Increased reports of measles in the Metropolitan City of Milan, northern Italy, September 2023 to March 2024

Since late 2023, the Metropolitan City of Milan and surrounding areas (northern Italy) have been experiencing a resurgence of measles, with most cases detected starting from January 2024. During this brief period, we observed measles in travellers from endemic areas, participants in international events, vaccinees and healthcare workers. Indigenous cases have also been identified. Even though we have not yet identified large and disruptive outbreaks, strengthening surveillance and vaccination activities is pivotal to help limit the impact of measles spread.

Preliminary results on an autochthonous dengue outbreak in Lombardy Region, Italy, August 2023

In August 2023, six locally acquired dengue virus 1 infections were detected in Lodi province, Lombardy Region, in northern Italy, where the vector Aedes albopictus is present. Four cases were hospitalised, none died. The viruses clustered with Peruvian and Brazilian strains collected between 2021 and 2023. This preliminary report highlights the importance of continued integrated surveillance of imported vector-borne virus infections and the potential for tropical disease outbreaks in highly populated regions of northern Italy where competent vectors are present.

[Reduction of adverse outcome due to COVID-19 infection in a high-risk population: evaluation of an informative intervention through active call by General Practitioners]

BACKGROUND

currently, individuals at risk of adverse outcomes for COVID-19 can access to vaccination and pharmacological interventions. But, during the first epidemic wave, there were no treatments or therapeutic strategies available to reduce adverse outcomes in patients at risk.

OBJECTIVES

to assess the impact of an intervention at 15-month follow-up developed by the Agency for Health Protection of the Metropolitan Area of Milan (ATS Milan) based on telephone triage and consultation by the General Practitioners (GPs) for patient with high-risk for adverse outcomes.

DESIGN

intervention on population.

SETTING AND PARTICIPANTS

a total of 127,292 patients in the ATS aged ≥70 years and with comorbidities associated with an increased risk of dying from COVID-19 infection were identified. Using a specific information system, patients were assigned to their GPs for telephone triage and consultation. GPs inform them about the risks of the disease, non-pharmacological prevention measures, and precautions in contacts with family members and other persons. No specific clinical intervention was carried out, only an information/training intervention was performed.

MAIN OUTCOME MEASURES

by the end of May 2020, 48.613 patients had been contacted and 78.679 had not been contacted. Hazard Ratios (HRs) of infection hospitalisation and death at 3 and 15 months were estimated using Cox regression models adjusted by confounder.

RESULTS

no differences in gender, age class distribution, prevalence of specific diseases, and Charlson Index were found between the two groups (treated such as called patients and not called). Called patients had a higher propensity for influenza and antipneumococcal vaccination and have more comorbidities and greater access to pharmacological therapies. Non-called patients have a greater risk for COVID-19 infection: HR was 3.88 (95%CI 3.48-4.33) at 3 months and 1.28 (95%CI 1.23-1.33) at 15 months; for COVID-19 hospitalization HR was 2.66 (95%CI 2.39-2,95) at 3 months and 1.31 (95%CI 1.25-1.37) at 15 months; for overall mortality HR was 2,52 (95%CI 2.35-2:72) at 3 months and 1.23 (95%CI 1.19-1.27) at 15 months.

CONCLUSIONS

the results of this study show a reduction in hospitalization and deaths and support, in case of pandemic events, the implementation of new care strategies based on adapted stratification systems in order to protect the population's health. This study presents some limits: it is not randomized; a selection bias is present (called patients were those most in contact with the GPs); the intervention is indication-based (on march 2020, the actual benefit of protection and distancing for high-risk groups was unclear), and the adjustment is not able to fully control for confounding. However, this study points out the importance to develop information systems and improve methods to best protect the health of the population in setting of territorial epidemiology.

First SARS-CoV-2 vaccine booster and influenza vaccination: risk assessment of COVID-19 hospitalisation and death

BACKGROUND

the influenza and SARS-CoV-2 viruses share a common respiratory symptomatology and transmission mode. COVID-19 and influenza R0 overlapped in the first epidemic wave. In autumn 2021-winter 2022, the influenza epidemic had a delayed onset compared to pre-COVID-19 years and lower incidence rates than in the pre-pandemic period. The SARS-CoV-2 and influenza vaccination campaign overlapped in 2021-2022.

OBJECTIVES

to evaluate in the SARS-CoV-2 vaccinated cohort the effect of different timing of influenza vaccination on hospitalisations for COVID-19 and overall mortality.

DESIGN

prospective cohort study.

SETTING AND PARTICIPANTS

subjects aged 65 years or older who were administered the first booster dose of SARS-COV-2 vaccine between 01.10.2021 and 01.03.2022. Based on the date of influenza vaccination, subjects were divided into the following 4 different mutually exclusive groups: 1. two vaccinations in the same vaccination session; 2. influenza vaccination following SARS-CoV-2 vaccination; 3. influenza vaccination preceding SARS-CoV-2 vaccination; 4. no influenza vaccination. Using Cox regression models, hazard ratio (HR) and corresponding 95% confidence intervals (95% CI) of hospitalisation and death were estimated for the influenza-vaccinated subjects compared to influenza-unvaccinated subjects.

MAIN OUTCOME MEASURES

ordinary hospital admissions for COVID-19 and general mortality.

