Applicability and performance of heart failure prognostic scores in dilated cardiomyopathy: the real-world experience of an Italian referral center for cardiomyopathies.

BACKGROUND: The performance of heart failure (HF) risk models is validated in the general population with HF but in specific aetiological settings, and specifically in dilated cardiomyopathy (DCM), has scarcely been explored. We tested eight of the main prognostic scores used in HF in a large real-world population of patients with DCM. METHODS: We included 784 consecutive DCM patients enrolled, both inpatients and outpatients, enrolled between January 2000 and December 2017. The risk of 1 and/or 3-year all-cause mortality/heart transplantation/durable left ventricular assist device (LVAD) implantation (D/HTx/LVAD) was estimated in our cohort according to the following risk scores SHFM, 3-CHF, CHARM, MAGGIC, GISSI-HF, MECKI, Barcelona Bio-HF, Krakow score and their accuracy calculated through the receiver operator characteristic (ROC) curve analysis. RESULTS: During a median follow-up of 5.8 years (Interquartile Range 3.2-7.6 years), 191 patients (20%) died or underwent HTx/LVAD (158 deaths, 30 heart transplantations, and 3 LVAD implantations). The high missing rate allowed to calculated only four prognostic models (MAGGIC, CHARM, 3-CHF and SHFM). All the scores overestimated the rate of D/HTx/LVAD. The prognostic accuracy was suboptimal for MAGGIC (AUC 0.754) and CHARM (AUC 0.720) scores and only modest for 3-CHF (AUC 0.677) and SHFM (AUC 0.667). CONCLUSIONS: Main prognostic scores for the risk stratification of HF are only partially applicable to real-world patients with DCM. MAGGIC and CHARM scores showed the best accuracy, despite the overestimation of risk. Our findings corroborate the need of specific risk scores for the prognostic stratification of DCM. CLINICAL PERSPECTIVE: What is new? The present study is the largest analysis in literature which investigate how the main existing heart failure prognostic risk scores performed in a real-world of dilated cardiomyopathy population, both in- and outpatients. What are the clinical implications? DCM is a stand-alone model of heart failure, where the performance of multiple heart failure prognostic scores for the risk stratification is quite limited. The need for contemporary, dedicated prognostic scores in this disease is increasingly evident.

Modeling Framework for the Generation of Synthetic RR Series during Atrial Arrhythmias.

We introduced a modeling framework for the generation of realistic ventricular interval (RR) series to be used in the validation of atrial arrhythmia detection algorithms. The framework included three previously proposed models, which reproduced the specific variability properties of RR series in normal sinus rhythm, atrial flutter (AFL) and atrial fibrillation (AF). Transitions between the three rhythms were governed by a three-state continuous-time Markov chain model, which could be tuned to obtain arrhythmic episodes of the requested length. As a representative application, the modeling framework was used to generate a database of RR series for the validation of a previously proposed AF detection algorithm, which was based on RR pattern similarity. The validation showed the deterioration of detector performance in presence of simulated AFL episodes. Thanks to the detailed reproduction of the specific features of the two most common atrial arrhythmias, our modeling framework may constitute a novel tool for the assessment and comparison of detection algorithm performance.

Corneal Opacity in Domestic Ducks Experimentally Infected With H5N1 Highly Pathogenic Avian Influenza Virus.

Domestic ducks can be a key factor in the regional spread of H5N1 highly pathogenic avian influenza (HPAI) virus in Asia. The authors performed experimental infections to examine the relationship between corneal opacity and H5N1 HPAI virus infection in domestic ducks (Anas platyrhyncha var domestica). A total of 99 domestic ducks, including 3 control birds, were used in the study. In experiment 1, when domestic ducks were inoculated intranasally with 2 H5N1 HPAI viruses, corneal opacity appeared more frequently than neurologic signs and mortality. Corneal ulceration and exophthalmos were rare findings. Histopathologic examinations of the eyes of domestic ducks in experiment 2 revealed that corneal opacity was due to the loss of corneal endothelial cells and subsequent keratitis with edema. Influenza viral antigen was detected in corneal endothelial cells and some other ocular cells by immunohistochemistry. Results suggest that corneal opacity is a characteristic and frequent finding in domestic ducks infected with the H5N1 HPAI virus. Confirming this ocular change may improve the detection rate of infected domestic ducks in the field.

Dynamics of AV coupling during human atrial fibrillation: role of atrial rate.

