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Thomsen AS, Petersen MP, Willesen JL, Bach MBT, Kieler IN, Kristensen AT, Koch J, Nielsen LN. Clinical bleeding diathesis, laboratory haemostatic aberrations and survival in dogs infected with Angiostrongylus vasorum: 180 cases (2005-2019). J Small Anim Pract 2024; 65:234-242. [PMID: 38332620 DOI: 10.1111/jsap.13701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 10/25/2023] [Accepted: 12/06/2023] [Indexed: 02/10/2024]
Abstract
OBJECTIVES Bleeding diathesis is a complication in dogs infected with Angiostrongylus vasorum. This retrospective study investigated clinical and laboratory haemostatic differences in A. vasorum-positive dogs with and without signs of bleeding and impact of bleeding on survival. MATERIALS AND METHODS Demographics, type of clinical bleeding, haematocrit and a range of haemostatic tests, including thromboelastography and derived velocity curves were retrospectively registered from A. vasorum-positive dogs. All parameters were compared between dogs with and without signs of bleeding using univariable analyses. Binomial and multinomial regression models were applied to examine specific indicators in the bleeding dogs. P-values were false discovery rate adjusted, and adjusted P<0.05 was considered significant. RESULTS One hundred and eighty dogs entered the study, including 65 dogs (36.1%) presenting with bleeding diathesis. Different types of cutaneous and mucosal bleeding were the most common clinical findings. Twenty dogs presented with neurological signs associated with intracranial and intra-spinal bleeding. One hundred and thirty-seven dogs had haematological and/or haemostatic laboratory analyses performed. Haematocrit, platelet count, thromboelastographic angle, maximum amplitude, global clot strength, maximum rate of thrombin generation and total thrombin generation were decreased, while prothrombin time was prolonged in bleeding dogs. Survival rate of bleeding dogs was lower at hospital discharge (76.9%) and 1 month after diagnosis (66.0%) than in dogs without signs of bleeding (94.8% and 90.1% at discharge and at 1 month, respectively). CLINICAL SIGNIFICANCE Several haemostatic aberrations were detected in A. vasorum-positive dogs with bleeding diathesis. Bleeding was identified as an important negative prognostic indicator in A. vasorum-positive dogs.
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Affiliation(s)
- A S Thomsen
- Dyrlaegehuset Gentofte, Brogaardsvej 10, 2820, Gentofte, Denmark
| | - M P Petersen
- Vejen Dyrehospital, Oestergade 12, 6600, Vejen, Denmark
| | - J L Willesen
- Department of Veterinary Clinical Sciences, University of Copenhagen, Dyrlaegevej 16, Copenhagen, Denmark
| | - M B T Bach
- Department of Veterinary Clinical Sciences, University of Copenhagen, Dyrlaegevej 16, Copenhagen, Denmark
| | - I N Kieler
- Department of Veterinary Clinical Sciences, University of Copenhagen, Dyrlaegevej 16, Copenhagen, Denmark
| | - A T Kristensen
- Department of Veterinary Clinical Sciences, University of Copenhagen, Dyrlaegevej 16, Copenhagen, Denmark
| | - J Koch
- Department of Veterinary Clinical Sciences, University of Copenhagen, Dyrlaegevej 16, Copenhagen, Denmark
| | - L N Nielsen
- Department of Veterinary Clinical Sciences, University of Copenhagen, Dyrlaegevej 16, Copenhagen, Denmark
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Martini F, Rostaher A, Favrot C, Fischer N. Interleukin 10 and transforming growth factor-beta 1 plasma levels in atopic dogs before and during immunotherapy. Vet Rec 2021; 190:e1270. [PMID: 34939678 DOI: 10.1002/vetr.1270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/28/2021] [Accepted: 11/28/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Human studies suggest that the cytokines, interleukin 10 (IL-10) and transforming growth factor-beta 1 (TGF-ß1) may play an important role in allergen-specific immunotherapy (ASIT). However, there is little known about the function of these cytokines in atopic dogs. This study compared the plasma levels of IL-10 and TGF-ß1 in atopic and control dogs and investigated their changes during different ASIT approaches. METHODS A total of 54 atopic and 32 control dogs were included. Immunotherapy was performed in 30 atopic dogs. The dogs undergoing immunotherapy were allocated to four groups of different ASIT approaches (namely subcutaneous, intralymphatic, sublingual ASIT and subcutaneous ASIT with recombinant allergens). Blood samples were collected at four timepoints throughout the one year of ASIT. Canine atopic dermatitis extent and severity index, pruritus visual analogue scale and medication score were recorded at each timepoint. Commercially available ELISA kits were used to quantify IL-10 and TGF-ß1 in plasma. RESULTS There was no significant difference in IL-10 and TGF-ß1 between atopic and control dogs. The IL-10 levels were significantly increased in the intralymphatic group at the end of the study. No significant differences were found in the other groups for both IL-10 and TGF-ß1. CONCLUSION The findings of this work suggest that IL-10 and TGF-ß1 cannot be used to monitor the course of the disease during ASIT.
