Risk factors for severe and fatal COVID-19 among patients admitted to an Italian hospital

Background

The epidemic of COVID-19 has spread dramatically affecting more than 140 million people and leading to more than 3 million deaths. We aimed to investigate what factors pose a risk for disease severity and death.

Methods

We prospectively included patients with laboratory-confirmed COVID-19 from San Marco Hospital (Catania, Italy), who had been admitted by Dec 31, 2020. Demographic, clinical, treatment, and laboratory data, were collected and compared between severe and non-severe patients, as well as between survivors and non-survivors. We used univariable and multivariable methods to explore the risk factors associated with disease severity and death.

Results

Overall, 463 patients were included, of whom 33.7% had severe disease and 14.0% died in hospital. Patients with severe disease were older (p < 0.001) and more likely to have had heart failure (p = 0.038). With respect to the risk of death, increasing age, hypertension, diabetes, ischemic heart disease, atrial fibrillation, heart failure, chronic obstructive pulmonary disease, cancer, and chronic renal failure were more common among non-survivors than survivors (p-values<0.05). In particular, a logistic regression model confirmed age (OR = 1.14; 95%CI=1.10-1.20; p < 0.001) and heart failure (OR = 14.8; 95%CI=2.7-80.8; p = 0.002) as the main risk factors for death. The comparison between the first and the second waves of the epidemic did not reveal differences in demographic and clinical characteristics, however, the treatment approach has changed significantly.

Conclusions

The risk of severe and/or fatal COVID-19 was higher among older patients with comorbidities. These findings lay the foundation for prediction models that could inform shielding policies and vaccine prioritisation strategies.

Key messages

The risk of severe and fatal COVID-19 is substantially elevated among older patients with previous comorbidities. These findings are important to inform shielding policies and vaccine prioritisation strategies.

Cost analysis of colorectal cancer screening with CT colonography in Italy

OBJECTIVE

Unit costs of screening CT colonography (CTC) can be useful for cost-effectiveness analyses and for health care decision-making. We evaluated the unit costs of CTC as a primary screening test for colorectal cancer in the setting of a randomized trial in Italy.

METHODS

Data were collected within the randomized SAVE trial. Subjects were invited to screening CTC by mail and requested to have a pre-examination consultation. CTCs were performed with 64- and 128-slice CT scanners after reduced or full bowel preparation. Activity-based costing was used to determine unit costs per-process, per-participant to screening CTC, and per-subject with advanced neoplasia.

RESULTS

Among 5242 subjects invited to undergo screening CTC, 1312 had pre-examination consultation and 1286 ultimately underwent CTC. Among 129 subjects with a positive CTC, 126 underwent assessment colonoscopy and 67 were ultimately diagnosed with advanced neoplasia (i.e., cancer or advanced adenoma). Cost per-participant of the entire screening CTC pathway was €196.80. Average cost per-participant for the screening invitation process was €17.04 and €9.45 for the pre-examination consultation process. Average cost per-participant of the CTC execution and reading process was €146.08 and of the diagnostic assessment colonoscopy process was €24.23. Average cost per-subject with advanced neoplasia was €3777.30.

CONCLUSIONS

Cost of screening CTC was €196.80 per-participant. Our data suggest that the more relevant cost of screening CTC, amenable of intervention, is related to CTC execution and reading process.

Hemoccult Sensitivity Estimate in a Screening Program for Colorectal Cancer in the Province of Florence

The sensitivity of Hemoccult testing (HO) in a population-based screening for colorectal cancer was evaluated. HO sensitivity estimates were calculated as the ratio of screen-detected HO-positives to total screen or interval-detected cancers. Sensitivity was estimated according to 1, 2, and 3-year rescreening intervals. Corresponding estimates are 69.4%, 61.8% and 57.7%, respectively. No significant correlation was observed between HO sensitivity and other variables, such as calendar period, tumor stage or site, or patient age or sex. HO sensitivity as estimated in the present experience is consistent with other reports of population-based screenings. Screening every year would achieve too limited an increase in sensitivity, compared to biennal screening, to be worth the difficulties of doubling organizational efforts and costs.

The Double Contrast Barium Enema in the Identification of Proximal Colonic Adenomas and Carcinomas beyond the Limits of Fiberoptic Sigmoidoscopy

Eight hundred and twenty patients were examined by fiberoptic sigmoidoscopy (SIG) and double contrast barium enema (DCBE) to detect colonic cancers or adenomas. Cancer or adenoma in the bowel tract proximal to the upper limit of SIG insertion was detected in 4-patients and in 12 on DCBE. The DCBE detection rate of proximal colonic lesions varied according to the hemoccult (HO) outcome. This was 1.16 % for cancer and 2.03 % for adenoma in HO+ patients and null for cancer and 1.23 % for adenoma in HO–- patients. The detection rate of proximal adenomas was higher in patients who presented adenomas on endoscopy in the distal bowel (SIG+), 2.46 % as compared to 0.48 % in SIG- patients,. independent of the HO reports. Routine DCBE is practically useless in HO-SIG- patients and questionable in HO-SIG+ patients since improvement of the detection rate is null for cancer and moderate for adenoma. It is recommended for HO+ patients because it increases the colonic cancer detection rate (10.5 % in this study).

Role of Double-contrast Barium Enema in Colorectal Cancer Screening Based on Fecal Occult Blood

Aims and Background

Screening for colorectal cancer by fecal occult-blood testing has been shown to be effective in reducing colorectal cancer mortality. Total colonoscopy is the test of choice for the assessment of fecal occult blood-positive subjects. Double-contrast barium enema is commonly employed to study the rest of the colon when colonoscopy is incomplete. The present study evaluated the contribution of double-contrast barium enema in detecting neoplastic lesions of the colon in fecal occult-blood-positive subjects with incomplete colonoscopy.

Methods

In the frame of a screening program for colorectal cancer in the Florence District, a new immunochemical fecal occult-blood test replaced the classic guaiac fecal occult-blood test in 1993. Subjects with a positive fecal occult-blood test were invited to undergo total colonoscopy. Incomplete colonoscopy prompted double-contrast barium enema. Type and rate of neoplastic lesions detected by endoscopy or double-contrast barium enema as single methods or combined were evaluated.

Results

A total of 38,829 subjects underwent fecal occult-blood testing in the period 1993-2000. Overall, 1,542 were positive. Assessment was refused by 235 subjects. Out of 1,307 subjects accepting assessment, total colonoscopy was attempted in 1,294: of these, it was not possible in 343 cases, and double-contrast barium enema was advised and performed in 261 subjects. Colorectal cancer was detected in 115 subjects, single or multiple adenomas in 323, hyperplastic polyps in 58, inflammatory, hamartomatous or not histologically confirmed polyps in 38, and other benign non-polypoid findings or no abnormality in 773. There were significant differences between the rates of detected colorectal cancers or adenomas of total and incomplete colonoscopy. There were also significant differences between incomplete colonoscopy and the combination of incomplete colonoscopy and double-contrast barium enema as regards rates of detected colorectal cancer, and between total colonoscopy and the combination of incomplete colonoscopy with double-contrast barium enema as regards rates of detected adenomas. Double-contrast barium enema associated to incomplete colonoscopy was responsible for an increase in detection rates of cancer or adenoma of 2.3‰ or 3.8‰, respectively.

