influenza VAE were reported in continental France: 18 in 2008 and 29 in 2009. The annual reporting rate was higher in 2009 (31.6 vs 16.6 VAE per 100,000 injections, respectively). The highest monthly incidence was observed in September 2009 (60.8 events per 100,000 injections). Two other peaks were observed in February 2008 and March 2009. The incidence in September 2009 was not significantly different from the incidences in February 2008 and March 2009. It was observed that incidence peaks occurred during influenza epidemic periods. One serious neurological VAE was observed. CONCLUSIONS: The increase in seasonal influenza VAE in late 2009 mainly involved non-serious events, and could reflect stimulated reporting in the context of the A(H1N1)pdm09 pandemic. VAE reporting rates were highest during influenza epidemic periods, which could be explained by VAE being wrongly attributed to the vaccine when symptoms could reflect coincident background cases of viral infection.

Novel influenza A(H1N1) outbreak among French armed forces in 2009: results of Military Influenza Surveillance System.

OBJECTIVES: An outbreak of novel A(H1N1) virus influenza, detected in Mexico in April 2009, spread worldwide in 9 weeks. The aim of this paper is to present the monitoring results of this influenza outbreak among French armed forces. STUDY DESIGN: The period of monitoring by the Military Influenza Surveillance System (MISS) was 9 months, from May 2009 to April 2010. METHODS: The main monitored events were acute respiratory infection (ARI), defined by oral temperature ≥38.5 °C and cough, and laboratory-confirmed influenza. Weekly incidence rates were calculated by relating cases to the number of servicepersons monitored. RESULTS: In continental France, the incidence of ARI increased from September 2009, with a weekly maxima of 401 cases per 100,000 in early December 2009 according to MISS. Estimations of the incidence of consultations which could be related to novel A(H1N1) influenza ranged from 48 to 57 cases per 100,000. CONCLUSIONS: The trends observed by MISS are compatible with French national estimations. The incidence of consultations which could be related to A(H1N1) influenza at the peak of the epidemic (194 cases per 100,000) was much lower than the national estimate (1321 cases per 100,000). This may be due to servicepersons who consulted in civilian facilities and were not monitored. Other explanations are the healthy worker effect and the younger age of the military population.

Cardiovascular risk and lupus disease.

AIM: Cardiovascular disease (CVD) is a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). The aim of this study was to evaluate subclinical atherosclerosis and to determine the prevalence of risk factors for CVD in SLE patients. METHODS: One hundred fifty-three patients (149 women and 4 men), aged (37±11.6) years with a definite diagnosis of SLE according to the revised criteria of the American College of Rheumatology (ACR), underwent physical examination, carotid and leg arteries B-mode ultrasound with a measure of ankle-brachial pressure index (ABPI); 94 patients had myocardial tomoscintigraphy. The laboratory check-up was: total cholesterol (TC), HDLc, LDLc, homocystein, glycemia, vascular cell adhesion molecules (VCAM-I). All patients had a normal renal function at the time of the study. RESULTS: The mean age is 37 years. Cardiovascular events were noticed in 15 patients (6 angina, 2 myocardial infarction and 7 strokes). Cardiovascular risk factors (CVRF) were: dyslipidemia (62.8%), moderate homocysteinemia (55%), BMI>25 (39%) and hypertension (35%) which is associated with a stroke (P<0.0006). The cumulative prednisone dose per patient was 45.5g. V.C.A.M-I level was high in 86.2 % of cases.95% of our patients had at least two CVRF. Myocardial perfusion stress scanning showed abnormalities in 21 patients (22.3%). Perfusion defects were linked with a stroke (P<0.01) and coronary events (P<0.02). Carotid atheroma was present in 32 patients (20.9%). Carotid plaques were associated with age (P<0.01), total cholesterol (TC)(P<0.05), and steroid dose (P<0.01). Intima-media-thickness was correlated with age (P<0.0003), TC (P<0.0007), LDLc (P<0.002), and homocysteine (P<0.03). 70% patients had a mediacalcinosis in femoral and popliteal arteries. The ABPI was correlated with V.C.A.M-I (P<0.0005). CONCLUSION: In Algeria, as elsewhere, young women with SLE have subclinical atherosclerosis which must be detected and they are at high risk of a vascular event.

[A(H1N1) influenza surveillance in the French armed forces: adapting the surveillance systems to the pandemic setting]. / Surveillance épidémiologique de la grippe A(H1N1) 2009 dans les armées françaises: adaptation des systèmes de surveillance au contexte pandémique.

