Lexicographic Optimization-Based Planning for Single and Multiple Brain Metastasis Radiosurgery with Coplanar Arcs

PURPOSE/OBJECTIVE(S)

This study validated a not yet commercially available fully-automated lexicographic optimization planning system (LOps) for single and multiple lesions intracranial stereotactic radiosurgery (SRS).

MATERIALS/METHODS

Forty-four consecutive SRS treatment plans (21 Gy/1 fx) delivered between November 2019 and August 2022 were retrospectively selected and automatically re-planned by LOps: 25 of them has 1 lesion, 13 had 2 lesions, 4 had 3 lesions, and 2 had 4 lesions. An a-priori assigned priority list, Wish List (WL), was used to define the sequential LO: 4 patient sets (tuning set) were necessary to tune each WL, for single lesion-plans (SLp) and multiple lesion-plans (MLp). While in manual plans (MP), the arc setup is freely chosen, the WL was tuned to use 2 coplanar arcs of 140° and 360° for SLp and MLp, respectively. A 0° and 90° collimator rotation were set for counter-clockwise and clockwise arcs, respectively. The fluence optimization is followed by a Monte Carlo calculation (MCc) with 1 mm-dose grid and 0.5%-statistical uncertainty. A target coverage as high as possible was requested, with at least 80% of the prescription dose covering 99% of the PTV. The main criteria for SLp approval were a brain V12Gy <10 cm3. In MLp this criterion can be overcome to get the minimum target coverage. The remaining 36 SRS plans (21 SL and 15 MLp) were automatically re-planned (testing set). Testing plans were compared in terms of dose-volume constraints, conformality, and monitor units (MUs). Statistical significance was assessed by performing the Wilcoxon test and plan delivery accuracy was verified by pre-treatment QA.

RESULTS

WLs-tuning took 3 days. Overall manual and automatic MCc time can be estimated at 8 hours and 3 hours, respectively. Statistically significant increases in SLp and MLp target coverage (GTV_D98%: +3.0% SL, +5.7% ML, PTV_D98%: +4.4% SL, +13.4% ML) and conformity index were registered. Automatic plans showed acceptably higher median brain V12Gy (SL: MP 7.2 cm3, SLp 7.6 cm3; ML: MP 8.7 cm3, MLp 10.3 cm3). The SLp registered a lower median MU number (-4.2%) while MLp were obtained with a higher median number of MU (+9.8%). This not statistically significant difference did not affect gamma passing rates.

CONCLUSION

The novel LOps produced high-quality clinically acceptable SRS SL and ML plans with coplanar arcs according to institutional-specific planning protocols, significantly reducing the overall planning time from about one working day for one MP to about 3 hours for one automatic plan. Together with comparable OAR sparing, the target coverage was significantly increased and the plan deliverability preserved.

Pelvic myeloid sarcoma: a multidisciplinary approach

Myeloid sarcoma (MS) is a rare tumor mass derived from the extramedullary proliferation of blasts of one or more of myeloid lineages. It usually occurs at an anatomical site other than the bone marrow (BM). Among the anatomical site which may be involved, female genital tract is a rare localization. When MS follows a previous history of myeloid pathology it is usually associated to a poor prognosis. To date this disease was managed with exploratory laparotomy or with surgical debulking. The authors report a case of laparosc6pic diagnosis of a pelvic myeloid sarcoma in a patient previously affected by acute mycloid leukemia, evidencing the importance of minimally invasive diagnosis and subsequent multidisciplinary management.

Histological evaluation of ureteral involvement in women with deep infiltrating endometriosis: analysis of a large series

STUDY QUESTION

In women with deeply infiltrating endometriosis (DIE) what is the prevalence of involvement of endometriotic tissue and fibrosis in ureteral endometriosis (UE), as assessed by histological staining?

SUMMARY ANSWER

In women with DIE, ureteral involvement is more often due to endometriotic tissue rather than fibrosis.

WHAT IS KNOWN ALREADY

In the current literature, histological evaluation of ureteral endometriosis is mainly based on the degree of wall infiltration by endometriosis instead of the tissue composition. A few studies reported ill-defined and contradictory histological data on the tissue composition of UE.