RESULTS

the cohort included 618,964 subjects: 16.3% received two vaccinations in the same vaccination session, 8.5% received the influenza vaccination after SARS-CoV-2 vaccination, 33.9% received it before and 41.1% did not receive an influenza vaccination. Those vaccinated against both SARS-CoV-2 and influenza had a combined HR of 0.73 (0.62-0.86) of hospitalisation for COVID-19 and 0.55 (0.49-0.62) of overall mortality compared to those vaccinated against SARS-CoV-2 only.

CONCLUSIONS

influenza vaccination combined with SARS-CoV-2 vaccination increases the protective effect against hospitalisations and overall mortality compared to SARS-CoV-2 vaccination alone. Both organisational and communication actions aimed to promote and encourage vaccination are required.

A Comparison Between Omicron and Earlier COVID-19 Variants' Disease Severity in the Milan Area, Italy

Background

In the context of the fourth wave of the COVID-19 pandemic in Italy, which occurred in correspondence with the outbreak of the Omicron variant, it became fundamental to assess differences in the risk of severe disease between the Omicron variant and the earlier SARS-CoV-2 variants that were still in circulation despite Omicron becoming prevalent.

Methods

We collected data on 2,267 genotyped PCR-positive swab tests and assessed whether the presence of symptoms, risk of hospitalization, and recovery times were significantly different between Omicron and the earlier variants. Multivariable models adjusted for sex, age class, citizenship, comorbidities, and symptomatology allowed assessing the difference in outcomes between Omicron and the earlier variants according to vaccination status and timing of administration.

Results

Compared to the earlier variants in the same period, Omicron was less symptomatic, resulted in fewer hospital admissions for those who were unvaccinated and for those who were already immunized after the booster dose, and was associated with quicker recovery, yet not in subjects with three vaccination doses.

Conclusion

Despite being milder, Omicron's higher transmissibility and vaccine resistance should not lead to underrating its damage potential, especially with regard to hospital and health service saturation.

Genome analysis of Legionella pneumophila ST23 from various countries reveals highly similar strains

ST23 isolated in Italy are analysed by cgMLST and SNP approaches and they are also compared with ST23 from other countries. They are found to be phylogenetically related independently on year, town, or country of isolation.

Legionella pneumophila serogroup 1 (Lp1) sequence type (ST) 23 is one of the most commonly detected STs in Italy where it currently causes all investigated outbreaks. ST23 has caused both epidemic and sporadic cases between 1995 and 2018 and was analysed at genomic level and compared with ST23 isolated in other countries to determine possible similarities and differences. A core genome multi-locus sequence typing (cgMLST), based on a previously described set of 1,521 core genes, and single-nucleotide polymorphisms (SNPs) approaches were applied to an ST23 collection including genomes from Italy, France, Denmark and Scotland. DNAs were automatically extracted, libraries prepared using NextEra library kit and MiSeq sequencing performed. Overall, 63 among clinical and environmental Italian Lp1 isolates and a further seven and 11 ST23 from Denmark and Scotland, respectively, were sequenced, and pangenome analysed. Both cgMLST and SNPs analyses showed very few loci and SNP variations in ST23 genomes. All the ST23 causing outbreaks and sporadic cases in Italy and elsewhere, were phylogenetically related independent of year, town or country of isolation. Distances among the ST23s were further shortened when SNPs due to horizontal gene transfers were removed. The Lp1 ST23 isolated in Italy have kept their monophyletic origin, but they are phylogenetically close also to ST23 from other countries. The ST23 are quite widespread in Italy, and a thorough epidemiological investigation is compelled to determine sources of infection when this ST is identified in both LD sporadic cases and outbreaks.

The early phase of the COVID-19 epidemic in Lombardy, Italy

Background

In the night of February 20, 2020, the first epidemic of the novel coronavirus disease (COVID-19) outside Asia was uncovered by the identification of its first patient in Lombardy region, Italy. In the following weeks, Lombardy experienced a sudden increase in the number of ascertained infections and strict measures were imposed to contain the epidemic spread.

Methods

We analyzed official records of cases occurred in Lombardy to characterize the epidemiology of SARS-CoV-2 during the early phase of the outbreak. A line list of laboratory-confirmed cases was set up and later retrospectively consolidated, using standardized interviews to ascertained cases and their close contacts. We provide estimates of the serial interval, of the basic reproduction number, and of the temporal variation of the net reproduction number of SARS-CoV-2.

Results

Epidemiological investigations detected over 500 cases (median age: 69, IQR: 57–78) before the first COVID-19 diagnosed patient (February 20, 2020), and suggested that SARS-CoV-2 was already circulating in at least 222 out of 1506 (14.7%) municipalities with sustained transmission across all the Lombardy provinces. We estimated the mean serial interval to be 6.6 days (95% CrI, 0.7–19). Our estimates of the basic reproduction number range from 2.6 in Pavia (95% CI, 2.1–3.2) to 3.3 in Milan (95% CI, 2.9–3.8). A decreasing trend in the net reproduction number was observed following the detection of the first case.

Conclusions

At the time of first case notification, COVID-19 was already widespread in the entire Lombardy region. This may explain the large number of critical cases experienced by this region in a very short timeframe. The slight decrease of the reproduction number observed in the early days after February 20, 2020 might be due to increased population awareness and early interventions implemented before the regional lockdown imposed on March 8, 2020.

•

Over 500 cases (median age: 69, IQR: 57–78) declaring symptom onset before the notification of the first case (20 February 2020) were retrospectively detected.