OBJECTIVES: An outbreak of A(H1N1) virus influenza, detected in Mexico during April 2009, spread around the world in nine weeks. French armed forces had to adapt their epidemiological surveillance systems to this pandemic. Our aim was to present surveillance results. DESIGN: There are two influenza surveillance systems in French armed forces: one permanent throughout the year and one seasonal, the Military influenza surveillance system (SMOG). The pandemic threat led to an early reactivation of SMOG, before the initiation of a daily surveillance system specifically dedicated to A(H1N1) influenza. RESULTS: In metropolitan France, the increase of respiratory infections was observed as of September 2009, with a maximum of 401 cases for 100,000 at the beginning of December according to SMOG. The estimated rate of consultations related to A(H1N1) influenza ranged between 46 and 65 cases for 100,000. For military units operating outside of metropolitan France, a peak of incidence was observed in August (400 cases for 100,000). CONCLUSION: The trends observed by influenza military surveillance networks were compatible with French ones. Concerning French forces in operations, the increase of incidence observed in August was the consequence of the influenza outbreak in the Southern hemisphere. Estimations of consultations rate related to A(H1N1) influenza, ranged between 127 and 194 cases for 100,000 at the beginning of December, lower than the national rate (1321 cases for 100,000), a consequence of the age pyramid in the military population.

[Assessment of myocardial perfusion in systemic lupus erythematosus]. / Evaluation de la perfusion myocardique au cours du lupus érythémateux systémique.

INTRODUCTION: Cardiovascular disease is a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Necropsy studies found a high incidence of myocardial and coronary injuries while clinical manifestations were observed in less than 10%. The purpose of this study was to evaluate myocardial perfusion in SLE patients. PATIENTS AND METHODS: The study was carried out in 153 patients with a definite diagnosis of SLE according to the revised criteria of the American College of Rheumatology. Ninety-four (61.4%) underwent 99mTc-tétrofosmine SPECT analysis at rest and after stress. RESULTS: The average disease duration was 11 years. Ninety-four patients (93 women and one man) with a mean age 37 years were assessed. Twelve had a past history of vascular event: six stroke, four angina pectoris and two myocardial infarctions. Cardiovascular risk factor included: high blood pressure (35.2%), dyslipidemia (62.3%), moderate hyperhomocysteinemia (55%), BMI greater than 25 (40%).The cumulative prednisone dose per patient was 45.5g. Myocardial perfusion stress scanning showed abnormal perfusion in 21 patients (22.3%). Among these, eight underwent coronary angiography which was normal in seven cases. One patient had a right coronary stenosis. Perfusion abnormalities were correlated with stroke (p<0.01) and coronary events (p<0.02). CONCLUSION: Myocardial perfusion scintigraphy can be a useful noninvasive method to identify subclinical myocardial involvement in systemic lupus erythematosus and patients at risk of later events.

[Real time epidemiological surveillance within the armed forces: concepts, realities and prospects in France]. / Surveillance épidémiologique en temps réel dans les armées; concepts, réalités et perspectives en France.

BACKGROUND: In 2002, the North Atlantic Treaty Organization took five initiatives in order to enhance the defence capacities against the massive destruction weapons, one of them concerned the development of an interoperable surveillance system, giving in real time some informations permitting early warning to the commanders. Thoughts in France to improve the military surveillance system, methodological constraints and first results are shown. METHODS: Medical, technological, human and organisational aspects had to be taken into account to develop real time surveillance within the armed forces, and also specific military constraints. In order to evaluate the validity of its methodology, the "Institut de médecine tropicale du service de santé des armées" developed a prototype, set up in French Guyana and which took part in a second time at a multinational exercise. RESULTS: The "surveillance spatiale des épidémies au sein des forces armées de Guyane" has been set up in 2004, formed by both a recording and an analysis networks. This system permits to provide in real time some dashboards directly operational for the commanders. The exhaustiveness rate has been evaluated at 104%, compared to the traditional surveillance. It permitted three times to detect outbreaks several weeks before the other systems. Some limits have been identified, as the use of personal digitalized assistants. The involvement in a multinational exercise showed the system's efficacy, by detecting two simulated outbreaks, but also its interoperability. In 2006, it has been decided to extend the concept by deploying its second generation within the French armed forces in Djibouti. The "alerte et surveillance en temps réel" disposal permitted to take into account multiple geographical localizations. CONCLUSION: A real time surveillance system is an essential alarm disposal, however it is only an information tool within the complex activity of piloting the sanitary situation. It must be integrated within the whole situation expertise supports, represented also by medical intelligence, epidemiological investigations and prediction of the epidemiological phenomenon evolution.

