Diagnostic accuracy of stress CMR to evaluate chronic coronary syndromes: an updated meta-analysis

Background

Stress cardiovascular magnetic resonance (CMR) imaging is utilised for the evaluation of patients with stable chest pain and intermediate or high pre-test likelihood of coronary artery disease (CAD).

Purpose

To provide an updated synthesis of diagnostic accuracy of stress CMR imaging for the diagnosis of anatomically and functionally significant CAD in patients with stable chest pain and suspected or known CAD.

Methods

After prospective registration and approval of the study protocol, we performed a systematic review and meta-analysis of studies published between 2000 through 2021, enrolling ≥100 patients, and reporting on the diagnostic accuracy of stress CMR imaging to diagnose anatomically and functionally significant CAD with invasive coronary angiography (ICA) or ICA and fractional flow reserve (FFR <0.80) as the reference standard. The novel split component synthesis method was used through the SCSmeta function in R. The meta-analysis yielded pooled diagnostic indicators including diagnostic odds ratio (DOR), sensitivity, specificity, positive likelihood ratio (pLR), negative likelihood ratio (nLR) and area under the curve (AUC).

Results

We identified a total of 32 studies pooling an overall population of 7,678 individuals (mean age 62 years, 70% males, CAD prevalence 52%). Compared with ICA (29 studies, 7,360 patients), stress CMR yielded a pooled DOR of 19.2 (95% CI: 12.5–29.4), a sensitivity of 84% (95% CI: 79–88%), a specificity of 79% (95% CI: 73–84%), a pLR of 3.9 (95% CI: 3.0–5.3), a nLR of 0.2 (95% CI: 0.2–0.3), and an AUC of 0.81 (95% CI: 0.78–0.84) for the detection of anatomically obstructive CAD. Compared with ICA and FFR (8 studies, 1,196 patients), stress CMR yielded a pooled DOR of 26.4 (95% CI: 10.6–65.9), a sensitivity of 81% (95% CI: 68–89), a specificity of 86% (95% CI: 75–93%), a pLR of 5.8 (95% CI: 3.0–11.4), a nLR of 0.2 (95% CI: 0.1–0.4), and an AUC of 0.84 (0.77–0.89) for the detection of functionally obstructive CAD. Higher diagnostic accuracy was observed for 3 Tesla myocardial perfusion imaging studies to detect both anatomically and functionally obstructive CAD, with pooled DORs of 24.3 and 33.2, respectively.

Conclusions

In patients with stable chest pain and known or suspected CAD, stress CMR imaging yields high diagnostic accuracy to detect both anatomically and functionally obstructive CAD. Stress CMR perfusion imaging at 3 Tesla is to be associated with overall greater diagnostic accuracy.

Funding Acknowledgement

Type of funding sources: None.

Prognostic yield of stress CMR to evaluate chronic coronary syndromes: a systematic review and meta-analysis

Background

Assessment of ischemia with stress cardiovascular magnetic resonance (CMR) imaging is recommended in patients with stable chest pain and intermediate or high pre-test probability of coronary artery disease (CAD).

Purpose

To provide an updated synthesis on prognostic significance of stress CMR imaging in patients with stable chest pain and suspected or known CAD.

Methods

After prospective registration and approval of the study protocol, we performed a systematic review and meta-analysis of studies published between 2000 through 2021, enrolling ≥100 patients, and reporting outcome data of CAD patients undergoing stress CMR. Odds ratios (ORs) and 95% confidence intervals (CIs) for all-cause death, cardiovascular (CV) death and major adverse cardiac events (MACE: CV death and myocardial infarction), were pooled through inverse variance random-effects meta-analysis to compute summary effect size. Annualized event rates (AERs) were extracted from each study and compared by χ2-statistic. A warranty period was defined as the time interval with an AER <1%.

Results

We identified a total of 33 studies pooling an overall tested population of 68920 patients (mean age 62 years; 56% males; known CAD 32%; 386117 person-years). Ischemia was found in 13617 (20%). Mean follow-up was 3.5±2.1 years. Presence of ischemia was associated with increased risk of all-cause death (OR 2.0 95% CI: 1.7–2.3), CV death (OR 6.4 95% CI: 4.5–9.1), and MACE (OR 5.0 95% CI: 3.6–6.8). Cumulative AERs for all-cause death, CV death and MACE were 2.97%, 2.51%, and 3.99% in patients with ischemia, and 1.40%, 0.59%, and 0.98% in patients without ischemia, respectively (p<0.0001 for all comparisons).

Conclusion

Stress CMR imaging yields robust prognostic information in patients with suspected or known CAD. Presence of ischemia is associated with increased risk of all-cause death, CV death and MACE. Patients with negative stress CMR have a very low risk (<1%) of CV death and MACE with a warranty period of at least 3.5 years.

Funding Acknowledgement

Type of funding sources: None.

Safety and reliability of dobutamine stress echocardiography in pediatric and young adult patients with coronary arteries abnormalities

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study was conducted with the support of Regione Marche, Italy

Background

Risk stratification in coronary arteries abnormalities (CAA), both anomalous aortic origin of a coronary artery (AAOCA) and myocardial bridges (MBs), is still challenging. A reliable method to detect myocardial ischemia is missing in these anomalies. We studied the safety and feasibility of dobutamine stress echocardiography (DSE), compared with exercise stress echocardiography (ESE), in pediatric and young adult patients with CAA.

