HINTS Outperforms ABCD 2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Objectives Dizziness and vertigo account for about 4 million emergency department ( ED ) visits annually in the United States, and some 160,000 to 240,000 (4% to 6%) have cerebrovascular causes. Stroke diagnosis in ED patients with vertigo/dizziness is challenging because the majority have no obvious focal neurologic signs at initial presentation. The authors sought to compare the accuracy of two previously published approaches purported to be useful in bedside screening for possible stroke in dizziness: a clinical decision rule (head impulse, nystagmus type, test of skew [ HINTS ]) and a risk stratification rule (age, blood pressure, clinical features, duration of symptoms, diabetes [ ABCD 2]). Methods This was a cross‐sectional study of high‐risk patients (more than one stroke risk factor) with acute vestibular syndrome ( AVS ; acute, persistent vertigo or dizziness with nystagmus, plus nausea or vomiting, head motion intolerance, and new gait unsteadiness) at a single academic center. All underwent neurootologic examination, neuroimaging (97.4% by magnetic resonance imaging [ MRI ]), and follow‐up. ABCD 2 risk scores (0–7 points), using the recommended cutoff of ≥4 for stroke, were compared to a three‐component eye movement battery ( HINTS ). Sensitivity, specificity, and positive and negative likelihood ratios ( LR +, LR –) were assessed for stroke and other central causes, and the results were stratified by age. False‐negative initial neuroimaging was also assessed. Results A total of 190 adult AVS patients were assessed (1999–2012). Median age was 60.5 years (range = 18 to 92 years; interquartile range [ IQR ] = 52.0 to 70.0 years); 60.5% were men. Final diagnoses were vestibular neuritis (34.7%), posterior fossa stroke (59.5% [105 infarctions, eight hemorrhages]), and other central causes (5.8%). Median ABCD 2 was 4.0 (range = 2 to 7; IQR  = 3.0 to 4.0). ABCD 2 ≥ 4 for stroke had sensitivity of 61.1%, specificity of 62.3%, LR + of 1.62, and LR – of 0.62; sensitivity was lower for those younger than 60 years old (28.9%). HINTS stroke sensitivity was 96.5%, specificity was 84.4%, LR + was 6.19, and LR – was 0.04 and did not vary by age. For any central lesion, sensitivity was 96.8%, specificity was 98.5%, LR + was 63.9, and LR – was 0.03 for HINTS , and sensitivity was 99.2%, specificity was 97.0%, LR + was 32.7, and LR – was 0.01 for HINTS “plus” (any new hearing loss added to HINTS ). Initial MRI s were falsely negative in 15 of 105 (14.3%) infarctions; all but one was obtained before 48 hours after onset, and all were confirmed by delayed MRI . Conclusions HINTS substantially outperforms ABCD 2 for stroke diagnosis in ED patients with AVS . It also outperforms MRI obtained within the first 2 days after symptom onset. While HINTS testing has traditionally been performed by specialists, methods for empowering emergency physicians ( EP s) to leverage this approach for stroke screening in dizziness should be investigated. Resumen Objetivos El mareo y el vértigo contabilizan aproximadamente 4 millones de visitas anuales a los servicios de urgencias ( SU ) en Estados Unidos, y de 160.000 a 240.000 (4% al 6%) tienen un origen cerebrovascular. El diagnóstico de ictus en los pacientes con vértigo o mareo es complejo debido a que la mayoría no tienen signos de focalidad neurológica evidentes en la atención inicial. Los autores comparan la certeza de dos aproximaciones previamente publicadas que resultaron ser de utilidad en el cribaje a pie de cama del posible ictus en el mareo: una regla de decisión clínica [ HINTS : Head Impulse (impulso de la cabeza), Nystagmus (nistagmo), Test of Skew (test de la desviación)], y una regla de estratificación del riesgo [ ABCD 2: Age (edad), Blood pressure (presión arterial), Clinical features (hallazgos clínicos), Duration of symptoms (duración de los síntomas), Diabetes (diabetes)]. Metodología Estudio transversal de pacientes de alto riesgo (más de un factor de riesgo de ictus) con síndrome vestibular agudo ( SVA ) (mareo o vértigo agudo persistente con nistagmo, más náuseas o vómitos; intolerancia a la movilización de la cabeza; e inestabilidad de la marcha aparecidos de novo ) realizado en un único centro universitario. Se llevó a cabo en todos los pacientes una exploración neurootológica, de neuroimagen (97,4% mediante resonancia magnética [ RM ]) y de seguimiento. Las puntuaciones de riesgo ABCD 2 (0–7 puntos), usando el punto de corte recomendado ≥ 4 para ictus, se compararon con una batería de movimiento ocular de tres componentes ( HINTS ). Se evaluaron la sensibilidad, la especificidad y las razones de probabilidad positiva y negativa ( RPP y RPN ) para ictus y otras causas centrales, y los resultados se estratificaron por edad. También se evaluaron los falsos negativos iniciales de la neuroimagen (RM). Resultados Se evaluaron 190 pacientes adultos con SVA (1999–2012). La mediana de edad fue de 60,5 años (rango 18 a 92 años; RIC 52,0 a 70,0 años); un 60,5% fueron hombres. Los diagnósticos finales fueron neuritis vestibular (34,7%), ictus de fosa posterior (59,5% [105 infartos, 8 hemorragias]) y otras causas centrales (5,8%). La mediana de ABCD 2 fue 4,0 (rango 2 a 7; RIC 3,0 a 4,0). ABCD 2 ≥4 para ictus tuvo una sensibilidad de un 61,1%, una especificidad de un 62,3%, una RPP de 1,62, y una RPN de 0,62; la sensibilidad fue menor para aquéllos que eran más jóvenes de 60 años (28,9%). La sensibilidad para el ictus del HINTS fue de un 96,5%, la especificidad de un 84,4%, la RPP de 6,19 y la RPN de 0,04, y no se modificó por la edad. Para cualquier lesión central, la sensibilidad fue de un 96,8%, la especificidad de un 98,5%, la RPP de 63,9 y la RPN de 0,03 para el HINTS ; y la sensibilidad de un 99,2%, la especificidad de un 97,0%, la RPP de 32,7 y la RPN de 0,01 para HINTS + (cualquier nueva pérdida de audición añadida al HINTS ). Las RM iniciales fueron falsamente negativas en 15 de 105 (14,3%) infartos, todas salvo una fueron hechas antes de las 48 horas del inicio de la clínica, y todos fueron confirmados por una RM diferida. Conclusiones El HINTS mejora sustancialmente el ABCD 2 para el diagnóstico de ictus en los pacientes con SVA en el SU . También supera a la RM obtenida en los primeros dos días tras el inicio de los síntomas. Dado que el test de HINTS se ha realizado tradicionalmente por especialistas, se deberían investigar métodos que permitan a los urgenciólogos hacer uso de esta aproximación para el cribado de ictus en el mareo.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/100264/1/acem12223.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/100264/2/acem12223-sup-0001-DataSupplementS1.pd