The causal relationship between atrial and ventricular activities during human atrial fibrillation (AF) is poorly understood. This study analyzed the effects of an increase in atrial rate on the link between atrial and ventricular activities during AF. Atrial and ventricular time series were determined in 14 patients during the spontaneous acceleration of the atrial rhythm at AF onset. The dynamic relationship between atrial and ventricular activities was quantified in terms of atrioventricular (AV) coupling by AV synchrogram analysis. The technique identified n:m coupling patterns (n atrial beats in m ventricular cycles), quantifying their percentage, maximal length, and conduction ratio (= m/n). Simulations with a difference-equation AV model were performed to correlate the observed dynamics to specific atrial/nodal properties. The atrial rate increase significantly affected AV coupling and ventricular response during AF. The shortening of atrial intervals from 185 ± 32 to 165 ± 24 ms (P < 0.001) determined transitions toward AV patterns with progressively decreasing m/n ratios (from conduction ratio = 0.34 ± 0.09 to 0.29 ± 0.08, P < 0.01), lower occurrence (from percentage of coupled beats = 27.1 ± 8.0 to 21.8 ± 6.9%, P < 0.05), and higher instability (from maximal length = 3.9 ± 1.5 to 2.8 ± 0.7 s, P < 0.01). Advanced levels of AV block and coupling instability at higher atrial rates were associated with increased ventricular interval variability (from 123 ± 52 to 133 ± 55 ms, P < 0.05). AV pattern transitions and coupling instability in patients were predicted, assuming the filtering of high-rate irregular atrial beats by the slow recovery of nodal excitability. These results support the role of atrial rate in determining AV coupling and ventricular response and may have implications for rate control in AF.

Delta-ADC (apparent diffusion coefficient) analysis in patients with idiopathic normal pressure hydrocephalus.

We have developed the delta-apparent diffusion coefficient (ADC), a new parameter of the water dynamics of brain tissue using MRI. Delta-ADC is the changes in regional ADC values of the brain during the cardiac cycle. The study included 6 idiopathic normal pressure hydrocephalus (iNPH) patients (iNPH group) and 12 healthy volunteers (control group). ECG-triggered single-shot diffusion echo planar imaging (b = 0 and 1,000 s/mm(2)) was used on a 1.5-T MRI. The delta-ADC image was calculated from the maximum minus the minimum ADC value of all cardiac phase images (20 phases) on a pixel-by-pixel basis. Delta-ADC values in the white matter of the frontal, temporal, and occipital lobe were obtained. Delta-ADC values in the iNPH group were significantly higher than those in the control group in all regions. ADC values in the iNPH were also significantly higher than those in the control group, but the differences in the ADC between the groups in each region were much lower than those for the delta-ADC. Although the changes in the delta-ADC and ADC values were similar, there was no significant correlation between the delta-ADC and the ADC. These results suggest that the ADC and the delta-ADC may reflect different kinds of water dynamics. The ADC depends on the water content in brain tissue. On the other hand, delta-ADC depends on not only the water content, but also on the degree of the fluctuation of the water molecules. Delta-ADC analysis makes it possible to obtain non-invasively new and more detailed information on the regional brain condition in iNPH.

Automatic reconstruction of activation and velocity maps from electro-anatomic data by radial basis functions.

The integration of mapping techniques with suitable methods for the characterization and visualization of propagation patterns may enhance the targeting of critical arrhythmic areas, thus optimizing the ablative treatment of atrial arrhythmias. In this study, we tested the feasibility of an innovative approach for the automatic determination of activation and velocity maps from sparse data as provided by electro-anatomic mapping systems. The proposed algorithm reconstructed the activation process by a radial basis function (RBF) interpolation of mapping point latencies. Velocity vectors were analytically determined by differentiation of the interpolation function. The method was tested by a multistate cellular automaton simulation model, implemented on a CARTO-derived atrial endocardial surface, and reconstruction accuracy was evaluated as a function of the number of mapping points. The RBF algorithm accurately reconstructed wave propagation patterns in simulated tissues with homogeneous and heterogeneous conduction properties, consistently with the data access afforded by clinical practice. These preliminary results suggest the possible integration of the method with clinically-used mapping systems to favor the identification of specific propagation patterns and conduction disturbances.

Long-term biatrial recordings in post-operative atrial fibrillation.

