Technological advances in body CT: a primer for beginners

Many technological advances have entered the clinical routine of Computed Tomography (CT) imaging. The new CT scanners have specific solutions in gantry design to bear the mechanical solicitations. The X-ray tubes have been improved for faster acquisitions at low radiation exposure, while the innovations in CT detectors provide a better image quality. The optimization of image quality and contrast, and the reduction of radiation dose, cannot be achieved without the implementation of adequate reconstruction software, such as Iterative Reconstructions (IR) and Artificial Intelligence (AI). In recent years, dual-energy (DECT) technology has expanded the indications of CT. In this narrative review, a panoramic overview of the technological novelties in CT imaging will be provided for optimal utilization of CT technology.

Non-traumatic non-cardiovascular thoracic emergencies: role of imaging

Patients presenting to the emergency with thoracic symptoms could have a wide variety of causes, even if the traumatic and vascular causes are excluded. Therefore, the diagnosis is often a challenge for emergency physicians. Anamnesis, physical examination and laboratory testing need to be integrated with imaging to get a rapid diagnosis and to distinguish among the potential causes. This review discusses the role of diagnostic imaging studies in the emergency setting in patients with non-traumatic non-cardiovascular thoracic symptoms. The use of chest x-ray, bedside lung Ultrasound and Computed Tomography in the diagnosis and care of these patients have been reviewed as well as the common findings on imaging.

Radiological assessment of peritoneal carcinomatosis: a primer for resident

The imaging has critical responsibility in the assessment of peritoneal lesions along with estimating the overall extent. Valuing disease burden is crucial for selection of combining cytoreductive surgery (CRS) and intraperitoneal hyperthermic chemotherapy (HIPEC) treatment. An approach that combines the strength of several imaging tools and increases diagnostic accuracy, should be chosen, even if the preferred imaging tool in patients with suspected Peritoneal Carcinomatosis (PC) is CT. The outcomes of PC are mainly correlated to tumor spread, localization, and lesion size. Accurate assessment of these features is critical for prognosis and treatment planning. These data can be evaluated by Peritoneal Cancer Index (PCI), a quantitative index suggested by Harman and Sugarbaker. Additionally, precise predictive biomarkers should be established to predict PC in patients at risk. The radiomics analysis could predict PC throughout the evaluation of cancers heterogeneity.

Diagnostic performance of LI-RADS in adult patients with rare hepatic tumors

OBJECTIVE

The rare hepatic tumor can have a wide spectrum of radiologic features, representing a diagnostic challenge. Our purpose is to report the experience of a National Cancer Center, emphasizing the radiological features encountered and assessing the LR-M categories in the diagnostic performances for these lesions.

PATIENTS AND METHODS

We assessed 113 patients who underwent surgical resection or biopsy for rare liver lesions from May 2010 to December 2020. For these patients a computerized search of radiological records was performed to identify which had been studied with MRI and CT. For each lesion, the radiologists recorded the attenuation on CT studies and signal intensity (SI) in T1 weighted (W), in T2-W, DWI and in the related map of the apparent diffusion coefficient (ADC). We assessed the presence and the type of contrast enhancement (CE) during contrast study on CT and MRI and the enhancement was categorized according to LI-RADS 2018. We also assessed the presence of other features in LR-M categories (ancillary LR-M features) in order to classify different subgroups. The lesions were classified according to LR categories, and the gold standard was histological analysis.

RESULTS

The final study population included 95 patients (46 females and 49 males), with a mean age of 51 years (range 38-83 years). 83 patients had solid lesions, 12 patients had cystic lesions (simple or complex). According to histological analysis, we categorized 79 patients with malignant lesions and 16 patients with benign lesions. According to radiological features we assessed as malignant 82 patients (79 true malignant and 3 false malignant), as benign 13 patients (all true benign). Therefore, sensitivity, specificity, positive predictive value, negative predictive value and accuracy of radiological features to identify benign and malignant lesions were 100.0%, 81.3%, 96.3%, 100.0% and 96.8%, respectively. We found no significant difference in signal and contrast enhancement appearance among all LR-M categories (p-value =0.34 at Chi square test). However, among LR-M categories the presence of satellite nodules was a feature typical of cHCC-CC (p-value < 0.05 at Chi square test). The presence of intra lesion necrosis and haemorrhage was suggestive of sarcoma (p-value < 0.05 at Chi square test).

