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Background: Multiple sclerosis (MS) requires multidisciplinary management. We evaluated differences in healthcare resource utilization and costs between Federico II and Vanvitelli MS Centres of Naples (Italy), representative of centralised (i.e., MS Care Unit) and local service-based models of multidisciplinary care, respectively. Methods: We included MS patients continuously seen at the same local healthcare services and MS Centre (Federico II = 187; Vanvitelli = 90) from 2015 to 2017. Healthcare resources for MS treatment and management were collected and costs were calculated. Adherence was estimated as the rate of medication possession ratio (MPR) during 3-years of follow-up. Mixed-effect linear regression models were used to estimate differences in all outcomes between Federico II and Vanvitelli. Results: Patients at Federico II had more consultations within the MS centre (p<0.001), blood tests (p<0.001), and psychological/cognitive evaluations (p = 0.040). Patients at Vanvitelli had more consultations at local services (p<0.001). Adherence was not-significantly lower at Vanvitelli (p = 0.060), compared with Federico II. Costs for MS treatment and management were 10.6% lower at Vanvitelli (12417.08±8448.32EUR) (95%CI = -19.0/-2.7%;p = 0.007), compared with Federico II (15318.57±10919.59EUR). Discussion: Healthcare services were more complete (and expensive) at the Federico II centralised MS Care Unit, compared with the Vanvitelli local service-based organizational model. Future research should evaluate whether better integration between MS Centres and local services can lead to improved MS management and lower costs. [ABSTRACT FROM AUTHOR]

Measuring disaster resilience is a key component of successful disaster risk management and climate change adaptation. Quantitative, indicator-based assessments are typically applied to evaluate resilience by combining various indicators of performance into a single composite index. Building upon extensive research on social vulnerability and coping/adaptive capacity, we first develop an original, comprehensive disaster resilience index (CDRI) at municipal level across Italy, to support the implementation of the Sendai Framework for Disaster Risk Reduction 2015–2030. As next, we perform extensive sensitivity and robustness analysis to assess how various methodological choices, especially the normalisation and aggregation methods applied, influence the ensuing rankings. The results show patterns of social vulnerability and resilience with sizeable variability across the northern and southern regions. We propose several statistical methods to allow decision makers to explore the territorial, social and economic disparities, and choose aggregation methods best suitable for the various policy purposes. These methods are based on linear and non-liner normalization approaches combining the OWA and LSP aggregators. Robust resilience rankings are determined by relative dominance across multiple methods. The dominance measures can be used as a decision-making benchmark for climate change adaptation and disaster risk management strategies and plans. [ABSTRACT FROM AUTHOR]

It is several years since national research evaluation systems around the globe started making use of quantitative indicators to measure the performance of researchers. Nevertheless, the effects on these systems on the behavior of the evaluated researchers are still largely unknown. For investigating this topic, we propose a new inwardness indicator able to gauge the degree of scientific self-referentiality of a country. Inwardness is defined as the proportion of citations coming from the country over the total number of citations gathered by the country. A comparative analysis of the trends for the G10 countries in the years 2000-2016 reveals a net increase of the Italian inwardness. Italy became, both globally and for a large majority of the research fields, the country with the highest inwardness and the lowest rate of international collaborations. The change in the Italian trend occurs in the years following the introduction in 2011 of national regulations in which key passages of professional careers are governed by bibliometric indicators. A most likely explanation of the peculiar Italian trend is a generalized strategic use of citations in the Italian scientific community, both in the form of strategic author self-citations and of citation clubs. We argue that the Italian case offers crucial insights on the constitutive effects of evaluation systems. As such, it could become a paradigmatic case in the debate about the use of indicators in science-policy contexts. [ABSTRACT FROM AUTHOR]

Background: In the last four decades, the Asian tiger mosquito, Aedes albopictus, vector of several human arboviruses, has spread from its native range in South-East Asia to all over the world, largely through the transportation of its eggs via the international trade in used tires. Albania was the first country invaded in Europe in 1979, followed by Italy in 1990 and other Mediterranean countries after 2000. Methods/Principal findings: We here inferred the invasion history and migration patterns of Ae. albopictus in Italy (today the most heavily-infested country in Europe), Greece and Albania, by analyzing a panel of >100,000 single nucleotide polymorphisms (SNPs) obtained by sequencing of double-digest Restriction site-Associated DNA (ddRADseq). The obtained dataset was combined with samples previously analyzed from both the native and invasive range worldwide to interpret the results using a broader spatial and historical context. The emerging evolutionary scenario complements the results of other studies in showing that the extraordinary worldwide expansion of Ae. albopictus has occurred thanks to multiple independent invasions by large numbers of colonists from multiple geographic locations in both native and previously invaded areas, consistently with the role of used tires shipments to move large numbers of eggs worldwide. By analyzing mosquitoes from nine sites across ~1,000-km transect in Italy, we were able to detect a complex interplay of drift, isolation by distance mediated divergence, and gene flow in shaping the species very recent invasion and range expansion, suggesting overall high connectivity, likely due to passive transportation of adults via ground transportation, as well as specific adaptations to local conditions. Conclusions/Significance: Results contribute to characterize one of the most successful histories of animal invasion, and could be used as a baseline for future studies to track epidemiologically relevant characters (e.g. insecticide resistance). [ABSTRACT FROM AUTHOR]

Ecoregionalization is the process by which a territory is classified in similar areas according to specific environmental and climatic factors. The climate and the environment strongly influence the presence and distribution of vectors responsible for significant human and animal diseases worldwide. In this paper, we developed a map of the eco-climatic regions of Italy adopting a data-driven spatial clustering approach using recent and detailed spatial data on climatic and environmental factors. We selected seven variables, relevant for a broad set of human and animal vector-borne diseases (VBDs): standard deviation of altitude, mean daytime land surface temperature, mean amplitude and peak timing of the annual cycle of land surface temperature, mean and amplitude of the annual cycle of greenness value, and daily mean amount of rainfall. Principal Component Analysis followed by multivariate geographic clustering using the k-medoids technique were used to group the pixels with similar characteristics into different ecoregions, and at different spatial resolutions (250 m, 1 km and 2 km). We showed that the spatial structure of ecoregions is generally maintained at different spatial resolutions and we compared the resulting ecoregion maps with two datasets related to Bluetongue vectors and West Nile Disease (WND) outbreaks in Italy. The known characteristics of Culicoides imicola habitat were well captured by 2/22 specific ecoregions (at 250 m resolution). Culicoides obsoletus/scoticus occupy all sampled ecoregions, according to its known widespread distribution across the peninsula. WND outbreak locations strongly cluster in 4/22 ecoregions, dominated by human influenced landscape, with intense cultivations and complex irrigation network. This approach could be a supportive tool in case of VBDs, defining pixel-based areas that are conducive environment for VBD spread, indicating where surveillance and prevention measures could be prioritized in Italy. Also, ecoregions suitable to specific VBDs vectors could inform entomological surveillance strategies. [ABSTRACT FROM AUTHOR]

Little is known about the types of social organization characterizing the pre-Roman Celtic populations of Italy. Here, we explore the funerary variability characterizing the late Iron Age site of Seminario Vescovile (SV: Verona, Italy, 3rd-1st c. BC), and test its possible correlation to diet and relative exposure to developmental stressors. Patterns on funerary treatment (N = 125), δ13C and δ15N (N = 90), and linear enamel hypoplasia (N = 47) from SV are compared, and their possible association with sex and age-at-death further discussed. Results point to the presence at SV of variable funerary customs while at the same time demonstrating a rather homogenous diet and exposure to developmental stressors: funerary treatment is mainly correlated to age-at-death but do not appear to be associated to either isotopic patterns or hypoplasia frequencies. Accordingly, even if some weak social differentiation may have characterized the individuals buried at SV, this was not reflected in markedly differing living conditions. Our study is the first to attempt an exploration of the links between age, sex, funerary variability, and diet in a pre-Roman Celtic community from Italy. While highlighting the potential of a multifaceted approach in bioarcheology, it also points to a series of analytical and theoretical issues relevant when trying to disentangle the cultural and biological dimensions of social differentiation in the past. [ABSTRACT FROM AUTHOR]

