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.

Incidence and prevalence of pressure ulcers in cancer patients admitted to hospice: A multicentre prospective cohort study

Pressure ulcers lead to discomfort for patients and may have an important impact on a patient's quality of life. Measure the incidence and prevalence of pressure ulcers in a Hospice environment; evaluate the risk factors associated with pressure ulcers; and calculate the incidence of Kennedy Terminal Pressure Ulcers. This multicentre prospective cohort study enrolled 440 cancer patients in advanced phase, consecutively admitted to five hospices of the AUSL della Romagna (Italy), during a period of 1 year. Five hundred more patients were excluded from the study because of inability to sign the consent form or refusal to participate. All patients were adults above 18 years of age. The National Pressure Advisory Panel Classification System was used to evaluate the pressure ulcers. Potential risk predictors were evaluated through the Braden Scale, the Numerical Scale, and the Pain Assessment in Advanced Dementia Scale. Starting in September 2016, 214 (48.6%) females and 226 (51.4%) males were analysed. The incidence of pressure ulcers in the total population was 17.3%. The risk factors that influence the development of pressure ulcers were age, proximity to death, and duration of stay in Hospice. The incidence of Kennedy Terminal Pressure Ulcers was 2.7%. This study demonstrates that 17.3% of all patients admitted to a hospice setting developed a pressure ulcer. The longer the patients stay in hospice and the clinical condition deteriorates, the higher the risk of developing a pressure ulcer.

Attribution of Listeria monocytogenes human infections to food and animal sources in Northern Italy

Listeriosis is a foodborne illness characterized by a relatively low morbidity, but a large disease burden due to the severity of clinical manifestations and the high case fatality rate. Increased listeriosis notifications have been observed in Europe since the 2000s. However, the reasons for this increase are largely unknown, with the sources of sporadic human listerioris often remaining elusive. Here we inferred the relative contributions of several putative sources of Listeria monocytogenes strains from listerioris patients in Northern Italy (Piedmont and Lombardy regions), using two established source attribution models (i.e. 'Dutch' and 'STRUCTURE') in comparative fashion. We compared the Multi-Locus Sequence Typing and Multi-Virulence-Locus Sequence Typing profiles of strains collected from beef, dairy, fish, game, mixed foods, mixed meat, pork, and poultry. Overall, 634 L. monocytogenes isolates were collected from 2005 to 2016. In total, 40 clonal complexes and 51 virulence types were identified, with 36% of the isolates belonging to possible epidemic clones (i.e. genetically related strains from unrelated outbreaks). Source attribution analysis showed that 50% of human listerioris cases (95% Confidence Interval 44-55%) could be attributed to dairy products, followed by poultry and pork (15% each), and mixed foods (15%). Since the contamination of dairy, poultry and pork products are closely linked to primary production, expanding actions currently limited to ready-to-eat products to the reservoir level may help reducing the risk of cross-contamination at the consumer level.

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.

In Vitro Susceptibility of Multidrug Resistant Strains of Salmonella to Essential Oils

Antimicrobial resistance has become a global threat to public health. There is a critical need to find new antimicrobial substances from natural sources. The aim of this study was to investigate the antimicrobial activity of essential oils (EOs) obtained from Origanum vulgare, Thymus serpyllum, Thymus vulgaris, and Melaleuca alternifolia against multidrug resistant strains of Salmonella isolated from samples of diverse animal origin. The strains were biochemically identified, serotyped, and characterized for their antimicrobial resistance profiles. The antimicrobial activity of the EOs against the strains was evaluated using the Kirby-Bauer diffusion method, followed by determination of the minimal inhibitory concentration and minimum bactericidal concentrations. The EOs of T. serpyllum and O. vulgare, which contain carvacrol as the main compound, show excellent antimicrobial activity.