Methods

In 2019-21, N = 27 CAA [median age 16 years (Q1–Q3: 11, 22)] (n= 23 AAOCA, n = 4 MBs) were assessed. ESE was performed 1-2 days before the DSE examination, double-blinded for examiners and patients. Hemodynamic response and major (cardiac arrest, myocardial infarction, ventricular arrhythmia) and minor [hypertension (≥ 200/120 mmHg), paradoxical bradycardia, chest pain, nausea/vomiting, skin rash, anxiety, dizziness, dyspnea] events were recorded. Differences between rest/stress and DSE/ESE for wall motion abnormalities (WMA) and global longitudinal strain (GLS) were evaluated. Inter-observer agreement was also tested using the kappa (k) coefficient.

Results

Heart rate and blood pressure increased significantly from baseline (p < 0.001) in both DSE and ESE exams. Only DSE tests reached a heart rate ≥ 150 bpm (p < 0.001), while younger patients barely reached the heart rate target and frequently showed less compliance to the test. No patient had major events, while 5 (18.5%) had minor events, the majority during DSE. Inducible WMA were observed only at DSE examinations. Inter-observer agreement for WMA and GLS changes was good for both examinations (95%, k = 0.85, p < 0.001).

Conclusions

DSE is feasible in pediatric and young adult patients with AAOCA and MBs to assess inducible WMA and GLS rest/stress changes. It can be performed safely with a low incidence of major/minor events, with a better performance when compared to ESE. DSE is potentially a valuable test for detecting myocardial ischemia and probably helpful in managing CAA patients.

Cardiovascular morbidity and mortality related to non-alcoholic fatty liver disease: a systematic review and meta-analysis of prospective studies

Background

Whether non-alcoholic fatty liver disease (NAFLD) is a risk factor for cardiovascular (CV) events is still debated. Currently available evidence derives from non-homogeneous studies yielding conflicting results.

Purpose

We set out to assess the relationship between NAFLD and CV morbidity and mortality by pooling results of previous studies.

Methods

We performed a systematic review and meta-analysis of prospective observational studies published from 1966 through 2021 reporting summary-level outcome data in subjects with and without NAFLD. Adjusted risk ratios (RRs) and 95% confidence intervals (CIs) for all-cause mortality, CV mortality, myocardial infarction (MI), stroke, major adverse cerebrocardiovascular events (MACCE) and atrial fibrillation (AF) were pooled through inverse variance random-effect meta-analysis to compute the summary effect size. We performed post-hoc subgroup analysis stratified by geographical region and univariate mixed-effect model meta-regression analysis to address statistical heterogeneity.

Results

We identified a total of 29 studies pooling an overall population of 5,626,573 middle-aged individuals (mean age 56±8; male sex 53%; NAFLD 5.8%, n=326,389). Mean follow-up was 10±6 years. Compared with control population, presence of NAFLD was associated with similar risk of all-cause death (RR 1.17; 95% CI 0.89–1.52) and CV death (RR 0.84; 95% CI 0.64–1.10). When analysed by geographic location, pooled estimates of RR (95% CI) for all-cause death were 1.57 (1.00–2.48) for Western countries, and 0.81 (0.52–1.1.26) for Eastern countries (test for subgroup difference, P=0.04). Meta-regression analysis showed a stronger relationship between NAFLD and all-cause mortality proportional to increasing body mass index (P=0.048). NAFLD was associated with increased risk of myocardial infarction (RR 1.35; 95% CI 1.09–1.68), stroke (RR 1.20; 95% CI 1.06–1.35), MACCE (RR 2.09; 95% CI 1.57–2.78) and atrial fibrillation (RR 1.37; 95% CI 1.05–1.78).

Conclusion

NAFLD portends excess all-cause mortality but only in Western countries. CV mortality was similar in NAFLD and non-NAFLD groups. NAFLD is associated with increased risk of incident MI, stroke, MACCE and AF.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

The predictive role of neutrophil-to-lymphocyte ratio in post-operative arrhythmias in pediatric patients after cardiopulmonary bypass surgery

Background

Postoperative arrhythmias (POA) are a common complication after cardiac surgical repairs for congenital heart disease (CHD), representing a substantial source of morbidity, mortality and prolonged total in-hospital stay, with an incidence of 7.5–48% in postoperative pediatric cardiac patients. The etiology is multifactorial, and it has been related to the direct surgical manipulation of the cardiac conduction system, to the local tissue inflammation in the myocardium adjacent to the conduction system and to the arrhythmogenic effects of cardiopulmonary bypass (CPB), inotropes and electrolyte disturbances. Recently, the prognostic role of neutrophil-to-lymphocyte ratio (NLR), a novel inflammation marker, has been evaluated in pediatric patients after CPB surgery.

Purpose

To evaluate the predictive role of NLR in POA in a population of pediatric CHD patients after CPB.