•

SARS-CoV-2 was already circulating in at least 222 out of 1506 (14.7%) municipalities of Lombardy.

•

The estimated mean serial interval was 6.6 days (95% CrI, 0.7–19).

•

The basic reproduction number in the 12 provinces of Lombardy ranged from 2.6 (95% CI, 2.1–3.2) to 3.3 (95% CI, 2.9–3.8).

•

A decreasing trend in the net reproduction number following the detection of the epidemic and the introduction of the first restrictive measures.

Type 1 Diabetes Patients' Practice, Knowledge and Attitudes towards Influenza Immunization

Diabetic patients are at higher risk of developing infectious diseases and severe complications, compared to the general population. Almost no data is available in the literature on influenza immunization in people with type 1 diabetes mellitus (T1DM). As part of a broader project on immunization in diabetic patients, we conducted a cross-sectional study to: (i) report on seasonal influenza coverage rates in T1DM patients, (ii) explore knowledge, attitudes, and practices (KAPs) towards seasonal influenza in this population, and (iii) identify factors associated with vaccine uptake, including the role of family doctors and diabetologists. A survey was administered to 251 T1DM patients attending the Diabetes Clinic at San Raffaele Research Hospital in Milan, Italy and individual-level coverage data were retrieved from immunization registries. Self-reported seasonal influenza immunization coverage was 36%, which decreased to 21.7% when considering regional immunization registries, far below coverage target of 75%. More than a third (36.2%) of T1DM patients were classified as pro-vaccine, 30.7% as hesitant, 17.9% as uninformed, and 15.1% as anti-vaccine. Diabetologists resulted to be the most trusted source of information on vaccines’ benefits and risks (85.3%) and should be more actively involved in preventive interventions. Our study highlights the importance of developing tailored vaccination campaigns for people with diabetes, including hospital-based programs involving diabetes specialists.

[Epidemiology and surveillance of hepatitis E in Italy: data from the SEIEVA surveillance system 2007-2019]

BACKGROUND

hepatitis E is a disease spread all over the world, with endemic levels varying according to ecological and socioeconomic factors. In developing countries, large epidemics spread mainly through contaminated water; in developed countries, hepatitis E has always been considered a sporadic disease, closely associated to the travels to endemic areas, especially in Southeastern Asia. In the last years, this perception is significantly changing, because of an increasing number of autochthonous cases reported in many European countries.

OBJECTIVES

to describe the epidemiological picture of hepatitis E in Italy from 2007 to 2019.

DESIGN

descriptive study based on the cases reported to the special surveillance of acute viral hepatitis (SEIEVA); case-control analytical study for the analysis of risk factors associated with hepatitis E.

SETTING AND PARTICIPANTS

hepatitis E cases reported to SEIEVA in the period 2007-2019.

MAIN OUTCOME MEASURES

number of cases notified by year, percentages of cases exposed to known risk factors, odds ratios.

RESULTS

from January 2007 to June 2019, 385 hepatitis E cases were notified to SEIEVA. The annual number increased from 12 in 2007 to 49 in 2018, the increasing trend continued in 2019, when 39 cases were observed in the first 6 months of the year. Northern and Central Regions reported most of the cases; only a few were diagnosed in Southern Regions. Based on SEIEVA data, the trend of hepatitis E notifications has increased according to the increasing propensity to the differentiated diagnosis, at least until 2018. However, only 46% of suspected cases are tested to detect the presence of anti-HEV IgM antibodies, during the observation period; the percentage of tested cases is significantly lower in the South than in Northern and Central Italy (p<0.001). The reported cases have a median age of 48 years (range: 5-87) and are mostly males (80%); 32% was observed in foreign citizens mainly from endemic areas of South Asia (Bangladesh, India, and Pakistan). In 72.5% of cases, the infection was contracted in Italy. The most frequent risk factor is the consumption of raw or undercooked pork meat, especially sausages (70% of cases), significantly associated with hepatitis E risk (OR 3.0; IC95% 1.4-6.1). Other important risk factors are wild boar sausages consumption (40% of cases, OR 4.6, not statistically significant), and travels to endemic areas during the six weeks before the disease (31% of cases, OR 3.2; IC95% 1.6-6.4).

CONCLUSIONS

hepatitis E can now be considered as endemic even in industrialized countries. In Italy, from 2007 an increasing number of cases has been reported. However, the real impact of HEV infection is still underestimated due to the limited number of clinical centres which perform tests for the search of anti-HEV IgM antibodies in cases of acute hepatitis. An ad hoc surveillance has been activated in January 2019 in some Local Health Units/Regions and extended to a national level starting from January 2020. This initiative is necessary in order to better dimension the burden of the disease associated with HEV infection, to study its epidemiology, and to increase awareness of this infection among health professionals.

Strategy to reduce adverse health outcomes in subjects highly vulnerable to COVID-19: results from a population-based study in Northern Italy

OBJECTIVES

This study describes a new strategy to reduce the impact of COVID-19 on the elderly and other clinically vulnerable subjects, where general practitioners (GPs) play an active role in managing high-risk patients, reducing adverse health outcomes.

DESIGN

Retrospective cohort study.

SETTING

Population-based study including subjects resident in the province of Milan and Lodi.

PARTICIPANTS

127 735 residents older than 70 years, with specific chronic conditions.