STUDY DESIGN, SIZE, DURATION

Retrospective observational study based on clinical records of women affected by DIE, laparoscopically treated for UE at a tertiary referral center, between January 2010 and March 2013. All cases of ureteral nodule excision or ureterectomy with histological examination of the specimens were included. Exclusion criteria were other identified causes of hydroureteronephrosis, medical therapy for a period of at least 3 months before surgery and previous surgery for DIE.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 77 patients were included in the study and among them seven (9%) presented with bilateral ureteral involvement, giving a total of 84 cases of UE available for analysis. All patients had stage IV endometriosis. According, respectively, to the presence of endometrial glands and/or stroma cells or of fibrotic tissue only, the endometriotic UE and fibrotic UE groups were compared with regard to hydroureteronephrosis at pre-operative urinary tract computerized tomography scan, type of surgical procedure performed to treat UE (nodule removal or ureterectomy), association with other locations of the disease and post-operative complications (ureteral fistula or stenosis).

MAIN RESULTS AND THE ROLE OF CHANCE

For the 84 cases of UE, 65 (77%) and 19 (23%), respectively, showed endometriotic tissue and fibrotic tissue only. Presence of hydroureteronephrosis and endometriotic pattern of UE showed a significant association [endometriotic UE 44/65 (68%) versus fibrotic UE 8/19 (42%); P = 0.04]. Fibrotic pattern of UE and presence of concomitant recto-vaginal endometriosis showed a significant association [endometriotic group: 29/65 (45%) versus fibrotic group 18/19 (95%); P < 0.001].

LIMITATIONS, REASONS FOR CAUTION

The retrospective and monocentric (tertiary referral center) study design.

WIDER IMPLICATIONS OF THE FINDINGS

Besides the distinction between extrinsic and intrinsic UE based on the degree of wall infiltration by endometriosis, a new classification according to the histological pattern of UE could be useful for clinicians, both in the diagnostic and therapeutic fields.

STUDY FUNDING/COMPETING INTERESTS

None.

Laparoscopic management of early stage ovarian cancer: is it feasible, safe, and adequate? A retrospective study

INTRODUCTION

Minimally invasive surgery to stage early ovarian cancer is still regarded as pioneering among gynecologic oncologists. Previous retrospective experiences demonstrated the safety and feasibility of laparoscopy in this field.

AIMS

To review the laparoscopic staging procedure in a series of patients with early ovarian cancer and compare results with the literature.

MATERIALS AND METHODS

From January 2004 to September 2011, 19 patients with apparent early stage ovarian/fallopian tube cancer Stage IA to IC underwent either primary treatment or completion staging by laparoscopy. Surgical, pathologic, and oncologic outcomes were analyzed.

RESULTS

The mean operative time was 212 +/- 69 minutes. Three patients (16%) underwent fertility sparing surgery. The mean estimated blood loss was two +/- two g/dl. The mean number of pelvic and para-aortic lymph nodes collected was 17 (range 7-27) and 14 (range 8-21), respectively. The mean volume of ovarian/tubal tumor was 119 cm3 (range 1.5-500). The disease was reclassified to a higher stage in ten women (52%). One major intraoperative complication (five percent) occurred which required the conversion to laparotomy. The mean follow up period was 30 +/- 16 months (range 10-74). Overall survival and disease-free survival were 100% and 84%, respectively.

CONCLUSIONS

Laparoscopic staging of early ovarian cancer appears to be feasible and comprehensive when performed by gynecologic oncologists experienced with advanced laparoscopy.

[5 days Cefaclor vs. 10 days amoxicillin/clavulanate in the treatment of childhood streptococcal pharyngitis. Data from a randomized clinical trial]

AIM

The duration of therapy represents a fundamental aspect in the compliance to the therapy of child pathologies, such as pharyngotonsillitis, treated with oral therapy. Although penicillin and amoxicillin are the first choice antibiotics in the case of a child suffering from pharyngotonsillitis with the proven presence of Group A β-hemolytic Streptococcus (GAS), the number of orally administered doses and 10 days of therapy, considerably lower the compliance.

METHODS

An open phase IV randomized multicenter clinical trial was conducted in parallel groups, involving 49 family pediatrician (FP), distributed over the entire national territory, enrolling 435 children suffering from GAS-FT. 210 children received Cefaclor, 50 mg/kg/day, administered twice daily for five days, whilst 213 children received amoxicillin/clavulanate 40 mg/kg/day administered twice daily for 10 days.