Although atrial fibrillation (AF) is a common complication of cardiac surgery, its pathophysiology remains unclear. The study of post-operative AF demands for the recording of cardiac electrical activity in correspondence of AF onset and progression. Long-term recordings in post-surgery patients could provide this information, but, to date, have been limited to surface signals, which precludes a characterization of the arrhythmic triggers and substrate. In this study we demonstrate the feasibility of a continuous long-term recording of atrial electrical activities from the right and left atria in post-surgery patients. Local atrial epicardial electrograms are acquired by positioning temporary pacing wires in the right and left atria at the end of the intervention, while three day recordings are obtained by a digital holter recorder, adapted to epicardial signal features. The capability of the system to map local atrial activity and the possibility to obtain quantitative information on atrial rate and synchronization from the processed epicardial signals are proven in representative examples. The quantitative description of local atrial properties opens new perspective in the investigation of post-surgery AF.

A latex agglutination test using a recombinant nucleoprotein for detection of antibodies against avian influenza virus.

A latex agglutination test (LAT) was developed for detecting antibodies against avian influenza virus. The recombinant avian influenza virus nucleoprotein expressed in Escherichia coli was purified, coupled with latex beads, and used as an antigen for the LAT. The LAT was capable of detecting anti-avian influenza virus antibodies irrespective of the avian-influenza subtype, and in most cases, the results correlated with the results of an agar gel precipitation test (AGPT). However, in comparison with the AGPT, the LAT could detect the anti-avian influenza virus antibodies for a longer period of time after the infection. The nonspecific agglutination observed in uninfected chicken sera was resolved by pretreating the sera with dried chicken-liver powder for 1 h. The LAT is easy to perform, and even after considering the time required for pretreatment of the serum, the total time required for obtaining the results is reduced in comparison to the time required in the case of the AGPT. This easy and rapid LAT is considered to be useful for monitoring avian influenza virus infection in the field.

Pathologic and immunohistochemical studies of Newcastle disease (ND) in broiler chickens vaccinated with ND: severe nonpurulent encephalitis and necrotizing pancreatitis.

Twenty-five 22- to 46-day-old broilers with Newcastle disease (ND) were investigated pathologically and immunohistochemically in order to evaluate the mechanism of ND outbreak in vaccinated broilers. The broilers were vaccinated with ND live vaccine via drinking water. Clinical signs were neurologic and respiratory in nature. Macroscopically, bursal atrophy, white spots on the pancreas, and discoloration and enlargement of kidneys and spleen were observed in the broilers. Histologically, perivascular cuffing, neuronal degeneration and necrosis, and glial proliferation were present in the cerebrum, cerebellum, and medulla oblongata. There was extensive rarefaction and malacia in the parenchyma of severely affected brains. There were extensive degeneration, necrosis, and depletion of acinar cells in the pancreas. There was proliferation of macrophages in the lungs with congestion, tubulointerstitial nephritis, hepatocytic necrosis with thrombi in the sinusoids, and lymphocytic depletion in the cloacal bursa. Immunohistochemically, ND virus antigens were detected in the lesions. ND virus isolated from the present cases did not cause encephalitis or pancreatitis in specific-pathogen-free chickens, but it induced mortality with hepatocytic sinusoidal thrombi, splenic necrosis, lymphoid necrosis and depletion, and conjunctival hemorrhage. Severe nonpurulent encephalitis with extensive rarefaction and malacia, and necrotizing pancreatitis in the present case may suggest a close possibly causal relation with vaccination.

An integrated approach based on uniform quantization for the evaluation of complexity of short-term heart period variability: Application to 24 h Holter recordings in healthy and heart failure humans.

We propose an integrated approach based on uniform quantization over a small number of levels for the evaluation and characterization of complexity of a process. This approach integrates information-domain analysis based on entropy rate, local nonlinear prediction, and pattern classification based on symbolic analysis. Normalized and non-normalized indexes quantifying complexity over short data sequences ( approximately 300 samples) are derived. This approach provides a rule for deciding the optimal length of the patterns that may be worth considering and some suggestions about possible strategies to group patterns into a smaller number of families. The approach is applied to 24 h Holter recordings of heart period variability derived from 12 normal (NO) subjects and 13 heart failure (HF) patients. We found that: (i) in NO subjects the normalized indexes suggest a larger complexity during the nighttime than during the daytime; (ii) this difference may be lost if non-normalized indexes are utilized; (iii) the circadian pattern in the normalized indexes is lost in HF patients; (iv) in HF patients the loss of the day-night variation in the normalized indexes is related to a tendency of complexity to increase during the daytime and to decrease during the nighttime; (v) the most likely length L of the most informative patterns ranges from 2 to 4; (vi) in NO subjects classification of patterns with L=3 indicates that stable patterns (i.e., those with no variations) are more present during the daytime, while highly variable patterns (i.e., those with two unlike variations) are more frequent during the nighttime; (vii) during the daytime in HF patients, the percentage of highly variable patterns increases with respect to NO subjects, while during the nighttime, the percentage of patterns with one or two like variations decreases.

