Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal pain (PREVSAM): a randomised controlled trial protocol.

BACKGROUND: Musculoskeletal pain is globally a leading cause of physical disability. Many musculoskeletal-related pain conditions, such as low back pain, often resolve spontaneously. In some individuals, pain may recur or persist, leading to ong-term physical disability, reduced work capacity, and sickness absence. Early identification of individuals in which this may occur, is essential for preventing or reducing the risk of developing persistent musculoskeletal pain and long-term sickness absence. The aim of the trial described in this protocol is to evaluate effects of an early intervention, the PREVSAM model, on the prevention of sickness absence and development of persistent pain in at-risk patients with musculoskeletal pain. METHODS: Eligible participants are adults who seek health care for musculoskeletal pain and who are at risk of developing persistent pain, physical disability, and sickness absence. Participants may be recruited from primary care rehabilitation centres or primary care healthcare centres in Region Västra Götaland. Participants will be randomised to treatment according to the PREVSAM model (intervention group) or treatment as usual (control group). The PREVSAM model comprises an interdisciplinary, person-centred rehabilitation programme, including coordinated measures within primary health care, and may include collaboration with participants' employers. The primary outcome sickness absence is operationalised as the number and proportion of individuals who remain in full- or part-time work, the number of gross and net days of sickness absence during the intervention and follow-up period, and time to first sickness absence spell. Secondary outcomes are patient-reported short-term sickness absence, work ability, pain, self-efficacy, health-related quality of life, risk for sickness absence, anxiety and depression symptoms and physical disability at 1 and 3 months after inclusion (short-term follow-up), and at 6 and 12 months (long-term follow-up). A cost-effectiveness analysis is planned and drug consumption will be investigated. DISCUSSION: The study is expected to provide new knowledge on the effectiveness of a comprehensive rehabilitation model that incorporates early identification of patients with musculoskeletal pain at risk for development of sickness absence and persistent pain. The study findings may contribute to more effective rehabilitation processes of this large patient population, and potentially reduce sickness absence and costs. TRIAL REGISTRATION: ClinicalTrials.gov Protocol ID: NCT03913325 , Registered April 12, 2019. Version 2, 10 July 2020. Version 2 changes: Clarifications regarding trial aim and inclusion process.

Wide recognition of Culex pipiens and lack of detection of Culex torrentium through biomolecular differentiation of mosquitoes in the Emilia-Romagna region, Northern Italy.

The Culex pipiens complex includes species with reported differences in vector competence for arthropod-borne viruses, many of which are of significant importance to human health such as the West Nile virus and the Sindbis virus. This group of mosquitoes is difficult to distinguish morphologically; particularly as adult females. In Europe, the two species of the complex, Culex pipiens Linnaeus 1758 and Culex torrentium Martini 1925, are often found sympatrically. With the aim to characterize the presence and spread of both species in the Emilia-Romagna region, Northern Italy, mosquitoes of the complex - collected during the West Nile virus surveillance plans - were tested by multiplex real-time PCR for the detection of the two species Cx. pipiens and Cx. torrentium. A total of 24 165 mosquitoes, collected between 2012 and 2014 from 105 sites, and sorted in 204 pools, were tested. All tested pools were found to be composed of Cx. pipiens, whereas Cx. torrentium was not detected. These results indicate a likely absence of Cx. torrentium mosquitoes within the surveyed territory, whereas Cx. pipiens is widely distributed in the area mentioned. This is in line with previous reports, which describe a pre-alpine distribution of Cx. torrentium in Italy.

Antimicrobial resistance of F4+ Escherichia coli isolated from Swine in Italy.

