Competence of final year otolaryngology residents with the bedside head impulse test.

BACKGROUND: The bedside head impulse test (bHIT) is a clinical method of assessing the vestibulo-ocular reflex (VOR). It is a critical component of the bedside assessment of dizzy patients, and can help differentiate acute stroke from vestibular neuritis. However, there is evidence showing the bHIT is often not performed in appropriate clinical settings or is performed poorly. To date, there have been no studies evaluating the bHIT competence of graduating physicians. METHODS: 23 final year Otolaryngology -Head &Neck Surgery (OTL-HNS) residents in Canada were evaluated on the use of bHIT using a written multiple-choice examination, interpretation of bHIT videos, and performance of a bHIT. Ratings of subject bHIT performance were completed by two expert examiners (DT, DL) using the previously published Ottawa Clinic Assessment Tool (OCAT). RESULTS: Using a cut-off of an OCAT score of 4 or greater, only 22% (rater DT) and 39% (rater DL) of residents were found able to perform the bHIT independently. Inter-rater reliability was fair (0.51, interclass correlation). The mean scores were 65% (14.1% standard deviation) on the video interpretation and 71% (20.2% standard deviation) on the multiple-choice questions. The scores on multiple choice examination did not correlate with bHIT ratings (Pearson r = 0.07) but there was fair correlation between video interpretation and bHIT ratings (Pearson r = 0.45). CONCLUSION: Final year OTL-HNS residents in Canada are not adequately trained in performing the bHIT, though low interrater reliability may limit the evaluation of this bedside skill. Multiple choice examinations do not reflect bHIT skill. These findings have implications for development of competency-based curricula and evaluations in Canada in critical physical exam skills.

25(OH) vitamin D and functional outcomes in older adults admitted to rehabilitation units: the safari study.

Vitamin D (25(OH)D) deficiency is associated with poor physical performance; little is known about its impact on geriatric rehabilitation. We found a positive non-linear relationship between 25(OH)D and functional gain, stronger in levels < 16 ng/ml (below the cutoff for "deficiency"). An early 25(OH)D dosage may be advisable for this population. INTRODUCTION: Vitamin D (25(OH)D) deficiency is highly prevalent in older people, and it is associated with poor muscular strength and physical performance. Its impact on functional outcomes during geriatric rehabilitation has been poorly studied. We aim to analyze the association between 25(OH)D and functional recovery in geriatric rehabilitation units. METHODS: We conducted a prospective multi-center cohort study including patients ≥ 65 years old admitted to 3 geriatric rehabilitation units in Italy and Spain, after orthopedic events or stroke. Outcomes were absolute functional gain (AFG, discharge-admission Barthel index) and ability to walk (AW) at 3 months after admission. The association between 25(OH)D quartiles (Q1-Q2-Q3-Q4) and outcomes was explored using linear or logistic regression models. RESULTS: We included 420 patients (mean age = 81.2 years [SD = 7.7], 66.4% females, mean 25(OH)D concentration = 13.5 ng/ml [SD = 8.7]) (to convert to nmol/l multiply by 2.496). A non-linear relationship between 25(OH)D and AFG was found, with a stronger association for 25(OH)D levels < 16 ng/ml. Compared to Q1 (25(OH)D ≤ 6 ng/ml), participants in Q3 (25(OH)D 11.5-18.2 ng/ml) had the best AFG and AW (mean AFG [SD], Q1 = 28.9 [27.8], Q2 = 32.5 [23.5], Q3 = 43.1 [21.9], Q4 = 34.5 [29.3], R2 = 7.3%; AW, Q1-Q2 = 80%, Q3 = 91%, Q4 = 86%). Regression models adjusted for potential confounders confirmed these results (AGF Q2, ß = 2.614, p = 0.49; Q3, ß = 9.723, p < 0.01; Q4, ß = 4.406, p = 0.22; AW Q2, OR [95% CI] = 1.84 [0.67-5.33]; Q3, OR [95% CI] = 4.01 [1.35-13.48]; Q4, OR [95% CI] = 2.18 [0.81-6.21]). CONCLUSIONS: In our study, 25(OH)D concentration showed a positive association with functional outcomes at 3 months. The association is stronger below the usual cutoff for "deficiency." Dosage of 25(OH)D concentration may help identify geriatric rehabilitation patients at risk for a worse functional recovery.