INTERVENTIONS

We developed a predictive algorithm for overall mortality risk based on demographic and clinical characteristics. All residents older than 70 years were classified as being at low or high risk of death from COVID-19 infection according to the algorithm. The high-risk group was assigned to their GPs for telephone triage and consultation. The high-risk cohort was divided into two groups based on GP intervention: patients who were not contacted and patients who were contacted by their GPs.

OUTCOME MEASURES

Overall mortality, COVID-19 morbidity and hospitalisation.

RESULTS

Patients with increased risk of death from COVID-19 were 127 735; 495 669 patients were not at high risk and were not included in the intervention. Out of the high-risk subjects, 79 110 were included but not contacted by their GPs, while 48 625 high-risk subjects were included and contacted. Overall mortality, morbidity and hospitalisation was higher in high-risk patients compared with low-risk populations. High-risk patients contacted by their GPs had a 50% risk reduction in COVID-19 mortality, and a 70% risk reduction in morbidity and hospitalisation for COVID-19 compared with non-contacted patients.

CONCLUSIONS

The study showed that, during the COVID-19 outbreak, involvement of GPs and changes in care management of high-risk groups produced a significant reduction in all adverse health outcomes.

Large community-acquired Legionnaires' disease outbreak caused by Legionella pneumophila serogroup 1, Italy, July to August 2018

In July 2018, a large outbreak of Legionnaires' disease (LD) caused by Legionella pneumophila serogroup 1 (Lp1) occurred in Bresso, Italy. Fifty-two cases were diagnosed, including five deaths. We performed an epidemiological investigation and prepared a map of the places cases visited during the incubation period. All sites identified as potential sources were investigated and sampled. Association between heavy rainfall and LD cases was evaluated in a case-crossover study. We also performed a case-control study and an aerosol dispersion investigation model. Lp1 was isolated from 22 of 598 analysed water samples; four clinical isolates were typed using monoclonal antibodies and sequence-based typing. Four Lp1 human strains were ST23, of which two were Philadelphia and two were France-Allentown subgroup. Lp1 ST23 France-Allentown was isolated only from a public fountain. In the case-crossover study, extreme precipitation 5-6 days before symptom onset was associated with increased LD risk. The aerosol dispersion model showed that the fountain matched the case distribution best. The case-control study demonstrated a significant eightfold increase in risk for cases residing near the public fountain. The three studies and the matching of clinical and environmental Lp1 strains identified the fountain as the source responsible for the epidemic.

Hepatitis A epidemic in men who have sex with men (MSM) in Milan, Italy

Background and aim of the work:

Hepatitis A is an infectious disease characterized by fecal-oral transmission; however, a rise in sexually-transmitted cases has been observed, particularly among “men who have sex with men”. In Europe, a Hepatitis A epidemic occurred among men who have sex with men between 2016 and 2018. The aim of this study is to describe this Hepatitis A epidemic in the city of Milan and to analyze the incidence of Sexually Transmitted Diseases co-infection among Hepatitis A cases.

Methods:

Hepatitis A cases were traced and identified. Epidemiological data were collected and Hepatitis A vaccination was investigated. Cases were georeferenced, calculating incidence rates for each Milan Municipality. Viral genotypic analysis was carried out.

Results:

353 cases were reported in Milan. Incidence rates resulted significantly higher in males (RR 18.1 CI9 5% 11.5 – 28.4). 70 cases reported foreign travel. 172 cases reported “Men who have Sex with Men” behaviour. Genotypic analysis revealed correlation with strains of the European “Men who have Sex with Men” epidemic. Georeferencing showed asymmetric case distribution. Only 12 cases reported Hepatitis A vaccination. The Relative Risk for syphilis infection among Hepatitis A cases was 133.9 (95% CI 81.7 – 219.7) and 29.7 (95%CI 9.5 – 92.7) for gonorrhea.

Conclusions:

Most genotyped cases (93.7%) correlated to the European Hepatitis A epidemic among Men who have Sex with Men. Georeferencing showed a greater incidence of Hepatitis A cases in areas characterized by the homosexual community. The higher incidence of Sexually Transmitted Diseases co-infection in Hepatitis A cases correlated to clusters responsible for the European Hepatitis A epidemic, suggests increased sexual promiscuity among Men who have Sex with Men. These data support the need for Hepatitis A vaccination programs and sensitization of Men who have Sex with Men to the adoption of safe sexual practices.

Tuberculosis among asylum seekers in Milan, Italy: epidemiological analysis and evaluation of interventions

In countries of the European Union, tuberculosis (TB) mainly affects marginalised people, including asylum seekers. Migratory flows from high-incidence countries to Italy have increased up to 2017, posing challenges to the national health system. This study sought to assess TB and latent TB infection (LTBI) prevalence among asylum seekers in Milan during the biennium 2016–2017 and to evaluate interventions in place.

A two-level active surveillance and screening system was developed for both TB and LTBI. Asylum seekers underwent an initial screening with a tuberculin skin test (TST) and a questionnaire at the receiving sites. At the Regional TB Reference Centre, those with a positive result underwent chest radiography. People aged <35 years with negative chest radiography results underwent further testing by interferon-γ release assay. If results of the assay were positive, LTBI treatment was offered. TB and LTBI prevalence were compared with literature data.