Methods

We retrospectively collected perioperative clinical and laboratory data of 146 patients (age 8.27±10.79 years; male gender: 60.8%) consecutively admitted to the cardiac surgery intensive care unit (ICU) of our institute after elective cardiac surgery with CPB in 2018. We grouped and analyzed our population over NLR tertiles evaluated at 24 hours from CPB and types of POA: supraventricular (SVT) and junctional (JET). The prognostic value of NLR and its association with POA was analyzed.

Results

Diagnoses of 146 patients included atrial septal defect (n=36), ventricular septal defect (n=20), pulmonary atresia/stenosis (n=10), tetralogy of Fallot (n=20), endocardial cushion defect (n=8), left ventricular outflow tract obstruction (n=14), anomalous origin of coronary artery (n=6), complex CHD (n=13), interrupted/hypoplastic aortic arch (n=12), anomalous pulmonary artery venous return (n=3). The mean CPB time was 121.6±84.6 minutes. The median ICU hospitalization was 48 hours [Q1, Q3: 24, 96]. Twelve patients experienced POA: 6 SVT and 6 JET. The frequency of POA incremented over NLR-tertiles (P-Trend 0.017), while SVT onset was associated with higher values of NLR and C-reactive protein (P=0.034 and P=0.011, respectively). Patients in the second and third tertiles of NLR had a prolonged hospitalization (Log-rank, P=0.029), especially when associated with POA (Log-rank, P=0.012). At the multivariable analysis, higher age and NLR values were independently associated with SVT [OR per year 1.22; 95% CI (1.02, 1.25), P=0.043 and OR per point 1.91; 95% CI (1.29, 2.82), P=0.012, respectively], but not with JET.

Conclusions

24-h post-CPB NLR can predict postoperative SVT in a population of pediatric CHD patients. Our data suggest that the NLR could be a useful, easy-to-obtain marker for postoperative outcome in pediatric patients who had undergone elective CPB.

Funding Acknowledgement

Type of funding sources: None.

Prognostic significance of cardiac amyloidosis in patients with aortic stenosis: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Background

 Cardiac amyloidosis (CA) has been increasingly recognized in elderly patients with aortic stenosis (AS), but with uncertain prognostic significance.

Objectives

We performed a systematic review and meta-analysis to clarify whether concurrent CA portends excess mortality in patients with aortic stenosis AS.

Methods

Our systematic review of the literature published through June 2020, sought observational studies reporting summary-level outcome data of all-cause mortality in AS patients with or without concurrent CA. Pooled estimate of Mantel-Haenszel odds ratio (OR) and 95% confidence intervals (CIs) for all-cause death was assessed as the primary endpoint. We performed subgroup analysis stratified by severity of left ventricular hypertrophy (LVH) and study-level meta-regression analysis to explore the effect of covariates on summary effect size and to address statistical heterogeneity.

Results

We identified 4 studies including 609 AS patients (9% AS-CA; 69% men; age, 84 ± 5 years). The average follow-up was 20 ± 5 months. Compared with lone AS, AS-CA was associated with 2-fold increase in all-cause mortality (pooled OR: 2.30; 95% CI: 1.02-5.18; I2 = 62%). When analysed according to LVH severity, pooled ORs (95% CI) for all-cause mortality were 1.29 (0.65-2.22) for mild LVH (≤16 mm), and 4.81 (2.19-10.56) for moderate/severe LVH (>16 mm). Meta-regression analysis confirmed a stronger relationship proportional to the degree of LVH, regardless of age and aortic valve replacement, explaining between-study heterogeneity variance.

Conclusions

CA heralds significantly higher risk of all-cause death in elderly patients with AS. Severity of LVH appears to be a major prognostic determinant in patients with dual AS-CA pathology.

Abstract Figure.

Ross procedure and aortic valve repair: long-term echocardiographic outcomes, quality of life and physical activity of different aortic valve surgery procedures

Funding Acknowledgements

Type of funding sources: None.

Background

 To compare long-term outcomes of aortic valve repair (AVr) and pulmonary autograft replacement (Ross procedure) in terms of echocardiographic parameters, quality of life (QoL), physical activity (PA).

Methods

 In 2005-19, 129 patients (median age 22 [13, 33 IQR], 75% males) underwent aortic surgery in our Department: 40 were Ross (22 years [19, 51 IQR]), 67 AVr (17 years [1, 50 IQR]) and 22 aortic valve replacements (52 years [30, 80 IQR]). We focused on Ross and AVr. Retrospectively, relevant data were collected from medical records and phone re-calls. Physical activity (spontaneous and active) and QoL were assessed utilizing the IPAQ and SF-36 questionnaires. All patients underwent echocardiography pre/post-surgery and the follow-up lasted 12 ± 4 years.

Results

 At the baseline, Ross patients had more aortic stenosis than insufficiency (P = 0.045). At the follow-up, Ross procedures presented more right-ventricle and aortic annulus dilatation (P = 0.002 and P = 0.030, respectively), but higher left-ventricular global longitudinal strain (LV GLS: 18 ± 3.2 % vs. 16 ± 3.3, P = 0.0027). Conversely, AVr experienced more re-do operations (Log-rank P = 0.005). Ross reported better QoL (SF-36: 0.8 ± 0.07 vs. 19 ± 0.4, P-0.045) and were also more active in daily PA (IPAQ ≥ 2500 Mets: 63.8% vs. 6%; P = 0.006). Ross patients practiced more sports activities than AVr (P = 0.011).