CONCLUSIONS

High diagnostic accuracy was obtained by LI-RADS classification between malignant and benign lesion. The presence of ancillary features could help the radiologist towards a correct diagnosis.

Diagnostic protocols in oncology: workup and treatment planning. Part 1: the optimitation of CT protocol

The increase in oncology knowledge and the possibility of creating personalized medicine by selecting a more suitable therapy related to tumor subtypes, as well as the patient's management with cancer within a multidisciplinary team has improved the clinical outcomes. Early detection of cancer through screening-based imaging is probably the major contributor to a reduction in mortality for certain cancers. Nowadays, imaging can also characterize several lesions and predict their histopathological features and can predict tumor behaviour and prognosis. CT is the main diagnostic tool in oncologic imaging and is widely used for the tumors detection, staging, and follow-up. Moreover, since CT accounts for 49-66% of overall patient radiation exposure, the constant reduction, optimization, dose inter- and intraindividual consistency are major goals in radiological field. In the recent years, numerous dose reduction techniques have been established and created voltage modulation keeping a satisfactory image quality. The introduction of CT dual-layer detector technology enabled the acquisition of spectral data without additional CT x-ray tube or additional acquisitions. In addition, since MRI does not expose the body to radiation, it has become a mainstay of non-invasive diagnostic radiology modality since the 1980s.

Diagnostic protocols in oncology: workup and treatment planning. Part 2: Abbreviated MR protocol

Magnetic resonance imaging (MRI) is a non-invasive imaging technique (non-ionizing radiation) with superior soft tissue contrasts and potential morphological and functional applications. However, long examination and interpretation times, as well as higher costs, still represent barriers to MRI use in clinical routine. Abbreviated MRI protocols have emerged as an alternative to standard MRI protocols. Abbreviated MRI protocols eliminate redundant sequences that negatively affect cost, acquisition time, patient comfort. However, the diagnostic information is generally not compromised. Abbreviated MRI protocols have already been utilized for hepatocellular carcinoma, for prostate cancer detection, and for nonalcoholic fatty liver disease screening.

Prevalence, incidence and residual risk of transfusion-transmitted hepatitis C virus and human immunodeficiency virus after the implementation of nucleic acid testing in Italy: a 7-year (2009-2015) survey

BACKGROUND

In Italy nucleic acid testing (NAT) became mandatory for hepatitis C virus (HCV) in 2002 and for human immunodeficiency virus (HIV) and hepatitis B virus in 2008. The aim of this study was to monitor the incidence and prevalence of HIV and HCV infections in Italian blood donors and the current residual risk of these infections after the introduction of NAT.

MATERIALS AND METHODS

The Italian national blood surveillance system includes data from tests used to screen for transfusion-transmissible infections. During the period of this survey (2009-2015), the NAT methods used were the transcription-mediated amplification test, for individual donor testing, and polymerase chain reaction analysis, mainly for pools of six donors. Prevalence and incidence were calculated. Three published formulae were applied to estimate the residual risk (the window period ratio model and the formulae recommended by the European Medicines Agency and the World Health Organization).

RESULTS

Overall, 12,258,587 blood donors and 21,808,352 donations were tested for HCV and HIV. The prevalence of HCV decreased from 110.3×10⁵ to 58.9×10⁵ in years 2009 and 2015, respectively, while that of HIV remained stable over time (15.5×10⁵ vs 15.4×10⁵). The incidence of HCV decreased from 3.19×10⁵ in 2009 to 1.58×10⁵ in 2015, while the incidence of HIV did not show any significant fluctuations (average incidence 4.39×10⁵). The residual risk of a viraemic unit entering the blood supply was estimated to be 0.077×10⁶ or 1 in 12,979,949 donations for HCV and 0.521×10⁶ or 1 in 1,917,250 for HIV, according to the window period ratio model, and lower with the other two formulae.

DISCUSSION

HCV infection has declined over time in both first-time and repeat donors, while the data for HIV infection are stable. All three methods employed in this study showed that the residual risk of transmitting HCV or HIV through an infected blood unit is currently very low in Italy, but there are considerable differences in estimates between methods. Thus, harmonisation of these methods is advisable.

The human pegivirus: A new name for an "ancient" virus. Can transfusion medicine come up with something new?

