Comparison of three rapid detection systems for type A influenza virus on tracheal swabs of experimentally and naturally infected birds.

The present paper reports of the comparison between three rapid virus detection systems and virus isolation (VI) from pooled tracheal swabs collected from naturally and experimentally infected birds with a low pathogenicity avian influenza virus of the H7N3 subtype. The relative sensitivity, specificity and agreement (K value) were calculated for a commercial antigen capture enzyme immunoassay (AC-EIA) and for two nucleic acid detection tests, a one-step reverse transcriptase-polymerase chain reaction (RT-PCR) and a real-time RT-PCR (RRT-PCR), both targeting the M gene. The results indicate that in experimentally infected turkeys VI was positive from the pooled tracheal swabs collected from day 3 to day 10. One-step RT-PCR was able to detect influenza RNA from samples collected from day 3 to day 12, while RRT-PCR amplified influenza RNA in swabs collected from day 3 to day 15. The AC-EIA test yielded positive results between day 5 and day 10 post-infection. On field samples, the K value between the AC-EIA and VI tests was 0.82. Compared with VI, the relative sensitivity of this test was 88.9% (CI95 = 85.2-92.6) and the relative specificity was 95.7% (CI95 = 93.7-97.7). The K value between the RT-PCR and VI tests was 0.88. Compared with virus isolation, the relative sensitivity of the one-step RT-PCR was 95.6% (CI95 = 93.1-98.0) and the relative specificity was 96.3% (CI95 = 94.4-98.1). The K value between the RRT-PCR and VI tests was 0.92. Compared with virus isolation, the relative sensitivity and specificity of RRT-PCR was 93.3% (CI95 = 90.4-96.3) and 98.4% (CI95 = 97.2-99.6), respectively. Generally speaking, comparison between virus isolation, the AC-EIA test and the two nucleic acid detection methods indicated excellent agreement. Data obtained from both experimental and field study suggest a higher sensitivity of the PCR-based methods compared with the AC-EIA. The economical and practical implications of using one of the rapid tests as an alternative to VI during an avian influenza epidemic are discussed.

Thyroid storm with encephalopathic symptoms due to Graves' disease and inappropriate secretion of thyrotropin.

A 41-year-old woman is described, first hospitalized in the neurosurgical department for a transient ischemic attack with left hemiparesis followed after 6 hours by tonic-clonic seizures starting from the left hemiface and quickly generalized. Brain computed tomography (CT) scan and magnetic resonance imaging were normal. Clinically the patient presented tremor, tachycardia, generalized muscle weakness, and profuse diaphoresis. T4 and T3 were elevated. The patient was transferred from the neurosurgical to the medical department where a thyroid storm due to autoimmune Graves' disease with normal thyrotropin (TSH) values responsive to thyrotropin-releasing hormone (TRH) stimulation was diagnosed. A syndrome of inappropriate secretion of TSH was suspected in an unusual presentation as autoimmune Graves' hyperthyroidism. The TSH alpha-subunit and alpha-subunit/TSH molar ratio were normal, which supported the diagnosis of non-neoplastic inappropriate secretion of TSH. However, severe autoimmune Graves' hyperthyroidism is very rare indeed because autoantibodies to thyroid antigens are generally non-detectable in such patients. Our patient was treated initially with barbiturates, then with dexamethasone, Lugol's solution, methimazole and propranolol. Treatment of this patient proved difficult, and definitive improvement was obtained only after triiodothyroacetic acid administration, but methimazole and propranolol administration could not be discontinued. Fine needle aspiration biopsies of the thyroid in 2 occasions showed follicular or follicular-papillary proliferation with lymphocytic infiltration as in chronic thyroiditis. The patient is now in good clinical conditions and is followed up regularly. Autoimmune Graves' hyperthyroidism may be associated in extremely rare instances with non neoplastic inappropriate secretion of TSH.

[Surveillance of adverse reactions of drugs and monitoring of drug prescriptions as routine in hospital activities]. / La sorveglianza delle reazioni avverse da farmaci e il monitoraggio delle prescrizioni mediche come attività "normali" di reparti ospedalieri.

Since January 1988 is taking place a multicentre experience on pharmaco-epidemiology named ARIES (Adverse Reaction Identification Evaluation System), with two primary aims: surveillance of drug adverse reactions and monitoring of medical prescriptions. At present 5 departments of internal medicine are involved in the study. The factual cooperation of the departmental doctors depends on the evaluation of benefits and costs of the study. The benefits for doctor are: (a) the possibility of contributing to the research in a field which has not been systematically investigated in a hospital setting; b) the acquisition of skill in monitoring adverse reactions: to facilitate doctors cooperation an algorithm has been developed to select the events to be entered into the system; c) the possibility of evaluating and improving the prescription habits. At present, data on 9,000 patients and 60,000 prescriptions are available. As an example of utilization study, we report a research on antibiotics prescribed for bronchopneumonia in two departments involved in the ARIES project. The remarkable differences in the prescription settings lead to some rethinking on the strategies of such different prescription choices. In each department, the contribution of doctors is integrated by a monitor, entering additional information on drugs and patients into the system. Thanks to the cooperation of doctors and contribution of monitors, the pharmaco-epidemiology research may become a "normal" component of the hospital activities, thus allowing to systematically retrieve and process some basic knowledges, which are not routinely used, derived from the daily activity of the departmental doctor.