RESULTS

The results showed percentages of eradication of 88.4% for the Cefaclor group and 94.3% for the amoxicillin/clavulanate group, and a positive clinical judgement of 92.3% for the Cefaclor group and 96.6% for the amoxicillin/clavulanate group. The two arms of the study did not have any significant statistical differences, neither for the eradication, nor for the clinical judgement nor for the reduction of the Milano Score between the beginning and the end of treatment, with a P=0.042 for amoxicillin/clavulanate for eradication.

CONCLUSION

This study confirms that the administration of Cefaclor for five days during GAS-FT has the same efficacy as a 10-day therapy with amoxicillin/clavulanate, with a clearly different compliance.

[Laparoscopic surgery for endometrial cancer in overweight women]

AIM

The aim of this study was to investigate the feasibility and safety of laparoscopic staging of overweight women with endometrial cancer and to compare the surgical outcomes among these patients with those managed by laparotomy.

METHODS

This was a retrospective analysis (Canadian Task-force Classification II-3). We reviewed operative and hospital records of 70 patients with a body mass index >25 kg/m2 who underwent surgical treatment for endometrial cancer between 2001 and 2008. Thirty-five patients treated laparoscopically were compared to an equivalent group of patients treated by laparotomy. Operative and postoperative variables were afterwards assessed.

RESULTS

Women in laparoscopic group had a significantly lower blood loss (median, 25th-75th percentiles: 1.2, 0.8-2.0 in laparoscopic versus 1.8, 1.0-2.8 in laparotomic group, P<0.05). No differences between both group in terms of operative time (median, 25th-75th percentiles: 165 min, 130-183 in laparoscopic versus 135 min, 110-170 in laparotomic; P>0.05) and mean number of pelvic and para-aortic lymph nodes removed (22 ± 8.4 versus 24 ± 6.2 and 9.2 ± 2.5 versus 9.3 ± 5 respectively; P>0.05). Length of urethral catheter and hospital stay were statistically higher in laparotomic group (two days versus three days; four days versus seven days respectively; P<0.05).

CONCLUSION

Laparoscopic surgery in overweight women with endometrial cancer had equivalent surgical staging than women operated by laparotomy. With regard to postsurgical variables, overweight women who underwent laparoscopic surgery had better results than those treated by laparotomy.

Observational study on the performance of the Narhinel method (nasal aspirator and physiological saline solution) versus physiological saline solution in the prevention of recurrences of viral rhinitis and associated complications of the upper respiratory tract infections (URTI), with a special focus on acute rhinosinusitis and acute otitis of the middle ear

AIM

The aim of this study was to assess the validity of Narhinel method in the prevention of recurrences of viral rhinitis and of any associated sequelae, in particular acute otitis of the middle ear (AOM) and acute rhinosinusitis (AR).

METHODS

This was a prospective observational study, in children aged from two months to two years, observed for five months during the cold season and carried out by family pediatricians (FIMP association) in Friuli Venezia Giulia, Italy. The study enrolled 435 patients. The observed population consisted of two groups: the first one of 238 children treated with Narhinel method and the second one of 197 patients treated only with the physiological saline solution. In compliance with the guidelines of an observational trial, the children were prescribed the therapeutic treatments used as a routine. The patients were recruited for the trial after the responsible parent had signed the informed consent form. The study protocol had been approved by the Ethics Committee of the area of Pordenone. In order to be recruited, patients had to comply with the following criteria: symptoms suggestive of the common cold; age > or =2 months < or =2 years; male and female. Patients presenting one or more of the following characteristics were not included: systemic diseases; congenital nasal obstruction (choanal atresia); infections of the upper and lower respiratory tracts other than common cold; systemic and/or topical use of antibiotics and/or corticosteroids at the moment of recruitment. During the five months of the observation period, all the therapies that the investigators had decided it was necessary to administer had been included and recorded in the CRF. Patients evaluations were carried out for five months. The clinical assessment was performed at baseline (B), in the first week (Fw) and monthly and described as M1 to 5; several clinical parameters were analyzed (anterior and posterior rhinorrhoea, oral respiration, noisy nasal respiration, and nasally transmitted thoracic sounds) and measured by the pediatrician at all examinations from B to M5. Other parameters were derived from the parents' daily observations, recorded in a diary and made note of the quality of sleep, diet and respiration, and the use of any drug during any relapse of acute rhinitis (common cold episode). Recurrence of AOM and AR was assessed by the pediatrician at M1-2-3-4-5. Safety of use was determined using the Italian Health Ministry incident/near incident report sheets for Medical Device and based on diaries where the parents took note of any events which occurred during the observation period. Parental satisfaction and compliance were assessed through a questionnaire given to the parents at the end of the last visit (M5).