Event oriented representation for collaborative activities (EORCA). A method for describing medical activities in severely-injured patient management.

OBJECTIVES: In this paper, we introduce a method that aims at describing components of medical activities that are performed by a medical team, including physicians and nurses, during patients' management in an ICU (intensive care unit). This method is based on formal task analyses developed in cognitive ergonomics. Our ultimate aim is to build a method covering the observation and the representation of collective activities during patients' management, which should be re-usable by the team members in order to prepare themselves for accreditation. METHODS: This method comprises two main steps:--the formal observations of medical staff's activities that occur during patient management,--a representation of the findings with regard to an ontology and a temporal flowchart, which describes actors and events related to patient management. RESULTS: This paper describes field studies performed in ICUs. This method has been used for analyzing the management of 24 cases of neurological and multiple traumas. We have represented the different actions of the medical team members (clinicians, nurses and outside medical consultants). CONCLUSION: The results allow us to identify the specific features of these complex and time-constrained situations, especially about the strong collaborative activities between members of the patient-care teams, especially the interaction between information management and medical actions.

[A study of action planning in patients with Alzheimer's disease using the zoo map test]. / Etude de la planification de l'action au moyen du test du plan du zoo dans la maladie d'Alzheimer.

INTRODUCTION: Executive dysfunction is regularly reported in patients with Alzheimer's disease. Nevertheless few studies have focused on planning ability in this neurodegenerative disease. OBJECTIVES: This study aimed to investigate the formulation and the execution of plans in Alzheimer's disease using an ecological planning subtask derived from the Behavioural Assessment of the Dysexecutive Syndrome test battery, the "Zoo Map Test". There are two trials. The first trial consists of a "high demand" version of the subtask in which the subjects must plan in advance the order in which they will visit designated locations in a zoo (formulation level). In the second, or "low demand" version, the subject is simply required to follow a concrete externally imposed strategy to reach the locations to visit (execution level). The test was given to 16 patients with Alzheimer's disease and 13 normal elderly subjects. RESULTS: The two way ANOVAs mainly showed more difficulties in patients with Alzheimer's disease than in healthy elderly in both conditions. The difference between formulation and execution was greater in patients with Alzheimer's disease than in healthy elderly. Planning impairments mainly correlated with behavioural changes (in particular motivational changes) observed by patient's relatives. CONCLUSION: These results suggest that patients with Alzheimer's disease have some problems to mentally develop logical strategies and to execute complex predetermined plans, which are partially related to behavioural changes.

[Fractures of the shaft of the humerus: systematic plate fixation. Anatomic and functional results in 156 cases and a review of the literature]. / Fractures diaphysaires de l'humérus : ostéosynthèse systématique par plaque. Résultats anatomiques et fonctionnels d'une série de 156 cas et revue de la littérature]

PURPOSE OF THE STUDY: Based on our experience with plate fixation of humeral shaft fractures and an analysis of the international literature, we attempted to answer the following questions. What functional outcome and what complications can be expected after surgery? Are the classical complications of open fracture surgery (screw fixation, wiring, plate fixation without compression.) as frequent after plate fixation using the Müller technique? MATERIAL AND METHODS: We reviewed our series of 156 humeral shaft fractures (61 p. 100 men, mean age 45 years) including 21 cases of multiple trauma and 24 multiple fractures. A floating elbow was present in 8 cases and skin opening in 16. Initial radial deficiency was observed in 28 cases. Plate fixation was the only method used for the humeral shaft fractures. We used the modified Stewart and Hundley classification. RESULTS: Postoperative paralysis occurred in 8 cases (5.1 p. 100, 5 complete paralysis); only one patient suffered persistent severe sequelae. There were also 8 malunions and 3 late consolidations. Consolidation rate was 94.2 p. 100, sepsis rate was 1.5 p. 100. Good or very good outcome was achieved in 86.6 p. 100 of the cases. DISCUSSION: In the literature, (71 series, 5 000 patients), plate fixation of humeral shaft fractures has given very good functional results with few initial failures, malunions or cases of sepsis. Radial paralysis is cited as a complication in 6.5 p. 100 of all plate fixations but is reversible in 90 p. 100 of cases. Classical orthopedic methods and centromedullar techniques produce more stiffness. The Sarmiento cuff can give good results after rigorous patient selection. CONCLUSION: Plate fixation according to the Müller technique is a reliable osteosynthesis method with few initial failures or malunions as evidenced by data in the literature. Infection is also rare. Although the radial nerve risk makes this technique rather difficult, excellent functional results can be achieved.