Four-hundred and forty-two F4+ pathogenic Escherichia coli were isolated in a period of 10 years (2002-2011), from pigs that were suffering from diarrhoea belonging to Italian swine herds. The strains were analysed for their susceptibility to 12 antimicrobials using the disc diffusion method. During the study period, a statistically significant proportion of isolates resistant to enrofloxacin (14.5-89.3%), marbofloxacin (5.4-60.7%), flumequine (49.1-92.9%), danofloxacin (21.6-80%), florfenicol (9.8-64.3%), thiamphenicol (50-92%) and cefquinome (3.8-44%) was recorded. An increase in resistance (not statistically significant) to gentamicin (63.6-85.7%), apramycin (61.8-82.1%), trimethoprim-sulphamethoxazole (75-89.3%), tetracycline (97-100%) and erythromycin (92.4-100%) was also observed. Based on antimicrobial multiresistance, the strains were collected into three groups: I. resistant to 2-5 antimicrobials; II. resistant to 6-8 antimicrobials; III. resistant to 9-12 antimicrobials. The number of isolates belonging to the first group showed a statistically significant decrease (P < 0.05; R(2)  = 0.896; r = -0.9608), while the isolates belonging to the second and third groups showed a statistically significant increase in resistance (P < 0.05; R(2)  = 0.753; r = 0.8890 and P < 0.05; R(2)  = 0.727; r = 0.8701, respectively) over the period of study. The results of this study suggest the need for continued monitoring of the development of resistance.

Human and entomological surveillance of Toscana virus in the Emilia-Romagna region, Italy, 2010 to 2012.

Toscana virus (TOSV), transmitted by phlebotomine sandflies, is recognised as one of the most important causes of viral meningitis in summer in Mediterranean countries. A surveillance plan based on both human and entomological surveys was started in 2010 in the Emilia-Romagna region, Italy. Clinical samples from patients with neurological manifestations were collected during 2010 to 2012. The surveillance protocol was improved during these years, allowing the detection of 65 human infections. Most of these infections were recorded in hilly areas, where sandflies reach the highest density. Entomological sampling around the homes of the patients resulted in a low number of captured sandflies, while later sampling in a hilly area with high number of human cases (n=21) resulted in a larger number of captured sandflies. Using this approach, 25,653 sandflies were sampled, of which there were 21,157 females, which were sorted into 287 pools. TOSV RNA was detected by real-time PCR in 33 of the pools. The results highlighted the role of Phlebotomus perfiliewi as the main vector of TOSV and a potential link between vector density and virus circulation. This integrated system shows that an interdisciplinary approach improves the sensitiveness and effectiveness of health surveillance.

The experience of West Nile virus integrated surveillance system in the Emilia-Romagna region: five years of implementation, Italy, 2009 to 2013.

Predicting West Nile virus (WNV) circulation and the risk of WNV epidemics is difficult due to complex interactions of multiple factors involved. Surveillance systems that timely detect virus activity in targeted areas, and allow evidence-based risk assessments may therefore be necessary. Since 2009, a system integrating environmental (mosquitoes and birds) and human surveillance has been implemented and progressively improved in the Emilia-Romagna region, Italy. The objective is to increase knowledge of WNV circulation and to reduce the probability of virus transmission via blood, tissue and organ donation. As of 2013, the system has shown highly satisfactory results in terms of early detection capacity (the environmental surveillance component allowed detection of WNV circulation 3­4 weeks before human cases of West Nile neuroinvasive disease (WNND) occurred), sensitivity (capacity to detect virus circulation even at the enzootic level) and area specificity (capacity to indicate the spatial distribution of the risk for WNND). Strong correlations were observed between the vector index values and the number of human WNND cases registered at the province level. Taking into consideration two scenarios of surveillance, the first with environmental surveillance and the second without, the total costs for the period from 2009 to 2013 were reduced when environmental surveillance was considered (EUR 2.093 million for the first scenario vs EUR 2.560 million for the second). Environmental surveillance helped to reduce costs by enabling a more targeted blood unit testing strategy. The inclusion of environmental surveillance also increased the efficiency of detecting infected blood units and further allowed evidence-based adoption of preventative public health measures.

Haemophilus parasuis serovars isolated from pathological samples in Northern Italy.