RESULTS

In the Narhinel group, the mean age was inferior (statistically significant): 8.9 compared to 11.4 months in the physiological saline solution group. The frequency of recurrences from viral rhinitis was very similar in the two groups and a decrease (statistical significant) was observed from M3 through M5 in both groups. Rhinorrhea, oral breathing, and other upper respiratory symptoms, improved in the two groups even if in the Narhinel one the improvement was more prominent during the first two months of observation. There was no difference in the frequency of AR between the groups: at M4 and M5, there was a statistically significant decrease in the frequency of episodes. The frequency of AOM varied in the two groups considering a comparison intra-groups: at M5 the decrease of episodes was statistically significant in the Narhinel group. In Narhinel group, AR and acute AOM seem to be more markedly controlled (frequency) especially for AOM. The frequency of adverse events (AEs) did not vary in the two groups: in the Narhinel one there was a difference (not statistically significant and not clinically relevant) in the number of patients with AEs, especially crying and nasal bleeding. One serious AE was reported in the physiological saline solution group. A 14-month-old child developed laryngospasm which recovered completely after hospital treatment with adrenaline. This event was not related to treatment with saline solution and causality was assessed as "unlikely" by the investigator. In the Narhinel group, one serious event of moderate convulsion febrile in a male patient (age of 0.9) was reported. The causality relationship was assessed by the investigator as improbable. Parents' satisfaction was higher (statistically significant) in the Narhinel group compared to the physiological saline solution alone group.

CONCLUSION

In acute rhinites (common cold) both medical devices are effective nevertheless Narhinel method is valid and shows better results in AOM and AR. Moreover Narhinel method was also more appreciated by parents than physiological saline solution. According to authors' experience, the Narhinel method is safe and its performance is valid in the prevention of AOM and AR in children.

Transcription profile analysis of vastus lateralis muscle from patients with chronic fatigue syndrome

Chronic fatigue syndrome (CFS) is a disabling condition characterized by unexplained chronic fatigue that impairs normal activities. Many body systems are affected and etiology has not yet been identified. In addition to immunological and psychological aspects, skeletal muscle symptoms are prominent in CFS patients. In an effort to establish which pathways might be involved in the onset and development of muscle symptoms, we used global transcriptome analysis to identify genes that were differentially expressed in the vastus lateralis muscle of female and male CFS patients. We found that the expression of genes that play key roles in mitochondrial function and oxidative balance, including superoxide dismutase 2, were altered, as were genes involved in energy production, muscular trophism and fiber phenotype determination. Importantly, the expression of a gene encoding a component of the nicotinic cholinergic receptor binding site was reduced, suggesting impaired neuromuscular transmission. We argue that these major biological processes could be involved in and/or responsible for the muscle symptoms of CFS.

Learning ability of 1-d-old partridges (Alectoris rufa) from eggs laid by hens fed with different n-3 fatty acid concentrations

1. The diets of commercial strains of laying partridge are usually lower in polyunsaturated fatty acids (PUFA) and n-3 fatty acids than the diets of wild partridges. The aim of this experiment was to examine the effects of three different PUFA and n-3 concentrations in partridge laying diets. 2. Offspring learning ability (passive avoidance test of 1-d-old chicks) was used to assess the effect of three different maternal diets (144 chicks were tested for each diet). A negative experience, allowing the bird to peck a bead bathed in a bitter liquid (methyl anthranilate-MA), was used for this purpose. The adults had been fed one of three different diets with n-3 contents of 0.48, 4.04 or 7.60 g/kg. 3. There was better memory retention in the offspring of adults fed the intermediate n-3 content compared to those fed the lower content. Discrimination ratio (DR) of the latency time toward the wrong (red) bead was less for the lower n-3 content (0.48) than for the middle n-3 PUFA content (0.43). DR of the number of pecks toward the wrong beads was greater for the lower n-3 content (0.51) than for the middle n-3 PUFA content (0.71). 4. The partridges fed the diet containing the lowest concentration of n-3 and PUFA were unable to express the expected behavioural score (neural embryo development index) given the genetic characteristics of the animals.