This article contributes to the literature on performance determinants in soccer by investigating country differences in goal scoring in the dying seconds of international soccer games (i.e. in the 90th minute or later). We analyse this goal-scoring behaviour in 1,008 recent soccer games played in the Union of European Football Associations (UEFA) Champions League and Europa League. In contrast to Gary Lineker’s well-known quote that “at the end, the Germans always win”, no significant evidence is found for German teams scoring a goal in the dying seconds more often than other teams. Our results indicate, however, that European clubs do have an interest in learning from the end-of-game tactics used by French and Spanish clubs in recent international games as these teams were less likely to concede a goal during the dying seconds. English teams were also in this situation but only if they had an English coach. [ABSTRACT FROM AUTHOR]

Background: The management of mentally ill offenders in the community is one of the great challenges imposed on community psychiatry. Aim: The aim of this study was to analyze the association between sociodemographic, clinical, and psychosocial factors and violent behavior in a sample of outpatients with severe mental disorders. Method: This was a prospective cohort study with a baseline cross-sectional design used to provide a detailed analysis of patients’ profiles, followed by a longitudinal design to measure aggressive and violent behavior during a 1-year follow-up. Patients with severe mental disorders, with or without a history of violence, were enrolled in four Italian Departments of Mental Health and underwent a comprehensive multidimensional assessment. Results: The sample included 247 outpatients, for a total of 126 cases and 121 controls. Compared to controls, patients with a history of violence had a greater frequency of lifetime domestic violence, a greater lifetime propensity to misuse substances, and a higher number of compulsory admissions. The forthnightly monitoring during the 1-year follow-up did show statistically significant differences in aggressive and violent behavior rates between the two groups. Verbal aggression was significantly associated with aggression against objects and physical aggression. Moreover, outpatients with an history of violence showed statistically significant higher MOAS scores compared to both residential patients with an history of violence, assessed in the first wave of this project, and all controls. Conclusions: Patients with a history of violence had specific characteristics and showed a greater occurrence of additional community violence during a 1-year observation period. Our results may assist clinicians in implementing standardized methods of patient assessment and violence monitoring in outpatient mental health services and may prompt improved collaboration between different community services. [ABSTRACT FROM AUTHOR]

Cystic echinococcosis (CE) is a complex zoonosis with domestic and sylvatic life-cycles, involving different intermediate and definitive host species. Many previous studies have highlighted the lack of a surveillance system for CE, its persistence in Italy, and endemicity in several Italian regions. Because of the absence of a uniform surveillance program for both humans and animals, disease occurrence is widely underestimated. This study aimed to estimate the prevalence of ovine CE in Italy. Survey data on the prevalence of Echinococcus granulosus complex infections in Italian sheep farms from 2010 to 2015 were obtained in collaboration with Regional Veterinary Epidemiology Observatories (OEVRs). Bayesian analysis was performed to estimate the true CE farm prevalence. The prior true CE prevalence was estimated using data from Sardinia. Second, Bayesian modelling of the observed prevalence in different regions and the true prevalence estimation from the first step were used to ultimately estimate the prevalence of ovine CE in Italy. We obtained survey data from 10 OEVRs, covering 14 Italian regions. We observed that the risk of CE infection decreased over the years, and it was strictly correlated with the density of susceptible species. Using Sardinia as prior distribution, where the disease farm prevalence was approximately 19% (95% CI, 18.82–20.02), we estimated that the highest endemic CE farm prevalence was in Basilicata with a value of 12% (95% BCI: 7.49–18.9%) and in Piemonte 7.64%(95% BCI: 4.12–13.04%). Our results provide spatially relevant data crucial for guiding CE control in Italy. Precise information on disease occurrence location would aid in the identification of priority areas for disease control implementation by the authorities. The current underestimation of CE occurrence should urge the Italian and European governments to become aware of the public health importance of CE and implement targeted interventions for high-risk areas. [ABSTRACT FROM AUTHOR]

Information on the population dynamics of a reservoir species have been increasingly adopted to understand and eventually predict the dispersal patterns of infectious diseases throughout an area. Although potentially relevant, to date there are no studies which have investigated the genetic structure of the red fox population in relation to infectious disease dynamics. Therefore, we genetically and spatially characterised the red fox population in the area stretching between the Eastern and Dinaric Alps, which has been affected by both distemper and rabies at different time intervals. Red foxes collected from north-eastern Italy, Austria, Slovenia and Croatia between 2006–2012, were studied using a set of 21 microsatellite markers. We confirmed a weak genetic differentiation within the fox population using Bayesian clustering analyses, and we were able to differentiate the fox population into geographically segregated groups. Our finding might be due to the presence of geographical barriers that have likely influenced the distribution of the fox population, limiting in turn gene flow and spread of infectious diseases. Focusing on the Italian red fox population, we observed interesting variations in the prevalence of both diseases among distinct fox clusters, with the previously identified Italy 1 and Italy 2 rabies as well as distemper viruses preferentially affecting different sub-groups identified in the study. Knowledge of the regional-scale population structure can improve understanding of the epidemiology and spread of diseases. Our study paves the way for an integrated approach for disease control coupling pathogen, host and environmental data to inform targeted control programs in the future. [ABSTRACT FROM AUTHOR]

The prevalence of osteopathic practitioners, their professional profile and features of their clinical practice, particularly where statutory regulation does not yet exist, are still significantly underreported. The Osteopathic Practitioners Estimates and RAtes (OPERA) project was developed as an European-based census dedicated to profiling the osteopathic profession across Europe. The present study aimed to describe the osteopathic practitioners and the profession in Italy. A voluntary, online based, closed-ended survey was distributed across Italy in the period between February and June 2017. An e-based campaign was set up to reach the Italian osteopathic professionals. Participants were asked to complete the forms by filling in the information regarding the demographics, working status and professional activities, education, consultation fees, patient complaints, treatment and management. The survey was completed by 4816 individuals. 196 people started the survey but did not finish, which corresponds to a 4% attrition rate. The majority of respondents were males (66.7%). The modal age group was 30–39 (40.0%). 73.8% of respondents had a previous academic degree, mainly in the fields of sports science (36.4%) and physiotherapy (25.3%). 25.6% declared not to have a previous academic degree. The majority of respondents declared to work alone (58.4%), while the remaining declared to work in association with other professionals. The osteopaths /citizens ratio was 8.0 osteopaths/100,000 citizens. The profile of osteopaths in Italy seems to be characterised by a self-employed young adult male working mostly as a sole practitioner, who has been trained as osteopath through a part-time curriculum and had a previous degree mostly in the fields of sports science or physiotherapy. These results provide important insights into the osteopathic profession in Italy. The varied professional educational backgrounds need to be considered with regard to the implementation of a professional licensing process and future pre-registration education in the country. The number of respondents is an estimate of the actual number of Italian osteopaths. Only the completion of the regulatory process and the creation of the mandatory official register will allow to know the number of Italy based osteopaths. [ABSTRACT FROM AUTHOR]

Background: Developmental dyslexia is one of the most common neurobehavioral disorders affecting children, but prevalence data on this condition are poor. The objective of the present study is to determine the prevalence of dyslexia in Italy in an unselected school population, using clearly defined diagnostic criteria and methods. Methods: Cross-sectional study carried out in nine Italian Regions: two located in Northern Italy (Friuli Venezia Giulia and Veneto), three in Central Italy (Marche, Lazio and Umbria) and four in Southern Italy (Abruzzo, Molise, Puglia and Sardegna). Three consecutive levels of screening were carried out: the first two at school, to screen the population and identify children with suspect dyslexia; the last in centers with multi-professional staff specialized in learning disabilities to confirm the diagnosis. The key outcome measure is the prevalence of dyslexia, defined as the ratio between the number of children confirmed positive at the third level of screening and the total number of children enrolled in the study. Results: We finally recruited 11094 children aged 8–10 years, of which 9964 constituted the final working sample after applying exclusion criteria and including only children who received parents’ consent to participate. The prevalence of dyslexia in the whole sample was 3.5% (95% CI 3.2–3.9%), with little differences between Northern, Central and Southern Italy (respectively 3.6%, 3.2% and 3.7%). In almost two out of three children with dyslexia the disorder had not been previously diagnosed. Conclusions: This study confirms that in primary school children at the age of 8–10 years in Italy dyslexia is widely underestimated. Reliable data on dyslexia prevalence are needed to allocate necessary human and financial resources both to Health Services and Schools, ensuring timely support to children and families. [ABSTRACT FROM AUTHOR]