A total of 5324 asylum seekers, mostly young (10–39 years; 98%), male (84%) and from sub-Saharan Africa (69%), were enrolled in the study. 69 active TB cases were diagnosed and 863 LTBI-positive individuals were detected. TB prevalence was high (1236 per 100 000 population) and LTBI prevalence was 28%. Despite losses (41%) during the transition from initial screening sites and the diagnostic centre, a good TB cure rate (84%) and optimal LTBI treatment completion (94%) were achieved.

Our study shows that TB incidence is high among asylum seekers in Milan and that well-coordinated screening measures are critical for early diagnosis and treatment. It also proves that rolling out successful at-scale interventions for both prophylaxis and disease management is feasible.

Ongoing large measles outbreak with nosocomial transmission in Milan, northern Italy, March-August 2017

A large measles outbreak has been ongoing in Milan and surrounding areas. From 1 March to 30 June 2017, 203 measles cases were laboratory-confirmed (108 sporadic cases and 95 related to 47 clusters). Phylogenetic analysis revealed the co-circulation of two different genotypes, D8 and B3. Both genotypes caused nosocomial clusters in two hospitals. The rapid analysis of epidemiological and phylogenetic data allowed effective surveillance and tracking of transmission pathways.

Meningococci of Serogroup X Clonal Complex 181 in Refugee Camps, Italy

Four cases of infection with serogroup X meningococci (MenX) (1 in 2015 and 3 in 2016) occurred in migrants living in refugee camps or reception centers in Italy. All MenX isolates were identified as clonal complex 181. Our report suggests that serogroup X represents an emerging health threat for persons arriving from African countries.

Outbreak of a new measles B3 variant in the Roma/Sinti population with transmission in the nosocomial setting, Italy, November 2015 to April 2016

A measles outbreak occurred from November 2015 to April 2016 in two northern Italian regions, affecting the Roma/Sinti ethnic population and nosocomial setting. Overall, 67 cases were reported. Median age of 43 cases in three Roma/Sinti camps was four years, nosocomial cases were mainly adults. The outbreak was caused by a new measles virus B3.1 variant. Immunisation resources and strategies should be directed at groups with gaps in vaccine coverage, e.g. Roma/Sinti and healthcare workers.

Legionnaires' disease contracted from patient workplace: First report of a severe case of coinfection with varicella-zoster virus

A middle-aged immunocompetent woman was diagnosed and treated for a severe pulmonary human herpesvirus 3 infection. During the treatment, an infection from Legionella pneumophila serogroup 1 was also diagnosed. This coinfection threatened the life of the patient and led to serious permanent sequelae. This report highlights the importance of preventing Legionella environmental contamination, suspecting Legionella coinfection in patients with viral pneumonia, and vaccinating susceptible adults against chickenpox.

Hepatitis C virus outbreak in a haemodialysis unit: learning from failures

The investigation of an outbreak of hepatitis C virus in an Italian haemodialysis (HD) centre showed that three patients acquired infection with the same strain, affecting a chronically hepatitis C virus (HCV)-infected patient receiving HD in the same room and during the same shifts. Through our observational analysis many possible modes of transmission were identified, but none could be definitively identified as the route of HCV spread in this small cluster. This outbreak confirms that repeated opportunities for nosocomial HCV transmission may occur among HD patients due to several breaches in the standard precautions for bloodborne infections by healthcare staff.

Socio-demographic and clinical characteristics of benzodiazepine long-term users: Results from a tertiary care center

OBJECTIVE

The use of benzodiazepines (BDZs) represents a critical issue since a long-term treatment may lead to dependence. This study aimed at evaluating socio-demographic and clinical characteristics of BZD long-term users who followed a detoxification program at a tertiary care center.

METHOD

Two hundred-five inpatients were evaluated. Socio-demographic (e.g., gender, age, education) and clinical information (e.g., BZD used, dose, reason of prescription) was collected. BZDs dose was standardized as diazepam dose equivalents and was compared via the Defined Daily Dose (DDD). Chi-square, Fisher test, ANOVA and Bonferroni analyses were performed.

RESULTS

Females were more frequently BDZ long-term users than males. Hypnotic BZDs were frequently prescribed for problems different from sleep disturbances. Lorazepam, alprazolam, and lormetazepam were the most prescribed drugs. Lorazepam was more frequently used by males, consumed for a long period, in pills, and prescribed for anxiety. Lormetazepam was more frequently consumed by females with a high school education, having a psychiatric disorder, taken in drops and prescribed for insomnia. Lormetazepam had the highest DDD.

CONCLUSION

A specific profile of BZD long-term user seems to exist and presents different socio-demographic and clinical characteristics according to the benzodiazepine taken into account.

A longitudinal study of streptococcus pneumoniae carriage in healthy children in the 13-valent pneumococcal conjugate vaccine era