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Affiliation(s)
- Franco Martini
- Dermatology Department, Clinic for Small Animal Internal Medicine, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Ana Rostaher
- Dermatology Department, Clinic for Small Animal Internal Medicine, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Claude Favrot
- Dermatology Department, Clinic for Small Animal Internal Medicine, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Nina Fischer
- Dermatology Department, Clinic for Small Animal Internal Medicine, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
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Silva LMR, Hindenberg S, Balzhäuser L, Moritz A, Hermosilla C, Taubert A. Pneumothorax in a persistent canine Angiostrongylus vasorum infection. Vet Parasitol Reg Stud Reports 2021; 26:100650. [PMID: 34879961 DOI: 10.1016/j.vprsr.2021.100650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/17/2021] [Accepted: 09/27/2021] [Indexed: 11/15/2022]
Abstract
Canine angiostrongylosis is a gastropod-borne parasitosis caused by the cosmopolitan nematode Angiostrongylus vasorum. It is associated with cardiorespiratory disorders and eventually fatal coagulopathies. A 6-months-old female dog previously diagnosed with bronchopneumonia and pneumothorax, treated accordingly without success, was hospitalized for further treatment. Complementary diagnostics confirmed previous findings plus pneumomediastinum, thoracic exudate, leucocytosis, thrombocytosis, hypercoagulability, and hyperglobulinemia. Coprological analysis showed a severe patent A. vasorum infection. After the third daily fenbendazole administration, all A. vasorum larvae were found dead in follow-up coprological analyses while in intensive care. Upon release, the dog was monitored until full clinical recovery 3 months later. Up to date, A. vasorum infection-related pneumothorax was rarely described, particularly with full recovery of such a young patient. Thus, a parasitological aetiology should be considered for dogs with severe bronchopneumonia or pneumothorax, especially in Europe and South America where increasing numbers of canine angiostrongylosis cases call for enhanced awareness of veterinary practitioners.
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Affiliation(s)
- L M R Silva
- Institute of Parasitology, Justus Liebig University Giessen, Schubert Str. 81, 35392 Giessen, Germany.
| | - S Hindenberg
- Department of Veterinary Clinical Sciences, Clinical Pathology and Clinical Pathophysiology, Justus Liebig University Giessen, Frankfurter Str. 114, 35392 Giessen, Germany
| | - L Balzhäuser
- Clinic for Small Animals, Internal Medicine, Faculty of Veterinary Medicine, Justus Liebig University Giessen, Frankfurter Str. 114, 35392 Giessen, Germany
| | - A Moritz
- Department of Veterinary Clinical Sciences, Clinical Pathology and Clinical Pathophysiology, Justus Liebig University Giessen, Frankfurter Str. 114, 35392 Giessen, Germany; Clinic for Small Animals, Internal Medicine, Faculty of Veterinary Medicine, Justus Liebig University Giessen, Frankfurter Str. 114, 35392 Giessen, Germany
| | - C Hermosilla
- Institute of Parasitology, Justus Liebig University Giessen, Schubert Str. 81, 35392 Giessen, Germany
| | - A Taubert
- Institute of Parasitology, Justus Liebig University Giessen, Schubert Str. 81, 35392 Giessen, Germany
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Bochniarz M, Zdzisińska B, Wawron W, Szczubiał M, Dąbrowski R. Milk and serum IL-4, IL-6, IL-10, and amyloid A concentrations in cows with subclinical mastitis caused by coagulase-negative staphylococci. J Dairy Sci 2017; 100:9674-9680. [PMID: 28964518 DOI: 10.3168/jds.2017-13552] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/17/2017] [Indexed: 01/22/2023]
Abstract
The aim of the study was to evaluate the concentrations of cytokines IL-4, IL-6, and IL-10 and acute phase protein amyloid A in milk and in serum from cows with subclinical mastitis caused by coagulase-negative staphylococci and from healthy cows. The blood and milk samples were obtained from 35 midlactation, multiparous (between parities 2 and 4) Holstein-Friesian cows. In the milk samples from 20 cows with subclinical mastitis, the following species of Staphylococcus were detected: Staphylococcus xylosus (8 samples), Staphylococcus chromogenes (6 samples), Staphylococcus haemolyticus (2 samples), Staphylococcus simulans (2 samples), and Staphylococcus sciuri (2 samples). The results of the present study indicate that the level of IL-6 in cows suffering from subclinical mastitis tended to be high in both serum and milk (432.09 and 254.32 pg/mL) compared with the level in healthy cows (164.47 and 13.02 pg/mL, respectively). Amyloid A value also was significantly higher in milk of unhealthy cows compared with cows without subclinical mastitis (790.2 and 360.5 ng/mL). No significant differences were found in levels of amyloid A in serum of both tested groups of cows (2,680.0 and 2,720.0 ng/mL). In contrast, concentration of IL-4 was significantly lower both in serum and in milk of cows with staphylococcal mastitis (86.1 and 123.17 pg/mL) compared with control animals (413.5 and 670.2 pg/mL). The level of IL-10 also was significantly higher in milk of healthy cows than in infected cows (39.78 and 22.5 pg/mL); however, differences in serum levels of this cytokine between tested groups were significantly less important (220.6 and 175.1 pg/mL).