In this study we characterized the presence and subtype (ST1-ST4) of Blastocystis in patients attended at a referral center for tropical diseases in Northern Italy. We also, evaluated the organism’s association with other intestinal parasites. Parasite screening was performed on 756 patients, from different geographical origins (namely, Italians, Africans, South Americans, Asian and non-Italian Europeans) in which Italians represented the largest group. Blastocystis was seen to be the most prevalent parasite in the study. Subtype 3 and 1 were the most frequently found in the Italians and Africans. Our data confirmed previous studies performed in Italy, in which ST3 proved to be the most prevalent subtype, but we highlighted also a high frequency of mixed subtypes, which were probably underestimated in former analyses. Interestingly, the mixed subtypes group was the most prevalent in all the analysed geographical areas. About half of our cases showed other co-infecting parasites and the most frequent was Dientamoeba fragilis. Our study confirms that, in Blastocystis infection, multiple subtypes and co-infecting parasites are very frequently present, in particular Dientamoeba fragilis. [ABSTRACT FROM AUTHOR]

The genetic variability of Infectious bronchitis virus (IBV) is one of the main challenges for its control, hindering not only the development of effective vaccination strategies but also its classification and, consequently, epidemiology understanding. The 624/I and Q1 genotypes, now recognized to be part of the GI-16 lineage, represent an excellent example of the practical consequences of IBV molecular epidemiology limited knowledge. In fact, being their common origin unrecognized for a long time, independent epidemiological pictures were drawn for the two genotypes. To fix this misinterpretation, the present study reconstructs the history, population dynamics and spreading patterns of GI-16 lineage as a whole using a phylodynamic approach. A collection of worldwide available hypervariable region 1 and 2 (HVR12) and 3 (HVR3) sequences of the S1 protein was analysed together with 258 HVR3 sequences obtained from samples collected in Italy (the country where this genotype was initially identified) since 1963. The results demonstrate that after its emergence at the beginning of the XX century, GI-16 was able to persist until present days in Italy. Approximately in the late 1980s, it migrated to Asia, which became the main nucleus for further spreading to Middle East, Europe and especially South America, likely through multiple introduction events. A remarkable among-country diffusion was also demonstrated in Asia and South America. Interestingly, although most of the recent Italian GI-16 strains originated from ancestral viruses detected in the same country, a couple were closely related to Chinese ones, supporting a backward viral flow from China to Italy. Besides to the specific case-study results, this work highlights the misconceptions that originate from the lack of a unified nomenclature and poor molecular epidemiology data generation and sharing. This shortcoming appears particularly relevant since the described scenario could likely be shared by many other IBV genotypes and pathogens in general. [ABSTRACT FROM AUTHOR]

Noroviruses are one of the leading causes of gastro-enteric diseases worldwide in all age groups. Novel epidemic noroviruses with GII.P16 polymerase and GII.2 or GII.4 capsid type have emerged worldwide in late 2015 and in 2016. We performed a molecular epidemiological study of the noroviruses circulating in Italy to investigate the emergence of new norovirus strains. Sentinel hospital-based surveillance, in three different Italian regions, revealed increased prevalence of norovirus infection in children (<15 years) in 2016 (14.4% versus 9.8% in 2015) and the emergence of GII.P16 strains in late 2016, which accounted for 23.0% of norovirus infections. The majority of the strains with a GII.P16 polymerase showed a GII.2 capsid genotype (79.5%). Also, a marked circulation of strains with a GII.17 capsid (14.0%) was observed, chiefly in early 2016. The emergence and global spread of non-GII.4 noroviruses pose challenges for the development of vaccine strategies. [ABSTRACT FROM AUTHOR]

Background and Aims: Patients who leave Emergency Department before physician’s visit (LWBS) or during treatment (LDT) represent a useful indicator of the emergency care's quality. The profile of patients LWBS was described: they are generally males, young, with lower urgency triage allocation and longer waiting time. They have a greater risk of ED re-admission compared to discharged patients, but effect on hospitalization and mortality are more controversial. The aims of this study are to identify determinants and adverse short term outcomes for LWBS and LDT patients. Methods: This is a retrospective cohort study that include all ED visits of LWBS, LDT and discharged patients in 2015 in the Lazio region, Central Italy. Determinants of LWBS or LDT were selected from gender, age, citizenship, residence area, triage category, chronic comorbidities, number of uncompleted ED visit in the previous year, mode of arrival in ED, time-band, day of the week, waiting time and ED crowding, using a multi-level logistic regression. A multivariate logistic regression was used to test if LWBS or LDT have a greater risk of short term adverse outcome compared to discharged patients. Results: The cohort consists in 835,440 visits in ED, 86.8% subjects visited and discharged, 8.9% subjects are LWBS patients and 4.3% LDT. LWBS and LDT patients are mainly young, males, with a less severe triage, with long waiting times in ED. Moreover, ED crowding and leaving ED before physician’s visit in the previous year are risk factors of self-discharging. LWBS and LDT patients have a higher risk of readmission (LWBS: OR = 4.63, 95%CI 4.5–4.7; OR = 2.89, 95%CI 2.8–2.9; LDT: OR = 3.12, 95%CI 3–3.2; OR = 2.25, 95%CI2.2–2.3 for readmissions within 2 and 7 days respectively) and hospitalization (LWBS: OR = 3.65, 95%CI 3.4–3.9; OR = 2.25, 95%CI 2.1–2.4; LDT: OR = 3.96, 95%CI 3.6–4.3; OR = 2.62, 95%CI 2.4–2.8 for hospitalization within 2 and 7 days respectively). Furthermore, we find a mortality excess of risk for LWBS patients compared to the reference group (OR = 2.56, 95%CI1.6–4.2; OR = 1.7, 95%CI 1.3–2.2 within 2 and 7 days respectively). Conclusions: Determinants of LWBS confirmed what already known, but LDT patients should be further investigated. There could be adverse health effects for people with LWBS and LDT behaviour. This could be an issue that the Regional Health System should deal with. [ABSTRACT FROM AUTHOR]

Background: Anisakiasis is a fish-borne zoonosis caused by the ingestion of marine food infected with Anisakis third-stage larvae, widespread marine parasitic nematodes. Gastrointestinal and/or allergic clinical signs and symptoms are not specific. While frequently reported in countries with large raw fish consumption as Japan, the global prevalence of anisakiasis may be severely underestimated due to limitations of available diagnostic tools and to diverse clinical manifestations. Recently, infective larvae were found in the same localization with gastrointestinal tumors. The occurrence of allergic exacerbation upon secondary exposure and the possible occupational exposure, highlight the need to increase scientific evidences on anisakiasis. Methods: We performed a retrospective descriptive study using analysis of Hospital Discharge Records (HDRs) from 2005 to 2015 in Italy, with particular attention to allergic manifestations. Descriptive statistics and multivariate analyses were performed using backward step-wise logistic regression models to assess spatial distribution and temporal trend as well as the variables independently associated with the allergic clinical signs and symptoms in Italian cases of anisakiasis. Results: HDRs reporting the ICD-9 code for anisakiasis were retrieved (370), with a higher number of cases reported from central and southern regions, with particular regard to populations inhabiting the coastal territories. Around 40% of patients presented allergic manifestations and half of them showed serious allergic reactions. The multivariate analyses showed an independent association between allergic manifestations and features as living in southern regions and female gender, while anaphylactic episodes was independently associated only with female gender. Conclusion: The present study is the first attempt to a better understanding of the epidemiological picture of anisakiasis in Italy, mining official data. A common strategy on data collection, monitoring and reporting would favor a more accurate epidemiological scenario in Italy, since the report of the diseases is not mandatory. [ABSTRACT FROM AUTHOR]

Although most countries in the WHO European Region were verified in 2017 as having interrupted endemic measles transmission, nine countries were still endemic. Among these, Italy accounted for the second highest number of measles cases reported in Europe in 2017. The elimination of measles is verified at national level by each country’s National Verification Committee (NVC) through the production of an Annual Status Update (ASU). Since in Italy decentralization has led to an inhomogeneous implementation of immunization strategies among the 21 administrative Regions, the Italian NVC proposed that measles elimination should also be documented at the subnational level through regional ASUs and Synthetic Regional Reports (SRRs). The regional ASUs and the SRRs for 2014, 2015 and 2016 were produced and appraised by the NVC to evaluate the Regions’ performances in each individual year as well as over the whole period. A specific analysis of vaccination coverage, including official immunization data for 2017, was performed. Moreover, the measles epidemic of 2017 was examined. Firstly, in the period 2014–2016, low immunization rates were registered in most Regions. Sixty-three per cent of southern Regions reported rates below the national mean and an overall low-quality performance. The approval of Italy’s mandatory vaccination law in 2017 resulted in a marked increase in vaccination coverage; however, this increase was not homogeneous among Regions. Secondly, more than 50% of Regions did not report any supplemental immunization activity (SIA) for the period 2014–2016. Thirdly, from 2014 to 2016, fewer than one-third of Regions improved their reporting of outbreaks. Finally, over the study period, only two Regions reached the target required by the WHO for measles laboratory investigations. In countries with decentralized health policies, subnational monitoring can help identify local barriers to measles elimination. In Italy it has highlighted the need for further SIAs and a stronger surveillance system. [ABSTRACT FROM AUTHOR]

