Impact of influenza during the post-pandemic season: epidemiological picture from syndromic and virological surveillance.

INTRODUCTION: Following the observation that 1 or 2 pandemic peak due to the circulation ofAHINlv had occurred in most countries and in most World Health Organization (WHO) Regions, WHO declared on August 10"h, 2010 that the world was moving into the post-pandemic period, whose surveillance presents considerable interest both from epidemiological and clinical point of view. We described the epidemiological picture emerged from syndromic and virological surveillance during the post-pandemic season in Liguria, Italy. MATERIALS AND METHODS: An Emergency Department Syndrome surveillance system, based on data collected at "San Martino" and IRCCS "G. Gaslini" Liguria Regional Reference University Hospitals for adults and children is active since July 2007. Monitored syndromes include "Influenza-Like Illness" (ILl) and "Low Respiratory Tract Infections" (LRTI). The Ligurian Regional Reference laboratory for Influenza virological surveillance and diagnosis offers rapid detection of influenza viruses by real-time and block RT-PCR, viral culture and genetic characterization by entire sequence analysis of haemagglutinin- and neuraminidase-coding regions in accordance with the international standards established by the global laboratory network. RESULTS AND DISCUSSION: The integration of syndromic surveillance system and laboratory surveillance for rapid detection and characterization of the disease responsible agent represented a specific and sensitive tool for influenza surveillance. The post-pandemic season was characterized by early onset and by the heaviest impacts for ILI and LRTI among the recent epidemic seasons. In contrast to the picture observed during the pandemic season, the 2010/11 winter was characterized by the intensive circulation of pandemic AH1N1v coupled with sustained activity due to influenza B and Respiratory Syncytial Virus (RSV). Antigenic and molecular characterization of influenza strains confirmed the good matching between circulating and 2010/11 vaccine viruses.

Emergency department syndromic surveillance system for early detection of 5 syndromes: a pilot project in a reference teaching hospital in Genoa, Italy.

Early detection is fundamental for achieving effective control of infectious disease outbreaks. We described the development of a local chief complaint emergency department (ED)-based syndromic surveillance system to improve public health response in Genoa, Italy. The five syndromes under investigation by the syndromic surveillance system were influenza-like illness (ILI), low-respiratory tract illness (LRTI), not-haemorrhagic gastroenteritis, acute hepatitis, fever-with-rash (maculo-papular or vescicular) syndrome. Syndrome coding, data capture, transmission and processing, statistical analysis to assess indicators of disease activity and alert thresholds, and signal response were operatively described. Preliminary results on ILI syndromic surveillance showed that new system allowed the activation of the alert state with a specificity of 90.3% and a sensitivity of 72.9% in predicting epidemiological relevant events, such as > or = 10 accesses to ED for ILI in 3 days. The new syndromic surveillance system allowed to alert the public health institutions 2.5 days before than the local surveillance system based on sentinel physicians and paediatricians, permitting the early activation of the necessary measures for the containment and for burden reduction of the epidemic event. It is noteworthy that the syndromic surveillance epidemic cut-off was overcome once before and 4 times after influenza outbreak detected by sentinel-based surveillance system: all episodes were contemporary with Respiratory Syncytial Virus and Parainfluenza Virus circulation, as detected by regional reference laboratory.

Intracranial haemorrhage in patients on antithrombotics: clinical presentation and determinants of outcome in a prospective multicentric study in Italian emergency departments.

BACKGROUND: Intracranial haemorrhage (ICH) is the type of stroke associated with the highest death rate, and about 30% of ICH occurs in patients on antithrombotic treatment. This study relates clinical presentations and outcome of ICH patients on oral anticoagulant (OA) or antiplatelet (AP) therapy admitted to 33 Italian emergency departments (ED). METHODS: Consecutive patients were enrolled after cranial computed tomography (CT). Primary outcome was the Modified Rankin Scale (MRS) score at 3 months of follow-up. Common descriptive statistics were computed after stratification for traumatic or spontaneous ICH and identification of the anatomical location of bleeding. Multivariate logistic regression was used to assess predictors of death. RESULTS: We recruited 434 patients on AP therapy and 232 on OA. There were 432 spontaneous and 234 traumatic ICH patients. The proportions of AP and OA patients undergoing neurosurgery were 21.8 and 19.4%, respectively, while < 30% underwent procoagulant medical treatment. At the 3-month follow-up, the case fatality rate was 42.0%, while disability or death (MRS 3-6) was 68.1%. The odds ratio for death in OA versus AP patients was 2.63 (95% CI 1.73-4.00) in the whole population and 2.80 (95% CI 1.77-4.41) in intraparenchymal event patients. Glasgow Coma Scale, age, spontaneous event and anticoagulant use were found to be predictors of death both in traumatic and spontaneous events. CONCLUSION: This study confirms the high prevalence of death or disability in OA and AP patients with ICH. As far as the determinants of mortality and disability are concerned, the results of this study might be useful in the clinical management and allocation of resources in the ED setting. The observed low use of procoagulant therapy highlights the need for ED educational programmes to heighten the awareness of available and effective haemostatic treatments.