Characterizing epidemiological and genotypic features of Mycobacterium bovis infection in wild dogs (Lycaon pictus)

Mycobacterium bovis (M. bovis) infects a wide range of wildlife species and has recently been discovered in the endangered African wild dog (Lycaon pictus). This study aimed to characterize the epidemiology of tuberculosis (TB) in wild dogs in endemic areas of South Africa. We describe 12 TB cases in wild dogs from Kruger National Park (KNP), Hluhluwe–iMfolozi Park (HiP) and a private facility in Hoedspruit from 2015 to 2017. Spoligotyping was used to identify the disease-causing M. bovis strain in these cases, and whole-genome sequencing was performed on 5 M. bovis isolates (KNP = 2 and HiP = 3) to investigate genomic diversity as well as the relationship to other isolates found in these geographical areas. Three distinct strain types were responsible for the M. bovis infections in this species. The SB0121 strain was observed in wild dogs from KNP, whereas SB0130 was responsible for infection in wild dogs from HiP. A novel strain, SB2681, was also identified in the HiP wild dogs. Whole-genome sequence analysis suggests that different infection sources exist among these wild dogs and that inter-species transmission most likely occurred between wildlife predators and prey located within shared geographical areas. This study highlights the importance of regular disease surveillance to identify and characterize potential threats for successful control of infection and protection of endangered species.The South African Medical Research Council and the National Research Foundation.http://wileyonlinelibrary.com/journal/tbedhj2022Paraclinical Science

Fatal Tuberculosis in a Free-Ranging African Elephant and One Health Implications of Human Pathogens in Wildlife

Tuberculosis (TB) in humans is a global public health concern and the discovery of animal cases of Mycobacterium tuberculosis (Mtb) infection and disease, especially in multi-host settings, also has significant implications for public health, veterinary disease control, and conservation endeavors. This paper describes a fatal case of Mtb disease in a free-ranging African elephant (Loxodonta africana) in a high human TB burden region. Necropsy revealed extensive granulomatous pneumonia, from which Mtb was isolated and identified as a member of LAM3/F11 lineage; a common lineage found in humans in South Africa. These findings are contextualized within a framework of emerging Mtb disease in wildlife globally and highlights the importance of the One Health paradigm in addressing this anthroponotic threat to wildlife and the zoonotic implications

Metabolite transport and associated sugar signalling systems underpinning source/ sink interactions