Salmonella enterica serovar Napoli (serovar Napoli) is an emerging cause of human salmonellosis in Northern Italy. No specific reservoirs of serovar Napoli have been identified in Italy, so far. However, the environment, especially surface waters, has been hypothesized as an important source of infection based on the observation that genotypically different clusters of serovar Napoli are detected in different geographical macro-areas. To further support the hypothesis of a spatially-restricted pattern of serovar Napoli diffusion, a spatial segregation of serovar Napoli lineages should be observed also at smaller geographical scale. However, classical genotyping techniques used for Salmonella, such as pulsed-field gel electrophoresis (PFGE), did not possess enough discriminatory power to highlight spatial clustering of serovar Napoli within the macro-areas. To this purpose, we performed phylogeographical analyses based on genome-wide single nucleotide polymorphisms to test whether spatio-temporal evolution patterns of serovar Napoli in Northern Italy could be recognized with high geographical resolution, i.e. at local level. Specifically, we analyzed the local spread of the main PFGE clonal group, responsible for more than 60% of human infections in the study area, that did not show any geographical differentiation by PFGE within Northern Italy, i.e. the macro-area considered in the study. Both discrete and continuous phylogeography highlighted the existence of two main geographically-restricted clades: a Southern clade corresponding to the Po Valley and a Northern clade corresponding to the Pre-Alps area. Furthermore, the phylogeographical analyses suggested that the most probable site of origin of the clone was in an area of the Po Valley at the confluence of the Po and Ticino rivers, one of the most important Italian wetlands. These findings provide further support to the hypothesis that environmental transmission may play an important role in the ecology of serovar Napoli. [ABSTRACT FROM AUTHOR]

Background: For many years, long-acting intramuscular (LAI) antipsychotics have been prescribed predominantly to chronic and severe patients, as a last resort when other treatments failed. Recently, a broader and earlier use of LAIs, particularly second-generation LAIs, has been emphasized. To date, few studies attempted to frame how this change in prescribing took place in real-world practice. Therefore, this study aimed to describe the clinical features of patients prescribed with LAIs, and to explore possible prescribing differences between first- and second-generations LAIs under ordinary clinical practice in Italy. Methods: The STAR Network “Depot” Study is an observational, longitudinal, multicenter study involving 35 centers in Italy. In the cross-sectional phase, patients prescribed with LAIs were consecutively recruited and assessed over a period of 12 months. Descriptive statistics and multivariable logistic regression analyses were employed. Results: Of the 451 recruited patients, 61% were males. The level of social and working functioning was heterogeneous, as was the severity of disease. Seventy-two per cent of the patients had a diagnosis of the schizophrenia spectrum. Seventy per cent were prescribed with second-generation antipsychotic (SGA) LAIs (mostly paliperidone, aripiprazole and risperidone). Compared to first-generation antipsychotic (FGA) LAIs, patients prescribed with SGA LAIs were more often younger; employed; with a diagnosis of the schizophrenia spectrum or bipolar disorder; with higher levels of affective symptoms; with fewer LAI prescriptions in the past. Discussion: LAIs’ prescribing practices appear to be more flexible as compared to the past, although this change is mostly restricted to SGA LAIs. [ABSTRACT FROM AUTHOR]

Background: Visceral leishmaniasis (VL) caused by Leishmania infantum is an ongoing health problem in southern Europe, where dogs are considered the main reservoirs of the disease. Current data point to a northward spread of VL and canine leishmaniasis (CanL) in Italy, with new foci in northern regions previously regarded as non-endemic. Methodology/Principal findings: Multilocus microsatellite typing (MLMT) was performed to investigate genetic diversity and population structure of L. infantum on 55 samples from infected humans, dogs and sand flies of the E-R region between 2013 and 2017. E-R samples were compared with 10 L. infantum samples from VL cases in other Italian regions (extra E-R) and with 52 strains within the L. donovani complex. Data displayed significant microsatellite polymorphisms with low allelic heterozygosity. Forty-one unique and eight repeated MLMT profiles were recognized among the L. infantum samples from E-R, and ten unique MLMT profiles were assigned to the extra E-R samples. Bayesian analysis assigned E-R samples to two distinct populations, with further sub-structuring within each of them; all CanL samples belonged to one population, genetically related to Mediterranean MON-1 strains, while all but one VL cases as well as the isolate from the sand fly Phlebotomus perfiliewi fell under the second population. Conversely, VL samples from other Italian regions proved to be genetically similar to strains circulating in dogs. Conclusions/Significance: A peculiar epidemiological situation was observed in northeastern Italy, with the co-circulation of two distinct populations of L. infantum; one population mainly detected in dogs and the other population detected in humans and in a sand fly. While the classical cycle of CanL in Italy fits well into the data obtained for the first population, the population found in infected humans exhibits a different cycle, probably not involving a canine reservoir. This study can contribute to a better understanding of the population structure of L. infantum circulating in northeastern Italy, thus providing useful epidemiologic information for public health authorities. [ABSTRACT FROM AUTHOR]

The interest in the promotion of entrepreneurship is significantly increasing, particularly in those countries, such as Italy, that suffered during the recent great economic recession and subsequently needed to revitalize their economy. Entrepreneurial intention (EI) is a crucial stage in the entrepreneurial process and represents the basis for consequential entrepreneurial actions. Several research projects have sought to understand the antecedents of EI. This study, using a situational approach, has investigated the personal and contextual determinants of EI, exploring gender differences. In particular, the mediational role of general self-efficacy between internal locus of control (LoC), self-regulation, and support from family and friends, on the one hand, and EI, on the other hand, has been investigated. The study involved a sample of 658 Italian participants, of which 319 were male and 339 were female. Data were collected with a self-report on-line questionnaire and analysed with SPSS 23 and Mplus 7 to test a multi-group structural equation model. The results showed that self-efficacy totally mediated the relationship between internal LoC, self-regulation and EI. Moreover, it partially mediated the relationship between support from family and friends and EI. All the relations were significant for both men and women; however, our findings highlighted a stronger relationship between self-efficacy and EI for men, and between support from family and friends and both self-efficacy and EI for women. Findings highlighted the role of contextual characteristics in addition to personal ones in influencing EI and confirmed the key mediational function of self-efficacy. As for gender, results suggested that differences between men and women in relation to the entrepreneur role still exist. Practical implications for trainers and educators are discussed. [ABSTRACT FROM AUTHOR]

The study assessed knowledge, attitudes, and medication use of a random sample of pregnant women attending outpatient Gynecology and Obstetrics clinics at randomly selected public General and Teaching hospitals in Naples, Italy. A total of 503 women participated. Those more likely to know that a pregnant woman with chronic condition must discuss whether or not to take a medication with the physician were Italian, aged 31–40 years, employed, with no history of abortion, having had a medical problem within the previous year, with a better self-perceived health status, who knew how to use medications during pregnancy, and who needed information on medications. The knowledge of the potential risk of using non-prescribed medications during pregnancy was significantly higher in employed women, who received information from physicians, who knew how to use medications during pregnancy, and who knew the possible damages related to medications use. More than half had used at least one medication. Those aged 26–35 years, Italian, non-graduated, in the third trimester, having had a medical problem within the previous year, with a risky pregnancy, and with a knowledge that women with chronic condition must discuss whether or not to take a medication with the physician were more likely to use medication. Less than half had used medication without a physician’s advice. Those who were more likely to self-medicate were older, Italian, multiparous, with no history of abortion, who knew that women with chronic condition must discuss whether or not to take a medication with the physician, who did not know the potential risk of using non-prescribed medication during pregnancy, who had used prescribed medication during pregnancy, and who needed information about medications. Educational programs for women about medication use are important to increase their knowledge of the potential risks to the pregnant women and the unborn child in order to reduce self-medication. [ABSTRACT FROM AUTHOR]