From January 2007 to December 2011, a total of 106 Haemophilus parasuis strains isolated from pigs were serotyped by agar gel diffusion test (DG). Serovar 4 was the most prevalent (24.5%), followed by serovar 13 (19.8%) and serovar 5 (11.3%). Twenty-nine strains were non-typeable (27.3%). The strains were divided into two groups, depending on whether they were isolated from specific pathological lesions of systemic disease such as polyserositis, arthritis or meningitis (73 cases of 106) or from the lower respiratory tract of pigs suffering from bronchopneumonia (33 cases of 106). Serovars 4 and 13 had a higher prevalence in systemic infection (polyserositis) than in respiratory disease only. Pasteurella multocida (14/106), Streptococcus suis (7/106), Actinobacillus pleuropneumoniae (4/106), Bordetella bronchiseptica (3/106) and Arcanobacterium pyogenes (3/106) were isolated in association with H. parasuis.

Survey of pleuritis and pulmonary lesions in pigs at abattoir with a focus on the extent of the condition and herd risk factors.

Cranioventral pulmonary consolidation (enzootic pneumonia-like lesions) and chronic pleuritis (CP) are common findings in slaughtered pigs. Pleural lesions involving dorsocaudal lobes are suggestive of pleuropneumonia due to Actinobacillus pleuropneumoniae. In this report the results of an abattoir survey of pleuritis and pulmonary lesions in pigs is presented with a focus on herd risk factors. A total of 4889 animals, ranging in age from 9 to 10 months, from 48 batches of pigs belonging to an equal number of herds, were included in the study. Bronchopneumonic lesions suggestive of enzootic pneumonia (EP-like lesions) were detected in 46.4% of the examined lungs. The EP-like lesion average value for all lungs was 1.03 (95% CI 0.98-1.08), ranging from 0.17 to 2.56 among the 48 batches; 47.5% of lungs showed chronic pleuritis. Dorsocaudal pleuritis suggestive of recovered pleuropneumonia (SPES score ≥2) was found in 25.1% of the lungs. The mean SPES (slaughterhouse pleuritis evaluation system) value of the overall 4889 lungs was 0.83 (95% CI 0.78-0.86). The mean SPES value of the batches ranged from 0.04 to 1.87. The mean Actinobacillus pleuropneumoniae index of all studied batches was 0.61 (95% CI 0.51-0.71), ranging from 0 to 1.84. Blood samples were collected from each herd to evaluate antibody titres to Mycoplasma hyopneumoniae, A. pleuropneumoniae, Aujeszky's disease virus, porcine reproductive and respiratory syndrome virus (PRRSV), and swine influenza virus. Herd characteristics were recorded using a questionnaire given to the farmers. A multivariable analysis was conducted to identify risk factors for pleuritis and EP-like lesions. High dorsocaudal pleuritis was associated with A. pleuropneumoniae seroprevalence and history of A. pleuropneumoniae isolation from pneumonic lungs of dead animals. Vaccination of weaners at 3-5 weeks of age against PRRS using a modified live vaccine was associated with a reduction in the percentage of cranioventral pulmonary consolidation (EP-like lesions).

Non-Viral Generation of Neural Precursor-like Cells from Adult Human Fibroblasts.

Recent studies have reported direct reprogramming of human fibroblasts to mature neurons by the introduction of defined neural genes. This technology has potential use in the areas of neurological disease modeling and drug development. However, use of induced neurons for large-scale drug screening and cell-based replacement strategies is limited due to their inability to expand once reprogrammed. We propose it would be more desirable to induce expandable neural precursor cells directly from human fibroblasts. To date several pluripotent and neural transcription factors have been shown to be capable of converting mouse fibroblasts to neural stem/precursor-like cells when delivered by viral vectors. Here we extend these findings and demonstrate that transient ectopic insertion of the transcription factors SOX2 and PAX6 to adult human fibroblasts through use of non-viral plasmid transfection or protein transduction allows the generation of induced neural precursor (iNP) colonies expressing a range of neural stem and pro-neural genes. Upon differentiation, iNP cells give rise to neurons exhibiting typical neuronal morphologies and expressing multiple neuronal markers including tyrosine hydroxylase and GAD65/67. Importantly, iNP-derived neurons demonstrate electrophysiological properties of functionally mature neurons with the capacity to generate action potentials. In addition, iNP cells are capable of differentiating into glial fibrillary acidic protein (GFAP)-expressing astrocytes. This study represents a novel virusfree approach for direct reprogramming of human fibroblasts to a neural precursor fate.