Active and passive surveillance for bat lyssaviruses in Italy revealed serological evidence for their circulation in three bat species.

The wide geographical distribution and genetic diversity of bat-associated lyssaviruses (LYSVs) across Europe suggest that similar viruses may also be harboured in Italian insectivorous bats. Indeed, bats were first included within the passive national surveillance programme for rabies in wildlife in the 1980s, while active surveillance has been performed since 2008. The active surveillance strategies implemented allowed us to detect neutralizing antibodies directed towards European bat 1 lyssavirus in six out of the nine maternity colonies object of the study across the whole country. Seropositive bats were Myotis myotis, M. blythii and Tadarida teniotis. On the contrary, the virus was neither detected through passive nor active surveillance, suggesting that fatal neurological infection is rare also in seropositive colonies. Although the number of tested samples has steadily increased in recent years, submission turned out to be rather sporadic and did not include carcasses from bat species that account for the majority of LYSVs cases in Europe, such as Eptesicus serotinus, M. daubentonii, M. dasycneme and M. nattereri. A closer collaboration with bat handlers is therefore mandatory to improve passive surveillance and decrypt the significance of serological data obtained up to now.

Analysis of volatile organic compounds: an innovative approach to heart failure characterization in older patients.

BACKGROUND: Analysis of exhaled volatile organic compounds (VOCs) may be applied for diagnostic purposes in some chronic diseases, but there are no data on their role for discriminating people with congestive heart failure (CHF), particularly in older patients where natriuretic peptides have lower accuracy. We evaluated whether VOCs analysis can discriminate patients with or without CHF, stratify CHF severity and predict the response to therapy of decompensated CHF. METHODS AND RESULTS: We recruited 89 subjects admitted to an acute care ward with acutely decompensated CHF, 117 healthy controls and 103 chronic obstructive pulmonary disease (COPD) controls. CHF patients performed echocardiography. VOCs were collected using the Pneumopipe® and analyzed with the BIONOTE electronic nose. Partial least square analysis was used to evaluate the discriminative capacity of VOCs. Accuracy in discrimination of CHF versus healthy and COPD controls was 81% and 69%, respectively; accuracy did not decrease in a sensitivity analysis excluding subjects younger than 65 and older than 80 years. In CHF patients VOCs pattern could predict with fair precision ejection fraction and systolic pulmonary arterial pressure, but not changes in weight due to therapy. CONCLUSIONS: VOCs pattern is able to discriminate older CHF patients from healthy people and COPD patients and correlates with cardiac function markers.

A Serological Protein Microarray for Detection of Multiple Cross-Reactive Flavivirus Infections in Horses for Veterinary and Public Health Surveillance.

