Genetic Diversity of Flavescence Dorée Phytoplasmas at the Vineyard Scale.

To study the role of wild areas around the vineyards in the epidemiology of flavescence dorée (FD) and track the origin of new foci, two phytoplasma genetic markers, dnaK and malG, were developed for FD phytoplasma (FDp) characterization. The two genes and the vmpA locus were used to genetically characterize FDp populations at seven agroecosystems of a wine-growing Italian region. Vitis vinifera, "gone-wild" V. vinifera and rootstocks, Clematis spp., and Scaphoideus titanus adults were sampled within and outside the vineyards. A range of genotypes infecting the different hosts of the FDp epidemiological cycle was found. Type FD-C isolates were fairly homogeneous compared to type FD-D ones. Most of the FD-D variability was correlated with the malG sequence, and a duplication of this locus was demonstrated for this strain. Coinfection with FD-C and FD-D strains was rare, suggesting possible competition between the two. Similar levels of FDp genetic variation recorded for grapevines or leafhoppers of cultivated and wild areas and co-occurrence of many FDp genotypes inside and outside the vineyards supported the idea of the importance of wild or abandoned Vitis plants and associated S. titanus insects in the epidemiology of the disease. Genetic profiles of FDp found in Clematis were never found in the other hosts, indicating that this species does not take part in the disease cycle in the area. Due to the robustness of analyses using dnaK for discriminating between FD-C and FD-D strains and the high variability of malG sequences, these are efficient markers to study FDp populations and epidemiology at a small geographical scale.IMPORTANCE Flavescence dorée, a threatening disease of grapevine caused by FD phytoplasma (FDp), is distributed within the most important wine-producing areas of Europe and has severe effects on both vineyard productivity and landscape management. FDp is a quarantine pest in Europe, and despite the efforts to contain the pathogen, the disease is still spreading. In this work, new genetic markers for the fine genetic characterization of FDp at local scale are presented. Our findings improve the knowledge of FDp epidemiological cycle and offer the possibility of tracking the route of the FDp infection. In particular, due to its high genetic variability, one of the newly developed markers could be sufficient to track the origin of new infection foci, either from the wild areas or from nurseries.

Red cell distribution width predicts mid-term prognosis in patients hospitalized with acute heart failure: the RDW in Acute Heart Failure (RE-AHF) study.

The aim of the study was to evaluate the prognostic role of red cell distribution width (RDW) in a broad population of patients hospitalized for acute heart failure (AHF). In a retrospective cohort observational study, 451 consecutive patients discharged for AHF were categorized in patients with low RDW (≤ 14.8%) and high RDW (> 14.8%). The rates of death from all causes or of hospital readmission for worsening heart failure and death were determined after a median follow-up of 18 months. The overall population has a median age of 80 years (IQR 72-85), 235 patients (52%) were males. Patients with a higher RDW have more comorbidities and a higher Charlson Index. At follow-up, 200 patients (44%) had died and 247 (54%) had died or were readmitted for HF: in the cohort with low RDW, 70 patients (36.4%) had died, whereas in the cohort with high RDW, 165 patients (63.7%) had died: the unadjusted risk ratio of patients with high RDW was 2.03 (log-rank test: p < 0.0001). In a multivariate Cox regression model, the hazard ratio for death from any cause in the 'high RDW' cohort is 1.73 (95% confidence interval 1.2-2.48; p = 0.003); the RDW adds prognostic information beyond that provided by conventional predictors, including age; etiology of HF; anemia; hyponatremia; estimated glomerular filtration rate; NT-proBNP levels; Charlson comorbidity score, atrial fibrillation, functional status, therapy with renin-angiotensin-aldosterone system inhibitors, beta-blockers. RDW is a powerful marker of worse long-term outcomes in patients with AHF, and its prognostic value is maintained beyond that provided by other well-established risk factors or biomarkers.

Hypoalbuminemia, systemic inflammatory response syndrome, and functional outcome in intracerebral hemorrhage.