Partial protection against challenge with the highly pathogenic H5N1 influenza virus isolated in Japan in chickens infected with the H9N2 influenza virus.

The protective effect of the A/Ck/Yoko/aq55/01 (H9N2) avian influenza virus against the highly pathogenic H5N1 virus, i.e., A/Ck/Yama/7/04 (genotype V), was examined. Three 5-week-old chickens were inoculated intranasally with the H9N2 virus (10(8.6) EID(50)/head) and were kept with two contact chickens. All of the infected chickens were reinoculated with the same virus at 20 weeks of age, and 10 days later, they were challenged intranasally with the H5N1 virus (10(4.0) EID(50)/head). Five chickens simultaneously challenged with only the H5N1 virus (challenge control) died within 4 days postchallenge (d.p.c.). In contrast, four out of the five challenged, immune chickens died from 5 to 8 d.p.c. The median time to death in the immune chickens (6.3 days) was significantly longer than that in the challenge controls (3.4 days) (P < 0.01). No H5N1 virus shedding into the tracheae and feces of the challenged, immune chickens were detected for 3 d.p.c., but H5 genes were detectable in only one chicken by a loop-mediated isothermal amplification method. The H5N1 viruses were detected in the tracheae and/or feces of the dead immune chickens at death or 1 to 2 days before death. Only one out of the five challenged, immune chickens survived the H5N1 challenge without any signs for 14 d.p.c., but the virus and H5 gene were sporadically detected in the trachea only 7 and 14 d.p.c., respectively. This study shows that the H9N2 viruses may have the potential to induce cross-protection to the challenge with a recent lethal H5N1 virus (genotype V).

Impact of different husbandry conditions on contact and airborne transmission of H5N1 highly pathogenic avian influenza virus to chickens.

Typically highly pathogenic avian influenza (HPAI) viruses spread very rapidly among chickens within sheds. However, the spread was slower than expected for the initial 10 days of the index farm in Japan during 2004. This slow spread, as well as the lack of gross lesions, clinical signs, or high mortality, hindered the field veterinarian from reporting a suspected HPAI outbreak to the veterinary office. To understand the field conditions for the slow virus spread, we examined contact and airborne transmission of the H5N1 virus to chickens in a negative-pressure isolator using various numbers of infected chickens and separate compartments. We found that the contact transmission did occur inefficiently when one or two chickens were infected, whereas the transmission was efficient when four chickens were infected. Airborne transmission of the HPAI virus was also dependent on the number of infected chickens and was less efficient than contact transmission. These data together with field observations suggested that number of infected chickens, chicken house types, and amount of environmental contamination might affect the virus transmission efficiency to chickens.

Characterization of H9N2 influenza A viruses isolated from chicken products imported into Japan from China.

We characterized eleven H9N2 influenza A viruses isolated from chicken products imported from China. Genetically they were classified into six distinct genotypes, including five already known genotypes and one novel genotype. This suggested that such multiple genotypes of the H9N2 virus have possibly already become widespread and endemic in China. Two isolates have amino-acid substitutions that confer resistance to amantadine in the M2 region, and this supported the evidence that this mutation might be a result of the wide application of amantadine for avian influenza treatment in China. These findings emphasize the importance of surveillance for avian influenza virus in this region, and of quarantining imported chicken products as potential sources for the introduction of influenza virus.

Pathology of fatal highly pathogenic H5N1 avian influenza virus infection in large-billed crows (Corvus macrorhynchos) during the 2004 outbreak in Japan.

Highly pathogenic H5N1 avian influenza viruses were isolated in 9 large-billed crows that died in Kyoto and Osaka prefectures in Japan from March to April in 2004. We studied 3 of the 9 crows using standard histologic methods, immunohistochemistry, and virus isolation. The most prominent lesions were gross patchy areas of reddish discoloration in the pancreas. The consistent histologic lesions included severe multifocal necrotizing pancreatitis, focal degeneration and necrosis of neuron and glial cells in the central nervous system, and focal degeneration of cardiac myocytes. All of these tissues contained immunohistochemically positive influenza viral antigens. The virus was isolated from the brain, lung, heart, liver, spleen, and kidney of the crows examined. Thus we concluded that highly pathogenic avian influenza virus was associated with clinical disease, severe pathologic changes, and death in the 3 crows.

Response of Japan to the introduction of exotic animal diseases.