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Affiliation(s)
- Mariola Bochniarz
- Department and Clinic of Animal Reproduction, Faculty of Veterinary Medicine, University of Life Sciences, Gleboka 30, 21-612 Lublin, Poland.
| | - Barbara Zdzisińska
- Department of Virology and Immunology, Maria Curie-Sklodowska University, Akademicka 19, 20-033 Lublin, Poland
| | - Władysław Wawron
- Department and Clinic of Animal Reproduction, Faculty of Veterinary Medicine, University of Life Sciences, Gleboka 30, 21-612 Lublin, Poland
| | - Marek Szczubiał
- Department and Clinic of Animal Reproduction, Faculty of Veterinary Medicine, University of Life Sciences, Gleboka 30, 21-612 Lublin, Poland
| | - Roman Dąbrowski
- Department and Clinic of Animal Reproduction, Faculty of Veterinary Medicine, University of Life Sciences, Gleboka 30, 21-612 Lublin, Poland
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Karlsson I, Hagman R, Johannisson A, Wang L, Södersten F, Wernersson S. Multiplex cytokine analyses in dogs with pyometra suggest involvement of KC-like chemokine in canine bacterial sepsis. Vet Immunol Immunopathol 2016; 170:41-6. [PMID: 26837616 DOI: 10.1016/j.vetimm.2016.01.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 12/18/2015] [Accepted: 01/18/2016] [Indexed: 12/17/2022]
Abstract
Clinical diagnostic criteria for sepsis (systemic inflammatory response syndrome caused by infection) are unspecific and, therefore, biomarkers for sepsis diagnosis are needed for appropriate treatment and patient survival. Pyometra, a common disease caused by bacterial infection of the uterus, results in sepsis in nearly 60% of cases in dogs. We used dogs with pyometra as a natural model for sepsis and collected serum samples from 39 dogs, of which 22 with pyometra and 17 healthy controls. Dogs with pyometra were further grouped into dogs with sepsis (n=18) and without sepsis (n=4). Serum concentrations of a panel of cytokines, including keratinocyte-derived chemokine (KC)-like, granulocyte-macrophages colony stimulating factor (GM-CSF), interleukin (IL)-2, IL-4, IL-6, IL-7, IL-8, IL-10, IL-15, IL-18, chemokine C-X-C motif ligand (CXCL)10 and tumor necrosis factor (TNF)-α, were measured using multiplex analyses. Serum C-reactive protein (CRP) levels were determined using an automated immunoturbidimetric assay. In addition to physical examination hematological and serum biochemical analyses were performed to evaluate the overall status of the dogs. Significantly higher concentrations of KC-like (757 vs 304 pg/ml) were detected in dogs with pyometra as compared to healthy dogs. Within the pyometra group, dogs with sepsis compared to dogs without sepsis had a higher KC-like concentration (873 vs 300 pg/ml). Hemoglobin levels were significantly lower in dogs with pyometra compared to healthy dogs, regardless of the presence or absence of sepsis, and correlated negatively with KC-like. KC-like concentrations correlated positively with CRP, number of hospitalization days, number of monocytes, concentrations of IL-8, and percentage band neutrophils. Our data suggest that bacterial infection triggers the expression of KC-like and further studies are warranted of KC-like as a possible biomarker for diagnosing sepsis and uterine bacterial infection in dogs.