Conclusions

Double-contrast barium enema was useful in detecting colorectal cancer beyond the range reached by incomplete colonoscopy, whereas our data confirmed a lower sensitivity of double-contrast barium enema for polyps. The diagnostic contribution observed in the present survey confirms the opportunity of performing double-contrast barium enema as a routine adjunct to incomplete colonoscopy. Nevertheless, in order to maximize the detection rate of adenomas, the rate of total colonoscopy should be kept as high as possible.

Colorectal Cancer Screening by Fecal Occult Blood Testing: Results of a Population-Based Experience

Aims and background

The study evaluated the results of an experimental screening protocol for colorectal cancer by fecal occult blood testing in a municipality of the Province of Florence.

Methods

A total of 15,235 subjects aged 50–70 years were invited to perform a 1-day immunochemical fecal occult blood testing without any dietary restrictions. All eligible subjects were sent a personal invitation letter, followed by a postal reminder to non-responders. Subjects with a negative stool test were advised to repeat screening after 2 years. Subjects with a positive screening test were invited to undergo full colonoscopy or a combination of left colonoscopy and a double contrast barium enema.

Results

A total of 6,418 subjects performed the screening test, with an overall compliance of 42.1%. A total of 268 compilers had positive test results. The positivity rate was 4.2%. Detection rate for cancer and for adenomas was 5.1‰ and 11.6‰, respectively. The positive predictive value was 14.3% for cancer and 32.5% for adenoma. A higher compliance was recorded in subjects born in the province of Florence or living in the centre of the town, in married subjects, and in women. The best results in compliance were associated with the direct distribution of fecal occult blood testing kits by general practitioners to their outpatients.

Conclusions

The study provides useful information about the efficiency and feasibility of a screening program for colorectal cancer using fecal occult blood testing. Compliance results confirm the importance of GP involvement in oncological screening.

Selection Criteria in Colorectal Cancer Screening

The authors report the results of a risk questionnaire (RQ) used in a population-based screening program for colorectal cancer. The positive predictive value (PPV) for cancer or adenoma was evaluated for the Hemoccult test (HO) and for all RQ items (symptoms, personal and familial risk) in 8,114 cases, by univariate and multivariate analysis. A significant correlation with the presence of cancer or adenoma was observed for HO-positive tests, whereas a significant correlation was absent for most RQ variables. The use of an RQ in screening practice is disregarded since it does not improve the rate of cancer detection. Moreover, the increase in the detection rate of HO-negative adenomas does not justify the high rate (0.18) of screening responders selected for endoscopic diagnostic workup, a figure which influences negatively the overall compliance to screening.

Evaluation of Diagnostic Accuracy of Screening by Fecal Occult Blood Testing (FOBT). Comparison of FOB Gold and OC Sensor Assays in a Consecutive Prospective Screening Series

We evaluated a new immunological fecal occult blood testing assay (FOB Gold, Sentinel = SENT) compared to the assay currently employed in the Florence screening program (OC-Hemodia, Eiken = OC). A total of 4,133 subjects were screened with both tests and underwent colonoscopy if positive (100 ng/mL Hb cutoff) to either test: 190 (4.59%) were positive (OC =140 (3.4%); SENT = 131 (3.2%)). The relative sensitivity for 7 cancers was 100% with OC and 67.9% with SENT, and for 48 high-risk adenomas (HRAs) it was 77.0% with OC and 66.6% with SENT. The positive predictive value (PPV) for cancer+HRA was 31.4% for OC and 28.2% for SENT and the specificity was 97.7 for both. The differences were not statistically significant. Adding SENT to OC increased the positivity rate by 32% and the cancer+HRA detection rate by 25%, and decreased the PPV by 10%. Both tests were performed on the same tubes in 1,601 cases, and in 18 of 47 cases they differed on different tubes but not on the same tube, suggesting inhomogeneous Hb content or varying fecal matrix influence in different samples. SENT has practical advantages for screening (fully automated, high output, requires no dedicated instrument), a comparable specificity and a lower sensitivity, though the latter difference may be partially ascribed to differences in sampling and not to the assay itself. Because of the statistical insignificance of the differences, further studies are needed for confirmation.

Reduced and Full-Preparation CT Colonography, Fecal Immunochemical Test, and Colonoscopy for Population Screening of Colorectal Cancer: A Randomized Trial

BACKGROUND

Population screening for colorectal cancer (CRC) is widely adopted, but the preferred strategy is still under debate. We aimed to compare reduced (r-CTC) and full cathartic preparation CT colonography (f-CTC), fecal immunochemical test (FIT), and optical colonoscopy (OC) as primary screening tests for CRC.

METHODS

Citizens of a district of Florence, Italy, age 54 to 65 years, were allocated (8:2.5:2.5:1) with simple randomization to be invited by mail to one of four screening interventions: 1) biennial FIT for three rounds, 2) r-CTC, 3) f-CTC, 4) OC. Patients tested positive to FIT or CTC (at least one polyp ≥6mm) were referred to OC work-up. The primary outcomes were participation rate and detection rate (DR) for cancer or advanced adenoma (advanced neoplasia). All statistical tests were two-sided.

RESULTS

Sixteen thousand eighty-seven randomly assigned subjects were invited to the assigned screening test. Participation rates were 50.4% (4677/9288) for first-round FIT, 28.1% (674/2395) for r-CTC, 25.2% (612/2430) for f-CTC, and 14.8% (153/1036) for OC. All differences between groups were statistically significant (P = .047 for r-CTC vs f-CTC; P < .001 for all others). DRs for advanced neoplasia were 1.7% (79/4677) for first-round FIT, 5.5% (37/674) for r-CTC, 4.9% (30/612) for f-CTC, and 7.2% (11/153) for OC. Differences in DR between CTC groups and FIT were statistically significant (P < .001), but not between r-CTC and f-CTC (P = .65).

CONCLUSIONS

Reduced preparation increases participation in CTC. Lower attendance and higher DR of CTC as compared with FIT are key factors for the optimization of its role in population screening of CRC.

Spread of a carbapenem- and colistin-resistant Acinetobacter baumannii ST2 clonal strain causing outbreaks in two Sicilian hospitals

BACKGROUND

Infections caused by multidrug-resistant (MDR) Acinetobacter baumannii have become an important healthcare-associated problem, particularly in intensive care units (ICUs).

AIM

To investigate the emergence of carbapenem- and colistin-resistant A. baumannii infections in two Sicilian hospitals.