Novel poly(L-lactide) PLLA/SWNTs nanocomposites for biomedical applications: material characterization and biocompatibility evaluation.

Poly(L-lactide) (PLLA)/single-walled carbon nanotubes (SWNTs) nanocomposite films were produced using the solvent casting method, and morphological, thermal and mechanical properties were investigated. Biocompatibility was evaluated by using human bone cells, performing adhesion and proliferation studies. The role of single-walled nanotube incorporation and functionalization on PLLA bio-polymers was investigated. Pristine (SWNTs) and carboxylated (SWNTs-COOH) carbon nanotubes were considered in order to control the interaction between PLLA and nanotubes. SWNTs and SWNTs-COOH showed a good dispersion in the polymer matrix and improved the PLLA crystallinity. Thermal, morphological and dynamic-mechanical analyses revealed that carboxylic groups on the tube sidewalls increased compatibility between PLLA and nanostructures. Mechanical properties demonstrated an enhancement related to introduction and functionalization of carbon nanotubes. Biological investigations showed osteoblasts cultured on PLLA/SWNTs-COOH nanocomposites has higher cell adhesion and proliferation than osteoblasts cultured on PLLA and PLLA/SWNTs nanocomposites. These studies suggest that combination of biodegradable polymers and SWNTs opens a new perspective in the self-assembly of nanomaterials and nanodevices for biomedical applications with tunable properties.

West Nile virus circulation in Emilia-Romagna, Italy: the integrated surveillance system 2009.

Following a large West Nile virus (WNV) epidemic in northeastern Italy in 2008, human and animal surveillance activities were implemented in Emilia Romagna. Human surveillance was performed by serology or genome detection on blood and cerebrospinal fluid for all suspected cases suffering from acute meningoencephalitis in the regional territory. Animal surveillance consisted of passive and active surveillance of horses and active surveillance of wild birds and mosquitoes. Between 15 June and 31 October 2009, nine of 78 possible cases of West Nile neuroinvasive disease were confirmed (three fatal). From May to October, 26 cases of neurological West Nile disease were confirmed among 46 horses. The overall incidence of seroconversion among horses in 2009 was 13%. In 2009, 44 of 1,218 wild birds yielded positive PCR results for WNV infection. The planned veterinary and entomological surveillance actions detected WNV activity from the end of July 2009, about 2-3 weeks before the onset of the first human neurological case. Passive surveillance of horses seems to be an early and suitable tool for the detection of WNV activity, but it will be less sensitive in the future, because an intensive programme of horse vaccination started in June 2009.

Immunohistochemical detection of aetiological agents of proliferative and necrotizing pneumonia in italian pigs.

Proliferative and necrotizing pneumonia (PNP) is a form of interstitial pneumonia that occurs in weaning and post-weaning pigs. PNP is characterized by hypertrophy and hyperplasia of type II pneumocytes and coagulative necrosis and granular debris within alveolar spaces. Canadian and European studies suggest that the porcine reproductive and respiratory syndrome virus (PRRSV) and porcine circovirus type 2 (PCV2) are the main causes of the disease, but Aujezsky's disease virus (ADV) and swine influenza virus (SIV) have also been considered as potential aetiological agents. An immunohistochemical study was carried out on the lungs of 28 Italian pigs with PNP in order to evaluate the role of PRRSV, PCV2 and ADV in PNP lesions. PRRSV infection was identified in the lungs of 11 pigs, PCV2 in the lungs of four pigs and coinfection with both viruses in the lungs of eight pigs. Neither virus was detected in the lungs of the remaining five pigs. ADV antigen was not detected in any sample. The principle aetiological agent of PNP in Italy therefore appears to be PRRSV. Coinfection with PRRSV and PCV2 is characterized by more severe microscopical changes in affected lungs.

The feasibility of developing a risk assessment for the impact of climate change on the emergence of Crimean-Congo haemorrhagic fever in livestock in Europe: a review.