The recent outbreak of Chikungunya virus in Italy represents a serious public health concern, which is attracting media coverage and generating public interest in terms of Internet searches and social media interactions. Here, we sought to assess the Chikungunya-related digital behavior and the interplay between epidemiological figures and novel data streams traffic. Reaction to the recent outbreak was analyzed in terms of Google Trends, Google News and Twitter traffic, Wikipedia visits and edits, and PubMed articles, exploiting structural modelling equations. A total of 233,678 page-views and 150 edits on the Italian Wikipedia page, 3,702 tweets, 149 scholarly articles, and 3,073 news articles were retrieved. The relationship between overall Chikungunya cases, as well as autochthonous cases, and tweets production was found to be fully mediated by Chikungunya-related web searches. However, in the allochthonous/imported cases model, tweet production was not found to be significantly mediated by epidemiological figures, with web searches still significantly mediating tweet production. Inconsistent relationships were detected in mediation models involving Wikipedia usage as a mediator variable. Similarly, the effect between news consumption and tweets production was suppressed by the Wikipedia usage. A further inconsistent mediation was found in the case of the effect between Wikipedia usage and tweets production, with web searches as a mediator variable. When adjusting for the Internet penetration index, similar findings could be obtained, with the important exception that in the adjusted model the relationship between GN and Twitter was found to be partially mediated by Wikipedia usage. Furthermore, the link between Wikipedia usage and PubMed/MEDLINE was fully mediated by GN, differently from what was found in the unadjusted model. In conclusion—a significant public reaction to the current Chikungunya outbreak was documented. Health authorities should be aware of this, recognizing the role of new technologies for collecting public concerns and replying to them, disseminating awareness and avoid misleading information. [ABSTRACT FROM AUTHOR]

Background: Chikungunya virus (CHIKV) is an emerging arbovirus, belonging to the Togaviridae family, Alphavirus genus, transmitted by Aedes spp. mosquitoes. Since 2007, two different CHIKV stains (E1-226A and E1-226V) have been responsible for outbreaks in European countries, including Italy, sustained by Ae. albopictus mosquitoes. Findings: In this study, we assessed the susceptibility to the CHIKV E1-226V, strain responsible for the Italian 2007 outbreak, of eight Ae. albopictus populations collected in Northern, Central, Southern, and Island Italy, by experimental infections. Vector competence was evaluated by estimating infection, dissemination, and transmission rates (IR, DR, TR), through detection of the virus in the bodies, legs plus wings, and saliva, respectively. Additionally, vertical transmission was evaluated by the detection of the virus in the offspring. The results of our study demonstrated that the Italian populations of Ae. albopictus tested were susceptible to CHIKV infection, and can disseminate the virus outside the midgut barrier with high values of IR and DR. Viral infectious RNA was detected in the saliva of three populations from Central, Southern, and Island Italy, also tested for TR and population transmission rate (PTR) values. No progeny of the first and second gonotrophic cycle were positive for CHIKV. Conclusions: This study strongly confirms the role of Ae. albopictus as a potential CHIKV vector in Italy. This may represent a threat, especially considering both the high density of this species, which is widespread throughout the country, and the increasing number of cases of imported arbovirus. [ABSTRACT FROM AUTHOR]

Background: Despite concerns about the representativeness of patients from ALS tertiary centers as compared to the ALS general population, the extent of referral bias in clinical studies remains largely unknown. Using data from EURALS consortium we aimed to assess nature, extent and impact of referral bias. Methods: Four European ALS population-based registries located in Ireland, Piedmont, Puglia, Italy, and Limousin, France, covering 50 million person-years, participated. Demographic and clinic characteristics of ALS patients diagnosed in tertiary referral centers were contrasted with the whole ALS populations enrolled in registries in the same geographical areas. Results: Patients referred to ALS centers were younger (with difference ranging from 1.1 years to 2.4 years), less likely to present a bulbar onset, with a higher proportion of familial antecedents and a longer survival (ranging from 11% to 15%) when compared to the entire ALS population in the same geographic area. Conclusions: A trend for referral bias is present in cohorts drawn from ALS referral centers. The magnitude of the possible referral bias in a particular tertiary center can be estimated through a comparison with ALS patients drawn from registry in the same geographic area. Studies based on clinical cohorts should be cautiously interpreted. The presence of a registry in the same area may improve the complete ascertainment in the referral center. [ABSTRACT FROM AUTHOR]

The 4th century BC marks the main entrance of Celtic populations in northern Italy. Their arrival has been suggested based on the presence of Celtic customs in Etruscan mortuary contexts, yet up to now few bioarchaeological data have been examined to support or reject the arrival of these newcomers. Here we use strontium isotopes, non-metric dental traits and funerary patterns to unravel the biocultural structure of the necropolis of Monterenzio Vecchio (Bologna, Italy). Subsamples of our total sample of 38 individuals were analyzed based on different criteria characterizing the following analyses: 1) strontium isotope analysis to investigate migratory patterns and provenance; 2) non-metric dental traits to establish biological relationships between Monterenzio Vecchio, 13 Italian Iron age necropolises and three continental and non-continental Celtic necropolises; 3) grave goods which were statistically explored to detect possible patterns of cultural variability. The strontium isotopes results indicate the presence of local and non-local individuals, with some revealing patterns of mobility. The dental morphology reveals an affinity between Monterenzio Vecchio and Iron Age Italian samples. However, when the Monterenzio Vecchio sample is separated by isotopic results into locals and non-locals, the latter share affinity with the sample of non-continental Celts from Yorkshire (UK). Moreover, systematic analyses demonstrate that ethnic background does not retain measurable impact on the distribution of funerary elements. Our results confirm the migration of Celtic populations in Monterenzio as archaeologically hypothesized on the basis of the grave goods, followed by a high degree of cultural admixture between exogenous and endogenous traits. This contribution shows that combining different methods offers a more comprehensive perspective for the exploration of biocultural processes in past and present populations. [ABSTRACT FROM AUTHOR]

Background: Food supplements, and in particular those containing botanicals (plant food supplements, PFS), have in recent decades been of great interest both to consumers and to food/pharmaceutical industries. Objectives: The aim of this paper is to examine replies by Italian consumers to the PlantLIBRA consumers' survey in order to: 1) assess the behaviour of an Italian population with respect to the use of PFS, and to compare it with that of other 5 countries involved in the whole survey; 2) identify different habits in the 4 Italian cities selected according to their geographical distribution; 3) collect independent information on the actual intake of PFS and consumers' behaviour. Subjects/setting: 397 Italian consumers enrolled, 187 males (49.5%) and 191 female (50.5%). The distribution of subjects among the 4 cities included was: Milan 99; Venice 90; Rome 96 and Catania 96. Results: The interest in PFS in Italy is high, the prevalence of "regular" consumers being 22.7%. Some differences were observed between the 4 cities involved: the pattern of use during the year was specific to each city; consumers in Milan reported reasons to use PFS significantly different from those in the whole Italian sample and did not indicate supermarkets as an important place of purchase; respondents from Rome and Catania more frequently used family doctors and pharmacists as a source of recommendation. Some significant difference among cities, sex and age groups were observed when the most frequently used botanicals were ranked. Conclusions: The results provide new insights on the socio-economic characteristics and lifestyle of Italian PFS consumers, on their reasons for and pattern of use, and on their behaviour and expectations. The value of this information is not restricted to the specific country (Italy) but allows for a more general evaluation of the pattern of use, according to habits and geographical area. [ABSTRACT FROM AUTHOR]

Action on social determinants is a main component of the World Health Organization End Tuberculosis (TB) Strategy. The aim of the study was to collect information on socioeconomic characteristics and biomedical risk factors in migrant TB patients in Italy and compare it with data collected among Italian TB patients. A cross-sectional study was conducted among TB patients aged ≥18 years over a 12-months enrolment period in 12 major Italian hospitals. Information on education, employment, housing and income was collected, and European Union Statistics on Income and Living Conditions index was used to assess material deprivation. Among migrants, we also analyzed factors associated with severe material deprivation. Migrants were compared with younger (18–64 years) and older (65+ years) Italians patients. Out of 755 patients enrolled (with a median age of 42 years, interquartile range: 31–53), 65% were migrants. Pulmonary, microbiologically confirmed, and new cases were 80%, 73%, and 87% respectively. Prevalence of co-morbidities (i.e. diabetes, chronic kidney disease, neoplastic diseases and use of immunosuppressive drugs) was lower among migrants compared to Italian TB patients, while indicators of socioeconomic status, income and housing conditions were worst in migrants. Forty-six percent of migrants were severely deprived vs. 9% of Italians (p<0.0001, 11.3% and 5.5% among younger and older Italians, respectively). Among migrants, being male, older, irregular, unemployed, with a shorter time spent in Italy, a lower education level, and without a co-morbidity diagnosis were factors associated with severe material deprivation at multi-variable logistic regression. Moreover, socioeconomic indicators for Italian patients did not differ from those reported for the general Italian population, while migrant TB patients seem to have a higher prevalence of severe material deprivation than other migrants residing in Italy. Intervention to address the needs of this population are urgent. [ABSTRACT FROM AUTHOR]