PURPOSE: Hypoalbuminemia and systemic inflammatory response syndrome (SIRS) are reported in critically-ill patients, but their relationship is unclear. We sought to determine the association of admission serum albumin and SIRS with outcomes in patients with intracerebral hemorrhage (ICH). METHODS: We used a multicenter, multinational registry of ICH patients to select patients in whom SIRS parameters and serum albumin levels had been determined on admission. Hypoalbuminemia was defined as the lowest standardized quartile of albumin; SIRS according to standard criteria. Primary outcomes were modified Rankin Scale (mRS) at discharge and in-hospital mortality. Regression models were used to assess for the association of hypoalbuminemia and SIRS with discharge mRS and in-hospital mortality. RESULTS: Of 761 ICH patients included in the registry 518 met inclusion criteria; 129 (25%) met SIRS criteria on admission. Hypoalbuminemia was more frequent in patients with SIRS (42% versus 19%; p<0.001). SIRS was associated with worse outcomes (OR: 4.68, 95%CI, 2.52-8.76) and in-hospital all-cause mortality (OR: 2.18, 95% CI, 1.60-2.97), while hypoalbuminemia was not associated with all-cause mortality. CONCLUSIONS: In patients with ICH, hypoalbuminemia is strongly associated with SIRS. SIRS, but not hypoalbuminemia, predicts poor outcome at discharge. Recognizing and managing SIRS early may prevent death or disability in ICH patients.

Hepatic brucelloma.

We present a case of hepatic abscess caused by Brucella melitensis (or hepatic brucelloma) diagnosed in a 59-year-old man 33 years after an episode of acute brucellosis that had completely resolved. Recovery from symptoms and a decrease in lesion size seen on radiological assessment were achieved through prolonged combined antibiotic therapy, without the need for surgery. Hepatic brucelloma is a rare complication of brucellosis, which is the most common zoonosis globally, mainly occurring in specific endemic areas and causing a range of clinical manifestations. In this Grand Round, we review the clinical manifestations, diagnostic approach (through laboratory, radiology, and histology findings), differential diagnosis, treatment, and prognosis of hepatic brucelloma.

Short-term prognosis of intracranial haemorrhage in patients on oral anticoagulant or antiplatelet drugs.

BACKGROUND: Intracranial haemorrhage (ICH) is the most feared complication of oral vitamin K antagonists (VKAs) and antiplatelet drugs. Little data are available on the clinical course of antithrombotic drug-associated ICHICH. The main aim of the VKA- and Antiplatelet Drug-Associated ICH Prognosis (VAIP) study is to investigate predictors of short-term prognosis in ICH patients, and to analyse characteristics and prognosis of patients with antithrombotic drugs-associated ICH. METHODS: VAIP is designed as a retrospective cohort study. Consecutive adult patients with an ICH objectively documented by neuroimaging, occurring during treatment with VKAs or ADs, admitted to the Cuneo hospital, Italy, from 2005 to 2010, were included. For a non-exposed group, we randomly selected patients with ICH not on antithrombotic treatment. RESULTS: Overall, 451 patients were included. In particular, 75 patients were on VKAs and 96 on antiplatelet drugs. The site of haemorrhage was intracerebral in 274 (60.8%) patients, subdural in 156 (34.6%), and subarachnoid in 21 (4.7%). Mortality rate was 35.8%, 4.5%, and 28.6%, respectively. In the multivariate analysis, independent predictors of in-hospital death were: age >80years (hazard ratio [HR] 2.3, 95% confidence interval 1.5-3.5), Glasgow Coma Scale [GCS]<8 (HR 7.8, 5.0-12.1), treatment with VKAs (HR 2.0, 1.2-3.4) and antiplatelet drugs (HR 1.8, 1.1-3.0). Neurosurgical treatment was an independent predictor of survival (HR 0.5, 0.3-1.0). Among patients with VKA-associated ICH, independent predictors of in-hospital death for ICH were: age >80years (HR 4.4, 1.6-12.0), GCS <8 (HR 12.0, 4.1-34.8), recent onset of symptoms (HR 4.2, 1.6-11.3), and neurosurgical treatment (HR 0.1, 0.0-0.8). CONCLUSION: Our results suggest that the main predictors of ICH in-hospital prognosis in a tertiary neurosurgical center are advanced age, GCS at admission, previous treatment with VKAs and antiplatelet drugs, and neurosurgical treatment.