Crimean-Congo haemorrhagic fever virus (CCHFV) is one of the most widespread of all medically important arboviruses with ticks of the Hyalomma spp. serving as the main vectors. Infection of livestock by CCHFV serves as a route of exposure to humans, as a reservoir of disease and as a route of importation. This study discusses the pathways and data requirements for a qualitative risk assessment for the emergence of CCHFV in livestock in Europe. A risk map approach is proposed based on layers that include the potential routes of release (e.g. by migrating birds carrying infected ticks) together with the main components for exposure, namely the distributions of the tick vectors, the small vertebrate host reservoirs and the livestock. A layer on landscape fragmentation serves as a surrogate for proximity of livestock to the tick cycle. Although the impact of climate change on the emergence of CCHF is not clear, comparing the distribution of risk factors in each layer currently with those predicted in the 2080s with climate change can be used to speculate how potential high-risk areas may shift. According to the risk pathway, transstadial and/or transovarial transmission in the tick vector are crucial for CCHFV spread. Vector competence and tick vector switching, however, remain critical factors for CCHFV colonization of new regions in Europe. The species of migratory bird is also an important consideration in the release assessment with greater abundance and biodiversity of ground-dwelling birds in southern Europe than in northern Europe.

Application of a protocol for the diagnosis of postweaning multisystemic wasting syndrome in Italy.

Samples of superficial inguinal and bronchial lymph nodes, ileum, tonsil and lung were taken from three to five pigs on each of 61 farms with a clinical history of postweaning multisystemic wasting syndrome (PMWS). The samples were examined histologically and by immunohistochemistry for porcine circovirus type 2 (PCV-2). PMWS was diagnosed in two stages: first, an evaluation of the haematoxylin and eosin-stained sections that identified the cases in which the characteristic PCV-2 cytoplasmic inclusion bodies were apparent, and secondly, a conclusive step in which immunohistochemistry was applied to confirm PMWS in the cases in which there were positive immunohistochemical results that coincided with lesions indicative of PMWS in at least one of the lymphoid and/or lung tissues. The location of PCV-2 in specific lesions (cell depletion in lymphoid organs and interstitial pneumonia) confirmed PMWS in 45 of the 61 farms, 31 of which were also infected with porcine reproductive and respiratory syndrome virus. The lymphoid tissues were more reliable than the lungs for the diagnosis of PMWS, both in individual pigs and in groups of pigs, and farm diagnoses based on a group of pigs were more reliable than diagnoses based on single pigs.

Usutu virus infection in a patient who underwent orthotropic liver transplantation, Italy, August-September 2009.

We report a case of Usutu virus (USUV)-related illness in a patient that underwent an orthotropic liver transplant (OLT). Post transplant, the patient developed clinical signs of a possible neuroinvasive disease with a significant loss of cerebral functions. USUV was isolated in Vero E6 cells from a plasma sample obtained immediately before the surgery, and USUV RNA was demonstrated by RT-PCR and sequencing. This report enlarges the panel of emerging mosquito-borne flavivirus-related disease in humans.

Chikungunya epidemic outbreak in Emilia-Romagna (Italy) during summer 2007.

During summer 2007, an outbreak due to the local transmission of CHIKV by Aedes albopictus mosquitoes occurred moreover in Italy, Emilia-Romagna Region, in the areas of Ravenna, Forli-Cesena, Rimini and Bologna cities. The original outbreak developed in Castiglione di Cervia and Castiglione di Ravenna, two small villages divided by a river. The first case was recorded on August 9th the epidemic outbreak then spread out, thus giving rise to smaller secondary outbreaks and further sporadic cases in the same area, for a total of 337 suspected cases, 217 of which confirmed by blood analysis. CHIKV has been isolated and characterized on both blood and mosquito samples.

Longitudinal study of Salmonella infection in Italian farrow-to-finish swine herds.