Few epidemiological data are available after the introduction of the 13-valent pneumococcal vaccine (PCV13) in 2010. We performed repeat nasopharyngeal swabs and evaluated the serotype distribution of Streptococcus pneumoniae (SP) and its association with PCV13 vaccine status in healthy Italian children aged 3-59 months. SP serotypes were assessed by the Quellung reaction. 618 children appropriately (28%) or incompletely (72%) vaccinated for age with PCV13 were available at baseline (T0). 515 were re-evaluated at 6 months from baseline (T6) and 436 at 12 months from baseline (T12). The percentage of appropriately vaccinated subjects at T0, T6 and T12 was 28%, 67% and 92%, respectively. Random effects logistic regression models with robust 95% confidence intervals was used to estimate the time-related changes in SP and PCV13 carriage and marginal probabilities were obtained from such models. The age-corrected probability of SP carriage was 0.31 (95% CI 0.22 - 0.41) at T0, 0.32 (0.24 - 0.40) at T6 and 0.28 (0.20 - 0.35) at T12. The probability of PCV13 serotypes carriage was 0.025 (0.001 - 0.050) at T0, 0.018 (0.001 - 0.039) at T6 and 0.010 (0.001 - 0.023) at T12. A decrease in PCV13 serotypes and a shift in non-PCV13 serotypes colonization was observed. In particular, the 15A serotype accounted for 4%, 8% and 23% of SP isolates at T0, T6 and T12, respectively. In conclusion, the benefits of the PCV13 vaccination on SP carriage increase with increasing coverage rates. The shift of SP isolates toward non-PCV13 serotypes needs to be studied further.

Acceptability of meningococcal serogroup B vaccine among parents and health care workers in Italy: a survey

A new meningococcal serogroup B vaccine (4 CMenB) has recently been licensed. This study assessed the acceptability of 4 CMenB vaccine among parents and healthcare workers (HCWs). From May to July 2013 in Milan, Italy, self-administered questionnaires were distributed to 2050 parents of infants presenting at immunization clinics for the mandatory hexavalent vaccination and submitted to 350 HCWs involved in immunization practices. 1842 parents (89.1%) responded to the survey; 64.4% of parents wanted their child to receive the 4 CMenB vaccine and 5.1% would not vaccinate their children. Multivariate analysis showed that recognition of the severity of meningitis [a life threatening vs a mild or unthreatening disease (Odds ratio (OR): 2.3; confidence interval (CI): 1.4-3.6], awareness of vaccination as a beneficial preventive measure (very beneficial vs not beneficial OR = 6.4; CI 3.0-13.7) and knowledge of the Meningococcal C vaccine (OR = 1.4; CI 1.1-1.8) were strongly associated to willingness to receive 4 CMenB vaccine. On the contrary, level of education was associated with refusal of immunization (university vs education level lower than middle school OR = 0.68; CI 0.47-0.97). Among the parents who were willing to immunize their children, 66.9% would agree with three injections to be administered during the same visit. A total of 291 HCWs (83.1%) agreed to participate in the survey; 73% considered 4 CMenB vaccine a priority in infants' immunization schedule; 26.8% of HCWs suggested the concomitant administration with routine infant immunization. Parental and HCWs acceptability of 4 CMenB vaccine was high. Increasing knowledge about meningitis and vaccine prevention might further increase the acceptability of this vaccine.

Serotype distribution and antimicrobial susceptibilities of nasopharyngeal isolates of Streptococcus pneumoniae from healthy children in the 13-valent pneumococcal conjugate vaccine era

Few epidemiological data are available since the introduction of 13-valent pneumococcal vaccine (PCV13) in 2010. We conducted a cross-sectional study to estimate the prevalence of Streptococcus pneumoniae (SP) nasopharyngeal carriage in healthy Italian infants and young children and to evaluate the impact of PCV13 on pneumococcal colonization. In the trimester September-December 2011 nasopharyngeal swabs were collected from healthy children aged 3-59 months presenting for routine well careat 16 primary care pediatricians in Milan. SP carriage isolates were serotyped and tested for antimicrobial resistance using EUCAST breakpoints. Among 1250 enrolled children, 618 had received at least 1 dose of PCV13, 292 at least 1 dose of PCV7, 94 a combination of the two vaccines and 246 were not vaccinated. The prevalence of SP carriage was 27% (95% confidence interval [CI] 25-30). At multivariable analysis, age≥25 months (prevalence ratio [PR]=0.74) and use of antibiotics in the previous 3 months (PR=0.67) were associated with lower SP carriage prevalence. Having siblings (PR=1.79 for 1 sibling and PR=2.23 for ≥2 siblings), day-care attendance (PR=2.27) and respiratory tract infections in the previous 3 months (PR=1.39) were associated with higher SP carriage prevalence. The immunization status for SP was not associated with SP carriage at univariable or at multivariable analysis. The most common carriage isolates were 6C, 19A and 23A. The prevalence of the six additional PCV13 serotypes carriage in children appropriately vaccinated with PCV13 was lower than in children appropriately vaccinated with PCV7 (0 vs. 0.060); the greater reduction in prevalence of carriage was observed for serotype 19A (0 vs. 0.041). Serotype 6C was the most common drug-resistant serotype (17.2%). Further epidemiological studies are needed to assess changes in circulating SP serotypes following the large-scale introduction of PCV13.

Tuberculosis outbreak in a primary school, Milan, Italy

Investigation of an outbreak of tuberculosis (TB) in a primary school in Milan, Italy, found 15 schoolchildren had active TB disease and 173 had latent TB infection. TB was also identified in 2 homeless men near the school. Diagnostic delay, particularly in the index case-patient, contributed to the transmission of infection.

[Ultrasonic videolaparoscopic cholecystectomy: evolution of a revolutionary technique]

AIM

The present retrospective study, which lasted about six months from the beginning of March to the end of August 2008, involved 60 patients suffering from symptomatic calculosis of the gall bladder.

METHODS

The patients were operated on with laparoscopy: 30 with traditional instruments, 30 using ultrasound multifunctional scissors.