Human pegivirus (HPgV, formerly called GB virus C/hepatitis G virus) is a poorly understood RNA virus of the Flaviviridae family. The HPgV infection is common worldwide and the virus is likely transmitted by blood products. At this time, no causal association between HPgV and human diseases has been identified. While waiting for new findings to better understand the Pegivirus genus, the aim of our narrative review is to discuss the currently available information on HPgV focusing on its prevalence in blood donors and its potential threat to transfusion safety.

Quality Control for Colposcopy in the Florence Screening Program for Cervical Cancer

The authors report on the quality control for colposcopy adopted in the Florence District screening program. The sensitivity of colposcopy was determined on all cases of CIN III recorded in the local cancer registry in a four-year period. However although this showed that a centralized colposcopic clinic employing a limited number of expert operators is superior to the performance of colposcopy in private practice, such a parameter was impractical for further routine quality control since differences among operators were too small and statistically insignificant. Other parameters for quality control were chosen, namely a) the rate of colposcopically directed biopsies performed, b) the detection rate of CIN II or more severe lesions, and c) the positive predictive value of a directed biopsy for CIN II or more severe lesions. Analysis of these indicators after stratification by cytologic report allows the identification of those operators who need additional training and provides useful information for colposcopists to optimize their diagnostic and operative criteria.

Testing Cervicography and Cervicoscopy as Screening Tests for Cervical Cancer

Aims and Background

Suboptimal sensitivity is currently reported for Pap test in screening for cervical cancer. Colposcopy is known to be more sensitive than cytology but its use as a screening test is not possible due to costs and complexity. Screening by cervicography has been suggested as a compromise being less costly and feasible. The present study evaluates the feasibility of screening by cervicography and cervicoscopy (naked eye examination of the cervix after acetic acid lavage) on a consecutive screening series.

Methods

Cervicography and cervicoscopy were performed by the smear taker in subjects consecutively attending a screening clinic. Women with abnormal cytology (atypia or more severe lesion) and/or abnormal cervicography or cervicoscopy (acetowhite lesion) underwent colposcopic assessment. The three screening methods were compared according to positivity rate, CIN 2-3 detection rate and positive predictive value.

Results

2105 consecutive subjects were screened. Positivity rate was 3.8 %, 15.3 % or 25.4 % for cytology, cervicography or cervicoscopy, respectively, 486 of 555 women attended the assessment phase, 281 directed biopsies were performed and 8 CIN 2-3 lesions were detected. Cytology, cervicography and cervicoscopy, detected 5.5, or 7 of 8 CIN 2-3 lesions, respectively. The positive predictive value was 0% for cytologic atypia, 25 % for cytologic SIL, 1.75 % for cervicography and 2.05% for cervicoscopy. Detecting one CIN 2-3 lesion at cytology cost $ 5,543. The cost per each additional cytologically negative CIN 2-3 lesion detected at cervicography or cervicoscopy was $ 12,947 or $ 3,916, respectively.

Conclusions

The study confirms the limited sensitivity of cytology for CIN 2-3. The association of cervicography was not cost effective. Cervicoscopy was poorly specific but increased the detection rate of CIN 2-3 at relatively low costs. Cervicoscopy is worth further evaluation as a screening test.

Response of Primary Breast Cancer to Tamoxifen Alone in Elderly Women

The authors report on a consecutive series of 62 evaluable, elderly (age > 69 years) women with primary operable breast cancer treated only with tamoxifen. The treatment schedule was 160 mg on day 1 followed by a daily maintenance dose of 20 mg. Compliance to treatment was excellent, and subjective side effects were minimal. The best response achieved after at least 6 months of treatment was complete in 7, partial in 22 and minor in 3, whereas stable disease or progression was observed in 28 and 2 patients, respectively. The response rate decreased and progressions increased with time. At 6, 12, 24, 36 and 48 months of treatment, the complete + partial response rates were 30.6 %, 45 %, 45.6 %, 38.7 % and 25% and the progressive disease rates 4.8%, 19.6%, 34.8%, 45.2 % and 66.6 %, respectively. These results do not confirm some previous reports of a high response to tamoxifen. This difference is only partially explained by the use of mammography, which is more sensitive than palpation, to assess tumor size and treatment response. The present study does not support primary hormone therapy as a current alternative to surgery, which should be the standard treatment in otherwise healthy elderly patients with operable breast cancer.

A Feasibility Study of Screening for Endometrial Carcinoma in Postmenopausal Women by Ultrasonography

Background

Abnormal endometrial thickness assessed by ultrasonography has been reported as a reliable indicator for early asymptomatic endometrial carcinoma.