Conclusions

 In a relatively small cohort of young and adults post aortic surgery patients, Ross procedures had better prognosis in terms of re-do operations; presented better ventricular function, as assessed by LV GLS. Ross patients had better long-term QoL and showed more spontaneous PA and involvement in sports activity.

1163 Diagnostic performance of a new echocardiographic method for coronary arteries abnormalities assessment

Background

The echocardiographic assessment of coronary arteries abnormalities (CCA) has always been challenging. In this view, we aimed to assess the performance of a new echocardiographic-based diagnostic method for CAA in pediatric and young adults’ population.

Methods

over 5 years, we examined all the outpatients undergoing routine echocardiography in our department. Our method consisted of 4-focused specific view scan: parasternal short-axis, parasternal long-axis, both left and right outflow tract, and apical 5-chamber view. Coronary-CT confirmed the CAA diagnosis. Two independent physicians retrospective reviewed the echocardiographic images, in a double-blinded fashion (coronary-CT and diagnosis), for performance analysis.

Results

in 2014-18, 5,998 outpatients underwent echocardiography (median age 14 years [6, 21 - IQR]). A total of 27 CAA were diagnosed: overall prevalence 0.0045%, 0.022% of incidence. N = 17/27 were anomalous aortic origin of coronary arteries (AAOCA), N = 3/27 anomalous coronary arteries from the pulmonary artery (ACAPA), and 7/27 fistulas. After the implementation, we found a progressive increment of CAA diagnosis (P for Trend = 0.038), in particular of AAOCA: both left and right coronaries (P-trend = 0.021 and P = trend 0.010, respectively). Our method showed better sensitivity than traditional CAA echocardiographic evaluation: 85% vs 55%, P = 0.032 [AUC 0.77, 95% CI (0.68, 0.87) and AUC 0.92, 95% CI (0.85, 0.99), respectively], with a good interobserver agreement for the adjudicated double-blinded retrospective diagnosis (99.75%, K = 0.73, P < 0.001).

Conclusions

the application of a new echocardiographic-based method for CAA-detection led to a significantly increased rate of identified anomalies. This approach demonstrated better sensitivity than traditional echocardiographic assessment. Implementing this protocol in clinical practice may improve the CAA diagnosis, and probably reduce the occurrence of CAA-related sudden cardiac death.

P6223Relationship between platelet indices and future cardiovascular events: results from a population-based cohort study

Background

Studies evaluating the relationship between platelet indices and cardiovascular outcome yielded conflicting results. In particular, the evidence from large, population-based, prospective studies with extended follow-up duration is scarce.

Purpose

We investigated the incidence of major adverse events in relation to baseline values of platelet count, mean platelet volume (MPV) and platelet distribution width (PDW) in the prospective cohort of the Malmö Diet and Cancer Study.

Methods

A total of 30,314 middle-aged individuals (mean age 57±8 years; 40% men) were overall included and followed up for a median of 16 years (in total, 468,490 person-years). The following outcome measures were considered: all-cause death, myocardial infarction (MI) and ischemic stroke.

Results

There was no relationship between increase in MPV or PDW values and adverse events during follow-up. In particular, the incidence of all-cause death, MI and stroke in patients in the 4thquartile of MPV was 19.8% (vs. 20.7% in the 1stquartile; p=0.08), 8.5% (vs. 8.2%; p=0.78) and 7.9% (vs. 7.1%; p=0.09), respectively. The rates of all-cause death, MI and stroke in patients in the 4thquartile of PDW were 20.1% (vs. 20.7% in the 1stquartile; p=0.16), 8.7% (vs. 8.1%; p=0.30) and 8.1% (vs. 7.2%; p=0.09), respectively. There was a significant rise in mortality by platelet count increase (log-rank p<0.001). In multivariable analysis, patients in the 4thquartile of platelet count (>264 x 109/L) showed a significantly higher incidence of all-cause death (HR 1.17, 95% CI 1.07–1.28; p=0.001), MI (HR 1.24, 95% CI 1.08–1.43; p=0.003) and stroke (HR 1.20, 95% CI 1.04–1.39; p=0.014) vs the 1stquartile. The higher mortality in the 4thquartile of platelet count was independent of the history of previous stroke, was significant in patients without prior MI (HR 1.18, 95% CI 1.08–1.29; p<0.001) and non-significant in those with prior MI (HR 0.86, 95% CI 0.56–1.33; p=0.51). The risk of MI in the 4thquartile of platelet count was higher regardless of the history of previous MI (p for interaction=0.11). The risk of stroke in the 4thquartile of platelet count was higher regardless of the history of previous stroke (p for interaction=0.15).

Conclusions

In this population-based, prospective, cohort study there was no difference in the incidence of adverse events across various strata of baseline platelet morphology. However, patients with highest platelet count at baseline showed a significantly higher risk of all-cause death, MI and stroke. Whether or not these individuals should be targeted by more aggressive primary prophylactic measures including antiplatelet treatment, remains to be proven.

P2555Efficacy and safety of oral anticoagulant versus antiplatelet therapy for secondary prevention of cardiovascular disease in patients without atrial fibrillation

Background

Anticoagulation is the mainstay of prevention of arterial thromboembolism in patients with atrial fibrillation, but it could be effective also in secondary prevention of patients who are in sinus rhythm.