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Affiliation(s)
- Iulia Karlsson
- Dept of Anatomy, Physiology and Biochemistry, Swedish University of Agricultural Sciences, Box 7011, SE-75007 Uppsala, Sweden
| | - Ragnvi Hagman
- Dept of Clinical Sciences, Swedish University of Agricultural Sciences, Box 7054, SE-75007 Uppsala, Sweden
| | - Anders Johannisson
- Dept of Clinical Sciences, Swedish University of Agricultural Sciences, Box 7054, SE-75007 Uppsala, Sweden
| | - Liya Wang
- Dept of Anatomy, Physiology and Biochemistry, Swedish University of Agricultural Sciences, Box 7011, SE-75007 Uppsala, Sweden
| | - Fredrik Södersten
- Dept of Biomedical Science and Veterinary Public Health, Swedish University of Agricultural Sciences, Box 7028, SE-75007 Uppsala, Sweden
| | - Sara Wernersson
- Dept of Anatomy, Physiology and Biochemistry, Swedish University of Agricultural Sciences, Box 7011, SE-75007 Uppsala, Sweden.
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Dąbrowski R, Pastor J, Szczubiał M, Piech T, Bochniarz M, Wawron W, Tvarijonaviciute A. Serum IL-6 and IL-10 concentrations in bitches with pyometra undergoing ovariohysterectomy. Acta Vet Scand 2015; 57:61. [PMID: 26410584 PMCID: PMC4584008 DOI: 10.1186/s13028-015-0153-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 09/21/2015] [Indexed: 11/29/2022] Open
Abstract
Background Pyometra is a serious bacterial infection of the uterus affecting female dogs and manifests as an accumulation of pus in the uterine lumen. The aim of the study was to assess changes in serum interleukin (IL)-6 and IL-10 concentrations in bitches with pyometra undergoing ovariohysterectomy. Findings Blood samples were collected from healthy bitches (controls) and bitches with pyometra before surgery, and 3 and 10 days after ovariohysterectomy. Before surgery, bitches with pyometra had significantly higher serum concentrations of IL-6 and IL-10 than the controls. After surgery, the serum concentration of IL-6 and IL-10 decreased significantly. In healthy dogs, the concentration of IL-6 and IL-10 showed a significant increase 3 days after surgery followed by a decrease on day 10. Conclusion An increase in serum concentrations of IL-6 and IL-10 was present before surgery in bitches with pyometra and 3 days after ovariohysterectomy in healthy controls. Concentrations decreased after ovariohysterectomy and/or proper healing, suggesting that these cytokines can be useful for assessment of the postoperative period in bitches.
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Bukowska D, Kempisty B, Zawierucha P, Ciesiółka S, Piotrowska H, Jopek K, Antosik P, Brüssow K, Nowicki M, Bruska M, Zabel M, Jaśkowski J. Microarray Analysis of Antigen-Dependent B-Cell Activation Gene Expression in Bitches with Pyometra. EUR J INFLAMM 2014. [DOI: 10.1177/1721727x1401200311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Canine pyometra is defined as a complex disease associated with activation and proliferation of immune specific cells, B and T cells, as well as synthesis and activation of immune and pro-inflammatory molecules. Although all of these mechanisms are well recognized in several human immune diseases and cancers, the possible role or dysfunction of these molecules in dogs with pyometra still requires investigation. This study was aimed to examine antigen-dependent B-cell activation gene expression (CD4, CD28, CD40, CD80, Fas, HLA-DRB1 and IL10) in a total of 24 mixed-breed bitch uteri with pyometra and 20 healthy controls. Using canine RNA microarray assays (Affymetrix) altogether 17,138 different transcripts were analyzed. A significant increase was found of CD28, CD40, HLA-DRB1 (P<0.001), and CD4, CD80, Fas and IL10 (P<0.01) in the group of bitches with pyometra, as compared to controls. In the affected group an increased share of CD4, CD28, CD40, CD80, Fas, HLA-DRB1 and IL10, (13.6-, 2.8-, 2.9-, 5.6-, 3.3-, 4.4-, and 6.5-fold increase, respectively) was also detected. It is suggested that an increased expression of B cell-specific immune response molecules may be associated with recruitment of immunologically specific cells in bitches with pyometra as well as with activation of pro-inflammatory proteins as a consequence of exposure to foreign antigens due to bacterial infection.