Study design

We evaluated the feasibility and the performance of screening by ultrasonography in a consecutive series of postmenopausal volunteers.

Results

A total of 2,025 women were screened, and 117 (5.8%) showed abnormal endometrial thickness. Ninety-eight subjects consented to be assessed by outpatient endometrial biopsy, which was not possible in 32 for cervical stenosis. Three cancers were detected among 66 assessed subjects, 34 not-assessed subjects were controlled by repeat sonography (no change), and 17 were lost to follow-up. No other cancer was recorded by the local Cancer Registry among screened subjects. The prevalence/incidence ratio was 2.65:1, and the cost per screen-detected cancer was 18,571,000 Italian lire.

Conclusions

Screening by endometrial sonography is feasible on a practical basis, but its efficacy needs to be proven by prospective controlled studies which would enroll large populations to ensure sufficient statistical power, considering the low incidence and the low lethality of the disease. Studies of screening for other carcinomas may be considered of higher priority.

Screening History of Incident Cases of Invasive Carcinoma of the Cervix. Florence District 1988-1989

Background

Incident cases of carcinoma of the cervix may be assumed as failures of a population-based cytologic screening program. Monitoring such cases would provide an estimate of screening effectiveness, and evaluating the causes of the failures would improve screening performance.

Study design

All incident cases of cervicocarcinoma registered in 1988 and 1989 in the Tuscany Tumor Registry were eligible for the study and were reviewed.

Results

Sixty-nine eligible cases were considered. Non- or irregular attendance (negative smear-to-diagnosis interval > 5 years) for the Pap smear was recorded in 53 subjects. A false-negative smear (smear-to-diagnosis interval < 5 years) and refused or inadequate assessment/treatment at private practices or local hospitals were recorded in 12 cases. False-negative smears by the local screening program were recorded in 4 cases only.

Conclusions

Non- or irregular attendance was the major cause of screening failures. Since cytologic screening or diagnostic assessment outside the screening program may be inadequate, central screening and follow-up is recommended. Non-attenders showed a strong negative attitude towards screening, and general practitioners and gynecologists need to be further stimulated for systematic screening promotion. Immediate evaluation of the screening history of incident cases of cervicocarcinoma should be mandatory in any screening program.

Endometrial Ultrasonography - An Alternative to Invasive Assessment in Women with Postmenopausal Vaginal Bleeding

Aims and background

To test the reliability of endometrial sonography in selecting women with abnormal postmenopausal vaginal bleeding for further diagnostic assessment.

Methods

Endometrial thickness was measured in 368 consecutive women by abdominal or vaginal sonography prior to invasive assessment (hysteroscopy, curettage). The association of abnormal endometrial thickness (4 mm or greater) with endometrial cancer was determined.

Results

Abnormal endometrial thickness was observed in 116 of 368 women. Subsequent assessment diagnosed endometrial carcinoma in 16 subjects, 15 of whom had abnormal endometrial thickness. One case with normal endometrial thickness was suspected at sonography because of the irregular appearance of the endometrium.

Conclusions

Had it been used to select subjects for further assessment, sonography would have missed no cancer, and unnecessary invasive assessment (under general anesthesia in 20% of cases) would have been spared in 68% (251/368) of the subjects. Endometrial sonography should be routinely used to select women with postmenopausal vaginal bleeding for further investigations.

Fine Needle Aspiration Cytology and Breast Cancer Diagnosis

The authors report on 315 histologically confirmed consecutive breast cancer (BC) cases undergoing fine needle aspiration cytology (FNAC). Inadequate smears were infrequent (7%), particularly when reaspiration of inadequate cases was employed (1–2%). FNAC suspected BC in 81% of the total or 88% of adequate smears. Univariate and multivariate (Cox's model) analyses showed no correlation between inadequacy or suspect/positive FNAC rate and patient age, T category or histologic type. Differences in the inadequacy and suspect/positive rate were recorded among 30 operators (surgeons, oncologists, radiologists) performing the sampling, but the average results were consistent with literature reports. FNAC was found to be a useful diagnostic tool for BC diagnosis, and proper training of the highest number of operators is recommended to allow the widest diffusion of this diagnostic technique.

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.