Purpose

We performed this meta-analysis to determine relative efficacy and safety of oral anticoagulant therapy (OAC) as compared with antiplatelet therapy (APT) in patients with prevalent cerebro-cardiovascular disease without atrial fibrillation.

Methods

Our systematic review of the literature published through January 31st, 2019 sought all phase III randomized controlled trials which compare OAC with APT in patients with sinus rhythm and report at least one of the following outcomes: ischemic stroke, death, myocardial infarction, and major bleeding, assessed at the longest available follow-up. We used random-effects models to estimate summary relative risk reduction (RRR) and 95% confidence intervals (95% CI).

Results

We identified a total of 9 randomized controlled trials including a total of 34,912 patients (ASA, n=17,726; adjusted-dose warfarin, n=4,460; rivaroxaban, n=12726), with a mean follow-up of 2.2 years. When compared with antiplatelet therapy, OAC was associated with reduced risk of ischemic stroke (RRR 38%, 95% CI: 1; 47; P=0.04; I2=72%) and myocardial infarction (RRR 13%, 95% CI: 0,23; P=0.05, I2=0%), but increased risk of major bleeding (RRR −52%, 95% CI: −129; −1; P=0.04; I2=76%). Compared to antiplatelet treatment, OAC did not significantly affect the risk of all-cause death (RRR 1%, 95% CI: −9; 10; P=0.86; I2=12%).

Conclusions

In sinus rhythm patients with prevalent cardiovascular disease, OAC reduces risk of ischemic stroke and myocardial infarction, but significantly increases risk of major bleeding. The choice of antithrombotic treatment does not appear to influence all-cause mortality.

4289Clinical outcomes of percutaneous mitral valve repair in secondary mitral regurgitation: a systematic review and meta-analysis

Background

The benefit of percutaneous mitral valve repair with mitraclip (PMVR) in patients with secondary mitral regurgitation (MR) is still debated.

Methods

In order to compare the outcome of PMVR with optimal medical therapy (OMT) versus OMT alone in patients with secondary MR, we performed a systematic review and meta-analysis of 2 randomized clinical trials (RCT) and 7 non-randomized observational studies (nROS). Hazard ratios (HR) and 95% confidence intervals (CI) were pooled through inverse variance random-effect model to compute the summary effect size for all-cause mortality, cardiovascular death and cardiac-related hospitalization. Subgroup and meta-regression analysis were also performed.

Results

An overall population of 3,118 individuals (67% men; mean age, 73 years) was included: 1,775 PMVR+OMT and 1,343 OMT patients, with mean follow-up of 24±15 months. PMVR+OMT was associated with a lower risk of all-cause death (HR: 0.77; 95% CI: 0.68–0.87), cardiovascular death (HR: 0.55; 95% CI: 0.34–0.89) and cardiac-related hospitalization (HR: 0.77; 95% CI: 0.64–0.92). Meta-regression analysis showed that larger left ventricular end-diastolic volume index (LVEDVI) portends higher mortality after PMVR (p<0.001).

Conclusions

This study-level meta-analysis shows that PMVR+OMT is associated with reduced all-cause death, cardiovascular death and cardiac-related hospitalization when compared with OMT alone in secondary MR. LVEDVI is a predictive marker of efficacy, as patients with smaller LVEDVI derive the largest benefit from PMVR.

First report of Salmonella 1,4,[5],12:i:- in free-ranging striped dolphins (Stenella coeruleoalba), Italy

Between 2015 and the beginning of 2018 (January-March), 30 cetaceans were found stranded along the Ligurian Sea coast of Italy. Necropsies were performed in 22 cases and infectious diseases resulted the most common cause of death. Three striped dolphins, showed a severe coinfection involving the monophasic variant of Salmonella Typhimurium (Salmonella 1,4,[5],12:i:-). The isolates were characterized based on antimicrobial resistance, Multiple-Locus Variable-number tandem-repeat Analysis (MLVA) and whole-genome sequencing (WGS). All isolates demonstrated the same multidrug resistant genotype (ASSuT isolates), showed three different MLVA profiles, two of which closely related, and were identified as Sequence Type 34. Moreover, Single nucleotide polymorphisms (SNP) analysis confirmed strong correlations between two out of the three isolates. To our knowledge, S. 1,4,[5],12:i:-, one of the most common serovars in cases of human infection and food sources worldwide, has not previously been described in marine mammals, and reports of Salmonella-associated disease in free-ranging cetaceans are rare. These results highlight the role of cetaceans as sentinel species for zoonotic and terrestrial pathogens in the marine environment, suggest a potential risk for cetaceans and public health along the North Western Italian coastline and indicate cetaceans as a novel potential reservoir for one of the most widespread Salmonella serovars.

Notch-1 signaling activation sustains overexpression of interleukin 33 in the epithelium of nasal polyps

BACKGROUND

Alterations in the nasal epithelial barrier homeostasis and increased interleukin 33 (IL-33) expression contribute to the pathogenesis of chronic rhinosinusitis with nasal polyps (CRSwNP).