Background: Country-specific forecasts of the growing non-communicable disease (NCD) burden in ageing HIV-positive patients will be key to guide future HIV policies. We provided the first national forecasts for Italy and the Unites States of America (USA) and quantified direct cost of caring for these increasingly complex patients. Methods and Setting: We adapted an individual-based model of ageing HIV-positive patients to Italy and the USA, which followed patients on HIV-treatment as they aged and developed NCDs (chronic kidney disease, diabetes, dyslipidaemia, hypertension, non-AIDS malignancies, myocardial infarctions and strokes). The models were parameterised using data on 7,469 HIV-positive patients from the Italian Cohort Naïve to Antiretrovirals Foundation Study and 3,748 commercially-insured patients in the USA and extrapolated to national level using national surveillance data. Results: The model predicted that mean age of HIV-positive patients will increase from 46 to 59 in Italy and from 49 to 58 in the USA in 2015–2035. The proportion of patients in Italy and the USA diagnosed with ≥1 NCD is estimated to increase from 64% and 71% in 2015 to 89% and 89% by 2035, respectively, driven by moderate cardiovascular disease (CVD) (hypertension and dyslipidaemia), diabetes and malignancies in both countries. NCD treatment costs as a proportion of total direct HIV costs will increase from 11% to 23% in Italy and from 40% to 56% in the USA in 2015–2035. Conclusions: HIV patient profile in Italy and the USA is shifting to older patients diagnosed with multiple co-morbidity. This will increase NCD treatment costs and require multi-disciplinary patient management. [ABSTRACT FROM AUTHOR]

Background: International migration rapidly increased in the last decade, raising a renewed attention to its impact on public health. We evaluated differences in rubella immunization rate (RIR) between immigrant and Italian women of childbearing age and tried to identify the driving factors causing them. Methods: We analyzed data from the Italian behavioral surveillance system PASSI collected in 2011–2015 in a nationally representative sample of residents in Italy. The analysis was performed using log-binomial models to compare RIR between 41,094 Italian women and 3140 regular immigrant women of childbearing age (18–49 years), stratifying the latter by area of origin and length-of-stay in Italy (recent: ≤ 5-years; mid-term: 6-10-years; long-term: > 10-years). Results: Immigrant women showed a RIR of 36.0% compared to 60.2% among Italian women (RIR-ratio = 0.60, 95% confidence interval (CI): 0.57–0.63). Adjusting for demographic characteristics (i.e., sex, age and area of residence), socio-economic factors (i.e., education, occupation, family composition and economic status) and an indicator of the presence of at least one health-risk behavior (i.e., physical inactivity, current cigarette smoking, excessive alcohol consumption and excess weight) did not significantly change this difference (RIR-ratio = 0.56, 95% CI: 0.53–0.59). Recent immigrants (RIR-ratio = 0.47, 95% CI: 0.42–0.53) and immigrants from high migratory pressure countries (HMPC) in sub-Saharan Africa (RIR-ratio = 0.41, 95% CI: 0.31–0.56) and Asia (RIR-ratio = 0.42, 95% CI: 0.33–0.53) showed the greatest differences in RIR compared with Italian women. Conclusions: Differences in RIR between immigrant and Italian women were not explained by different demographic, socioeconomic and health-risk behaviors characteristics. As entitlement to free-of-charge immunization in Italy is universal, regardless of migration status, other informal barriers (e.g., cultural and barriers to information access) might explain lower RIRs in immigrant women, especially recent immigrants and those from HMPC in sub-Saharan Africa and Asia. Further investigations are needed to identify obstacles and appropriate promotion and access-enabling strategies for rubella immunization. [ABSTRACT FROM AUTHOR]

Infectious bronchitis virus (IBV) represents one of the poultry industry major threats, particularly in high density producing countries. The emergence and spread of new IBV genotypes have frustrated the various disease control efforts implemented over time. Despite that, few comprehensive and large scale studies have been performed to understand the international and local spreading dynamics of this virus. In the present work, these phenomena were evaluated by implementing a Bayesian phylodynamic approach to reconstruct the epidemiological patterns and population history of the QX genotype (currently renamed GI-19 lineage), the most relevant IBV lineage of the Old-World. Our analysis, based on 807 partial S1 sequences of strains collected from 18 countries between 1993 and 2015, demonstrates that this genotype originated in China well before its first identification. After a prolonged local circulation, it started spreading to other European, Asian and Middle East countries in successive waves, which were mirrored by concomitant fluctuations in viral population size. Interestingly, the within-Europe spread was characterized by a higher estimated migration rate compared with the inter-continental one, potentially reflecting the closer geographic and economic relationships among these countries. Nevertheless, the colonization of new states by the GI-19 lineage appeared to occur mostly by single introduction events in both intra and inter-continental spread, likely because of epidemiological factor and health policy combination which seems to prevent the frequent introduction and mixing of different strains. On the other hand, the within Italy QX circulation reconstruction showed a much more intricate connection network among different locations, evidencing the difficulty in controlling IBV spread especially in highly densely poultry populated areas. The presence of several well supported epidemiological links among distantly related Italian regions testifies that animal transportation and indirect transmission routes rather than local airborne diffusion contribute to the QX success and persistence at local scale. Globally, the spreading dynamics and evolution of the QX genotype were reconstructed from its very origin to nowadays, demonstrating the need of more effective direct control measures, particularly within each country. Unfortunately, the incompleteness of available molecular epidemiology data represents an insurmountable limit which leaves many questions currently unsolved, thus highlighting the compulsoriness of a structured monitoring and data sharing system implementation. [ABSTRACT FROM AUTHOR]

Introduction: Animal agriculture has exponentially grown in recent decades in response to the rise in global demand for meat, even in countries like Italy that traditionally eat a Mediterranean, plant-based diet. Globalization related dietary changes are contributing to the epidemic of non-communicable diseases and to the global climate crisis, and are associated with huge carbon and water footprints. The objective of the study is to assess inequalities in health impacts and in attributable greenhouse gases-GHG emissions in Italy by hypothesizing different scenarios of reduction in red and processed meat consumption towards healthier consumption patterns more compliant with the recommendations of the Mediterranean food pyramid. Methods: We used demographic and food consumption patterns from national surveys and risk relationships between meat intake and cardiovascular and colorectal cancer mortality from IARC and other meta-analyses. From the baseline data (year 2005–2006, average 406 gr/week beef and 245 gr/week processed meat), we considered hypothetical meat reduction scenarios according to international dietary guidelines such as the Mediterranean pyramid targets. For each geographical area (Northwest, Northeast, Centre, and South) and gender, we calculated the number of avoidable deaths from colorectal cancer, and cardiovascular disease among the adult population. Moreover, years of life gained by the adult population from 2012 to 2030 and changes in life expectancy of the 2012 birth cohort were quantified using gender-specific life tables. GHG emission reductions under Mediterranean scenario were estimated only for beef by applying the Global Warming Potential (GWP) coefficient to total consumption and to a low carbon food substitution in adult diet. Results: The deaths avoidable (as percentage change compared to baseline) according to the three reduction scenarios for beef consumption were between 2.3% and 4.5% for colorectal cancer, and between 2.1% and 4.0% for cardiovascular disease; higher benefits would be observed in Northwestern areas and among males. In parallel, 5% and 6.4% of colorectal cancer and CVD deaths would be avoided if the Italian population ate the advised quantity of processed meat. Life table analysis suggests that the scenario that is fully compliant with the Mediterranean diet model would save 5 million years of life lost prematurely among men and women over the next 18 years and would increase average life expectancy of future generations by over 7 months. Considering the environmental impact, emissions associated with the actual total intake of beef range from 12,900 to 21,800 Gg CO2 eq; emissions saved according to the Mediterranean scenario are in the range 8000–14000 Gg CO2 eq per year. The per capita reduction is 263 KgCO2eq/year/person with higher reductions in Northwestern and Central areas. Conclusions: In Italy, scenarios for reducing beef consumption are consistent with significant health and environmental co-benefits on current and future generations. Results support introducing policies to promote healthier behavior towards red and processed meat in the adult population within an overall balanced and healthy dietary pattern. Interventions should address gender, vulnerable population groups, and geographical differences in order to be more effective. [ABSTRACT FROM AUTHOR]