Genome-Wide Profiling of Enterotoxigenic Staphylococcus aureus Strains Used for the Production of Naturally Contaminated Cheeses

Staphylococcus aureus is a major human pathogen and an important cause of livestock infections. More than 20 staphylococcal enterotoxins with emetic activity can be produced by specific strains responsible for staphylococcal food poisoning, one of the most common food-borne diseases. Whole genome sequencing provides a comprehensive view of the genome structure and gene content that have largely been applied in outbreak investigations and genomic comparisons. In this study, six enterotoxigenic S. aureus strains were characterised using a combination of molecular, phenotypical and computational methods. The genomes were analysed for the presence of virulence factors (VFs), where we identified 110 genes and classified them into five categories: adherence (n = 31), exoenzymes (n = 28), genes involved in host immune system evasion (n = 7); iron uptake regulatory system (n = 8); secretion machinery factors and toxins' genes (n = 36), and 39 genes coding for transcriptional regulators related to staphylococcal VFs. Each group of VFs revealed correlations among the six enterotoxigenic strains, and further analysis revealed their accessory genomic content, including mobile genetic elements. The plasmids pLUH02 and pSK67 were detected in the strain ProNaCC1 and ProNaCC7, respectively, carrying out the genes sed, ser, and selj. The genes carried out by prophages were detected in the strain ProNaCC2 (see), ProNaCC4, and ProNaCC7 (both positive for sea). The strain ProNaCC5 resulted positive for the genes seg, sei, sem, sen, seo grouped in an exotoxin gene cluster, and the strain ProNaCC6 resulted positive for seh, a transposon-associated gene. The six strains were used for the production of naturally contaminated cheeses which were tested with the European Screening Method for staphylococcal enterotoxins. The results obtained from the analysis of toxins produced in cheese, combined with the genomic features represent a portrait of the strains that can be used for the production of staphylococcal enterotoxin-positive cheese as reference material.

Arcobacter spp. in raw milk from vending machines in Piedmont and occurrence of virulence genes in isolates

Arcobacter spp. has been recognized as an emerging foodborne pathogen and a hazard to human health. In the dairy chain, it has been isolated from different sources, nevertheless data on Arcobacter occurrence in raw milk provided by vending machines are few. This study aimed to identify potentially pathogenic Arcobacter spp. in raw milk intended for human consumption sold through vending machines located in Piedmont. In an 8-month period, 37 raw milk samples were collected from 24 dairy farms: 12 (32,4%) were collected directly in farm from bulk tank milk and 25 (67,6%) from vending machines. Eight (21,6%) out of the 37 milk samples and 7 (29,2%) out of the 24 dairy farms were positive for Arcobacter spp. by culture examination. Four (16%) out of the 25 samples from vending machines and 4 (33,3%) out of the 12 samples from bulk tank milk were positive. All 8 isolates were identified as A. butzleri both by MALDI-TOF MS and multiplex end-point PCR. According to the detection of virulence genes, a total of four Patho-types were highlighted: 5 isolates in P-type 1 and only one isolate for each of the P-types 2-3-4. A. butzleri isolates carrying encoding virulence factors genes were isolated from raw milk intended for human consumption: these findings strengthen the compulsory consumption after boiling as required by current legislation and suggest the need of enlarging the analytical investigations to other microorganisms not yet included in the food safety criteria.

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.

Outbreak of febrile gastroenteritis caused by Listeria monocytogenes 1/2a in sliced cold beef ham, Italy, May 2016

In May 2016, two separate clusters of febrile gastroenteritis caused by Listeria monocytogenes were detected by the local health authority in Piedmont, in northern Italy. We carried out epidemiological, microbiological and traceback investigations to identify the source. The people affected were students and staff members from two different schools in two different villages located in the Province of Turin; five of them were hospitalised. The epidemiological investigation identified a cooked beef ham served at the school canteens as the source of the food-borne outbreak. L. monocytogenes was isolated from the food, the stools of the hospitalised pupils and the environment of the factory producing the cooked beef ham. All isolates except one were serotype 1/2a, shared an indistinguishable PFGE pattern and were 100% identical by whole genome sequencing (WGS). By combining a classical epidemiological approach with both molecular subtyping and WGS techniques, we were able to identify and confirm a Listeria gastroenteritis outbreak associated with consumption of sliced cold beef ham.

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.