The response of Japan to the introduction of exotic animal diseases is used as an example of methods used to control these diseases. Japan had been free from the major animal exotic diseases for many years until outbreaks of foot and mouth disease (FMD) occurred in 2000, highly pathogenic avian influenza (HPAI) in 2004 and bovine spongiform encephalopathy (BSE) was detected in 2001. In spring 2000, four outbreaks of FMD were recorded. In early 2004, four outbreaks of HPAI were recorded. Without resorting to vaccination, both diseases were eradicated in several months through depopulation of infected farms, movement controls, surveillance and other measures. The first case of BSE was detected in September 2001. Since then, 23 additional cases were detected by the end of March 2006, despite a strict ban on the use of meat-and-bone meal for feed and other eradication measures. The authors describe how these diseases occurred or were detected in Japan and discuss how Japan responded to them. Details are given on how they were introduced into Japan, the impact on Japanese farming and society and the lessons learned.

Rapid detection and differentiation of Newcastle disease virus by real-time PCR with melting-curve analysis.

In order to rapidly detect and differentiate Newcastle disease virus (NDV) isolates, a method based on real-time PCR SYBR Green I melting-curve analysis of the fusion (F) protein gene was developed. The detection limit of real-time PCR was 9 x 10(2) plasmid copies and was 100 times more sensitive than conventional PCR. Thirty eight reference NDV strains were rapidly identified by their distinctive melting temperatures (T(m)s): 89.23 +/- 0.27 degrees C for velogenic strains, 90.17 +/- 0.35 degrees C for pigeon mesogenic strains, 91.25 +/- 0.14 degrees C for two lentogenic strains (B1 and Ishii). No amplification was detected from unrelated RNA samples by this method. This real-time PCR directly detected NDV from infected tissues and eliminated the gel electrophoretic step for analyzing PCR product using ethidium bromide. The total time for a PCR run was less than 1 hour. The results obtained in this study showed that the real-time PCR presented here is a good screening test for the identification of NDV.

Control of an outbreak of highly pathogenic avian influenza, caused by the virus sub-type H5N1, in Japan in 2004.

An outbreak of highly pathogenic avian influenza (HPAI), caused by the virus sub-type H5N1, occurred at four premises in three prefectures in Japan during January and March 2004. As a result, 274,654 poultry died or were slaughtered. This was the first outbreak of HPAI in Japan since 1925. (The earlier outbreak was caused by H7N7.) The disease was successfully eradicated within three-and-a-half months, following an eradication campaign that included depopulating the affected premises, implementing movement controls and intensive surveillance. Control measures were conducted in accordance with the National Manual of HPAI Control. However, during the eradication campaign, some key issues arose, such as delays in notification by the affected farmers. As a result of these experiences, the relevant laws and HPAI Control Manual have been appropriately revised.

Non-invasive measurement of intracranial compliance using cine MRI in normal pressure hydrocephalus.

The aim of this study is to clarify biophysics of normal pressure hydrocephalus (NPH) based on non-invasive intracranial compliance measurement using magnetic resonance imaging (MRI). Patients with NPH after subarachnoid hemorrhage (NPH group, n = 5), brain atrophy or asymptomatic ventricular dilation (VD group, n = 5), and healthy volunteers (control group, n = 12) were included in this study. Net blood flow (bilateral internal carotid and vertebral arteries, and jugular veins) and cerebrospinal fluid (CSF) flow in subarachnoid space at the C2 level of cervical vertebra were measured using phase-contrast cine MRI. CSF pressure gradient and intracranial volume changes during a cardiac cycle were calculated based on Alperin's method. Compliance index (Ci = delta V/delta P) was obtained from the maximum pressure gradient and volume changes. Pressure volume response (PVR) was measured in the NPH group during a shunt operation. Ci in the NPH group was the lowest among the three studies groups. No difference was found between the control and VD groups. There was a linear correlation between Ci and PVR. In conclusion, intracranial compliance can be determined by cine MRI non-invasively. It is well known that NPH has relatively low intracranial compliance, this non-invasive method can be used for the diagnosis of NPH.

Phylogenetic analysis of avian infectious bronchitis virus strains isolated in Japan.

To define the origin and evolution of recent avian infectious bronchitis virus (IBV) in Japan, a genetic analysis was performed. By phylogenetic analysis based on the S1 gene including the sequence of the hypervariable regions, IBV isolates in Japan were classified into five genetic groups, which included two already-known groups (Mass and Gray). Among them, three major genetic groups were associated with the recent outbreaks of IB in Japan. One group is indigenous to Japan and could not be placed within the known existing groups in other countries. The remaining two groups, which have emerged recently, are related to isolates in China and Taiwan.