AIMS

As Notch-1 signaling is crucial in repair processes of mucosa, the current study assessed Notch-1/Jagged-1 signaling and IL-33 in the epithelium of nasal polyps biopsies from allergic (A-CRSwNP; n = 9) and not allergic (NA-CRSwNP; n = 9) subjects by immunohistochemistry. We also assessed, in a model of nasal epithelial cells, the effects of stimulation of Notch-1 with Jagged-1 on the expression of IL-33 (by flow cytometry, immunofluorescence, and immunocytochemistry), Jagged-1 (by flow cytometry), and p-CREB transcription factor (by western blot analysis).

RESULTS

Ex vivo (a) in normal epithelium, the expression of Notch-1 and IL-33 were higher in NA-CRSwNP than in A-CRSwNP; (b) in metaplastic epithelium, the expression of Notch-1, Jagged-1, and IL-33 were higher in NA-CRSwNP than in A-CRSwNP; (c) in hyperplastic epithelium, the expression of Notch-1, Jagged-1, and IL-33 were higher in A-CRSwNP than in NA-CRSwNP; and (d) in basal epithelial cells, no differences were observed in the expression of Jagged-1, IL-33, and Notch-1. The expression of Notch-1 significantly correlated with the expression of IL-33. In vitro, stimulation of Notch-1 with Jagged-1 induced the expression of (a) Jagged-1; (b) IL-33; and (c) p-CREB transcription factor. The inhibitor of Notch-1, DAPT, reduced all the effects of Jagged-1 on nasal epithelial cells.

CONCLUSIONS

The data herein provided support, for the first time, a putative role of Notch-1/Jagged-1 signaling in the overexpression of IL-33 in the epithelium of nasal polyps from patients with CRSwNP.

Short communication: Characterization of Staphylococcus aureus isolated along the raw milk cheese production process in artisan dairies in Italy

Staphylococcus aureus is a common cause of food-borne intoxications. Several staphylococcal food poisoning outbreaks have been linked to consumption of raw milk cheeses and artisanal cheese production. However, information on Staph. aureus isolated from artisanal raw milk cheeses and small-scale dairy production environments is very limited. Therefore, we aimed to characterize Staph. aureus isolated along the artisanal raw milk production chain by determining (1) the population structure, and (2) the presence/absence of enterotoxin genes, mecA/C, and pvl. We collected 276 samples from different production stages (raw milk, whey, curd, brine, drying worktops, and cheese) at 36 artisan dairies in Italy. A total of 102 samples from 25 dairies tested positive for Staph. aureus, with 80% positive samples among the tested artisan cheeses. All isolates were further characterized by spa typing and PCR screening for staphylococcal enterotoxin genes, the mecA/mecC genes characteristic for methicillin-resistant Staph. aureus, and the pvl gene encoding Panton-Valentine leukocidin. The 102 isolates represented 15 different spa types and were assigned to 32 different Staph. aureus strains. The spa type most frequently detected was t2953 (30%), which is associated with genotype B strains causing high within-herd levels of bovine mastitis. In addition, 3 novel spa types (t13269, t13277, and t13278) were identified. Although none of the strains harbored mecA/mecC or pvl, 55% of the isolates exhibited at least one enterotoxin gene. Many strains were present in samples from multiple dairies from different regions and years, highlighting the spread of Staph. aureus in small-scale cheese production plants. Our findings demonstrate that enterotoxigenic Staph. aureus and in particular t2953 (genotype B) isolates commonly occur in artisanal dairies and raw milk cheeses in Italy. It is particularly alarming that 80% of the artisan cheeses sampled in our study were positive for Staph. aureus. These findings stress the need for effective measures preventing staphylococcal food poisoning by limiting Staph. aureus growth and enterotoxin formation along the production chain and in the final product.

Clarithromycin in the Management of Chronic Rhinosinusitis: Preliminary Results of a Possible Its New Use

The aim of this study is to evaluate the efficacy and safety of prolonged therapy with low-dose clarithromycin in patients with chronic rhinosinusitis with polyps (CRSwP) after endoscopic sinus surgery (ESS). A total of 10 patients with CRSwP were identified and subjected to bilateral ESS. In post-operative patients they were treated with nasal wash with saline solution and steroid sprays (beclomethasone). During follow-up, after 30-40 days after the operation (M = 35.4 SD = +4.33), patients reported a worsening of symptoms with onset of nasal obstruction; reduction/loss of smell; headache; onset of viscous secretions and therefore all patients continued therapy with saline nasal irrigation, topical steroid therapy and started macrolide (clarithromycin 500 mg/pill: 1 pill/day for 3 days a week for 1 month). 22-item SinoNasal Outcome Test (SNOT-22) and a score to the endoscopic evaluation (endoscopic appearance score, EAS) before and after treatment were performed to evaluate efficacy of treatment. The results of the SNOT-22 and EAS showed statistically significant improvements (p < 0.05) for some parameters such as: the need to blow nose, sneezing, hyposmia, viscous mucous secretions about the SNOT-22 and reduction of secretions and edema of the nasal mucosa about the EAS. The preliminary results of our study show that the low-dose clarithromycin for a period of 1 month can improve patient complaints with CRSwP not only through the antibacterial properties but also for the immunomodulatory characteristics.