Background: The approval of Sativex for the management of multiple sclerosis (MS) spasticity opened a new opportunity to many patients. In Italy, the healthcare payer can be fully reimbursed by the involved pharma company with the cost of treatment for patients not responding after a 4 week (28 days) trial period (Payment by Results, PbR), and 50% reimbursed with the cost of 6 weeks (42 days) treatment for other patients discontinuing (Cost Sharing, CS). The aim of our study was to describe the Sativex discontinuation profile from a large population of spasticity treated Italian MS patients. Methods: We collected data of patients from 30 MS centres across the country starting Sativex between January 2014 and February 2015. Data were collected from the mandatory Italian Medicines Agency (AIFA) web-registry. Predictors of treatment discontinuation were assessed using a multivariate Cox proportional regression analysis. Results: During the observation period 631 out of 1597 (39.5%) patients discontinued Sativex. The Kaplan-Meier estimates curve showed that 333 patients (20.8%) discontinued treatment at 4 weeks while 422 patients (26.4%) discontinued at 6 weeks. We found after adjusted modeling that a higher NRS score at T1 (adjHR 2.23, 95% 2.07–2.41, p<0.001) and a lower baseline NRS score (adjHR 0.51 95% CI 0.46–0.56, p<0.001) were predictive of treatment discontinuation. Conclusion: These data show that the first 6 weeks are useful in identifying those patients in which Sativex could be effective, thus avoiding the cost of longer term evaluation. [ABSTRACT FROM AUTHOR]

Background: Cystic echinococcosis (CE) is an important neglected zoonotic parasitic infection belonging to the subgroup of seven Neglected Zoonotic Disease (NZDs) included in the World Health Organization’s official list of 18 Neglected Tropical Diseases (NTDs). CE causes serious global human health concerns and leads to significant economic losses arising from the costs of medical treatment, morbidity, life impairments and fatality rates in human cases. Moreover, CE is endemic in several Italian Regions. The aim of this study is to perform a detailed analysis of the economic burden of hospitalization and treatment costs and to estimate the Disability Adjusted Life Years (DALYs) of CE in Italy. Methods and findings: In the period from 2001 to 2014, the direct costs of 21,050 Hospital Discharge Records (HDRs) belonging to 12,619 patients with at least one CE-related diagnosis codes were analyzed in order to quantify the economic burden of CE. CE cases average per annum are 901 (min—max = 480–1,583). Direct costs include expenses for hospitalizations, medical and surgical treatment incurred by public and private hospitals and were computed on an individual basis according to Italian Health Ministry legislation. Moreover, we estimated the DALYs for each patient. The Italian financial burden of CE is around € 53 million; the national average economic burden per annum is around € 4 million; the DALYs of the population from 2001 to 2014 are 223.35 annually and 5.26 DALYs per 105 inhabitants. Conclusion: In Italy, human CE is responsible for significant economic losses in the public health sector. In humans, costs associated with CE have been shown to have a great impact on affected individuals, their families and the community as a whole. This study could be used as a tool to prioritize and make decisions with regard to a surveillance system for this largely preventable yet neglected disease. It demonstrates the need of implementing a CE control program aimed at preventing the considerable economic and social losses it causes in high incidence areas. [ABSTRACT FROM AUTHOR]

Several studies have demonstrated the efficacy of the oral pre-exposure prophylaxis (PrEP) with tenofovir (with or without emtricitabine) on preventing HIV-negative partners of HIV infected patients to become infected through sexual contacts. PrEP is already available in the United States and now is approved by European Medicine Agency. In this setting we would like to gauge physicians’ knowledge, acquaintance with and attitude to include PrEP in their clinical practice. A cross sectional survey was conducted among Italian physicians expert on antiretroviral therapy. Out of 146 physicians, 35% of participants declared to be familiar with PrEP but only 46% of them believed that, currently, there are not enough reasons to make it available in Italy. 51% of physicians have already been attracted to prescribe it and 63.4% have been openly asked about PrEP. The main concerns noticed were: the risk of acquire other sexual transmitted diseases (STDs) (70% of physicians feared that PrEP could favor STDs spread), the potential harmful of PrEP if not adequately implemented and, especially the risk of possible side effects if not properly used. Nevertheless, 55.9% of participants believed that Health Authorities face an ethical obligation to make PrEP available as part of the strategies to protect from HIV transmission and half of the respondents asked for further researches to better define the role for PrEP. Attitudes regarding PrEP impact on Italian National Health Organization were also very interesting: 57.5% of participants did not believe that investing in PrEP would be an appropriate use of healthcare resources, while 70.6% affirmed that PrEP’s financial coverage should not be funded by the Italian National System of Health (SSN). This survey showed a high awareness of PrEP potential among Italian physicians coupled with a great deal of skepticism about how and if implementing it in clinical practice. [ABSTRACT FROM AUTHOR]

West Nile virus lineage 2 (WNV-2) was mainly confined to sub-Saharan Africa until the early 2000s, when it was identified for the first time in Central Europe causing outbreaks of human and animal infection. The aim of this study was to reconstruct the origin and dispersion of WNV-2 in Central Europe and Italy on a phylodynamic and phylogeographical basis. To this aim, discrete and continuous space phylogeographical models were applied to a total of 33 newly characterised full-length viral genomes obtained from mosquitoes, birds and humans in Northern Italy in the years 2013–2015 aligned with 64 complete sequences isolated mainly in Europe. The European isolates segregated into two highly significant clades: a small one including three sequences and a large clade including the majority of isolates obtained in Central Europe since 2004. Discrete phylogeographical analysis showed that the most probable location of the root of the largest European clade was in Hungary a mean 12.78 years ago. The European clade bifurcated into two highly supported subclades: one including most of the Central/East European isolates and the other encompassing all of the isolates obtained in Greece. The continuous space phylogeographical analysis of the Italian clade showed that WNV-2 entered Italy in about 2008, probably by crossing the Adriatic sea and reaching a central area of the Po Valley. The epidemic then spread simultaneously eastward, to reach the region of the Po delta in 2013, and westward to the border area between Lombardy and Piedmont in 2014; later, the western strain changed direction southward, and reached the central area of the Po valley once again in 2015. Over a period of about seven years, the virus spread all over an area of northern Italy by following the Po river and its main tributaries. [ABSTRACT FROM AUTHOR]

Land quality, a key economic capital supporting local development, is affected by biophysical and anthropogenic factors. Taken as a relevant attribute of economic systems, land quality has shaped the territorial organization of any given region influencing localization of agriculture, industry and settlements. In regions with long-established human-landscape interactions, such as the Mediterranean basin, land quality has determined social disparities and polarization in the use of land, reflecting the action of geographical gradients based on elevation and population density. The present study investigates latent relationships within a large set of indicators profiling local communities and land quality on a fine-grained resolution scale in Italy with the aim to assess the potential impact of land quality on the regional socioeconomic structure. The importance of land quality gradients in the socioeconomic configuration of urban and rural regions was verified analyzing the distribution of 149 socioeconomic and environmental indicators organized in 5 themes and 17 research dimensions. Agriculture, income, education and labour market variables discriminate areas with high land quality from areas with low land quality. While differential land quality in peri-urban areas may reflect conflicts between competing actors, moderate (or low) quality of land in rural districts is associated with depopulation, land abandonment, subsidence agriculture, unemployment and low educational levels. We conclude that the socioeconomic profile of local communities has been influenced by land quality in a different way along urban-rural gradients. Policies integrating environmental and socioeconomic measures are required to consider land quality as a pivotal target for sustainable development. Regional planning will benefit from an in-depth understanding of place-specific relationships between local communities and the environment. [ABSTRACT FROM AUTHOR]