An Attempt to Increase Compliance to Cervical Cancer Screening through General Practitioners

The authors report the results of a campaign aimed at increasing compliance to cervical cancer screening by promoting general practitioners’ (GPs) cooperation. Different types of intervention were tested, namely mailing lists of non responders to the GP, visiting the GP at the office, or both. No active intervention was made in a sample of GPs who served as a control group. Overall 288 GPs assisting 75,853 women aged 25 to 59 were enrolled in the study. Compliance before and after the campaign was studied and the association between compliance and different variables such as age, residence and type of intervention was tested by univariate and multivariate analysis. The proportion of previous non responders who performed a Pap test after the campaign was 6.7 %, the response being dependent on age (25-29 = 11.5 %, 30-39 = 8.8 %, 40-49 = 6.5 %, 50-59 = 4.2 %) and place of residence (urban = 7.2 %, suburban = 5.9 %, rural = 4.0 %). Compliance was better in the case of the active campaign (list mailing = 8.3 %, visit = 7.0 %, list+visit = 7.2 %) with respect to controls (2.9 %) although no significant differences were detected between different types of active intervention. Compliance to cervical cancer screening may be increased by promoting GPs cooperation but the benefit is limited. Mailing lists of non responders was found the most cost effective policy in this study.

« T » Category and Operable Breast Cancer Prognosis

The authors report on 4,034 consecutively operated breast cancer cases, evaluating the correlation between clinical T category and long term survival. Age and pathologic nodal status were also considered as independent prognostic factors. Univeriate and multivariate (Cox's) analysis confirmed N status as the most powerful single prognostic indicator and did not reveal any prognostic correlation with age. T category was a strong prognostic indicator, independently of N status, the 10 year overall survival of T1, T2 or T3-4 cases being 0.86, 0.76 and 0.73 in N– and 0.73, 0.56 and 0.35 in N+ subgroups respectively. T category should be carefully considered not only in deciding the extent of surgical excision but also in planning adjuvant postoperative treatment.

The Role of Fine Needle Aspiration Cytology in the Differential Diagnosis of Suspected Breast Cancer Local Recurrences

The authors report on 228 cases of suspected breast cancer local recurrences studied by fine needle aspiration cytology (FNAC). The nature (malignant = 133, benign = 95) of suspected lesions was assessed on histology (no. = 46) or according to unequivocal follow-up (no. = 182). Inadequacy rate was 0.20, 0.09 or 0.35 in total, cancer or benign cases, respectively, and was particularly high (0.50) for benign chest wall lesions. Accuracy was determined on adequate smears; dubious reports were assumed as positive. Sensitivity and specificity were 0.96 and 0.97, respectively. The routine use of FNAC is recommended since it helps in the differential diagnosis of suspicious cases and may bypass surgical biopsy of positive cases not eligible for surgical treatment.

Telethermography and Breast Cancer Risk Prediction

The authors report on 4,624 noncancer women classified by telethermography (TH1-2 vs TH3) and followed for an average of 6.6 years (range, 2–12). Breast cancer occurring beyond the sixth month from TH were recorded according to a Cancer Registry, and the association between breast cancer incidence and thermographic class or patient age was evaluated. Univariate analysis showed a significant association of age and thermography with further cancer incidence, but multivariate analysis (Cox's model) confirmed a significant association only for age. Thermography (TH3) showed a nonsignificant odds ratio of 1.6 with respect to TH1-2 cases. Thus thermography did not show any practical role as a breast cancer risk indicator. Possible biases affecting previous reports suggesting the use of thermography as a breast cancer risk indicator are discussed.

Training in Colposcopy: Experience with a Videocolposcopy Test

The authors evaluate the results of a videocolposcopy test (330 total cases, 12 cases of histologically confirmed CIN2 or more severe lesions) taken by 9 accredited and 17 unaccredited colposcopists during 1995. Seven of 9 accredited and 4 of 13 unaccredited colposcopists reached the requested standard (sensitivity >90%, biopsy rate «60%). Performance was definitely better when the test was not blind to the cytologic report (4 of 13 reached the requested standard) with respect to blind reading (none of 17). The study confirmed that colposcopy at unaccredited practices is poorly accurate. Colposcopy assessment of patients with abnormal smears should be centralized in accredited practices, which should undergo periodic quality control to guarantee screening efficacy. Tape-recorded videocolposcopy tests are a good, simple, practical and inexpensive method for interobserver quality control of colposcopic performance.