Vitamin a decreases after a maximal incremental stress test in non-professional male runners with low aerobic performance

The data on the effects of aerobic training on plasma antioxidant vitamins are conflicting. Additionally, most studies focus on the oxidative profiles of professional athletes, but limited information is available for amateur athlete populations. The aim of this study was to evaluate the effects of high-intensity exercise on antioxidant vitamins in non-professional runners with varying levels of aerobic power. Eighty-one male runners underwent an incremental test to exhaustion. The study population was then divided into the following tertiles according to VO2max: Group L (LowVO2max, less than 44.2 mLkg-1min-1), Group M (MediumVO2max, 44.2-49.7 mLkg-1min-1) and Group H (HighVO2max, >49.7). Comparative analyses were performed between Groups L and H. The total antioxidant capacity (TAC), Vitamin (Vit) E, Vitamin A, β-carotene, lycopene and thiobarbituric acid-reactive substances (TBARS) were determined before and 60 min after exercise testing. After the stress test, Vit A decreased and TBARS increased in Group L, whereas no changes in the vitamin concentrations, TAC induction and TBARS reduction were observed in group H. In individuals with low VO2max, an incremental test determined lipid-peroxidation and Vitamin A consumption, whereas H Group increases TAC that buffer TBARS production.

Increased left atrial size in obese children and its association with insulin resistance: a pilot study

Subclinical cardiac abnormalities represent predisposing factors for cardiovascular disease (CVD) in obese subjects. The aim of this study was to evaluate early cardiac abnormalities in obese youth and the potential association with insulin resistance (IR). Thirty obese (12 males (M)/18 females (F); age = 11.5 ± 2.4 years; body mass index (BMI)-standard deviation score (SDS) = +2.1 ± 0.5) and 15 normal weight (10 M/5 F; age = 12.8 ± 3.1 years; BMI-SDS = +0.3 ± 0.9) children and adolescents underwent Doppler two-dimensional echocardiographic assessments of left atrial (LA) and ventricular (LV) geometry and LV diastolic function (peak early [E] and late waves, E wave deceleration time, myocardial flow velocities). Homeostasis model assessment of IR (HOMA-IR) was used as an IR index. LA size was increased in obese children, as indicated by higher LA diameter (4.9 ± 0.5 vs 4.1 ± 0.4 cm, p < 0.001), area (14.3 ± 2.5 vs 10.7 ± 2.0 cm(2), p < 0.001), and volume (33.8 ± 10.6 vs 23.7 ± 6.4 ml, p = 0.003). LV mass was also increased in obese children (87.0 ± 16.6 vs 68.8 ± 13.2 g, p = 0.003), who also showed subtle diastolic dysfunctions, as indicated by higher values of E (97.1 ± 14.3 vs 86.2 ± 11.9 cm/s, p = 0.02). All the above parameters were significantly associated with BMI-SDS (p < 0.05). In addition, HOMA-IR was independently associated with LA diameter, area, and volume (β = 0.314, p = 0.040; β = 0.415, p = 0.008; β = 0.535, p = 0.001).

CONCLUSION

Obese children feature increased LA size, which emerged to be mainly correlated to, and possibly driven by IR, suggesting an increased CVD risk.

WHAT IS KNOWN

Left atrial and ventricular alterations have been reported in obese adults, and they represent predisposing factors for cardiovascular disease. There is some evidence suggesting that obese children show increased left ventricular mass and also increased atrial size, although with conflicting results.

WHAT IS NEW

Obese normotensive children showed a moderately increased atrial size, subtle alterations in left cardiac diastolic function, and ventricular mass. An association between insulin resistance and left cardiac changes was found, although its mechanism remains to be determined.

Methicillin resistance in Staphylococcus aureus strains isolated from food and wild animal carcasses in Italy

Following the detection of methicillin-resistant Staphylococcus aureus (MRSA) ST398 in food-producing animals, both livestock and wildlife, and derived products, are considered potential sources of MRSA in humans. There is a paucity of data on MRSA in foods in Italy, and the data regarding wild animals are particularly scarce. A total of 2162 food samples collected during official monitoring activities in 2008 were analyzed for the detection of S. aureus. Also, samples from 1365 wild animals collected by the National Reference Center for Wild Animal Diseases in 2003-2009 were subjected to anatomopathological examination. S. aureus isolates were processed for phenotypic and molecular methicillin resistance determinations. S. aureus was found in 2.0% of wild animal carcasses and in 3.2% of wild boar lymph nodes: none showed methicillin resistance. The prevalence of S. aureus in food was 17.1%. Two MRSA strains, both from bulk tank milk (prevalence 0.77%) were isolated: the strains were resistant to tetracycline, had spa-type t899, and were negative for the Panton-Valentine leukocidin gene. The low prevalence of MRSA suggests that the risk of transmission to humans via food is limited. However, attention should be paid to the cattle food chain, which may be a potential route of transmission of LA-MRSA.

Bipolar Quantum Molecular Resonance versus Blunt Dissection tonsillectomy

OBJECTIVES

This study compared a quantum molecular resonance tonsillectomy (QMRT) to a standard blunt dissection tonsillectomy (BDT) for effectiveness and safety.