Recolonization and recovery dynamics of the macrozoobenthos after sand extraction in relict sand bottoms of the Northern Adriatic Sea

The long-term effects of sand extraction on macrozoobenthic communities were investigated in an offshore area in the Northern Adriatic Sea characterised by relict sands formed during the last Adriatic post-glacial transgression. Surveys were carried out before, during and 1, 6, 12, 18, 24 and 30 months after extraction at three impacted and seven reference stations. The operations did not influence the physical characteristics of the sediment, but they caused almost complete defaunation at dredged sites. Univariate and multivariate analyses highlighted that the macrozoobenthic community responses to the dredging operations were (1) a rapid initial recolonisation phase by the dominant taxa present before dredging, which took place 6-12 months after sand extraction; (2) a slower recovery phase, that ended 30 months after the operations, when the composition and structure of the communities were similar in the dredged and reference areas. This pattern of recolonisation-recovery fits well with the commonly encountered scenario where the substratum merely remains unchanged after marine aggregate extraction.

Interlaboratory reproducibility of liquid-based equivocal cervical cytology within a randomized controlled trial framework

Within a multicentre controlled trial framework, an external quality control (EQC) was scheduled to evaluate the interlaboratory reproducibility of liquid-based cytology. In particular, this EQC intended to evaluate the reproducibility of the ASCUS diagnosis.A selected set of 30 slides (4 within normal limit cases, 16 atypical squamous cells of undetermined significance; 4 low-grade squamous intraepithelial lesions and 6 high-grade squamous intraepithelial lesions) circulated among the 13 laboratories involved in the trial.Kappa values were obtained from the comparison between individual laboratory diagnoses and majority diagnoses with target diagnoses. Specific kappa values resulted moderate to high for HSIL and low to moderate for LSIL and WNL. Meanwhile, the specific kappa for ASCUS was below 0.4 in 12 of 13 participating laboratories. The lack of reproducibility for ASCUS was not a result of the introduction of this new technology but rather to the low reproducibility of the ASCUS category itself stemming from intrinsic uncertainties in the reporting criteria.

Interlaboratory reproducibility of atypical glandular cells of undetermined significance: a national survey

OBJECTIVE

The aim of this study was to evaluate the inter-laboratory reproducibility for atypical glandular cells (AGC) (The Bethesda System (TBS) 2001) of the laboratories involved in the screening programmes in Italy.

METHODS

A set of 35 selected slides were circulated among 167 laboratories involved in local population-based cervical screening programmes. Each laboratory provided one single diagnosis per smear. The smears were read blind to the original diagnosis and to the diagnoses provided by other laboratories. A 'majority' diagnosis was defined for each case and assumed as the reference standard. The diagnosis provided from each laboratory was compared with the majority diagnosis.

RESULTS

According to the majority report the 35 slides in the set were classified as negative in nine cases, AGC in eight, adenocarcinoma in eight, and squamous lesion or squamous + glandular lesion in 10. The crude agreement between all pairs of laboratories was 49.43%. K-values were 0.46, 0.21, 0.34, 0.36 and 0.32 for negative, AGC/AIS (adenocarcinoma in situ of endocervix), AdenoCa, Sq/Sq + Gl and all reporting categories respectively. Concordance according to overall K was moderate to substantial in 77% of the participating laboratories.

CONCLUSIONS

The present study shows that the AGC category is not easily reproducible. The data confirmed the importance, in a screening scenario, of AGC/AIS diagnoses, but also presented difficulties in differentiating between the two diagnoses. In addition to the results obtained from the circulation of the slides, laboratories which had annually a low number of cervical smears were able to gain experience focused on particular morphological pictures.