Cervical Cancer Screening in Tuscany: A Survey of the Actual State of Cervical Cancer Prevention in the Local Sanitary Units of the Tuscan Region

Every Local Sanitary Unit (USL) of the Tuscan Region was contacted to define screening variables, such as adequacy of the staff involved in prevention, smear technique, data collection and evaluation, laboratory quality control, and modalities of invitations to screening. The reported data show that 21 of 40 USL, but only 9 of 28 USL outside the Florence province (where a common screening program is performed), are performing active invitations to screening. The most serious staff inadequacies concern data evaluation and personnel performing the test. Sixteen of 28 USL outside Florence suggest an annual rescreening, which causes overcrowding of services and a poor availability for the unscreened population. Moreover, the poor quality of data collection makes it impossible to evaluate the benefit offered by the screening programs in the 28 USL outside Florence. Cytologic quality control is often lacking, and the smear technique is inadequate in 10 of 28 USL outside Florence. The lack in the USL of epidemiologic competence and of cost/benefit considerations and the need for political decisions about cancer prevention programs are stressed.

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.

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.

Comparing regional models of congenital bleeding disorders: preliminary steps in the Italian context

Background

Among these diseases, congenital bleeding disorders (CBD) represent a significant societal burden in terms of high morbidity costs and health outcomes. In Italy, the organization and provision of health care is a regional responsibility and regions must assure equity and quality to all their residents. This is also true for CBD care which is provided by 54 multidisciplinary Hemophilia Treatment Centers (HTCs) distributed among the regions. With the present study, we intend to stimulate a debate on the effect that the decentralization process have in the delivery of services to CBD patients across Italy.

Methods

The available comparable measures of caseloads per center and interregional patient mobility, as proxies of quality and responsiveness of the regional network of HTCs, were first analyzed for the using data from the Italian Hemophilia Centers Association for the year 2012.

Results

Nine thousand one hundred and thirty four Italian residents with CBD received care in at least one of the Italian HTC in 2012. Preliminary findings suggested room for improvement in health care delivery for CBD patients. In 2012, 16 HTCs out of 51 (31.4%) treated a number of patients under the minimum requirement for treatment center accreditation (10 severe patients). Moreover, data on interregional patient mobility highlighted differences in the ability of each region to retain its own residents or to attract residents from other regions.

Conclusions

Preliminary study results showed significant disparities among regions in terms of volumes and mobility of residents with CBDs that cannot be completely explained by the different geographical characteristics. Therefore, the central government should consider taking concrete measures to bridge the gap between regions to assure access to quality care for all individuals with CBD independently from where they live and therefore to move toward a more integrated and homogeneous national network of care centers. Typology of disease, patients’ needs, and cost for outcomes, should have high priority on the political agenda. For CBD patients, even in a federal healthcare system, the national government should have the global responsibility to guaranteeing uniform levels of quality care over the country and overcome local institutions when necessary.

Health Technology Assessment of pathogen reduction technologies applied to plasma for clinical use

Although existing clinical evidence shows that the transfusion of blood components is becoming increasingly safe, the risk of transmission of known and unknown pathogens, new pathogens or re-emerging pathogens still persists. Pathogen reduction technologies may offer a new approach to increase blood safety. The study is the output of collaboration between the Italian National Blood Centre and the Post-Graduate School of Health Economics and Management, Catholic University of the Sacred Heart, Rome, Italy. A large, multidisciplinary team was created and divided into six groups, each of which addressed one or more HTA domains.Plasma treated with amotosalen + UV light, riboflavin + UV light, methylene blue or a solvent/detergent process was compared to fresh-frozen plasma with regards to current use, technical features, effectiveness, safety, economic and organisational impact, and ethical, social and legal implications. The available evidence is not sufficient to state which of the techniques compared is superior in terms of efficacy, safety and cost-effectiveness. Evidence on efficacy is only available for the solvent/detergent method, which proved to be non-inferior to untreated fresh-frozen plasma in the treatment of a wide range of congenital and acquired bleeding disorders. With regards to safety, the solvent/detergent technique apparently has the most favourable risk-benefit profile. Further research is needed to provide a comprehensive overview of the cost-effectiveness profile of the different pathogen-reduction techniques. The wide heterogeneity of results and the lack of comparative evidence are reasons why more comparative studies need to be performed.

Impact of cord blood banking technologies on clinical outcome: a Eurocord/Cord Blood Committee (CTIWP), European Society for Blood and Marrow Transplantation and NetCord retrospective analysis

BACKGROUND

Techniques for banking cord blood units (CBUs) as source for hematopoietic stem cell transplantation have been developed over the past 20 years, aimed to improve laboratory efficiency without altering the biologic properties of the graft. A large-scale, registry-based assessment of the impact of the banking variables on the clinical outcome is currently missing.