METHODS

From October 2008 to May 2011, a period which included two Italian Nosocomial Infections Surveillance in ICUs network (SPIN-UTI) project surveys, all carbapenem-resistant A. baumannii isolates from the ICUs of two hospitals in Catania, Italy, were prospectively collected. Minimum inhibitory concentrations (MICs) were measured by agar dilution, and phenotypic testing for metallo-β-lactamase (MBL) production was performed. Carbapenem resistance genes and their genetic elements were identified by polymerase chain reaction and sequencing. Genotypic relatedness was assessed by pulsed-field gel electrophoresis (PFGE) and multi-locus sequence typing. Patient-based surveillance was conducted using the SPIN-UTI protocol and previous antibiotic consumption was recorded.

FINDINGS

Twenty-six carbapenem-resistant A. baumannii were identified. Imipenem and meropenem MICs ranged from 4 to >32 mg/L, and 15 isolates exhibited high-level colistin resistance (MICs >32 mg/L). PFGE demonstrated that all isolates belonged to a unique clonal type and were assigned to ST2 of the international clone II. They harboured an intrinsic blaOxA-51-like carbapenemase gene, blaOxA-82, which was flanked upstream by ISAba1.

CONCLUSIONS

The dissemination of clonally related isolates of carbapenem-resistant A. baumannii in two hospitals is described. Simultaneous resistance to colistin in more than half of the isolates is a problem for effective antibiotic treatment. Prior carbapenem and colistin consumption may have acted as triggering factors.

The impact of immunochemical faecal occult blood testing on colorectal cancer incidence

BACKGROUND

The efficacy of colorectal cancer screening based on faecal immunochemical test, in terms of reduction of colorectal cancer incidence, is under debate. In the district of Florence, an organized screening programme based on faecal immunochemical test has been running since the early 1990s. The aim of this study was to compare the risk of developing colorectal cancer for subjects undergoing faecal immunochemical test with those who did not undergo the test in the same period.

METHODS

Two cohorts were analyzed: subjects who underwent an initial faecal immunochemical test between 1993 and 1999 ("attenders"), and unscreened residents in the same municipalities invited to perform the faecal immunochemical test in the same period ("non-attenders"). Kaplan-Meier and Cox regression analysis were performed to evaluate the risk of developing colorectal cancer.

RESULTS

The attenders' and non-attenders' cohorts included 6961 and 26,285 subjects, respectively. Cox analysis showed a reduction in colorectal cancer incidence of 22% in the attenders' compared to the non-attenders' cohort (hazard ratio = 0.78, 95% Confidence Interval: 0.65-0.93).

CONCLUSION

Our results support the hypothesis that screening based on a single faecal immunochemical test every 2 years produces a significant decrease in colorectal cancer incidence after an average follow-up observation period of 11 years.

Computed tomographic colonography in subjects with positive faecal occult blood test refusing optical colonoscopy

BACKGROUND

Refusal of colonoscopy is a drawback of colorectal cancer screening programmes based on faecal occult blood test. Computed-tomographic-colonography is generally more accepted than colonoscopy.

AIM

To compare adherence to computed-tomographic-colonography and second-invitation colonoscopy in subjects with positive faecal test refusing colonoscopy.

METHODS

We performed a prospective study in 198 subjects with positive faecal test who refused first referral to colonoscopy in one endoscopy service of the Florence screening programme. Subjects were randomly invited to computed-tomographic-colonography (n = 100) or re-invited to colonoscopy (n = 98). Mail invitation was followed by a questionnaire administered by phone. Computed-tomographic-colonography findings were verified with colonoscopy.

RESULTS

32 subjects could not be reached, 71 (35.9%) had undergone colonoscopy on their own; 4 were excluded for contraindications; 30/48 (62.5%) in the computed-tomographic-colonography arm and 11/43 (25.6%) in the colonoscopy arm accepted the proposed examinations (p < 0.001). Four advanced adenomas and 1 cancer were found in the 28 subjects who ultimately underwent computed-tomographic-colonography and 2 advanced adenomas and 2 cancers in the 9 subjects who ultimately underwent second-invitation colonoscopy.

CONCLUSION

Subjects with positive faecal occult blood test refusing colonoscopy show a higher adherence to computed-tomographic-colonography than to second invitation colonoscopy.

Screening for colorectal cancer with FOBT, virtual colonoscopy and optical colonoscopy: study protocol for a randomized controlled trial in the Florence district (SAVE study)

BACKGROUND

Colorectal cancer (CRC) is the most frequent cancer in Europe. Randomized clinical trials demonstrated that screening with fecal occult blood test (FOBT) reduces mortality from CRC. Accordingly, the European Community currently recommends population-based screening with FOBT. Other screening tests, such as computed tomography colonography (CTC) and optical colonoscopy (OC), are highly accurate for examining the entire colon for adenomas and CRC. Acceptability represents a critical determinant of the impact of a screening program. We designed a randomized controlled trial to compare participation rate and diagnostic yield of FOBT, CTC with computer-aided diagnosis, and OC as primary tests for population-based screening.

METHODS/DESIGN

A total of 14,000 subjects aged 55 to 64 years, living in the Florence district and never screened for CRC, will be randomized in three arms: group 1 (5,000 persons) invited to undergo CTC (divided into: subgroup 1A with reduced cathartic preparation and subgroup 1B with standard bowel preparation); group 2 (8,000 persons) invited to undergo a biannual FOBT for three rounds; and group 3 (1,000 persons) invited to undergo OC. Subjects of each group will be invited by mail to undergo the selected test. All subjects with a positive FOBT or CTC test (that is, mass or at least one polyp ≥ 6 mm) will be invited to undergo a second-level OC. Primary objectives of the study are to compare the participation rate to FOBT, CTC and OC; to compare the detection rate for cancer or advanced adenomas of CTC versus three rounds of biannual FOBT; to evaluate referral rate for OC induced by primary CTC versus three rounds of FOBT; and to estimate costs of the three screening strategies. A secondary objective of the study is to create a biological bank of blood and stool specimens from subjects undergoing CTC and OC.

DISCUSSION

This study will provide information about participation/acceptability, diagnostic yield and costs of screening with CTC in comparison with the recommended test (FOBT) and OC.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01651624.

Familial risk of colorectal cancer in subjects attending an organised screening programme

BACKGROUND

First degree relatives of colorectal cancer patients are at increased risk for the same disease.

AIMS

To evaluate the prevalence of familial risk and its association with the occurrence of pathological significant lesions in subjects with positive faecal occult blood testing leading to colonoscopy.

METHODS

Faecal occult blood testing is offered biennially to subjects aged 50-70. Subjects with a positive faecal test are invited to undergo colonoscopy. Familial history for colorectal cancer in subjects undergoing colonoscopy was routinely recorded.