Metabolite transport between organelles, cells and source and sink tissues not only enables pathway co-ordination but it also facilitates whole plant communication, particularly in the transmission of information concerning resource availability. Carbon assimilation is co-ordinated with nitrogen assimilation to ensure that the building blocks of biomass production, amino acids and carbon skeletons, are available at the required amounts and stoichiometry, with associated transport processes making certain that these essential resources are transported from their sites of synthesis to those of utilization. Of the many possible posttranslational mechanisms that might participate in efficient co-ordination of metabolism and transport only reversible thiol-disulphide exchange mechanisms have been described in detail. Sucrose and trehalose metabolism are intertwined in the signalling hub that ensures appropriate resource allocation to drive growth and development under optimal and stress conditions, with trehalose-6-phosphate acting as an important signal for sucrose availability. The formidable suite of plant metabolite transporters provides enormous flexibility and adaptability in inter-pathway coordination and source-sink interactions. Focussing on the carbon metabolism network, we highlight the functions of different transporter families, and the important of thioredoxins in the metabolic dialogue between source and sink tissues. In addition, we address how these systems can be tailored for crop improvement

Communications Biophysics

Contains reports on nine research projects split into four sections.National Institutes of Health (Grant 5 P01 NS13126)National Institutes of Health (Grant 5 K04 NS00113)National Institutes of Health (Training Grant 5 T32 NS07047)National Institutes of Health (Grant 5 ROl NS11153-03)National Institutes of Health (Fellowship 1 T32 NS07099-01)National Science Foundation (Grant BNS77-16861)National Institutes of Health (Grant 5 ROl NS10916)National Institutes of Health (Grant 5 ROl NS12846)National Science Foundation (Grant BNS77-21751)National Institutes of Health (Grant 1 RO1 NS14092)Health Sciences FundNational Institutes of Health (Grant 2 R01 NS11680)National Institutes of Health (Grant 2 RO1 NS11080)National Institutes of Health (Training Grant 5 T32 GM07301

The genetic architecture of the human cerebral cortex

The cerebral cortex underlies our complex cognitive capabilities, yet little is known about the specific genetic loci that influence human cortical structure. To identify genetic variants that affect cortical structure, we conducted a genome-wide association meta-analysis of brain magnetic resonance imaging data from 51,665 individuals. We analyzed the surface area and average thickness of the whole cortex and 34 regions with known functional specializations. We identified 199 significant loci and found significant enrichment for loci influencing total surface area within regulatory elements that are active during prenatal cortical development, supporting the radial unit hypothesis. Loci that affect regional surface area cluster near genes in Wnt signaling pathways, which influence progenitor expansion and areal identity. Variation in cortical structure is genetically correlated with cognitive function, Parkinson's disease, insomnia, depression, neuroticism, and attention deficit hyperactivity disorder

Evaluation of a new Epstein-Barr virus Combi test for rapid serologic diagnosis of infectious mononucleosis

We evaluated the EBV Combi Test (Virion) in serum samples from 574 children with a clinical presentation suggestive of infectious mononucleosis (IM) and compared its performance with several other EBV serological tests. Out of 574 sera 66 gave an acute LM pattern, 406 gave a past infection pattern and 102 were found negative in the EBV Combi Test. Positive VCA IgM and VCA IgG IFA results, in the absence of EBNA antibodies, were found in 62 cases in which the EBV Combi Test gave an acute IM pattern. In addition, 4 to the 574 tested sera gave an acute positive result in the EBV Combi Test (two of them were VCA IgM positive and the other two VCA IgM negative but also EBNA negative). None of these four sera were CMV IgM or Toxoplasma gondii IgM positive. The heterophile antibody test was positive in only 28, and VCA IgM EIA positive in 44 of the 62 IM cases. These data confirm the necessity for an EBV serological diagnosis in children where the clinical diagnosis of EBV infectious mononucleosis must be confirmed or ruled out.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

International Common Otology Database: taste disturbance after stapes surgery

OBJECTIVE: To use a study on dysgeusia to assess the usefulness of an otology database. STUDY DESIGN: Data were extracted from the international Common Otology Database. INTERVENTION: Primary stapes operations. MAIN OUTCOME MEASURE AND RESULTS: From a cohort of 14 otologists, only 8 (57%) were able to satisfy external validation and maintain data input for a period of at least 6 months. The rates of dysgeusia varied from 0 to 39% at 3 months and 0 to 27% at 6 months. The percentages of patients with taste disturbance at 6 months in the "nerve-cut" and "nerve-preserved" groups were 22.7 and 10.9%, respectively, although this was not statistically significant (chi2; p = 0.325). CONCLUSION: Many surgeons found it difficult to maintain a prospective otology database. The rates of certain subjective symptoms such as dysgeusia are influenced by how vigorously the reviewers prompt the response from the patients. Dysgeusia after stapes surgery is common even if the chorda tympani nerve is preserved. Many patients whose chorda tympani nerve is divided may not complain of dysgeusia