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Affiliation(s)
- D. Bukowska
- Institute of Veterinary Sciences, Faculty of Animal Breeding and Biology, Poznan University of Life Sciences, Poznan, Poland
| | - B. Kempisty
- Department of Histology and Embryology, Medicine Faculty II, Poznan University of Medical Sciences, Poznan, Poland
- Department of Anatomy, Medicine Faculty II, Poznan University of Medical Sciences, Poznan, Poland
| | - P. Zawierucha
- Department of Histology and Embryology, Medicine Faculty II, Poznan University of Medical Sciences, Poznan, Poland
- Department of Anatomy, Medicine Faculty II, Poznan University of Medical Sciences, Poznan, Poland
| | - S. Ciesiółka
- Department of Histology and Embryology, Medicine Faculty II, Poznan University of Medical Sciences, Poznan, Poland
| | - H. Piotrowska
- Department of Toxicology, Poznan University of Medical Sciences, Poznan, Poland
| | - K. Jopek
- Department of Histology and Embryology, Medicine Faculty II, Poznan University of Medical Sciences, Poznan, Poland
| | - P. Antosik
- Institute of Veterinary Sciences, Faculty of Animal Breeding and Biology, Poznan University of Life Sciences, Poznan, Poland
| | - K.P. Brüssow
- Institute of Reproductive Biology, Department of Experimental Reproductive Biology, Leibniz Institute for Farm Animal Biology, Dummerstorf, Germany
| | - M. Nowicki
- Department of Histology and Embryology, Medicine Faculty II, Poznan University of Medical Sciences, Poznan, Poland
| | - M. Bruska
- Department of Anatomy, Medicine Faculty II, Poznan University of Medical Sciences, Poznan, Poland
| | - M. Zabel
- Department of Histology and Embryology, Medicine Faculty II, Poznan University of Medical Sciences, Poznan, Poland
- Department of Histology and Embriology, Wroclaw Medical University, Wroclaw, Poland
| | - J.M. Jaśkowski
- Institute of Veterinary Sciences, Faculty of Animal Breeding and Biology, Poznan University of Life Sciences, Poznan, Poland
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Dvir E, Mellanby R, Kjelgaard-Hansen M, Schoeman J. Plasma IL-8 concentrations are increased in dogs with spirocercosis. Vet Parasitol 2012; 190:185-90. [DOI: 10.1016/j.vetpar.2012.06.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 06/08/2012] [Accepted: 06/10/2012] [Indexed: 02/04/2023]
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Yu DH, Nho DH, Song RH, Kim SH, Lee MJ, Nemzek JA, Park J. High-mobility group box 1 as a surrogate prognostic marker in dogs with systemic inflammatory response syndrome. J Vet Emerg Crit Care (San Antonio) 2010; 20:298-302. [DOI: 10.1111/j.1476-4431.2010.00539.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Rossi S, Rossi G, Giordano A, Paltrinieri S. Homocysteine Measurement by an Enzymatic Method and Potential Role of Homocysteine as a Biomarker in Dogs. J Vet Diagn Invest 2008; 20:644-9. [DOI: 10.1177/104063870802000520] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In humans, homocysteine (Hcy) is employed to monitor renal, cardiovascular, and other diseases and their complications. The aim of the current study was to define the analytical performances of an enzymatic method not yet validated in dogs for measuring homocysteine, and to assess the possible clinical usefulness of Hcy measurement. Using conventional approaches, the analytical performances were investigated by assessing, imprecision, inaccuracy, and interference of hemoglobin, triglycerides, and bilirubin. The possible clinical usefulness of Hcy determination was assessed by comparing the results of healthy dogs ( n = 8) with those of dogs with heart disease ( n = 10), inflammation ( n = 6), gastrointestinal disorders ( n = 7), neoplasia ( n = 8), renal failure ( n = 4), trauma ( n = 7), and other miscellaneous diseases ( n = 6). Preliminary evaluation of this enzymatic method showed it to be precise at Hcy levels close to or higher than the values in dogs with renal or cardiac disorders that had the highest Hcy levels. By contrast, at low Hcy levels, which were recorded basically in control dogs, the method suffers from high imprecision. The sample of choice is serum. The use of icteric samples should be avoided, while hemoglobin and lipids have only a minor effect on Hcy measurement. In conclusion, the enzymatic method employed in the current study provides useful information in dogs and could be used to monitor cardiac and renal disorders, in which Hcy concentrations are elevated.
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Affiliation(s)
- Silvia Rossi
- Veterinary Clinic Malpensa-Samarate, Varese, Italy
| | - Gabriele Rossi
- Department of Veterinary Pathology, Hygiene and Public Health, University of Milan, Milan, Italy
| | - Alessia Giordano
- Department of Veterinary Pathology, Hygiene and Public Health, University of Milan, Milan, Italy
| | - Saverio Paltrinieri
- Department of Veterinary Pathology, Hygiene and Public Health, University of Milan, Milan, Italy
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