Transient global amnesia: disease or syndrome?

Transient global amnesia (TGA) has been defined as the presence of an impairment of short-term memory, retrograde amnesia and repetitive queries, without any other neurological signs or symptoms. The precise pathophysiology of TGA is unclear, although thromboembolic, epileptic, migrainous and metabolic mechanisms have been suggested. We have studied the clinical, biohumoral, electroencephalographic and neuro-imaging data relating to 25 patients with TGA, and found a prevalence of hypertension and hypercholesterolemia. We also found a higher incidence of electrical changes in the patients whose TGA was of shorter duration, whereas brain CT scans revealed ischemic lesions more frequently in the patients with TGA of longer duration. Our findings seem to confirm the hypothesis that TGA is a heterogeneous clinical syndrome consisting of pure and ischemic forms.

[The application of a new diagnostic protocol for stroke in the young]. / Applicazione di un nuovo protocollo diagnostico dell'ictus giovanile.

Cerebral infarction before the age of 45 years accounts for 4-6% of all strokes. The etiology remains unexplained in a significant proportion of patients even after extensive investigations. The reported risk factors of this age group are cardiopathies, hypertension, smoking, hypercholesterolemia, reduction of anticoagulant proteins, hypercoagulable states, antiphospholipid antibodies primary syndrome, antiphospholipid antibodies secondary syndrome, some hemoglobinopathies, hyperviscosity syndromes, vasculitis, collagen vascular diseases, fibromuscular dysplasia, arterial dissections, migraine, myopathy encephalopathy lactic acidosis stroke like episodes, homocystinuria, familial amyloid angiopathy, microangiopathy with retinopathy encephalopathy and deafness, systemic lupus erythematosus, use of cocaine, traumas or manipulations of neck, AIDS. From 1/1/94 to 04/30/95 we observed 19 patients with cerebral infarctions and 9 patients with transitory ischemic attacks in young people. The aim of our study was to apply a diagnostic protocol by sequential tests of first level and second level. According to this protocol we found that the more common risk factors were ischemic cardiopathy, hypertension, smoking and hypercholesterolemia. Moreover we observed other independent risk factors, although less frequent, like the antiphospholipid antibodies, neurolupus, AIDS, deficit of protein S.

Insulin resistance of stress: sites and mechanisms.

1. Stress is associated with a severe, yet reversible, form of insulin resistance. The aim of this study was to quantify the kinetics of insulin action (sensitivity and responsiveness) on intermediary metabolism during post-surgical stress. 2. We studied nine patients 6-8 h after major uncomplicated surgery, and eight healthy subjects matched for age, weight, glucose tolerance and duration of fast. A three-step isoglycaemic insulin clamp was combined with indirect calorimetry, [6-3H]glucose infusion and the forearm technique. 3. The following significant (P < 0.05 or less) abnormalities were found in the patients. Hepatic glucose production was higher at baseline, and less suppressed by insulin. Whole-body glucose disposal was impaired at all insulin doses (by 33-60%). Glucose oxidation was depressed throughout the dose range but its increments in response to insulin were normal. In contrast, non-oxidative glucose disposal was essentially unresponsive. At all insulin levels, forearm glucose extraction was markedly depressed and forearm lactate release was in excess of concurrent glucose uptake, suggesting ongoing glycogenolysis despite insulin. Total lipolysis (plasma free fatty acid and glycerol levels) promptly responded to insulin but remained higher than in the control subjects throughout. In the forearm, even the highest insulin dose could not suppress net free fatty acid and glycerol release. Total lipid oxidation was increased throughout the insulin range, and calculated direct free fatty acid (as opposed to plasma free fatty acid) oxidation was virtually unaffected by insulin. Protein oxidation was slightly (35%) increased, but was suppressed normally in response to insulin. Energy expenditure was 20% higher at baseline, and failed to rise with insulin. Arterial blood pH values were consistently (if slightly) lower, and net forearm proton release was higher, both at baseline and during insulin infusion. 4. Post-surgical insulin resistance is characterized by normal sensitivity but decreased responsiveness of glucose oxidation, lipolysis and plasma free fatty acid oxidation, whereas glycogen synthesis and direct free fatty acid oxidation are virtually unresponsive. For both glucose and lipid metabolism, the insulin resistance is particularly severe in forearm tissues, in which mild metabolic acidosis may play an additional role.