RESULTS

From 1995 to 2009, 4833 screenees with positive faecal occult blood test undergoing colonoscopy were enrolled. Twelve percent reported a positive first degree family history. Multivariate analysis evidenced that the probability of detecting pathological significant lesions was statistically associated with age, gender, type of test, repeated or first screening, and having at least 1 first degree relative with colorectal cancer.

CONCLUSIONS

Subjects attending colonoscopy reporting a positive first degree family history are at increased risk for pathologically significant lesions.

CT colonography before colonoscopy in subjects with positive faecal occult blood test. Preliminary experience

PURPOSE

We report a preliminary evaluation of the performance of computed tomography colonography (CTC) systematically obtained before optical colonoscopy (OC) in subjects with positive faecal occult blood test (FOBT) within a population-based screening programme for colorectal cancer (CRC).

MATERIALS AND METHODS

Seventy-nine subjects with positive FOBT from a regional screening programme were invited to perform same day CTC and OC. CTC was performed with standard bowel preparation. OC with segmental unblinding was the reference standard. A per-patient per-adenoma analysis was performed.

RESULTS

Forty-nine of 79 subjects (62%) with positive FOBT adhered to the study and completed both examinations. Twenty-two (44.9%) of the 49 had a cancer or an adenoma ≥6 mm. Per-patient sensitivity, specificity, negative predictive value and positive predictive value for cancer or adenoma ≥6 mm were 95.5% (95%CI:77.2%-99.9%), 51.9% (95%CI:32.0%-71.3%), 93.3% (95%CI:68.1%-99.8%) and 61.8% (95%CI:43.6%-77.8%).

CONCLUSIONS

In the setting of a FOBT-based screening programme for CRC, CTC showed a high sensitivity, but relatively low specificity and positive predictive value, for cancer and adenoma ≥6 mm. Probably performing CTC without faecal tagging as second line test after a positive FOBT is not a cost-effective strategy.

Comparing different strategies for colorectal cancer screening in Italy: predictors of patients' participation

OBJECTIVES

The objective of this study was to study predictors of patients' participation in colorectal cancer (CRC) screening.

METHODS

Men and women, aged 55-64 years, were randomized to the following: (i) biennial fecal occult blood test (FOBT) delivered by mail (n=2,266); (ii) FOBT delivered by a general practitioner (GP)/screening facility (n=5,893); (iii) "once-only" sigmoidoscopy (FS) (n=3,650); (iv) FS followed by FOBT for screenees with negative FS (n=10,867); and (v) patient's choice between FS and FOBT (n=3,579). A stratified (by screening arm) random sample of attenders and nonattenders was contacted by trained interviewers 4 months after the initial invitation. Subjects giving their consent were administered a questionnaire (available online) investigating perceptions of individual CRC risk, attitudes toward prevention, adoption of health protective behaviors, and reasons for attendance/nonattendance. Adjusted prevalence odds ratios (ORs) were computed by multivariable logistic regression.

RESULTS

The response rate was 71.9% (701 of 975) among nonattenders and 88.9% (773 of 870) among attenders. Adjusting for screening arm, center, gender, age, and education, participation was significantly higher among people who consulted their GP before undergoing screening (OR: 4.24; 95% confidence interval (CI): 3.11-5.78), who mentioned one first-degree relative with CRC (OR: 3.62; 95% CI: 2.02-6.49), who reported regular physical activity (OR: 1.85; 95% CI: 1.33-2.55), and who read the mailed information (letter only: OR: 1.85; 95% CI: 1.23-2.78; letter+leaflet: OR: 3.18; 95% CI: 2.12-4.76). People who considered screening to be ineffective (OR: 0.12; 95% CI: 0.08-0.19), those who considered it to be effective but reported even moderate levels of anxiety (OR: 0.32; 95% CI: 0.23-0.45), and those who mentioned previous knowledge of CRC screening tests were less likely to accept the invitation (OR: 0.49; 95% CI: 0.34-0.70).

CONCLUSIONS

Adoption of health protective behaviors is associated with a higher attendance rate, whereas anxiety represents a strong barrier, even among people who deemed screening to be effective. Increasing the proportion of people who consult their GP when making a decision regarding screening might enhance participation.

Propofol sedation in a colorectal cancer screening outpatient cohort

AIM

Colorectal cancer screening colonoscopies require sedation for both anxiety and pain. Propofol is used worldwide and allows for rapid and profound sedation with quick recovery after cessation of infusion. However, there is still a debate about whether it should be administered by anesthetists, gastroenterologists, or trained nurses. The aim of the study was to assess the number and proportion of patients who might benefit from the quality and safety of sedation under propofol during colonoscopies in a cohort of colorectal cancer screening outpatients.

METHODS

Patients' genders, ages, numbers of operative procedures, and prior experience with colonoscopies were recorded, and differences were tested between sedated and unsedated patients. The need for mask ventilation and the rate of anesthetically, medically, or surgically related complications were compared between sedated and unsedated patients. The number of complete colonoscopies, length of the procedures, and time to reach the ileocecal valve were compared between sedated and unsedated patients.

RESULTS

Of 135 colonoscopies, 101 were performed under sedation. All sedated patients underwent complete endoscopic examinations, while 8.9% of unsedated patients had their examination stopped due to excessive discomfort or pain. Colonoscopies tended to be shorter in sedated than unsedated patients. No anesthesia-related complications occurred. In 3/135 patients, a short period (<3 min) of mask ventilation was necessary. One surgical complication occurred among the sedated patients. One unsedated patient suffered a medical complication (dyspnea and ST-T elevation).

CONCLUSIONS

Propofol sedation can be safely applied to colorectal cancer screening outpatients. Sedation was managed by a dedicated anesthetic staff and no patient suffered anesthesia-related complications.

Cost evaluation in a colorectal cancer screening programme by faecal occult blood test in the District of Florence

OBJECTIVES

To evaluate the direct costs of first and repeat colorectal cancer screening by immunochemical faecal occult blood testing (I-FOBT).

METHODS

Florence district residents aged 50-70 were invited to undergo one-time I-FOBT every two years. Full colonoscopy was recommended for FOBT-positive subjects. Direct cost analysis was carried out separately for the first and repeat screening. All relevant resources consumed by the programme were calculated.

RESULTS

Among 25,428 or 62,369 subjects invited to the first or repeat screening, respectively, the corresponding participation rate was 47.8% or 52.3%, and the positivity rate was 4.4% and 3.3%. Corresponding detection rates and positive predictive values for cancer and advanced adenoma were 11.3% or 8.9% and 32.4% or 32.8%, respectively. The assessment phase accounted for the major cost, as compared with recruitment and screening. All cost indicators were slightly higher in the first screening compared with repeat screening. Cost per cancer and advanced adenoma detected was similar in the first or repeat screening. A higher than observed participation rate would have substantially reduced screening cost.

CONCLUSION

Analysis of I-FOBT-organized population-based screening cost demonstrates lower cost at repeat compared with first screening and provides reference for decision-making in screening implementation.