Insight Into the Distribution of Staphylococci and Their Enterotoxins in Cheeses Under Natural Conditions

Staphylococcal food poisoning outbreaks are a major cause of food-borne illness in the European Union and their notification has been mandatory since 2005. Criteria for the enumeration of coagulase-positive Staphylococci (CPS) and the detection of staphylococcal enterotoxins (SEs) in cheese have been set down in Commission Regulation EC 2073/2005. Currently, few information are available about the distribution of SEs in naturally contaminated cheeses, including raw-milk and artisanal dairy products. The aim of this study was therefore to investigate at both the CPS enumeration and the succession of the enterotoxigenic Staphylococcus aureus and produced enterotoxins levels on the rind and the core of a raw-milk semi-hard cheese, produced on farm. The study has been conducted in three steps: (I) seven wheels at different time of ripening where tested for the presence of SEs. (II) from each wheel, four portions were subsequently sampled from four different areas (peripheral rind, central rind, peripheral core and central core). (III) two cheese wheels, characterized by the highest and lowest CPS numbers and SEs quantification, based on the second step of the study, were further analyzed. A significant difference has been observed in the distribution of CPS and SEs in the four areas sampled, irrespectively of the batch and the time of ripening. The results of this study provided a set of previously unknown information on the influence of natural conditions on the distribution of CPS and SEs thereof in the cheese matrix, filling a gap in the understanding of SEs biosynthesis process.

Characterization of A Staphylococcal Food Poisoning Outbreak in A Workplace Canteen during the Post-Earthquake Reconstruction of Central Italy

In summer 2017, a foodborne outbreak occurred in Central Italy, involving 26 workers employed in the post-earthquake reconstruction. After eating a meal provided by a catering service, they manifested gastrointestinal symptoms; 23 of them were hospitalized. The retrospective cohort study indicated the pasta salad as the most likely vehicle of poisoning. Foods, environmental samples, and food handlers' nasal swabs were collected. Bacillus cereus (Bc) and coagulase-positive staphylococci (CPS) including S. aureus, together with their toxins, were the targets of the analysis. CPS, detected in all the leftovers, exceeded 10⁵ CFU/g in the pasta salad, in which we found Staphylococcal Enterotoxins (SEs) (0.033 ng SEA/g; 0.052 ng SED/g). None of the environmental and human swabs showed contamination. We characterized 23 S. aureus from foods. They all belonged to the human biotype, showed the same toxigenic profile (sea, sed, sej, and ser genes), and had the same Pulsed Field Gel Electrophoresis (PFGE) pattern; none of them harbored mecA or mupA genes. We also detected Bc contamination in the pasta salad but none of the isolates harbored the ces gene for the emetic toxin cereulide. The EU Reference Laboratory for CPS confirmed the case as a strong-evidence outbreak caused by the ingestion of SEs produced by a single strain of S. aureus carried by the same human source. This outbreak was successfully investigated despite the emergency situation in which it occurred.

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.

A Set of Multiplex Polymerase Chain Reactions for Genomic Detection of Nine Edible Insect Species in Foods

On 1 January 2018, a new regulation on 'Novel Food' has come into application in the EU. Insects and insect-based products are therefore included among the categories of food which constitute novel foods. Insects are nutrient-rich, produce fewer greenhouse gases and ammonia than conventional livestock, and have high feed conversion efficiency. Insects may be an alternative food source in the near future, but consideration of insects as a food requires scrutiny due to the risk of allergens. The aim of the present study was to develop a set of multiplex polymerase chain reaction (PCR) to detect nine edible insect species directly in foods. Four sets of mPCRs were designed to detect Locusta migratoria migratorioides (Reiche & Fairmaire, 1849) (Orthoptera: Acrididae), Tenebrio molitor (Linnaeus, 1758) (Coleoptera: Tenebrionidae) (mPCR-I), Acheta domesticus (Linnaeus, 1758) (Orthoptera: Gryllidae), Bombyx mori (Linnaeus, 1758) (Lepidoptera: Bombycidae (mPCR-II), Alphitobius diaperinus (Panzer, 1797) (Coleoptera: Tenebrionidae), Schistocerca gregaria (Forskål, 1775) (Orthoptera: Acrididae), Zophobas atratus (Fabricius, 1775) (Coleoptera: Tenebrionidae) (mPCR-III), Galleria mellonella (Linnaeus, 1758) (Lepidoptera: Pyralidae), and Gryllodes sigillatus (Walker, 1869) (Orthoptera: Gryllidae) (mPCR-IV). Results demonstrate that the panel of mPCRs allowed a rapid genetic identification of the insect species and has proved to be a sensible and highly discriminatory method. The assay is a potential tool in issues related to the labeling of products and food safety, in case of allergic consumers.