RESULTS

The numerous advantages for the patient and surgeon are immediately evident; in addition, from the economic viewpoint the procedure is advantageous compared to the traditional method because single-use material is employed exclusively. We found less tissue trauma and a lower incidence of short-term complications, such as reoperation for faulty closure of the cystic duct and the cystic artery. It was never necessary to use permanent haemostatic clips. The use of a single instrument for gripping, sectioning and closing haematic and biliary vessels permitted faster, safer and more accurate surgery in the absence of any production of smoke.

CONCLUSIONS

In lithiasic pathology of the gall bladder, videolaparoscopy for cholecystectomy is presently considered the operation of first choice. The technique enables the surgeon to respect to the utmost the patient's physical and mental integrity. As the third millennium dawns, technological innovation is able to bring a significant improvement to this procedure. The ultrasound dissector Ultracision is symbolic of development and constant progress.

[Gynaecological pelvic mass. Emergency clinical assessment]

BACKGROUND

The authors report the gynaecological pathology of surgical interest occurring in an Emergency Department in the first half of 2000 and occasionally found during an operation in women who presented a pelvic mass or abdominal pain.

METHODS

Six women, average age of 50 years, reached the Emergency Department: five of them were operated with an emergency procedure.

RESULTS

Of the 6 cases, 1 patient was affected by uterine mass, 1 by uterine-ovarian mass and 3 by ovarian mass; in one patient, affected by ovarian tumour, another intervention was necessary for intestinal metastasis.

CONCLUSIONS

The authors have considered the clinical aspect of the abdominal masses, the age of the patients, the diagnostic laboratory and instrumental implications, the surgical approach and the histological result, referring to literature. Their contribution is related to the need for an appropriate surgical approach in emergency where it may, sometimes, solve or, at least, stabilize an uncertain clinical case, thanks to the implicit basic knowledge of multidisciplinary surgical technique.

[CT pulmonary density mapping: surgical utility]

BACKGROUND

The present paper considers the technique of CT scan maps of pulmonary isodensity, examining lung density differences as a function of the type of disease and considering their significance for the purposes of refined, useful diagnosis in a surgical context. METHODS. The method is used to examine 3 groups of subjects selected on a clinical/anamnestic basis and a further group already admitted for surgery. For each patient we obtained 2 thoracic density scans during the phase of maximum inspiration and expiration. On each scan we constructed 50 isodensity maps, the equivalent of more than 2500 measurements: the preliminary standard was represented by 100 wide windows to produce total "illumination" of the pulmonary fields. The isodensity windows were then codified differently. Subsequently, the density scans were analysed with the technique of scalar decomposition.

RESULTS

The CT scan maps of lung isodensity proved useful for certain lung diseases in which early diagnosis, topographic extent of the pathology and the refined definition of the pathological picture provide important solutions as regards the indication and planning of surgical treatment and for the evaluation of the operative risk and prognosis.

CONCLUSIONS

We consider that the technique is rapidly performed, not complex and inexpensive and is able to supply detailed information on the lung parenchyma such as to be used not only as a routine technique but also in emergencies.

[Rupture of the urinary bladder caused by trivial trauma. Case report]

The urinary bladder occupies the deep pelvic cavity and is well protected from the bacin: this is the reason why it can rarely be traumatized. Anyway it could suffer traumas, which can cause extraperitoneal and intraperitoneal ruptures. A classification of traumas that can injure the urinary bladder and the treatments of these lesions are presented. A clinical case personal observed regarding a 78 year-old female patient is described. An accidental fall and direct trauma in the hypogastrium caused a rupture of her urinary bladder. In this case, the patient was anuric, though the macrohematuria and microhematuria can be present in the 85% of the urinary bladder lesions. This is an interesting case since it deals with a urinary bladder wall rupture, due to a trivial trauma on the bladder.

[Combined complex surgical procedures: cardiovascular and general surgery]

BACKGROUND

Aim of the paper is to evaluate the surgical indication in patients with cardiac and concomitant pathology.

METHODS

In this study, are examined ten combined surgical sessions performed from 1992 at 1999, in patients affected by both cardiac and neoplastic disease with surgical indication. Eight men and two women, mean age 59.4 (range 50-68 years), eight affected by thoracic or abdominal tumour, one affected by hypersplenism and one by pulmonary cystic dysplasia with recurring pneumothorax. Anatomic resection and in two patient wedge-resection were performed except one woman who was splenectomized and one man who underwent atypical resection and pulmonary decortication. All subjects required extracorporeal circulation.

RESULTS

No peri-operative deaths were observed and mean survival was 34 months (range 6-72 months). Moreover, there were no hemorrhages due to coagulation values of extracorporeal circulation. This approach proved useful both from the economic point of view and hospitalization time.

CONCLUSIONS

According to personal experience this can be considered a successful therapeutic choice in selected patients. These observations suggest further considerations on combined operations surgery risk and mortality-morbidity appears to be reduced by a better myocardial revascularization.

Isolated presence of antibody to hepatitis B core antigen in injection drug users: do they need to be vaccinated?

In a study of 497 injection drug users who had isolated presence of antibody to hepatitis B core antigen (anti-HBc) at the time of enrollment, 404 (81%) retained this condition after a mean of 49 months of follow-up, during which time no new hepatitis B surface antigen marker was detected. These findings support the hypothesis that patients with isolated presence of anti-HBc have strong resistance to reinfection and do not need vaccination.