Synthesis of La and Nb doped PZT powder by the gel-combustion method

Lanthanum and niobium doped PZT with composition (Pb0.93La0.07)[(Zr0.60Ti0.40)]0.9825Nb0.0175O3 (PZTLN) was prepared by the gel-combustion method. A precursor sol was obtained from lead nitrate, zirconyl nitrate, lanthanum oxide, peroxo-citrato-niobium and a peroxo-citrate complex of titanium isopropoxide as starting precursors. Various molar ratios of citrate/nitrate (CA/NO3(-) = 1.3, 0.36 and 0.09) were used to prepare very fine powders of PZTLN. The gels resulting from these sols were transformed into powders by an auto-combustion process at ≤400 °C. The powders consisted of rhombohedral PZT (PbZr0.60Ti0.40O3), pyrochlore (Pb2Ti2O6) and lead carbonate (Pb2O·CO3) phases. The pure rhombohedral phase is found in PZTLN pellets sintered at 1100 °C for all citrate/nitrate ratios. Titanium and niobium precursors were modified with peroxo radicals. During the gel-combustion reaction, the temperature of the gel increases, leading to lead evaporation. The loss of lead as well as the particle size increases as the CA/NO3(-) ratio decreases. The smallest grained powder (about 50 nm) was obtained with the ratio CA/NO3(-) equal to 0.09.

Effects of long-term dumping of harbor-dredged material on macrozoobenthos at four disposal sites along the Emilia-Romagna coast (Northern Adriatic Sea, Italy)

Sediment from harbors of the Emilia-Romagna (Northern Adriatic Sea) were dredged and dumped in four disposal areas characterized by muddy bottoms. The long-term effects of the dumping on macrozoobenthic communities were investigated before and after 6 month, 8 month, 2 years and 4 years. The disposal of dredged material did not influence the granulometry and %TOC in the sediment, and no alterations in the structure of the macrobenthic communities were observed in the four areas. The lack of impact could be ascribed to the environmental characteristics and precautionary measures taken to minimize the effects of the dumping. It appears that: (1) the communities of the dumping areas are well adapted to unstable environments; (2) the sediments were disposed gradually and homogeneously over relatively large areas; Other factors that help to reduce the impact of sediment disposal are the low concentrations of contaminants in dredged materials and the similarity of sediment in the dredged and disposal areas. Off-shore discharge appears a sustainable strategy for the management of uncontaminated dredged sediments from the Northern Adriatic Sea harbors.

Impact of the introduction of organised screening for cervical cancer in Turin, Italy: cancer incidence by screening history 1992-98

After an organised cervical screening programme was introduced in Turin in 1992, the age-adjusted cervical cancer incidence ratio in 1992-98 was 0.81 (95% confidence interval (CI) 0.59-1.09) for invited vs not invited women and 0.25 (95% CI 0.13-0.50) for attenders vs non attenders. An organised screening programme can further reduce cervical cancer incidence in an area where substantial spontaneous activity was previously present.

The effects of sand extraction on the macrobenthos of a relict sands area (northern Adriatic Sea): results 12 months post-extraction

Sands for the nourishment of beaches along the Emilia-Romagna coast (northern Adriatic Sea) were dredged from an offshore area characterised by relict sands formed during the last Adriatic post-glacial transgression. The short-term effects of the sand extraction on macrozoobenthic communities were investigated before, during and 1, 6 and 12 months after dredging at three impacted stations and seven control stations. Sand extraction activities did not significantly influence the granulometry and %TOC in the sediment but caused almost complete defaunation at dredging stations. Yet, just 12 months after the extraction, the recolonisation of communities at the impacted stations was at an advanced stage. Unlike other studies on the effects of extraction of marine sand, no significant settlement of opportunistic species was observed. The limited impact of the sand extraction operation on the physical characteristics of the sediment and hydrological-sedimentary characteristics in the relict sand area should aid its rapid recovery and the restoration of the original community in a short period of time (2-4 years after dredging).

Morphological and phenotypical characterization of Bacillus sporothermodurans

AIMS

Enumeration of resistant bacteria in ultra-high temperature (UHT) treated milk; morphological characterization and phenotyping of resistant strains by traditional and nontraditional methods and their identification by molecular biology.

METHODS AND RESULTS

Modified standard plate count agar (PCA) and modified brain-heart infusion (BHI) agar were used for colony counts. Physiological culture traits were determined as suggested by Bergey's Manual of Systematic Bacteriology or in modified J-broth or in modified BHI agar. Scanning electron microscope (SEM) was used for microscopic examination. Strain identification was carried out by polymerase chain reaction (PCR). A total of 125 (62.81% of 199) samples were positive and the bacterial load was higher than 10(5) CFU ml(-1) in 46 samples (28.80% of 125). The 16S rRNA sequence of bacterial cultures obtained from UHT-treated milk was similar to that of Bacillus sporothermodurans M215 type strain((T)) and different biotypes were found by analysis of colony appearance, cell morphology and physiological traits.