Microbiological Parameters in the Primary Production of Berries: A Pilot Study

The primary production of fresh soft fruits was considered to be a suspected critical point for the contamination of frozen berries that were responsible for the large 2013⁻2014 Hepatitis A virus (HAV) outbreak in Europe. In this study, an Italian berries’ production area was studied for its agro-technical characteristics, and the fresh fruits were analyzed for the presence of enteric viruses (HAV and Norovirus (NoV) genogroup I and genogroup II (GGI and GGII)), the enumeration of hygienic quality parameters, and the prevalence of bacterial pathogens. A total of 50 producers were sampled, who specialized in the exclusive or shared cultivation of berries. Escherichia coli was detected in two blackberry samples, whereas HAV and Norovirus were not detected. The samples were negative for Salmonella spp., Listeria monocytogenes, and Shiga toxin-producing Escherichia coli (STEC). The farms’ attributes were not associated with positive samples, apart from the presence of E. coli and the aerobic mesophilic bacteria for blackberry that were statistically correlated. In blueberries, the high aerobic mesophilic count could likely be associated with the resistance of the outer layer to handling. However, the two pathogens (Salmonella spp. and STEC) and the targeted viruses (HAV, NoV GGI and GGII) were not detected, highlighting the low risk of foodborne pathogens and viral contamination at the primary production stage of the berry food chain in the area considered in this pilot study.

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.

Molecular Epidemiology of Methicillin-Resistant and Methicillin-Susceptible Staphylococcus aureus in the Ovine Dairy Chain and in Farm-Related Humans

Staphylococcus aureus is a major cause of clinical infections in humans and its enterotoxins cause foodborne disease. In the present study, we tested a total of 51 isolates of S. aureus from small-ruminant dairy farms with artisan dairy facilities, all located in Latium, Italy. The farms have a known history of a high prevalence of methicillin-resistant S. aureus (MRSA). Most of the MRSA isolates (27 of 51) belonged to spa-type t127 (43.1%), followed by t2678 (3.9%), t044 (2%), t1166 (2%), and t1773 (2%). PFGE performed on mecA positive strains identified one cluster (≥ 80% of similarity), comprising 22 MRSA. Nine of twenty-two MRSA isolates were assigned human host origin, and 13 isolates did not belong to a specific host. During the characterization study, one strain isolated from bulk tank milk samples harbored the pvl gene; the strain was not enterotoxigenic with a non-specific host according to the biotyping scheme, highlighting the possible emerging risk of transmission of bacterial virulence factors by foods, the environment, and foodhandlers. These findings stress the importance of hygienic measures at all processing steps of the food production chain and underline that monitoring for the presence of MRSA throughout the food chain is essential for public health.

Investigation of a Staphylococcal Food Poisoning Outbreak from a Chantilly Cream Dessert, in Umbria (Italy)

On August 28, 2015, a staphylococcal food poisoning outbreak occurred in Umbria, Italy, affecting 24 of the 42 customers who had dinner at a local restaurant. About 3 h after ingesting a variety of foods, the customers manifested gastrointestinal symptoms. Within 24 h of notification from the hospital emergency department, Sanitary Inspectors of the local Public Health Unit performed an epidemiological investigation. A retrospective cohort study was conducted among the customers. Food and environmental samples were collected. Due to the rapid onset of symptoms (vomiting, diarrhea), the food samples were analyzed for the presence of toxigenic bacteria and their toxins; nasopharyngeal swabs were collected from the waiters and cooks. Among the food tested, high levels of coagulase-positive staphylococci (CPS) (3.4 × 10⁸ CFU/g) and staphylococcal enterotoxins (2.12 ng SEA/g) were only detected in the Chantilly cream dessert. CPS were also detected on the surface of a kitchen table (10 CFU/swab), and five food handlers were positive for Staphylococcus aureus. In total, five enterotoxigenic S. aureus isolates were recovered from three food handlers, a kitchen surface, and the Chantilly cream dessert. These isolates were further characterized by biotyping, pulsed-field gel electrophoresis, and multiplex polymerase chain reaction assays for the detection of eleven enterotoxin encoding genes (sea, seb, sec, sed, see, seg, seh, sei, sej, sep, and ser) and three genes involved in antibiotic resistance (mecA, mecC, and mupA). Three sea-positive strains, isolated from the dessert, environment, and one of the cooks, had the same pulsed-field gel electrophoresis profile and belonged to the human biotype, suggesting that the contamination causing the outbreak most likely originated from a food handler. Moreover, improper storage of the dessert, at room temperature for about 5 h, permitted microbial growth and SEA production. This study underlines the importance of both laboratory evidence and epidemiological data for outbreak investigation.