The genus Flavivirus in the family Flaviviridae includes some of the most important examples of emerging zoonotic arboviruses that are rapidly spreading across the globe. Japanese encephalitis virus (JEV), West Nile virus (WNV), St. Louis encephalitis virus (SLEV) and Usutu virus (USUV) are mosquito-borne members of the JEV serological group. Although most infections in humans are asymptomatic or present with mild flu-like symptoms, clinical manifestations of JEV, WNV, SLEV, USUV and tick-borne encephalitis virus (TBEV) can include severe neurological disease and death. In horses, infection with WNV and JEV can lead to severe neurological disease and death, while USUV, SLEV and TBEV infections are mainly asymptomatic, however, and induce antibody responses. Horses often serve as sentinels to monitor active virus circulation in serological surveillance programmes specifically for WNV, USUV and JEV. Here, we developed and validated a NS1-antigen protein microarray for the serological differential diagnosis of flavivirus infections in horses using sera of experimentally and naturally infected symptomatic as well as asymptomatic horses. Using samples from experimentally infected horses, an IgG and IgM specificity of 100% and a sensitivity of 95% for WNV and 100% for JEV was achieved with a cut-off titre of 1 : 20 based on ROC calculation. In field settings, the microarray identified 93-100% of IgG-positive horses with recent WNV infections and 87% of TBEV IgG-positive horses. WNV IgM sensitivity was 80%. Differentiation between closely related flaviviruses by the NS1-antigen protein microarray is possible, even though we identified some instances of cross-reactivity among antibodies. However, the assay is not able to differentiate between naturally infected horses and animals vaccinated with an inactivated WNV whole-virus vaccine. We showed that the NS1-microarray can potentially be used for diagnosing and distinguishing flavivirus infections in horses and for public health purposes within a surveillance setting. This allows for fast, cheap, syndrome-based laboratory testing for multiple viruses simultaneously for veterinary and public health purposes.

A novel variant of the infectious bronchitis virus resulting from recombination events in Italy and Spain.

Infectious bronchitis is considered to be one of the most devastating diseases in poultry. Control of its spread is typically attempted through biosecurity measures and extensive vaccination. However, the remarkable genetic and antigenic variability of the virus, which originate from both mutations and recombination events, represents an unsolved challenge for this disease. The present study reports on the emergence and spread of recombinant clusters detected in Italy and Spain between 2012 and 2014. A total of 36 Spanish and Italian infectious bronchitis virus (IBV) field strains were investigated and genetically characterized using phylogenetic, molecular, recombination and selection pressure analyses of the complete S1 gene. Based on the partial S1 sequencing, 27 IBV strains originating from Spain and nine from Italy were initially classified as being closely related to the Guandong/Xindadi (XDN) genotype. Phylogenetic analysis of the complete S1 gene revealed that the XDN strains formed a homogeneous clade with the Spanish IBV isolates within the QX genotype, whereas there was higher variability within the Italian strains. Recombination analysis determined that these strains belonged to four groups, which originated from independent recombination events between the QX and 793B IBV genotypes. Our data support the hypothesis of two different scenarios: firstly, in Spain, the large and homogeneous clade probably originated from a single offspring of the recombinant founder, which became dominant and spread throughout the country. Secondly, the nine Italian recombinants, which are characterized by three different recombination patterns, probably represent less fitted strains, because they were less viable with respect to their recombinant parents.

West Nile Virus Surveillance in the Lombardy Region, Northern Italy.

In 2013, the circulation of West Nile virus (WNV) was detected in the Lombardy region and the following year a surveillance programme was activated with the aim of early identification of the viral distribution in mosquitoes and wild birds. A total of 50 959 Culex spp. mosquitoes grouped in six hundred and forty-seven pools as well as 1400 birds were screened by RT-PCR for the presence of West Nile virus leading to the identification of the viral genome in 32 mosquito pools and 13 wild birds. The surveillance was able to detect the WNV circulation on an average of 42 days (CI 95% 29.98-53.86; Student's t-distribution) before the occurrence of human West Nile disease (WND) cases in the same area. These results demonstrate the presence of WNV in the Lombardy region and confirm entomological and wild birds surveillance as an effective measure for the early identification of WNV circulation in infected areas, thus providing a useful and cost-effective tool for the public health authorities in the application of measures to prevent human infection.

Expression and antigenic characterization of bubaline herpesvirus 1 (BuHV1) glycoprotein E and its potential application in the epidemiology and control of alphaherpesvirus infections in Mediterranean water buffalo.