Colorectal cancer mortality in two areas of Tuscany with different screening exposures

Several randomized trials have demonstrated the efficacy of colorectal cancer screening by the fecal occult blood test in reducing colorectal cancer mortality, but an evaluation of population-based screening programs is still lacking. We compared the colorectal cancer mortality rates (both adjusted rates and 3-year moving average rates) during 1985-2006 for two geographic areas in the provinces of Florence and Prato in the Tuscany region of Italy that began active population-based screening for colorectal cancer at different times: the Empolese-Mugello district, in the early 1980s, and the rest of the Florence and Prato provinces, in early 2000. A log-linear Poisson model was used to estimate the annual percent change in mortality and to examine whether geographic area modified the effect of calendar year on it. The Empolese-Mugello district had a greater decrease in colorectal cancer mortality than the rest of the Florence and Prato provinces (estimated annual percent change in age-adjusted colorectal cancer mortality rate, 2.7% decrease per year [95% confidence interval {CI} = 1.7% to 3.7%] vs 1.3% decrease per year [95% CI = 0.8% to 1.7%], respectively). The interaction between calendar period and area was statistically significant (P < .001). Our results support the hypothesis that the implementation of colorectal cancer screening in the early 1980s in the Empolese-Mugello district, where approximately 17 500 people were tested each year with the fecal occult blood test, was associated with a larger reduction in colorectal cancer mortality than that observed in the rest of Florence and Prato provinces, where screening started 15-20 years later and where approximately 38 000 people were screened each year beginning in 2000.

CT colonography after incomplete colonoscopy in subjects with positive faecal occult blood test

AIM: To report our experience with computed tomography colonography (CTC) systematically performed in subjects with positive faecal occult blood test (FOBT) and an incomplete colonoscopy in the setting of a population-based screening for colorectal cancer (CRC).

METHODS: From April 2006 to April 2007, 43 290 individuals (age range 50-70) who adhered to the regional screening program for the prevention of CRC underwent immunochemical FOBT. FOBT was positive in 1882 subjects (4.3%). 1463 (77.7%) of these subjects underwent colonoscopy, 903 performed in a single center. Of 903 colonoscopies 65 (7.2%) were incomplete. Forty-two of these subjects underwent CTC. CTC was performed with a 16-MDCT scanner after standard bowel prep (polyethylene glycole) in both supine and prone position. Subjects whose CTC showed polyps or masses were referred to the endoscopist for repeat colonoscopy under sedation or underwent surgery. Per-lesion and per-segment positive predictive values (PPV) were calculated.

RESULTS: Twenty-one (50%) of 42 CTCs showed polyps or masses. Fifty-five of these subjects underwent a repeat colonoscopy, whereas 2 subjects underwent surgery for colonic masses of indeterminate nature. Four subjects refused further examinations. CTC correctly identified 2 colonic masses and 20 polyps. PPV for masses or polyps greater than 9 mm was of 87.5%. Per-lesion and per-segment PPV were, respectively, 83.3% and 83.3% for polyps greater or equal to 10 mm, and 77.8% and 85.7% for polyps of 6-9 mm.

CONCLUSION: In the context of a screening program for CRC based on FOBT, CTC shows high per-segment and per-lesion PPV for colonic masses and polyps greater than 9 mm. Therefore, CTC has the potential to become a useful technique for evaluation of the non visualized part of the colon after incomplete colonoscopy.

Comparing attendance and detection rate of colonoscopy with sigmoidoscopy and FIT for colorectal cancer screening

BACKGROUND & AIMS

We conducted a study to estimate population coverage and detection rate (DR) achievable through different strategies of colorectal cancer (CRC) screening.

METHODS

A population-based multicenter randomized trial comparing 3 strategies was used: (1) biennial immunologic fecal occult blood test (FIT), (2) "once only" sigmoidoscopy (FS), and (3) "once only" colonoscopy (TC). A random sample of men and women, aged 55 to 64 years, was drawn from general practitioners' (GP) rosters. Eligible subjects, randomized within GP, were mailed a personal invitation. Nonresponders in groups 2 and 3 were invited again at 12 and 24 months. Screenees with "high-risk" distal polyps (villous component >20%, high-grade dysplasia, CRC, size >or=10 mm, >2 adenomas) at FS, or with positive FIT, were referred for TC.

RESULTS

The attendance rate was 32.3% (1965/6075) for FIT, 32.3% (1944/6018) for FS, 26.5% (1597/6021) for TC. FIT detected 2 patients with CRC (0.1%) and 21 with an advanced adenoma (1.1%). The corresponding figures were as follows: 12 (0.6%) and 86 (4.5%) patients, respectively, for FS; 13 (0.8%) and 100 (6.3%) patients, respectively, for TC. To detect 1 advanced neoplasm, it would be necessary to invite 264 people with FIT, 60 with FS, 53 with TC. FS would have detected 27.3% of the proximal advanced neoplasms detected at TC. Assuming the same participation rate at TC as at FS, 48 TCs would be necessary to detect 1 additional advanced neoplasm missed by FS.

CONCLUSIONS

When participants are offered 1 screening test, participation is lower in a TC than in an FS program. However, DR of advanced neoplasia is higher with TC.

Sensitivity of latex agglutination faecal occult blood test in the Florence District population-based colorectal cancer screening programme

We evaluated the sensitivity for colorectal cancer (CRC) of the latex agglutination test (LAT), an immunochemical test routinely used in the Florence District screening programme since 2000. Sensitivity was calculated by the proportional interval cancer incidence method in a population of 27,503 consecutive subjects screened in 2000-2002, interval cancers being identified by linkage to the Tuscany Cancer Registry files. Sensitivity was calculated overall and by gender, age, time since last negative LAT, CRC site, and rank of screening. Overall 1- and 2-year sensitivity estimates were 80.7 and 71.5%, respectively, suggesting that faecal occult blood testing screening sensitivity may be suboptimal due to testing or programme quality problems. Increasing screening sensitivity might be achieved if the detection rate of advanced adenomas could be increased without unacceptable loss in specificity.

Gastric cancer after positive screening faecal occult blood testing and negative assessment

BACKGROUND

Gastric cancer may be suspected with otherwise unexplained positive faecal occult blood testing.

AIMS

To assess the frequency of gastric cancer following positive faecal occult blood testing and negative colonoscopy.

SUBJECTS

Age 40-74 cohort at first screening (1985-2001) with (a) faecal occult blood testing- (83,489), (b) faecal occult blood testing +/colonoscopy+ (2025), or faecal occult blood testing+/colonoscopy- (3555).

METHODS

Gastric cancer incidence in faecal occult blood testing subsets, compared with expected standardized incidence rates.