Tolerance and feasibility of perioperative treatment with interferon-alpha 2a in advanced cancers.

BACKGROUND: Major surgery impairs the cellular immune response. In order to stimulate the immunological system during the perioperative period, we have studied the clinical and biological tolerance, and the immunological and histological effects of a perioperative treatment using progressive doses of Interferon-alpha 2a, from the third preoperative day (D-3) until the tenth postoperative day (D10). MATERIALS AND METHODS: Twenty-three patients undergoing a major surgical procedure for advanced cancer were included. The clinical and biological parameters evaluated were the body temperature and the blood cell counts. Immunological effects were evaluated by counting the total number of lymphocytes, lymphocyte subsets, natural killer cells (NK), and by analysis of the NK activity, and lymphokine-activated killer cell (LAK) assay. RESULTS: Hyperthermia was the most toxic effect of Interferon-alpha but the overall toxicity was minor, even at the highest dose level. In the early postoperative period there was a significant decrease in total lymphocytes, and in most lymphocyte subset counts when compared with D-3. Overall NK and LAK activities significantly increased from D-3 to D-1 (p < 0.02). A postoperative decrease in NK activity was noted that was not significant when compared to pretherapeutic values, whereas a significant decrease in LAK activity did occur on D4 despite the interferon treatment (p < 0.03). Since we found a dose-dependent effect on some lymphocyte subsets, there was not a clear dose-dependent effect on NK and LAK activities. CONCLUSIONS: Perioperative alpha 2a administration is a safe treatment in advanced cancer patients that may allow a postoperative preservation of NK activity and a destruction of potential circulating metastatic cells. Further studies are ongoing on perioperative immunotherapy in advanced cancer patients.

Electrocardiographic changes and halofantrine plasma level during acute falciparum malaria.

The aim of this study was 1) to assess the incidence of electrocardiographic changes after treatment with halofantrine and 2) to study the relationship between these changes and plasma levels of halofantrine and its main metabolite, N-desbutyl-halofantrine. Thirty-four male patients with uncomplicated falciparum malaria were enrolled in this study. Halofantrine was administered on two separate days at a total oral dosage of 24 mg/kg/day in three doses over a 12-hr period. The interval between the two treatments was seven days. Twelve-lead electrocardiography (ECG) was performed to measure the QT interval (QTc), ambulatory ECG monitoring was done to detect ventricular arrhythmia, signal-averaged ECG was performed to detect late ventricular potentials, and blood tests were performed to determine plasma concentrations of halofantrine and N-desbutyl-halofantrine. Maximum QTc was observed at 12 hr after both the first (P < 0.0002) and second treatments (P < 0.03). Signal-averaged ECG revealed late potentials in four cases (72 hr after the first treatment in one case and 24 hr after the second treatment in three cases). Ventricular arrhythmia was not observed. Significantly higher plasma concentrations of halofantrine were observed 2 hr after the second treatment. At this time, both the time effect and time interaction were significant (P < 0.008 and P < 0.02, respectively). The QTc interval was significantly correlated with the plasma halofantrine level (r = 0.41, P < 0.01) but not with the plasma N-desbutyl-halofantrine level (r = 0.30, not significant). In three cases, late ventricular potentials were associated with a maximum concentration of halofantrine. Our findings indicate that electrocardiographic changes are dose-dependent and that a second treatment at the same dosage may be hazardous.

[Feasibility and tolerance evaluation of 2 routes of preoperative administration of interleukin 2]. / Faisabilité et évaluation de la tolerance de deux schémas d'administration préopératoire d'interleukine 2.

Preoperative interleukin 2 (IL2) administration has been performed, in order to diminish the post-operative immunodepression in cancer patients. The aim of this study was to compare two different ways of preoperative IL2 administration, ie, intravenous (iv) and subcutaneous (sc), in terms of feasibility and tolerance. Nineteen surgical procedures were performed in 18 patients: a) 10 following the administration of 12 IU/m2/24 hours IL2 IV, with a continuous infusion, from day 5 to day 3 before surgery; b) 9 following the administration of 18 IU IL2, in 2 SC injections per day, from day 4 to day 2 before surgery. Tolerance was evaluated by both clinical and biological parameters, before, during, and after surgery. Hyperthermia and capillary leak syndrome were more important in the iv versus sc injection group. Insomnia and digestive troubles were more frequent in the iv injection group as well. However, we noticed few and equivalent cutaneous and respiratory complications in both groups. In conclusion, the tolerance of IL2 was better after sc versus iv injection. However, the toxicity of iv infusion of IL2 was moderate and could be limited by preventive treatments; moreover there was no consequence on the scheduled surgical procedure.