Background: Real-life data on access and response to direct antiviral agents (DAA) in HIV-HCV coinfected individuals are lacking. Methods: HCV viremic, HIV-positive patients from Icona and Hepaicona cohorts naïve to DAA by January 2013 were included. Access and predictors of starting DAA were evaluated. Switches of antiretroviral drugs at starting DAA were described. We calculated sustained virological response (SVR12) in those reaching 12 weeks after end-of-treatment (EOT), and defined treatment failure (TF) as discontinuation of DAA before EOT or non-SVR12. Statistical analyses included Kaplan-Meier curves, univariable and multivariable analyses evaluating predictors of access to DAA and of treatment outcome (non-SVR and TF). Results: 2,607 patients included. During a median follow-up of 38 (IQR:30–41) months, 920 (35.3%) patients started DAA. Eligibility for reimbursement was the strongest predictor to access to treatment: 761/1,090 (69.8%) eligible and 159/1,517 (10.5%) non-eligible to DAA reimbursement. Older age, HIV-RNA≤50 copies/mL were associated to faster DAA initiation, higher CD4 count and HCV-genotype 3 with delayed DAA initiation in those eligible to DAA reimbursement. Up to 28% of patients (36% of those on ritonavir-boosted protease inhibitors, PI/r) underwent antiretroviral (ART) modification at DAA initiation. 545/595 (91.6%) patients reaching EOT achieved SVR12. Overall, TF occurred in 61/606 patients (10.1%), with 11 discontinuing DAA before EOT. Suboptimal DAA was the only independent predictor of both non-SVR12 (AHR 2.52, 95%CI:1.24–5.12) and TF (AHR: 2.19; 95%CI:1.13–4.22). Conclusions: Only 35.3% had access to HCV treatment. Despite excellent rates of SVR12 rates (91.6%), only 21% (545/2,607) of our HIV-HCV co-infected patients are cured. [ABSTRACT FROM AUTHOR]

Purpose: During economic recession people with mental health problems have higher risk of losing their job. This paper analyses the issue by considering the Italian rates of unemployment amongst individuals with and without mental health problems in 2005 and 2013, that is prior and during the economic crisis. Methods: We used data from the National surveys on “Health conditions and use of health services” carried out by the Italian National Institute of Statistics (ISTAT) for the years 2005 and 2013. The surveys collected information on the health status and socioeconomic conditions of the Italian population. Self-reported unemployment status was analysed amongst individuals with and without reported mental health problems. In addition, descriptive statistics were performed in order to detect possible differences in the risk of unemployment within different regional contexts characterised by different socio-economic conditions. Results: The recession determined increased disparities in unemployment rates between people with and without mental health problems. Regardless to the presence of mental health problems, young people were more likely to be unemployed. Among people who reported mental health problems, males were more likely to be unemployed than females. People with low education level were more likely to be unemployed, particularly during the recession and in presence of mental health problems. Changes in unemployment rates due to the crisis showed different patterns across different regions of the Country. Conclusions: These analyses confirm that in periods of economic crisis people with mental health problems are at risk of experiencing exclusion from labour market. In addition, the impact is even worse within the group with low education and younger age. These findings emphasise the importance of specific interventions aimed at promoting labour market participation and reintegration for people with mental health problems. [ABSTRACT FROM AUTHOR]

The monitoring of seasonal influenza yearly epidemics remains one of the main activity of national syndromic surveillance systems. The development of internet-based surveillance tools has brought an innovative approach to seasonal influenza surveillance by directly involving self-selected volunteers among the general population reporting their health status on a weekly basis throughout the flu season. In this paper, we explore how Influweb, an internet-based monitoring system for influenza surveillance, deployed in Italy since 2008 has performed during three years from 2012 to 2015 in comparison with data collected during the same period by the Italian sentinel doctors surveillance system. [ABSTRACT FROM AUTHOR]

The aim of this multicentre study was to assess incidence of influenza like illness (ILI) among Italian medical residents (MRs) during 2011–2012 influenza season, to detect variables associated with ILI and to compare estimated ILI incidence among MRs and general population. A cross-sectional survey was carried out throughout an anonymous questionnaire administered to all MRs attending the post-graduate medical schools of 18 Italian Universities. At the same time an analysis of the ILI incidence in the Italian general population was conducted through the Italian Influenza Surveillance Network. Of a total of 2,506 MRs, 1,191 (47.5%) reported at least one ILI episode. A higher proportion of ILIs was reported by MRs of Central (25.0% with ILI vs 20.2% without ILI) and Southern Italy (40.2% with ILI vs. 36.4 without ILI) compared to Northern Italy (34.8% with ILI vs. 43.4% without ILI) (p<0.001). Italian MRs had a higher cumulative incidence of ILIs (546.7 episodes per 1,000 vs. 75.9 episodes per 1,000) and an earlier peak (January 2012 vs. February 2012), compared to general population due to higher number of contacts in hospital setting. MRs reported a high rate of ILI infection probably in association with their working activities. These data suggest the need to offer an earlier influenza vaccination to HCWs than general population with the aim to both prevent ILI and its transmission to patients. [ABSTRACT FROM AUTHOR]

Background: Due to their increased vulnerability, immigrants are considered a priority group for communicable disease prevention and control in Europe. This study aims to compare influenza vaccination coverage (IVC) between regular immigrants and Italian citizens at risk for its complications and evaluate factors affecting differences. Methods: Based on data collected by the National Institute of Statistics during a population-based cross-sectional survey conducted in Italy in 2012–2013, we analysed information on 42,048 adult residents (≥ 18 years) at risk for influenza-related complications and with free access to vaccination (elderly residents ≥ 65 years and residents with specific chronic diseases). We compared IVC between 885 regular immigrants and 41,163 Italian citizens using log-binomial models and stratifying immigrants by area of origin and length of stay in Italy (recent: < 10 years; long-term: ≥ 10 years). Results: IVC among all immigrants was 16.9% compared to 40.2% among Italian citizens (vaccination coverage ratio (VCR) = 0.42, 95% confidence interval (CI): 0.36–0.49). Adjusting for sex, age and area of residence, this difference was greatly reduced but remained statistically significant (VCR = 0.71, 95 CI: 0.61–0.81). Further adjustment for socio-economic factors (education, occupation, family composition and economic status) and a composite indicator of health-services utilization did not affect the difference (VCR = 0.78, 95% CI: 0.68–0.90). However, after adjustments, only long-term immigrants from Africa (VCR = 0.49, 95% CI: 0.28–0.85) and recent immigrants (VCR = 0.58, 95% CI: 0.43–0.78) showed a significantly different IVC compared to Italian citizens. Conclusions: Differences in demographic characteristics, socio-economic conditions and health-services utilization explained the reduced IVC in most long-term immigrants compared to Italian citizens. By contrast, these differences did not explain the reduced IVC in long-term immigrants from Africa and recent immigrants. This suggests that IVC in these sub-groups is affected by other informal barriers (e.g., cultural and linguistic) that need to be investigated to promote effective immunization access strategies. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate vitamin D status in internationally adopted children at first medical evaluation in Italy and to identify possible risk factors for hypovitaminosis D in this population. Methods: 25-hydroxyvitamin D [25(OH)D] levels were analyzed in internationally adopted children consecutively recruited at one Italian Center between 2010 and 2014 as part of the first screening protocol. Demographic, clinical and laboratory data were prospectively collected. Serum 25(OH)D levels <10 ng/mL, <20 ng/mL, and <30 ng/mL were used to define severe vitamin D deficiency, vitamin D deficiency and hypovitaminosis D, respectively. Results: 962 internationally adopted children (median age: 5.47 years; IQR:3.14–7.93) were included in the study. Median 25(OH)D level was 22.0 ng/mL (IQR:15.0–30.0 ng/mL); 710/962 (73.8%) children showed hypovitaminosis D (<30 ng/mL), 388/962 (40.3%) had vitamin D deficiency (<20 ng/dL), and 92/962 (9.6%) had severe vitamin D deficiency (<10ng/mL). No case of clinical rickets was observed. Hypovitaminosis D was particularly frequent (>90%) in children adopted from Ethiopia, Peru, India, Bulgaria and Lithuania. At multivariate analysis an increased risk of hypovitaminosis D was found to be associated with: age ≥ 6 years, time spent in Italy ≥ 3 months, blood sample taken in winter, spring or fall, compared to summer. Gender, ethnicity/continent of origin, tubercular infection, intestinal parassitosis and BMI-z-score < -2 were not associated with vitamin D status. Conclusion: Hypovitaminosis D is common in internationally adopted children, from all ethnic group. The evaluation of serum 25(OH)D level could be useful early after the adoption to promptly start vitamin D supplementation/treatment if needed. [ABSTRACT FROM AUTHOR]

This article is a first application of an integrable nonautonomous Lotka–Volterra (LV) model to the study of tourism dynamics. In particular, we analyze the interaction in terms of touristic flows among three Italian regions. Confirming an hypothesis advanced by recent theoretical works, we find that these regions not only compete against each other, but at times they also proceed in mutualism. Moreover, the kind and the intensity of the interaction changes over time, suggesting that dynamic models can play a vital role in the study of touristic flows. [ABSTRACT FROM AUTHOR]