A new glucose clamp algorithm: clinical validation.

A new glucose clamp technique for in vivo studies of insulin sensitivity was validated clinically. Eighteen patients (10 males, 8 females, age 35-80 years, body mass index 34.6-17.04) were connected to a computer-assisted artificial pancreas "Betalike R", using a new algorithm based on a "minimal model", to carry out the glucose clamp technique automatically and especially to overcome the well-known problems of its priming phase. We performed the euglycemic hyperinsulinemic clamp in four patients and the hyperglycemic hyperinsulinemic clamp in 14. In one patient both clamps were done. The mean priming time to reach steady-state glycemia was 20 min. Plasma insulin concentrations were measured every 20 min. This new automatic glucose clamp technique enables the priming phase to be run without any significant overshoot, and accidental variations of glycemia in steady state were reduced to a minimum. The system showed satisfactory safety and stability in controlling the patient's glycemia and assured high speed of the priming phase.

[Evaluation of a new immunoturbidimetry technique for measuring microalbuminuria]. / Valutazione di una nuova tecnica immunoturbidimetrica per il dosaggio della microalbuminuria.

Subclinical elevation of urinary albumin excretion is a good predictor of later clinical proteinuria. A simple, sensitive and rapid immunoturbidimetric method was developed to quantify urinary albumin excretion (URIN-PAK ImmunoMICRO LAB, Miles Italia Spa). In the presence of polyethylene glycol 6000, immunocomplex between human albumin and its specific antibody are rapidly formed (5-50 min, at room temperature). Absorbance reading are mode U 340 nm (Automatic Analyzer RA 1000, Technicon). The test is specific for albumin failing to cross react with other plasma proteins present in urine, as well as with glibenclamide, chlorpropamide, phenformin, hemoglobin, glucose, urea and thymol. The present method correlates with SCLAVO H-ALBUMIN RIA Kit (r = 0.9917). The test is suitable for clinical use.

[Cardioinhibitory reflex provoked by stimulation of carotid sinus in normal subjects and those with cardiovascular disease]. / Il riflesso cardioinibitore provocato dalla stimolazione del seno carotideo nei soggetti normali e con malattie cardiovascolari.

The normal range and the reproducibility of the cardioinhibitory carotid sinus reflex were studied in 288 apparently healthy subjects of different ages (aged from 17 to 84 yrs., 156 males, 132 females). In each subject we chose the longest RR interval as an activation index of the reflex obtained by carotid sinus massage; its mean value increased slightly with advancing age. In the were 1, 5, 2, 5, 3, 3 sec. respectively, with a 99% confidence limit. No sex difference was found. We studied also a group of 105 patients (aged from 39 to 82 yrs., 67 males, 38 females) with various types of cardiovascular disorders, without a previous history of spontaneous syncope. Abnormal maximum RR values were found in 18 of them (17%). This percentage was significantly higher than in normals (2%). In 11 patients (10%) the carotid sinus stimulation evoked a syncopal attack. It seems therefore that a statistically abnormal carotid sinus hypersensitivity can occur in a substantial number of cardiovascular patients without necessarily leading to spontaneous syncopal attacks. Finally the reproducibility of the cardioinhibitory reflex was tested in 42 patients with maximum RR interval values ranging from normal to extremely abnormal. In each subject a significant correlation (r = 0.79) was found between the maximum RR interval values tested in two occasions at intervals ranging from 1 hour to 3 months; besides a concordance in normal or abnormal result was present in 93% of the cases.