[Lessons of the socioeconomic structure of a cohort of 50 drug addicts infected with HIV and followed up over a year]. / Enseignements d'ordre socio-économique à partir d'une cohorte de 50 toxicomanes infectés par le VIH et suivis pendant un an.

Fifty drug addicts, users of intravenous heroin and infected by HIV, with an average age of 28 years, were followed for a period of one year. The purpose was to analyze, as precisely as possible, the medical and social cost of their illness as a function of the stage of the infection to which they belonged. The costs vary significantly according to the age and sex of the patients, and are higher in those patients with stage IV (confirmed clinical AIDS) than with stage II and stage III HIV infection. Although the population of drug addicts infected by HIV is likely to stabilize, the medical and social cost of caring for HIV-infected drug addicts is very heavy, and can be estimated at about 4 to 5 billion french francs by year.

[Imported falciparum malaria in Marseilles hospitals in 1987. Apropos of 104 cases]. / Le paludisme d'importation à Plasmodium falciparum dans les hôpitaux de Marseille en 1987. A propos de 104 cas.

Patients were composed of 85 adults and 19 children; 70 were European, 23 Comorian; malaria was contracted by 9 patients in French Guyana, 60 in Africa, 23 in Comoro Islands; prophylaxis was correct for 45 patients (nearly all of the cases with chloroquine) when the first symptoms occurred. Every case of malaria appeared during the month following their return from an endemic area. Fever was often moderate or intermittent, altered by prophylaxis and previous treatments. Some patients had a clinical profile of "visceral evolutive malaria" and 3 a cerebral malaria. The most frequent biologic alteration was thrombopenia (40 times under 100,000/microliters). No relation between parasites density and clinical profile has been identified. The sensitivity of the strains for antimalarial drugs has been studied 35 times: 28 strains were chloroquine resistant, 3 have a decreased sensitivity for quinine. Most of the resistant strains came from Central Africa. Two patients died.

[Current clinical aspects and role of parasitic density in the manifestations of falciparum malaria]. / Aspects cliniques actuels et rôle de la densité parasitaire dans l'expression du paludisme à Plasmodium falciparum.

56 patients carriers of Plasmodium falciparum were observed throughout 1987: 47 males and 9 females of a mean age of 32. The following clinical aspects were observed: Falciparum malaria: 35 cases, malaria with a low parasitaemia (less than 1,000 HPM): 5 cases, tropical splenomegaly syndrome: 3 cases, isolated bi- or tricytopenia: 10 cases, cerebral malaria: 1 case, asymptomatic carriers: 2 cases. Statistically speaking, no significant correlation was observed between parasitaemia and the following clinical and biological symptoms: fever, splenomegaly, Hb level, platelet count. However, we noted a level of parasitaemia higher in the acute forms of malaria (Falciparum malaria and cerebral malaria) than in the non typical forms (chronic visceral malaria, haematological disorders). All asymptomatic carriers, who represent "malaria infection", presented a low parasitaemia (less than 1,000 HPM).

[Identification of the principal species of the genus Serratia by a simplified system]. / Identification des principales espèces du genre Serratia par une galerie simplifiée.

A reduced identification system for the genus Serratia is proposed. The usefulness of this system was shown by identification of 720 strains from clinical specimens or natural environment. Computation of "diagnosis ability coefficient" and principal component analysis made it possible to reduce this identification system to 9 tests. Numerical taxonomy displayed the 9 recognized species.

Diagnosis of endocarditis in acute Q-fever by immunofluorescence serology.

The authors compared two groups of 20 patients suffering from Q fever using microimmunofluorescence (micro IF) serology. One group had endocarditis and the other conventional symptoms of acute Q fever but no endocarditis. Determination of the levels of antibodies against the two phases of rickettsiae in each of the three immunoglobulin classes (IgG, IgM and IgA), allowed to determine the type of infection using a single serum sample. Patients having IgA class antiphase I antibodies at a level equal to/or higher than 1:25 as well as those whose antibody levels fulfilled the conditions for the equation (IgG anti-phase I greater than or equal to IgG anti-phase II) + (IgA anti-phase I greater than or equal to IgA anti-phase II) were suffering from endocarditis. The positive predictive value of these tests was 100% and 94.1%, respectively.