RESULTS

Gastric cancer risk was increased (standardized incidence rate=146.7; 95% confidence interval: 105.8-203.4) in faecal occult blood testing+/colonoscopy- subjects. A four-fold excess incidence occurred during first year (observed cases=10, standardized incidence rate=408.3; 95% confidence interval: 219.7-758.8), irrespective of faecal occult blood testing type (guaiac, immunological). No excess risk occurred in faecal occult blood testing- (observed cases=53, standardized incidence rate=91.2; 95% confidence interval: 84.1-98.8) or in faecal occult blood testing+/colonoscopy+ subjects (observed cases=2, standardized incidence rate=101.9; 95% confidence interval: 25.5-407.4). Assuming a 100% 3-year study sensitivity for gastric cancer, faecal occult blood testing positive predictive value would be 0.4% (40-74 years) or 0.7% (> or =60 years) in faecal occult blood testing+/colonoscopy- subjects.

CONCLUSIONS

Data suggest an association of faecal occult blood testing+/colonoscopy- and excess gastric cancer incidence in the following year. Due to low faecal occult blood testing+ positive predictive value, routine upper digestive tract endoscopy in these subjects is questionable.

Association of FOBT-assessed faecal Hb content with colonic lesions detected in the Florence screening programme

We assessed the correlation between quantitative results of immunological faecal occult blood testing (I-FOBT) and colonic lesions (191 colorectal cancers, 890 adenomas) detected at colonoscopy in 2597 FOBT+ (cutoff 100 ng ml⁻¹ Hb) subjects. At univariate analysis, a higher average faecal Hb content was significantly associated with male gender (P=0.003), age (P=0.02), and colonoscopy findings (P=0.000). Among adenomas, higher faecal Hb content was significantly associated with size (P=0.0000), presence of severe dysplasia (P=0.0001), presence of villous component (P=0.0002), and location in the left colon (P=0.003). At multivariate analysis adjusting for potential confounders, age (P=0.03), size (P=0.0000), and location in the left colon (P=0.0005) were confirmed as having an independent association with higher faecal Hb content. Immunological FOBT is confirmed to be a specific screening test to detect cancer and adenoma, with a low positivity rate (3.7%) and a high positive predictive value (41.5%). Faecal Hb content is significantly higher for those lesions (cancer and high-risk adenomas) screening is aimed at detecting.

Nipple sparing subcutaneous mastectomy: sixty-six months follow-up

AIM

Validation of oncological and reconstructive efficacy of nipple sparing subcutaneous mastectomy.

METHODS

We enrolled 50 patients on behalf of Humanitas Centro Catanese di Oncologia fulfilling appropriate reconstructive and oncological criteria to undergo nipple sparing subcutaneous mastectomy. We preferably selected women with medium size-small breast affected by early stage breast cancer peripherally located with intra-operative negative frozen section of the major ducts.

RESULTS

fourty-six patients were alive after a mean follow-up of 5.5 years. We observed a single case of local recurrence in the nipple successfully treated with local excision. Five patients presented metastatic disease. One is currently alive, 4 died because of progressive disease.

CONCLUSIONS

Our study supports other findings regarding safety and efficacy of nipple sparing subcutaneous mastectomy for selected patients.

Randomized Trial of Different Screening Strategies for Colorectal Cancer: Patient Response and Detection Rates

BACKGROUND

Although there is general consensus concerning the efficacy of colorectal cancer screening, there is a lack of agreement about which routine screening strategy should be adopted. We compared the participation and detection rates achievable through different strategies of colorectal cancer screening.

METHODS

From November 1999 through June 2001 we conducted a multicenter, randomized trial in Italy among a sample of 55-64 year olds in the general population who had an average risk of colorectal cancer. People with previous colorectal cancer, adenomas, inflammatory bowel disease, a recent (< or =2 years) colorectal endoscopy or fecal occult blood test (FOBT), or two first-degree relatives with colorectal cancer were excluded. Eligible subjects were randomly assigned, within the roster of their general practitioner, to 1) biennial FOBT (delivered by mail), 2) biennial FOBT (delivered by general practitioner or a screening facility), 3) patient's choice of FOBT or "once-only" sigmoidoscopy, 4) "once-only" sigmoidoscopy, or 5) sigmoidoscopy followed by biennial FOBT. An immunologic FOBT was used. Participation and detection rates of the strategies tested were compared using multivariable logistic regression models that adjusted for age, sex, and screening center. All statistical tests were two-sided.

RESULTS

Of 28 319 people sampled, 1637 were excluded and 26 682 were randomly assigned to a screening arm. After excluding undelivered letters (n = 427), the participation rates for groups 1, 2, 3, 4, and 5 were 30.1% (682/2266), 28.1% (1654/5893), 27.1% (970/3579), 28.1% (1026/3650), and 28.1% (3049/10 867), respectively. Of the 2858 subjects screened by FOBT, 122 (4.3%) had a positive test result, 10 (3.5 per 1000) had colorectal cancer, and 39 (1.4%) had an advanced adenoma. Among the 4466 subjects screened by sigmoidoscopy, 341 (7.6%) were referred for colonoscopy, 18 (4 per 1000) had colorectal cancer, and 229 (5.1%) harbored an advanced adenoma.

CONCLUSIONS

The participation rates were similar for sigmoidoscopy and FOBT. The detection rate for advanced neoplasia was three times higher following screening by sigmoidoscopy than by FOBT.

Colorectal cancer screening programme by faecal occult blood test in Tuscany: first round results

Screening with faecal occult blood test (FOBT) has been shown to be effective in reducing mortality from colorectal cancer. Tuscany was the first region in Italy in which a screening programme for colorectal cancer by FOBT was initiated region-wide. The aim of the paper was to describe organizational aspects, a quality control model and the results of this experience. From June 2000 to December 2001, 192583 subjects aged 50-70 were invited to undergo a 1-day immunochemical test without any dietary restriction. A total of 78505 subjects (41%) performed the screening test, of whom 4537 responders had a positive test result (5.8%). Among them, 1122 refused any form of assessment or underwent a colonoscopy outside the screening referral centres, with an overall assessment compliance of 75.3%. Malignancies were found in 193 patients and at least a high-risk adenomatous polyp in 692 patients. In about a quarter of the positive subjects who underwent assessment, cancer or high-risk adenoma was detected. In conclusion, data from this experience supported the feasibility of biennial colorectal screening programme by FOBT, particularly regarding invitation compliance and positivity rate. Further efforts are necessary to implement screening extension and to improve data collection.

Feasibility study of colorectal cancer screening by immunochemical faecal occult blood testing: results in a northern Italian community

AIM

Screening by means of faecal occult blood testing (FOBT) has proved to be effective in reducing colorectal cancer incidence and mortality. We performed a pilot screening for colorectal cancer by latex immunological FOBT in two municipalities of the region Valle d'Aosta, Italy, focusing on problems and obtaining indications for the feasibility and extension of the screening programme on a regional basis.

METHODS

A total of 2961 subjects aged 50-74 years were invited by mail to perform a one-day immunochemical FOBT without any dietary restrictions and with a positive threshold put at 100 ng/ml. Patients with positive tests were then invited to undergo colonoscopy and double-contrast barium enema if colonoscopy was incomplete.