Bubaline herpesvirus 1 (BuHV1) is a member of ruminant alphaherpesviruses antigenically related to bovine herpesvirus 1 (BoHV1). The impact of BuHV1 infection in infectious bovine rhinotracheitis control program is difficult to establish, due to the lack of specific diagnostic test. The ectodomain of glycoprotein E of BuHV1 was expressed as recombinant secreted protein and used in indirect ELISA as well as in a discriminatory test using the BoHV1 counterpart. A panel of monoclonal antibodies was produced against BuHV1; 6 out of 7 anti-gE monoclonal antibodies specifically recognized the BuHV1 gE. Results indicated BuHV1 gE as a sensitive marker of infection compared to seroneutralization (SN) test or blocking ELISA. When BoHV1 and BuHV1 gEs were immobilized in different wells of the same ELISA microplate, bovine and water buffalo sera were more reactive against the respective infecting virus. About one third of seropositive buffaloes with no history of contact with cattle and having higher SN titres, reacted in BoHV1 gE blocking ELISA, possibly because of steric hindrance. Since in two occasions BuHV1 was also isolated from water buffalo scoring gB+/gE+ BoHV1 blocking ELISA, we conclude that the combination of the two blocking ELISAs is not suitable to differentiate between BoHV1 and BuHV1.

Clinical and echocardiographic characteristics of elderly hospitalized patients with high levels of NT-proBNP without clinical diagnosis of heart failure.

BACKGROUND: Patients with high NT-proBNP levels but without heart failure (HF) diagnosis have a higher risk of cardiovascular events and mortality; however, there are few data about their characteristic, especially in the elderly. AIMS: To compare the clinical and echocardiographic characteristics of elderly hospitalized patients with and without increased NT-proBNP and with and without a diagnosis of HF. METHODS: We reviewed 209 charts of patients admitted to an acute care ward (mean age 78.9 years, SD 10.2, 62% women). We classified the patients into four groups: no HF with or without increased (>900 pg/mL) NT-proBNP (HF-/BNP-, N = 89 and HF-/BNP+, N = 41), and HF with or without increased NT-proBNP (HF+/BNP-, N = 4 and HF+/BNP+, N = 75). The groups were compared with respect to demographic and clinical characteristics, symptoms at admission, comorbidities, echocardiographic parameters, and cardiovascular events at 180 days. RESULTS: Patients in the groups HF+/BNP+ and HF-/BNP+ were older, with higher serum creatinine, blood urea nitrogen, and lower serum hemoglobin compared to patients in the HF-/BNP- group. The prevalence of ischemic heart disease, pulmonary hypertension, and atrial fibrillation progressively decreased across the HF+/BNP+, HF-/BNP+, and HF-/BNP- groups. The prevalence of abnormal echocardiographic findings in the HF-/BNP+ group was intermediate compared to the other two groups for severe aortic or mitralic regurgitation, monophasic transmitralic pattern, biatrial atriomegaly, ejection fraction, akinesia extension, and PAPs. The same pattern was observed for cardiovascular events at follow-up. DISCUSSION: Elderly patients without a diagnosis of HF, but with high NT-proBNP serum concentration have intermediate clinical characteristics compared to the other two groups. CONCLUSION: NT-proBNP may be a useful marker of silent cardiac damage.

Genomic characterization of pseudorabies virus strains isolated in Italy.