CONCLUSIONS

Bacillus sporothermodurans was the predominant sporigenous micro-organisms in UHT milk.

SIGNIFICANCE AND IMPACT OF THE STUDY

BHI agar is more suitable than PCA for quality control of milk after UHT treatment. Modified J-broth medium is useful to determine selected physiological traits of B. sporothermodurans. The strains characterized and identified as B. sporothermodurans were significantly different compared with the type strain.

Interlaboratory reproducibility of atypical squamous cells of undetermined significance report: a national survey

The study was aimed at assessing interlaboratory reproducibility in the reporting of cervical smears in the atypical squamous cells of undetermined significance (ASCUS) category. A set of 50 selected slides circulated among 89 laboratories, currently involved in population-based screening programmes for cervical cancer, which provided a diagnostic report according to four main reporting categories based on the 1991 Bethesda system. Interlaboratory agreement was determined according to kappa (K) statistics: overall and weighted K values were determined for each laboratory and for single reporting categories. The results showed a very low reproducibility for the ASCUS category. This finding supports the Bethesda system 1991 recommendation to limit the use of this reporting category and suggests that the clinical response to ASCUS reports should be decided locally, based on the observed positive predictive value for cervical intraepithelial neoplasia 2 or more severe lesions.

Effect of circulation and discussion of cervical smears on agreement between laboratories

The study objective was assessing whether circulation of smears and discussion of those with differing interpretation can increase reproducibility between laboratories. The study included: the blind interpretation of a first set of 194 smears among seven laboratories, the discussion of smears with discrepant diagnoses during the previous phase and the blind interpretation of a second set of smears of same size and characteristics. After discussions, the overall weighted kappa increased in five laboratories (substantially in three : +50%, +27% and +20%). However, no change was observed in one laboratory and a slight decrease (-4%) in another. The latter interpreted the second set of smears at a longer time interval from discussions. Agreement improved for all diagnostic classes except low grade intraepithelial neoplasia (LSIL). Overall, the intervention increased diagnostic agreement, but its effect varied with laboratory and by diagnostic class and could be transient. Continued programmes of smear exchange and discussion appear to be advisable.

Papnet-assisted cytological diagnosis intensifies the already marked variability among cytological laboratories

OBJECTIVE

The main objective was to assess the sensitivity, specificity and reliability of PAPNET-assisted diagnosis in comparison with conventional screening.

SETTING

Seven Italian and one English University or Research Institutes, and a random sample of an other 20 Italian Laboratories of the Italian National Health Service (INHS) provided the cervical smears.

METHODS

During the training phase every center examined in rotation four sets of slides for a total of 300 representative slides. Afterwards, 900 "positive" slides were added to the 3,100 slides which were collected consecutively without any selection or exclusion. The eight main centers were divided into four couples and each couple of centers examined 775 slides with the PAPNET system, "blindly" to the original diagnosis. An expert cytopathologist (M.A.) of the National Institute of Health (NIH) reassessed 40% of the slides with an original negative diagnosis to evaluate the false negative rate. Two expert NIH cytopathologists (M.A., G.M.) re-examined all slides where a disagreement had been observed between the original and one or both of the study diagnoses. The main analyses concerned the following three main categories: WNL and unsatisfactory for evaluation; ASCUS, AGUS and LSIL; HSIL and carcinoma. A special algorithm was devised to define the reference diagnosis for sensitivity and specificity assessment.

RESULTS

Laboratories, even belonging to the same couple, classified as "no review" a very different proportion of slides ranging from 35% to 74%. The index of kappa agreement between the members of couples examining the same sets of slides was low or very low, ranging from 0.30 to 0.03. The sensitivity of the review classification was particularly low in some laboratories. Surprisingly, only a small correlation was observed between the sensitivity of the review classification and the proportion of slides classified as "review". The "tentative" diagnosis on PAPNET tiles of the "review" slides was almost as reliable as the microscopic diagnosis. In the overall performance, there were many significant differences among the eight laboratories. The best laboratory had a sensitivity of 95% and a specificity of 96%. At least three laboratories displayed unacceptably low sensitivity and one a very low specificity.

CONCLUSION

Altogether these results seem to confirm that there are wide differences among cytological laboratories per se, and that these differences are intensified by the use of an instrument like PAPNET. The huge variation in performance may be explained by differences in basic skills and by different training, but it is difficult to understand exactly what could have been done to reduce it.