METHODOLOGY

From January 2011 to September 2012, we recruited 80 children (ages 3 to 16 y) with paediatric obstructive sleep apnoea syndrome and/or recurrent tonsillitis. Patients were randomly assigned to receive QMRT (N = 40) or BDT (N = 40). The operating time and blood loss during surgery were evaluated. During the first postoperative week, the patients' parents completed a questionnaire to evaluate bleeding, ear and neck pain, nausea, vomiting, interrupted sleep, oral liquid intake or discomfort in fluid assumption, and analgesic consumption.

RESULTS

The average tonsillectomy duration was significantly shorter in the QMRT group (22.07 min ± 9.05) than in the BDT group (35.12 min ± 13.32; p < 0.000005). The average blood loss during tonsillectomy was significantly lower for the QMRT group (5.62 ml ± 7.44) than for the BDT group (43 ml ± 33.20; p < 000000001). However, the BDT group reported significantly lower pain scores than the QMRT group on days 2 (p < 0.05), 5 (p < 0.05), and 6 (p < 0.05); on other days, the groups were not significantly different. The BDT group reported two early and one late bleeding episodes; the QMRT group recorded only two late bleeding episodes.

CONCLUSIONS

QMRT significantly reduced the operating time and intra-operative blood loss. No significant differences were found between the two techniques in postoperative pain or bleeding.

Reproducibility study for the detection of Staphylococcal enterotoxins in dairy products between official Italian national laboratories

Staphylococcal food poisoning is a common foodborne disease caused by the ingestion of staphylococcal enterotoxins (SEs) produced mainly by enterotoxigenic strains of Staphylococcus aureus. To date, 21 SEs and/or enterotoxin-like types have been identified, several of which represent a potential hazard for consumers. To protect consumer health and to reduce the amount of SE-contaminated food entering the market, European Union legislation regulating food safety requires testing for SEs. The Italian National Reference Laboratory organized a ring trial to test technical and analytical proficiency in the national network of official food laboratories. Twenty-four laboratories took part, and each received and analyzed 24 blind dairy samples. Reproducibility of the results from the laboratories was assessed by the Cohen k index, and accuracy (sensitivity and specificity) was evaluated according to the International Organization for Standardization definition (ISO 16140:2003). Trial results revealed partially satisfactory agreement: 254 of 276 possible paired participants (92%) reached a k value >0.60, which is conventionally recognized as satisfactory. Accuracy was deemed satisfactory; 100% sensitivity and 100% specificity were achieved by 22 and 18 of the 24 laboratories, respectively.

Glioblastoma multiforme and hepatitis B: do the right thing(s)

OBJECTIVE

Hepatitis B virus (HBV) reactivation is a well-known complication related to immunosuppression. Clinical manifestations of HBV relapse range from self-limiting anicteric hepatitis to acute hepatic failure. Temozolomide (TMZ) is an alkylating agent used for the treatment of glioblastoma multiforme (GBM), the most common and deadliest of malignant primary brain tumors.

CASE REPORT

We report the case of a 52-year old man with a history of serological positivity for hepatitis B surface antigen (HBsAg) who was diagnosed with GBM. Since the tumor was multifocal and thus inoperable, the patient received radiotherapy with concomitant TMZ and corticosteroids, without a prophylactic therapy for HBV infection. Acute hepatitis developed five months later the beginning of anticancer therapy. We started antiviral entecavir, which led to a decrease of HBV-DNA titer to 20 IU/ml, allowing the prosecution of the TMZ therapy.

CONCLUSIONS

Up to now only four other cases of HBV relapse during TMZ therapy have been reported in literature. These cases underline the need of HBV screening and antiviral prophylaxis before starting TMZ administration.

Staphylococcal poisoning foodborne outbreak: epidemiological investigation and strain genotyping

In June 2011, an outbreak of Staphylococcus aureus enterotoxin food poisoning gastroenteritis occurred in Turin, Italy, following a catered dinner party at a private home. Within a few hours, 26 of the 47 guests experienced gastrointestinal illness, and 9 were hospitalized. A retrospective cohort study using a standardized questionnaire was carried out, and the risk ratios for each food item were calculated. The analysis indicated consumption of seafood salad as the most probable cause of the outbreak (risk ratio = 11.72; 95 % confidence interval, 1.75 to 78.54). Biological samples were collected from four of the hospitalized guests (stool and vomit), nasal mucosa swabs from three food handlers employed with the caterer, and available food residuals. All stool and vomit samples tested positive for enterotoxigenic S. aureus. As residues of the seafood salad were no longer available for sampling, suspected contamination could not be verified. However, no other food was found contaminated by S. aureus or its enterotoxins. All isolates from the biological samples were characterized at the genomic level by means of two multiplex PCR protocols to determine the presence of genes encoding staphylococcal enterotoxins, pulsed-field gel electrophoresis and staphylococcal protein A gene (spa) typing to describe their genetic profiles. All the isolates presented genes encoding SEA and SEI; the pulsed-field gel electrophoresis genetic profiles revealed the same pulsotype in the microorganism isolated from the hospitalized guests as in one of the isolates from a food handler's nasal mucosa, and the spa typing analysis reported two closely related spa types (t701 and t267), implicating the food handler as the most likely outbreak source.