STUDY DESIGN AND METHODS

A total of 677 single cord blood transplants (CBTs) carried out for acute leukemia in complete remission in centers affiliated with the European Society for Blood and Marrow Transplantation were selected. An extensive set of data concerning CBU banking were collected and correlations with clinical outcome were assessed. Clinical endpoints were transplant-related mortality, engraftment, and graft-versus-host disease (GVHD).

RESULTS

The median time between collection and CBT was 4.1 years (range, 0.2-16.3 years). Volume reduction (VR) of CBUs before freezing was performed in 59.2% of available reports; in half of these the frozen volume was less than 30 mL. Cumulative incidences of neutrophil engraftment on Day 60, 100-day acute GVHD (II-IV), and 4-year chronic GVHD were 87, 29, and 21 ± 2%. The cumulative incidence of nonrelapse mortality (NRM) at 100 days and 4-year NRM were, respectively, 16 ± 2 and 30 ± 2%. Neither the variables related to banking procedures nor the interval between collection and CBT influenced the clinical outcome.

CONCLUSION

These findings indicate a satisfactory validation of the techniques associated with CBU VR across the banks. Cell viability assessment varied among the banks, suggesting that efforts to improve the standardization of CBU quality controls are needed.

Patient blood management: a fresh look at a fresh approach to blood transfusion

The overall use of allogeneic blood transfusions in clinical practice remains relatively high and still varies widely among centres and practitioners. Moreover, allogeneic blood transfusions have historically been linked with risks and complications: some of them (e.g. transfusion reactions and transmission of pathogens) have been largely mitigated through advancements in blood banking whereas some others (e.g. immunomodulation and transfusion-related acute lung injury) appear to have more subtle etiologies and are more difficult to tackle. Furthermore, blood transfusions are costly and the supply of blood is limited. Finally, evidence indicates that a great number of the critically ill patients who are being transfused today may not be having tangible benefits from the transfusion. Patient blood management is an evidence-based, multidisciplinary, multimodal, and patient-tailored approach aimed at reducing or eliminating the need for allogeneic transfusion by managing anaemia, perioperative blood conservation, surgical haemostasis, and blood as well as plasma-derivative drug use. From this point of view, the reduction of allogeneic blood usage is not an end in itself but a tool to achieve better patient clinical outcome. This article focuses on the three-pillar matrix of patient blood management where the understanding of basic physiology and pathophysiology is at the core of evidence-based approaches to optimizing erythropoiesis, minimising bleeding and tolerating anemia. Anesthesiologists and critical care physicians clearly have a key role in patient blood management programmes are and should incorporate its principles into clinical practice-based initiatives that improve patient safety and clinical outcomes.

HIV-positive blood donors unaware of their sexual at-risk behaviours before donation in Italy

BACKGROUND AND OBJECTIVES

Despite the procedures adopted for the selection of blood donors, in Italy the HIV prevalence per 100 000 repeat tested donors (RTD) and first-time tested donors (FTD) is high compared to most other Council of Europe member states. To evaluate the effectiveness of predonation procedures, we studied both the characteristics and the undisclosed risk behaviours of HIV-positive donors.

MATERIALS AND METHODS

We analysed the data from the Italian blood donor surveillance system in 2009, 2010 and 2011. Based on the postdonation interview, HIV-positive donors were classified by risk behaviour (heterosexual, MSM, 'non-sexual' and 'not determined') and by time elapsed from risk behaviour to donation. In Italy, the temporary deferral for exposure to behaviour at risk is 4 months.

RESULTS

In the postdonation interview, 113 HIV-positive donors (32·4%), who denied at-risk behaviours in the predonation selection, reported sexual risk behaviours <4 months prior to donation; they were predominantly males (84·1%) and RTD (63·7%). The main reason for not having reported the risk behaviour in the predonation selection was 'not realizing having engaged in at-risk behaviour' (66·4%).

CONCLUSION

These findings underline the need for more comprehensible educational material, a clearer predonation questionnaire, and effective information campaigns to improve the awareness of HIV sexual risk behaviours among blood donors.

Human T-lymphotropic virus and transfusion safety: does one size fit all?