In this study, we undertook the genomic characterization of 54 pseudorabies virus (PRV) strains isolated in Italy during 1984-2010. The characterization was based on partial sequencing of the UL44 (gC) and US8 (gE) genes; 44 strains (38 for gene gE and 36 for gC) were isolated on pig farms; 9 originated from dogs and 1 from cattle. These porcine PRV strains, which were closely related to those isolated in Europe and America in the last 20 years, and the bovine strain bovine/It/2441/1992 belong to cluster B in both phylogenetic trees. Six porcine strains that do not belong to cluster B are related in both gE and gC phylogenetic trees to the 'old' porcine PRV strains isolated in the 1970s and 1980s. In the last two decades, the presence of these strains in domestic pig populations has been reduced drastically, whereas they are prevalent in wild boar. The two remaining strains have an interesting genomic profile, characterized by the gC gene being closely related to the old porcine PRV strains, and the gE gene being similar to that of recently isolated strains. Three strains originating from working dogs on pig farms are located in cluster B in both phylogenetic trees. Five strains isolated from hunting dogs have a high degree of correlation with PRV strains circulating in wild boar. The last isolate has a gC gene similar to that in the two porcine strains mentioned previously, and the gE gene is correlated with the strains isolated from hunting dogs. These results provide interesting insight into the genomic characterization of PRV strains and reveal a clear differentiation between the strains isolated from hunting dogs that are related to the wild boar strains and those originating from domestic pigs.

Identification of Mammalian orthoreovirus type 3 in Italian bats.

Summary This study describes the isolation and molecular characterization of Mammalian orthoreovirus (MRV) in microbats. Faecal samples and dead individuals available from rehabilitation centres or collected from known roost sites were virologically tested. In total, 112 carcasses of bats found dead, and 44 faecal samples were analysed. Nineteen viral strains were isolated by in vitro cell culture from faecal and tissue samples of different bat species (Pipistrellus khulii, Tadarida teniotis, Rhinolophus hipposideros and Vespertilio murinus), and they were morphologically identified as reoviruses by negative staining electron microscopy observation. The definitive assignment of all isolates to MRV was confirmed by RT-PCR assays targeting the L1 gene. Through a multiplex RT-PCR assay targeting the S1 gene, we typed 15 of 19 isolates as MRV type 3. Partial L1 (416 bp) and complete S1 (1416 bp) sequences of the isolates were analysed and compared with those of reference strains obtained from GenBank, belonging to the three serotypes. Molecular analysis of the S1 gene revealed that the amino acid residues associated with neurotropism (198-204NLAIRLP, 249I, 350D and 419E) were highly conserved among the Italian bat strains. These results suggest that potentially neurotropic MRV type 3 strains are widespread among Italian bats. Furthermore, the identification of MRV type 3 in bat species such as Pipistrellus Khulii, which is common in urban areas and known for its close contact with humans, underlines the need for vigilance.

Molecular characterization and phylogenetic analysis of VP1 of porcine enteric picornaviruses isolates in Italy.

Porcine enterovirus (PEV), Porcine Teschovirus and Porcine sapelovirus, belonging to the family Picornaviridae, are ubiquitous and mainly cause asymptomatic infections in pigs. In this study, a total of 40 Italian porcine picornavirus isolates were characterized by sequencing the capsid VP1-encoding gene. This procedure turned out to be a useful diagnostic tool for the molecular identification of porcine enterovirus, teschovirus and sapelovirus strains and for the study of molecular epidemiology and evolution of these viruses confirming the possibility of correlating virus genotype to serotype.

Detection of Hepatitis E Virus (HEV) in Italian pigs displaying different pathological lesions.

In this study we investigated the HEV prevalence in Italian pigs displaying different pathological lesions, possible risk factors related to the infection, and the possible relations occurring between HEV and other concomitant pig pathogens. Genetic characterization of some of the identified strains was also performed. Detection of HEV RNA was accomplished using a nested reverse-transcription polymerase chain reaction on bile samples from 137 pigs of 2-4months of age submitted for diagnostic purposes. Forty-one of the 137 examined pigs (29.9%) tested positive for HEV RNA. Animals of 80-120days of age showed a higher prevalence of HEV infection (46.9% against 20% of younger animals). No statistically significant correlations between HEV positivity and the presence of other pathological conditions detected at necropsy, or concomitant coinfections with PCV2 and/or PRRSV were detected. All identified strains belonged to genotype 3, and were similar to other HEV subtypes 3e, 3f, 3c circulating in Europe.