RESULTS

A total of 1631 subjects performed the screening test with an overall compliance of 55.1%. Seventy-two subjects had a positive FOBT. Detection rates for cancer and adenomas were 1.8 per thousand and 16.6 per thousand, respectively. Positive predictive values (PPVs) for cancer and adenomas were 4.5% and 40.3%, respectively.

CONCLUSIONS

Screening had an adequate attendance rate and the majority of the indicators were satisfactory. The use of a one-day quantitative latex FOBT with no dietary restrictions, automation of the analytical procedure, and a positive threshold of 100 ng/ml has shown that a programme based on this test is feasible in both organizational and attendance terms. On the basis of this experience, the extension of the screening on a regional basis is suggested.

Basic variables at different positivity thresholds of a quantitative immunochemical test for faecal occult blood

OBJECTIVES

Screening by faecal occult blood testing (FOBT) is effective in decreasing mortality and incidence of colorectal cancer (CRC). Immunochemical tests have proved to be more cost effective than guaiac FOBTs. The latex agglutination test (LAT) has the advantage of being a fully automated, quantitative test. The aim of this study is to interpret the overall experience with LAT according to different positivity thresholds.

SETTING

A population based screening programme is currently running involving subjects aged 50-70, invited every 2 years to have an FOBT. LAT is the standard screening test and has a positivity threshold for further diagnostic tests of 100 ng haemoglobin/ml of sample solution.

METHODS

Positivity rates, detection rates for CRC high risk adenomas, and positive predictive values for CRC, high risk adenomas, and low risk adenomas were calculated for several positivity thresholds.

RESULTS

19,132 attendances at screening were recorded (11,774 at first screening, 7358 at subsequent screenings). Progressively increasing the positivity threshold from 100 to 200 ng/ml showed (a) a decrease in positivity rate; (b) a decrease in detection rates for CRC or high risk adenomas; (c) an increase in positive predictive values for cancer; (d) an increase in positive predictive value for high risk adenomas.

CONCLUSIONS

Increasing the positivity threshold of the LAT reduces recall rate and improves positive predictive value for cancer or high risk adenomas but substantially decreases the detection rate of CRC and high risk adenomas. For this reason increasing the positivity cut off for LATs is not advisable. On the other hand decreasing the positivity threshold would increase recall rate and sensitivity of screening. Careful evaluation of sensitivity of the quantitative results of the LAT for interval cancers is needed to definitively assess the optimal positivity threshold for LATs in population based screening programmes.

Interobserver agreement in the histologic diagnosis of colorectal polyps. the experience of the multicenter adenoma colorectal study (SMAC)

Current clinical practice guidelines for patients with colorectal polyps are mainly based on the histologic characteristics of their lesions. However, interobserver variability in the assessment of specific polyp characteristics was evaluated in very few studies. The purpose of this study was to evaluate the interobserver agreement of four pathologists in the diagnosis of histologic type of colorectal polyps and in the degree of dysplasia and of infiltrating carcinoma in adenomas. A stratified random sample of 100 polyps was obtained from the 4,889 polyps resected within the Multicentre Adenoma Colorectal Study (SMAC), and the slides were blindly reviewed by the four pathologists. Agreement was analyzed using kappa statistics. A median kappa of 0.89 (range 0.79-1.0) was estimated for the interobserver agreement for the diagnosis of hyperplastic polyp vs. adenoma. The agreement in the diagnosis of tubular, tubulovillous, and villous type, was given by median kappa values of 0.50, 0.15, and 0.36, respectively. The median kappa for the diagnosis of infiltrating carcinoma was 0.78 (range 0.73-0.84). Agreement on diagnosis of adenoma histologic subtypes, degrees of dysplasia, or infiltrating carcinoma in adenoma was moderate. A simpler classifications might help to better identify patients at different risk of colorectal cancer.

Oral beclomethasone dipropionate in patients with mild to moderate ulcerative colitis: a dose-finding study

Systemic glucocorticosteroids have demonstrated efficacy in ulcerative colitis (UC) but cause undesired systemic side effects. Beclomethasone dipropionate (BDP) has potent topical activity and is extensively metabolized. This randomized double-blind study investigated an oral gastroresistant controlled-release preparation of BDP in 57 patients with mild to moderately severe extensive or left-sided UC. Patients were assigned to receive BDP 5 or 10 mg/d; a third group took a clinically inactive dose (1.6 g/d) of 5-aminosalicylic acid (5-ASA). Both BDP doses displayed excellent efficacy confirmed by results of endoscopy, biopsy, and clinical evaluation. Significant improvement from baseline occurred in most signs and symptoms of UC, particularly stool frequency, rectal bleeding, and mucus in the stool (P<.01). Tolerability was good in both BDP groups. Morning plasma cortisol levels decreased significantly from baseline with BDP 10 mg, but no significant changes in vital signs were observed at the end of treatment. Despite a small sample size and the open comparison with 5-ASA, this multicenter study showed the therapeutic equivalence of BDP 5 and 10 mg/d in alleviating clinical symptoms and improving endoscopic and biopsy scores in patients with mild to moderate UC. BDP 5 mg/d displayed better general tolerability and less reduction of plasma cortisol levels, however, and may be preferable to the higher dose in this indication.

Measuring interval cancers in population-based screening using different assays of fecal occult blood testing: the District of Florence experience

The fecal occult blood test (FOBT) has demonstrated its efficacy in reducing mortality from colorectal cancer (CRC). The guaiac-based FOBT has been criticized for its low sensitivity. In this study, two different assays for FOBT (guaiac or an immunochemical test based on reversed passive hemagglutination [RPHA]) were tested for comparison within a population-based screening program for colorectal cancer in the province of Florence (Italy). The proportional incidence method was used to calculate sensitivity for both FOBTs, according to rank of screening (first or repeat), age at entry (two groups of 50 to 59 and 60 to 70 years old) and lesion site (colon or rectum). When comparing FOBTs, the sensitivity multivariate Poisson regression was used to adjust for other variables. The sensitivity after the first 2 years was 50% (95% confidence interval [CI] 34% to 63%) for the guaiac test versus 82% (95% CI 67% to 92%) for RPHA. At multivariate analysis the risk of developing an interval cancer after a guaiac test is almost 3 times that after RPHA (rate ratio = 2.64; 95% CI 1.3 to 5.4). Our study confirms that RPHA is more sensitive than the guaiac test. The assumption that FOBT screening for CRC has to be based on a guaiac test should be reconsidered, and RPHA should be recommended as the standard FOBT for screening purposes.