Diversity and persistence of Listeria monocytogenes within the Gorgonzola PDO production chain and comparison with clinical isolates from the same area

Listeria monocytogenes causes invasive syndromes with high fatality rates in specific population groups. Cheeses have been commonly implicated in outbreaks worldwide. Gorgonzola is a cheese only produced in Northwestern Italy (it is the third Italian cheese in terms of production and export) and L. monocytogenes is frequently isolated from the production chain. The aims of this study were to assess the distribution of L. monocytogenes Virulence Types (VTs) in isolates collected in Gorgonzola processing plants and to determine the presence of Epidemic Clones (ECs). Fifty-Six L. monocytogenes strains collected between 2004 and 2016 from cheese and environmental samples were subtyped with Multi-Virulence-Locus Sequence Typing (MVLST) and compared to previously typed strains. Most isolates (n=50) belonged to two new VTs (VT113 and VT114). The remaining isolates belonged to previously identified VTs: VT14-ECVIII (milk chocolate outbreak, 1994, USA) and VT80 (ricotta salata outbreak, 2012, USA). VT14, VT80 and VT113 were shared with isolates from apparently sporadic human cases in the same geographical area and temporal period (Piedmont and Lombardy, 2005-2016). The overall L. monocytogenes population appears to be homogeneous and may be characteristic of Gorgonzola production. Nevertheless, the detection in cheese and environmental samples of VTs observed in clinical isolates or outbreak related strains (VT80, VT14) contributed to better describe the current scenario and pointed out the need for increased surveillance.

Food Safety and Sustainable Nutrition Workshops: Educational Experiences for Primary School Children in Turin, Italy

European control and prevention policies are focused to guarantee a high level of protection of consumers' health. Food-borne diseases as obesity, diabetes, food allergy, and food-borne outbreaks are increasing. To prevent food-borne diseases, it is fundamental to involve consumers, in particular children, in educational experiences aimed to learn the proper behaviours to be applied. In this context, we designed and performed 5 educational workshops about food safety, hidden allergens in food and nutrition aimed to involve children attending primary and summer school. These experiences let us collect observations about children knowledge and behaviours. From May to October 2015, a total of 1708 children aged 6 to 11 years joined our workshops. Children were involved in listening activities, laboratory experiments, handling games and sensory experiences. All participants were familiar with food allergy and were interested to know how to behave with allergic people. Children showed great curiosity in discovering that many foods normally contain live bacteria. Less than 25% of children reported to skip breakfast, to have it watching TV or to spend few minutes for it. Many of them (>75%) thought that fruits and vegetables are all year-round available and are not related to a specific period. Very few participants (<25%) knew that freezing is the treatment to be applied to make fresh fish safe from parasites. Children involved in food safety and nutrition educational experiences have the opportunity to increase their awareness about the correct behaviours to prevent food-borne diseases and to improve their own critical thinking about food consumption.

Salmonella bongori 48:z35:– The first Italian case of human infection outside Sicily

<em>Salmonella bongori</em> 48:z35:– is considered endemic to Sicily (Italy) due to its epidemiological peculiarity. To our knowledge, no previous cases of human infection caused by <em>S. bongori</em> 48:z35:– have ever been reported in mainland Italy. Here we describe the isolation of <em>S. bongori</em> 48:z35:– from a 1-year-old symptomatic child in northwest Italy (Piedmont Region). The strain showed no antimicrobial resistance. Reporting of <em>S. bongori</em> 48:z35:– in a previously safe area is important to identify epidemiological changes.