[Hemorrhoids: epidemiology and correlation with chronic constipation]

Following a review of international literature, AA report main results and refer their opinion about the correlation of hemorrhoidal disease with constipation, considering some variants as well as age, sex, breed, social-economic condition and geographic distribution in USA, England and Wales. Epidemiologically ten millions of people, in USA, are affected by hemorrhoidal disease; the incidence rate is 4.4% with an age distribution that shows a prevalence between 45-65 years old subject while constipation has an exponential increase with aging. Hemorrhoidal disease is significantly influenced by sex and geographic distribution that is in white breed more than in black, in social high class and in men more than women. In black breed constipation and hemorrhoidal disease present especially in lower social classes. Based on these results hemorrhoidal disease shows on epidemiological pattern that differ from constipation's one. Many questions are still present about correlations between hemorrhoidal disease and chronic constipation regarding etiopathogenesis. Only future case-control studies will solve the problem.

[Biliary complications during videolaparoscopic cholecystectomy. Remarks on methodology and indications in the training period]

In our study we have considered the activity of a surgeon working in our Surgery Department during his laparoscopic training period. We focus our attention on a date related to the same complications checked in 27 cases of cholelithiasis operated by the same surgeon. We have observed three cases of biliary cholelithiasis fistulas, all of them during the three last operations. The examination of the above mentioned cases considers the clinical post-surgery situation and the therapeutic standards we adopted to work out the complications. Now we can precisely state, according to our experience, the particular directions for the videolaparoscopic training period. In addition we can propose one simple mathematical formula to value the IRL (Laparoscopic Risk Index) concerning three variables: the experience of the surgeon; the instruments condition; the clinical situation of the patient. The relation of these three factors turned in numbers suggests the chance of success of a videolaparoscopic operation. We conclude our study mentioning the gasless videolaparoscopic technique that seems to have a large indication, according to the same Surgery School. This technique is particulary indicated on those classes of patients in which the CO2 insufflation into abdominal cavity and the increase of endocavity pressure can represent a contraindication to the videolaparoscopic approach: in this case the surgeon will follow the surgical indication to solve the clinical situation, as happens in war surgery.

[Hemorrhoid disease. Physiopathology, etiopathology and surgical approach]

The authors report a number of cases of hemorrhoid disease and describe the therapeutic iter followed with particular reference to the surgical approach used. After a description of the physiopathological aspects linked to the disease, bearing in mind the use of electromanometry and electromyography in diagnosis, the authors underline the contemporary presence of varices in the lower limbs and hemorrhoid disease, as well as the frequent finding of hemorrhoids in a syndrome of portal hypertension. They then affirm how it is impossible to establish the causes of this pathology with any certainty and how a single standardised treatment plan is untenable. The authors then indicate the guidelines used to choose the most appropriate form of surgery rather than pharmacological treatment, based on the ideal cases and conditions for surgery. The ultimate goals of surgery are also outlined. The study compares four possible surgical techniques, providing synthetic information regarding their adaptability to the various cases treated and the characteristics of their use. This means that, once decided, surgery must successfully resolve the patient's problems. In conclusion, once hemorrhoid disease has been diagnosed, it is important to intervene with appropriate medical treatment to control the evolution of the pathology; if this is not sufficient, surgery becomes an inevitable choice.

Safety and immunogenicity of MF59-adjuvanted influenza vaccine in the elderly

Safety and immunogenicity of the influenza vaccine adjuvanted with MF59 (FLUAD) were compared to those of a non adjuvanted subunit vaccine in elderly subjects during three consecutive influenza seasons. Geometric mean titres and proportions of subjects with either a > or = four-fold increase in antibody titres or with an HI titre > or = 128 after immunisation were higher in FLUAD recipients. The adjuvant effect on the magnitude of the responses was most pronounced in subjects with pre-vaccination titres < or = 40. Although associated with more frequent mild local reactions, the adjuvanted vaccine was well tolerated. Thus, the addition of MF59 increased the immunogenicity of the subunit influenza vaccine in elderly persons with low pre-vaccination titres, who are at greatest risk of developing severe influenza disease and vaccine failure, without a clinically important increase in reactogenicity.

[Medullary carcinoma of the thyroid. A clinical case]

A case of medullary thyroid carcinoma is reported. Moreover, the main peculiarity, the correct diagnostic approach and the therapeutic indication of this rare pathology are described.

[Tracheobronchial ruptures in closed thoracic trauma]

Authors refer about their experience on five cases of thoracic trauma. Following a review of international literature, they analyze the clinical, diagnostic and therapeutic aspects of this kind of injuries.

Estimation of lumbar disc areas by means of anthropometric parameters

In order to standardize the results of different biomechanical studies concerning stresses on lumbar discs, it may be useful to estimate the disc dimensions of the examined subjects and to refer the stress values to a unit surface area (square centimeter). The association between anthropometric parameters and discal areas at the L3-L4, L4-L5 and L5-S1 levels, examined by computed axial tomography, was studied in a group of 32 subjects (16 male; 16 female) with the aim of estimating lumbar disc areas with a simple method. Bony structure weight, which is computed by an equation that takes into account the diameters of the wrist, elbow, knee, and ankle and the stature, is the anthropometric parameter best associated with the areas of lumbar discs. The wrist diameter also shows a good association with the same areas. On the contrary, the association between body weight and disc areas was found to be less adequate for this purpose. The equations of the relative regression lines are reported as well as the criteria for their practical applications.