Measuring interval cancers in population-based screening using different assays of fecal occult blood testing: the District of Florence experience

The fecal occult blood test (FOBT) has demonstrated its efficacy in reducing mortality from colorectal cancer (CRC). The guaiac-based FOBT has been criticized for its low sensitivity. In this study, two different assays for FOBT (guaiac or an immunochemical test based on reversed passive hemagglutination [RPHA]) were tested for comparison within a population-based screening program for colorectal cancer in the province of Florence (Italy). The proportional incidence method was used to calculate sensitivity for both FOBTs, according to rank of screening (first or repeat), age at entry (two groups of 50 to 59 and 60 to 70 years old) and lesion site (colon or rectum). When comparing FOBTs, the sensitivity multivariate Poisson regression was used to adjust for other variables. The sensitivity after the first 2 years was 50% (95% confidence interval [CI] 34% to 63%) for the guaiac test versus 82% (95% CI 67% to 92%) for RPHA. At multivariate analysis the risk of developing an interval cancer after a guaiac test is almost 3 times that after RPHA (rate ratio = 2.64; 95% CI 1.3 to 5.4). Our study confirms that RPHA is more sensitive than the guaiac test. The assumption that FOBT screening for CRC has to be based on a guaiac test should be reconsidered, and RPHA should be recommended as the standard FOBT for screening purposes.

Screening for colorectal cancer by faecal occult blood test: comparison of immunochemical tests

OBJECTIVE

To compare two immunochemical faecal occult blood tests based on reversed passive haemagglutination (RPHA) or latex agglutination (Hdia) in a population based screening setting.

METHOD

Hdia was interpreted according to three positivity thresholds: 100, 150, or 200 ng of haemoglobin/mg of specimen solution. A total of 5844 subjects were recruited into the study, from 17432 invited subjects aged 50-70.

RESULTS

Positivity rates were 3.3% for RPHA, Hdia100 3.5%, Hdia150 2.5%, Hdia200 2.0%. Among subjects complying with the diagnostic work up, colorectal cancer (CRC) was detected in 19 subjects (17 RPHA positive, 16 Hdia100 positive, 15 Hdia150 positive, 14 Hdia200 positive) and high risk adenoma/s in 41 subjects (28 RPHA positive, 32 Hdia100 positive, 29 Hdia150 positive, 25 Hdia200 positive). The prevalence of screen positive CRC in the population was for RPHA 2.9 per thousand, Hdia100 2.7 per thousand, Hdia150 2.6 per thousand, Hdia200 2.4 per thousand. The prevalence of screen positive high risk adenomas in the population was for RPHA 4.8 per thousand, Hdia100 5.5 per thousand, Hdia150 5.0 per thousand, Hdia200 4.3 per thousand.

CONCLUSION

Hdia100 was as sensitive as RPHA for cancer and high risk adenomas. As Hdia is less technically complex than RPHA, it is a valid alternative to the latter, provided that full automation of the development procedure is available. Increasing the positivity threshold of Hdia up to 150 or 200 ng of haemoglobin/mg of specimen solution is not advisable as the increase in specificity is too small to justify the corresponding decrease in the detection of screen positive cancers in the population.

[Dermatofibrosarcoma protuberans: authors' experience]

Dermatofibrosarcoma protuberans is an uncommon slow-growing cutaneous neoplasm. Surgical excision is an effective therapeutic approach although a significant number of local recurrences has been documented in the literature. In the present paper the Authors report 3 cases of dermatofibrosarcoma protuberans. All cases have been surgically treated with a wide local excision extended up to 3 cm from the tumor borders. No local recurrence has been reported. The Authors conclude that the surgical technique employed could reduce the local recurrence rate of dermatofibrosarcoma protuberans.

Do patients with rectosigmoid adenomas 5 mm or less in diameter need total colonoscopy?

BACKGROUND

The need for colonoscopy in the care of patients with rectosigmoid adenoma 5 mm or less in diameter is still debatable.

METHODS

We estimated the prevalence of proximal adenomas among 3052 consecutive subjects undergoing total colonoscopy. Rectosigmoid adenoma was classified as diminutive (5 mm), small (6 to 10 mm), or large (>/=11 mm). Advanced proximal adenoma was 10 mm in diameter or larger, or with a villous component, severe dysplasia, or infiltrating adenocarcinoma.

RESULTS

Proximal adenoma was found in 212 of 2483 patients (8.5%, 95% CI [7.5, 9.7]) without distal neoplastic polyps, 49 of 214 (22.9%, 95% CI [17.6, 29.2]) with diminutive, 44 of 174 (25.3%, 95% CI [19.1, 32.5] with small, and 70 of 181 (38.7%, 95% CI [31.6, 46.2]) with large distal adenoma. Advanced proximal adenoma was found in 49 (2.0%, 95% CI [1.5, 2.6]), 8 (3.7%, 95% CI [1.7, 7.5]), 17 (9.8%, 95% CI [6.0, 15.4]), and 29 patients (16.0%, 95% [11.2, 22.4]), respectively. In patients with distal adenoma risk for proximal lesions increased with increasing age, size, and number of distal adenomas (p = 0.01). Size of distal adenoma was the strongest predictor of the presence of proximal advanced adenoma (multivariate analyses).

CONCLUSIONS

In a clinical setting, the decision to perform colonoscopy should take into account proximal lesions of clinical interest, life expectancy, costs, and risks associated with the procedure. When detection of advanced proximal adenoma is the goal, presence of distal diminutive adenoma alone might not be an indication for total colonoscopy.

[The immediate reconstruction of the breast after a mastectomy for carcinoma. Our experience]

The authors surgically treated 281 consecutive women with breast cancer by breast conservation techniques (45.2%) or by mastectomy (38.8%), during a four-year period. Forty-five of these 281 patients (16%) were treated in the same period of time by mastectomy and immediate reconstruction (IR) of the breast. IR of the breast was performed by inserting a submuscular tissue expander at the same time of mastectomy (first stage of reconstruction). A second operation allowed the replacement of the expander with a prosthesis (second stage of reconstruction) and the simultaneous symmetrization of the contralateral breast (not always performed, however). In some cases nipple-areola complex was eventually reconstructed with a delayed surgical procedure (third stage of reconstruction). In the present paper the authors analyze the results and outline the advantages of IR. This easy and safe technique slightly increased the average operative time of a mastectomy, did not interfere with routine oncological follow-up, did definitely reduce patient's psychological trauma following mastectomy. The authors conclude that IR of the breast undoubtedly plays a major role in the so called "onco-plastic"" surgical management of breast cancer.

[The sporadic use of intraoperative cholangiography during laparoscopic cholecystectomy]

The authors report their experience with 850 consecutive laparoscopic cholecystectomies performed from May 1990 to July 1997. In this series, despite a sporadic use of intraoperative cholangiography (IOC), there were no lesions of main biliary tract and there was only a biliary leaking cystic duct resolved with conservative treatment. The authors are satisfied with selective use of endoscopic cholangiography and sphincterotomy for the management of choledocholithiasis, and conclude that the use of IOC is not so essential to avoid iatrogenic lesions of main biliary tract, that could be avoid by applying a meticulous operative technique.