A longitudinal study of Salmonella enterica infection was carried out in five Italian farrow-to-finish swine herds previously known to be infected by Salmonella. Five litters were randomly selected from each herd and in each litter six piglets were randomly selected and individually identified. Thus, the study included 30 pigs from each farm. At weaning, individual blood samples were collected for serological examination from all selected piglets and on the same day from all sows in the farrowing unit. Piglets were bled again at approximately 60, 90, 150, 210 and 270 days of life whereas the last blood sample was collected at slaughtering. In one of the herds, in which the duration of productive cycle was about 12 months, the last blood samples were collected at 350 days of life. With the same time scheduling, five pen pooled faecal samples were collected from each herd for bacteriological examination. At slaughtering, mesenteric lymph nodes were collected from each ear-tagged pig. Sero-prevalence (cut off S/P ratio 0.25) in sows varied from 93.8% to 100%. In four herds, sero-prevalence in piglets showed a similar profile with complete decline of maternal antibodies at day 60 and clear sero-conversion between day 90 and day 150. In one herd, sero-conversion was observed earlier and 56% of piglets were positive at day 90. The peak of sero-prevalence was observed between day 210 and day 270. Sero-prevalence at slaughtering varied from 66% to 100%. Salmonella was isolated from faecal samples in four of five herds. No Salmonella was isolated from mesenteric lymph nodes at slaughter in two of the herds. Culture prevalence from mesenteric lymph nodes in the other three herds ranged from 3.3% to 30%. This longitudinal study provides original information about epidemiological dynamics of Salmonella enterica infection in Italian swine herds in consideration of the unique extended fattening period typical of the Italian production.

Infection with chikungunya virus in Italy: an outbreak in a temperate region.

BACKGROUND: Chikungunya virus (CHIKV), which is transmitted by Aedes spp mosquitoes, has recently caused several outbreaks on islands in the Indian Ocean and on the Indian subcontinent. We report on an outbreak in Italy. METHODS: After reports of a large number of cases of febrile illness of unknown origin in two contiguous villages in northeastern Italy, an outbreak investigation was done to identify the primary source of infection and modes of transmission. An active surveillance system was also implemented. The clinical case definition was presentation with fever and joint pain. Blood samples were gathered and analysed by PCR and serological assays to identify the causal agent. Locally captured mosquitoes were also tested by PCR. Phylogenetic analysis of the CHIKV E1 region was done. FINDINGS: Analysis of samples from human beings and from mosquitoes showed that the outbreak was caused by CHIKV. We identified 205 cases of infection with CHIKV between July 4 and Sept 27, 2007. The presumed index case was a man from India who developed symptoms while visiting relatives in one of the villages. Phylogenetic analysis showed a high similarity between the strains found in Italy and those identified during an earlier outbreak on islands in the Indian Ocean. The disease was fairly mild in nearly all cases, with only one reported death. INTERPRETATION: This outbreak of CHIKV disease in a non-tropical area was to some extent unexpected and emphasises the need for preparedness and response to emerging infectious threats in the era of globalisation.

Pneumonia disease assessment using a slaughterhouse lung-scoring method.

The aims of this study were the evaluation of a quantitative method for the assessment of pneumonia lesions applied to heavy-weight slaughtered pigs, the identification of risk factors connected with the increase in the prevalence and severity of the lesions and the evaluation of a possible correlation between the presence of pneumonia lesions and the decrease in the carcass quality. The lungs of 10 041 pigs (109 slaughtered batches) coming from 91 farms located in Northern Italy were examined. Lung lesions were scored using the method developed by Madec and Kobisch (Journ. Rech. Porc. Fr., 14, 1982, 405). Before the scoring, anamnestic information regarding the farm of origin of each batch were collected. For 41 batches (3603 pigs), information about carcass quality were also collected. Pneumonia lesions were found in 59.6% of the lungs (range 3-91%), and the average batch score was 2.11 (range 0.03-7.15). We identified as farm risk factors those related to an increase in the severity of the lung lesions, the presence of breeders within the herd, the starting of a growing cycle during the winter season and the lack of vaccination programmes to Mycoplasma hyopneumoniae. Moreover, we also found a statistically significant association between the increase in the mean lung score of the batch and the decrease of the carcass quality.