Human T-cell leukemia viruses (HTLV-1 and HTLV-2) are associated with a variety of human diseases, including some severe ones. Transfusion transmission of HTLV through cellular blood components is undeniable. HTLV screening of blood donations became mandatory in different countries to improve the safety of blood supplies. In Japan and Europe, most HTLV-infected donors are HTLV-1 positive, whereas in the United States a higher prevalence of HTLV-2 is reported. Many industrialized countries have also introduced universal leukoreduction of blood components, and pathogen inactivation technologies might be another effective preventive strategy, especially if and when generalized to all blood cellular products. Considering all measures available to minimize HTLV blood transmission, the question is what would be the most suitable and cost-effective strategy to ensure a high level of blood safety regarding these viruses, considering that there is no solution that can be deemed optimal for all countries.

Collection, storage, and allogeneic use of cord blood: informed consent form used by the italian biobank network

The National Blood Centre, the National Transplant Centre, and the Bioethics Unit of the Istituto Superiore di Sanità have compared the information leaflets and forms regarding the collection of informed consent used by each of the 18 biobanks that comprise the Italian network. With a view to harmonize the provision of information to couples and the collection of informed consent within the Italian Cord Blood Network, the 3 organizations have prepared a standard information leaflet and informed consent form to be used for the collection, storage, and allogeneic use of cord blood. The proposed model can be a useful tool for the development of specific informed consent forms for cord blood banking that comprises the minimum information necessary to meet ethical and regulatory requirements also in other countries.

The Italian institutional accreditation model for Haemophilia Centres

BACKGROUND

In Italy, basic health needs of patients with inherited bleeding disorders are met by a network of 50 haemophilia centres belonging to the Italian Association of Haemophilia Centres. Further emerging needs, due to the increased life expectancy of this patient group, require a multi-professional clinical management of the disease and provide a challenge to the organisation of centres.In order to achieve harmonised quality standards of haemophilia care across Italian Regions, an institutional accreditation model for haemophilia centres has been developed.

MATERIAL AND METHODS

To develop an accreditation scheme for haemophilia centres, a panel of experts representing medical and patient bodies, the Ministry of Health and Regional Health Authorities has been appointed by the National Blood Centre. Following a public consultation, a technical proposal in the form of recommendations for Regional Health Authorities has been formally submitted to the Ministry of Health and has formed the basis for a proposal of Agreement between the Government and the Regions.

RESULTS

The institutional accreditation model for Haemophilia Centres was approved as an Agreement between the Government and the Regions in March 2013. It identified 23 organisational requirements for haemophilia centres covering different areas and activities.

DISCUSSION

The Italian institutional accreditation model aims to achieve harmonised quality standards across Regions and to implement continuous improvement efforts, certified by regional inspection systems. The identified requirements are considered as necessary and appropriate in order to provide haemophilia services as "basic healthcare levels" under the umbrella of the National Health Service. This model provides Regions with a flexible institutional accreditation scheme that can be potentially extended to other rare diseases.

Glucose-6-phosphate dehydrogenase deficiency in Italian blood donors: prevalence and molecular defect characterization

BACKGROUND

In the countries with high G6PD deficiency prevalence, blood donors are not routinely screened for this genetic defect. G6PD deficiency is often asymptomatic, blood donors may be carriers of the deficiency without being aware of it. The aim of the study was to evaluate the prevalence of G6PD deficiency among the Italian blood donors.

DESIGN AND METHODS

From October 2009 to April 2011, 3004 blood donors from a large hospital transfusion centre were screened for G6PD deficiency using differential pH-metry and the characterization of G6PD mutations was performed on G6PD-deficient subjects. The haematological features of G6PD-deficient and normal donors were also compared.

RESULTS

Thirty-three subjects (25 men and 8 women) with low G6PD activity were identified, corresponding to 1·1% of the examined blood donor population. The frequencies of class II severe alleles (Mediterranean, Valladolid, Chatham and Cassano) and class III mild alleles (Seattle, A- and Neapolis) were 48% and 43%, respectively. The haematological parameters of G6PD- donors were within normal range; however, the comparison between normal and G6PD- class II donors showed significant differences.

CONCLUSION

In Italy, the presence of blood donors with G6PD deficiency is not a rare event and the class II severe variants are frequent. The identification of G6PD-deficient donors and the characterization of the molecular variants would prevent the use of G6PD-deficient RBC units when the haemolytic complications could be relevant especially for high risk patients as premature infants and neonates and patients with sickle cell disease submitted to multiple transfusions.