Accuracy of stereotactic localisation with magnetic resonance compared to CT scan: experimental findings

BACKGROUND

Stereotactic localisation of proper targets can be obtained with Magnetic Resonance imaging (MRI), pending correction of the well-known inaccuracy of MRI in reproducing exact geometrical dimension. The aim of the experimental work was to determine the real extent of the MRI distortion and to correct it.

METHODS

PVC phantoms and fixed human brains were used as target simulators: stereotactic targeting was obtained with CT and MRI: the results were compared and, finally, the real stereotactic values were measured on a commercial stereotactic device. To optimise MRI targeting it was necessary to abate the "chemical-shift", to modify the head-coil receiver (tuning the "off-resonance" frequencies) and to correct the targeting directly on the images (especially for the Y axis values); careful quality control and environmental tests were also necessary to maintain good performances along the time.

RESULTS

172 measurements were carried out using both CT, plain X-ray and MRI on PVC phantom. The values obtained from CT were considered as reference. Significant geometrical accuracy was found with CT targeting, except for the Z co-ordinate, due to the slice thickness. Mean value differences between the targets on MRI and their real geometric position are about 1 mm on X and Z axises and about 2 mm on Y axis. Similar results were obtained on fixed brains, where absolute values of X and Y co-ordinates of the simulators were measured using a millimetre grid placed over the brain slice.

INTERPRETATION

Experimental findings concerning stereotactic targeting with MRI suggest accuracy adequate for clinical practice, even when extreme geometrical precision is required, such as in radiosurgery or functional stereotaxy. Careful quality control and intensive experimental setting of the MRI device are mandatory to obtain satisfactory results.

Obligations to provide appropriate patient management

The Pap test is a successful method of preventing cervical cancer, but it does have significant false negative and false positive rates. The main aim of screening is the detection of precursor lesions, both regression and progression of which may occur, making it difficult to decide upon follow-up and further therapy. Around the world there are many differences, as a far as the frequency of the disease, the organization and economic background of the health care system, the use of different additional diagnostic tools and even the terminology considered. All these factors underline the importance of a consensus on a "minimum level" of obligations to provide appropriate patient management. The screening interval should be two to five years, in some cases even annually. The cytopathologist has an obligation to recommend repeat smears in cases of cytologic abnormalities likely to regress. We recommend the use of standard terminology and stress the importance of a "common language" in cervical cytology. Colposcopy and biopsy are obligatory in cases of HSIL and cancer. We suggest that in severe cases women should be provided with detailed written and verbal information.

A phase II study of sequential 5-fluorouracil, epirubicin and cyclophosphamide (FEC) and paclitaxel in advanced breast cancer (Protocol PV BC 97/01)

Sequential administration of the association of 5-fluorouracil, epirubicin and cyclophosphamide (FEC) and paclitaxel could be better tolerated than the association of an anthracycline and paclitaxel while having a similar antitumour effect. 69 patients with advanced breast cancer previously untreated with anthracyclines or paclitaxel entered a phase II multicentre study in which FEC was followed by paclitaxel. Both regimens were administered 4 times every 21 days. The median follow-up is 20 months and 38/69 patients have died. Grade III-IV toxicity was acceptable. Leukopenia occurred in 26% of patients, thrombocytopenia in 2% and anaemia in 4%. One patient had reversible heart failure during FEC therapy. Peripheral neuropathy and arthralgia-myalgia occurred in 9% and 4% of patients, respectively and one patient had respiratory hypersensitivity during paclitaxel treatment. 9 patients did not complete therapy because of: treatment refusal (n = 1), cardiac toxicity (n = 1), early death during FEC chemotherapy (n = 1), major protocol violations (n = 4), hypersensitivity reaction (n = 1) and early death during paclitaxel chemotherapy (n = 1). The overall response rate was 65% (95% CI = 53-76), and 7% of patients had stable disease. Therapy was defined as having failed in 28% of patients because they were not evaluable (13%) or had progressive disease (15%). The median time to progression and survival are 13.2 and 23.5 months, respectively. Sequential FEC-paclitaxel is a suitable strategy for patients with metastatic breast cancer who have not been previously treated with anthracyclines and/or taxanes. In fact, it avoids major haematologic toxicity and has a good antitumour effect.