Improving Diagnosis of Intestinal Parasites Towards a Migrant-Friendly Health System

Purpose of Review

This study describes the results obtained by the World Health Organization (WHO) collaborating centre (CC) for the diagnosis of intestinal helminths and protozoa (WHO CC ITA-116) during the first 2 years of its activity on (i) the prevalence of intestinal parasites in migrants in southern Italy and (ii) the development and application of new diagnostic tools for intestinal helminths (e.g. FLOTAC, Mini-FLOTAC Kit 200 tests, Kubic FLOTAC microscope (KFM)).

Recent Findings

Almost 23.3% of migrants examined were positive for at least one intestinal parasite. Moreover, a significant correlation was found between the duration of stay in Italy and positivity for intestinal parasites. The results of the comparison between diagnostic techniques showed a perfect agreement between FLOTAC and Mini-FLOTAC Kit 200 tests whereas no statistically significant differences were found between the count of helminth eggs obtained by Mini-FLOTAC with optical microscope and KFM.

Summary

The results obtained by WHO CC ITA-116 during the first 2 years of its activity provide important information on innovations in parasitological diagnosis and add data to the parasitological scenario of migrants arriving in southern Italy, highlighting the importance of regular parasitological monitoring.

Advances in diagnosis of gastrointestinal nematodes in livestock and companion animals

Diagnosis of gastrointestinal nematodes in livestock and companion animals has been neglected for years and there has been an historical underinvestment in the development and improvement of diagnostic tools, undermining the undoubted utility of surveillance and control programmes. However, a new impetus by the scientific community and the quickening pace of technological innovations, are promoting a renaissance of interest in developing diagnostic capacity for nematode infections in veterinary parasitology. A cross-cutting priority for diagnostic tools is the development of pen-side tests and associated decision support tools that rapidly inform on the levels of infection and morbidity. This includes development of scalable, parasite detection using artificial intelligence for automated counting of parasitic elements and research towards establishing biomarkers using innovative molecular and proteomic methods. The aim of this review is to assess the state-of-the-art in the diagnosis of helminth infections in livestock and companion animals and presents the current advances of diagnostic methods for intestinal parasites harnessing (i) automated methods for copromicroscopy based on artificial intelligence, (ii) immunodiagnosis, and (iii) molecular- and proteome-based approaches. Regardless of the method used, multiple factors need to be considered before diagnostics test results can be interpreted in terms of control decisions. Guidelines on how to apply diagnostics and how to interpret test results in different animal species are increasingly requested and some were recently made available in veterinary parasitology for the different domestic species.

A five-year retrospective study on ascarid infections in dogs in southern Italy

INTRODUCTION

A 5-year retrospective analysis of ascarid infections (Toxocara canis and Toxascaris leonina) in dogs from southern Italy was performed to update the epidemiological scenario of these parasites and to identify the risk factors which may favour these infections in animals in this study area. A total of 8,149 dogs, referred to our labs for copromicroscopic analysis using the FLOTAC technique, was considered. A sub-sample of 500 faecal samples were analysed also with the Mini-FLOTAC technique. Of the overall dog samples analysed, 9,2 % (95 % CI = 8,6-9,8) resulted positive for T. canis while 0,5 % (95 % CI = 0,4-0,7) resulted positive for T. leonina. Co-infections with T. canis and T. leonina were found in 0,1 % of dogs (95 % CI = 0,0-0,1). The results obtained by the FLOTAC and Mini-FLOTAC examinations showed a nearly perfect k agreement (k = 0,99, P < 0,001) between these two techniques. Chi-square test showed positivity to T. canis and T. leonina significantly (P < 0,001) associated with dogs housed outdoor (i.e., that lived in garden or in kennel). Moreover, the positivity for T. canis was significantly associated (P < 0,001) also with age (i.e., puppies), as shown by the logistic regression. The decreasing overall prevalence both for T. canis and T. leonina during the years of monitoring, showed that, as suggested by the European Scientific Counsel Companion Animal Parasites, the regular diagnosis could contribute to an efficient control of these parasites.

An integrated approach to control Cystic Echinococcosis in southern Italy

Cystic echinococcosis (CE) is a severe zoonosis, caused by the larval stage of the tapeworm Echinococcus granulosus. This helminth infection is of increasing public health and socio-economic concern due to the considerable morbidity rates that cause economic losses both in the public health sector and in the livestock industry. Control programmes against E. granulosus are considered long-term actions which require an integrated approach and high expenditure of time and financial resources. Since 2010, an integrated approach to control CE has been implemented in a highly endemic area of continental southern Italy (Campania region). Innovative procedures and tools have been developed and exploited during the control programme based on the following strategies: i) active and passive surveillance in livestock (using geospatial tools for georeferencing), ii) diagnosis in dogs (using the FLOTAC techniques and molecular analysis), iii) targeted treatment of farm dogs (using purpose-built confinement cages), iv) early diagnosis in livestock (by ultrasonography), v) surveillance in humans (through hospital discharge records analysis), vi) monitoring the food chain (analysing raw vegetables), vii) outreach activities to the general public (through dissemination material, e.g. brochures, gadgets, videos, virtual reality). Over eight years, the integrated approach and the new strategies developed have resulted in a noteworthy reduction of the parasite infection rates in livestock (e.g. up to 30 % in sheep). The results obtained so far highlight that using a one health multidisciplinary and multi-institution effort is of pivotal importance in preparing CE control programmes at regional level and could be extended to other endemic Mediterranean areas.

Bilastine safety in drivers who need antihistamines: new evidence from high-speed simulator driving test on allergic patients

OBJECTIVE

Bilastine is a highly selective, non-sedating antihistamine, indicated for the symptomatic treatment of allergic rhinoconjunctivitis and urticaria. Available data suggest that bilastine interferes neither with driving ability nor with flying-related performance. However, no data are available on the effect of bilastine on the driving ability in extreme conditions. Here we analyzed the effect of 7 days treatment with 20 mg bilastine in patients with allergic rhinitis and/or chronic urticaria, on psychophysical performance assessed by the Formula One (F1) high-speed simulator-driving test.

PATIENTS AND METHODS

This study is a phase IV, interventional, prospective, mono-centric, single arm, open-label trial. Eighteen outpatients affected by allergic rhinitis and/or chronic urticaria, able to perform a preliminary driving test on F1 simulator were considered (V-1). First, the patients had a screening visit to assess their eligibility (V0). Visit 1 (V1), at the end of placebo before bilastine treatment and Visit 2 (V2), at the end of bilastine treatment. The primary variable parameter was the ability to maintain the vehicle in a central position at different speeds (50, 150, and 250 km/h).

RESULTS

Bilastine had a good safety profile and was well tolerated in terms of adverse events, laboratory parameters and vital signs. Bilastine did not have any negative effect on the ability to maintain the requested path, a constant speed as well as on attention and reactivity levels, even in extreme driving conditions.

CONCLUSIONS

This study is the first done in patients with allergic rhinitis and/or chronic urticaria using a F1-high speed simulator-driving test evaluating subjects' performance under bilastine treatment.

Predictors of response to omalizumab and relapse in chronic spontaneous urticaria: a study of 470 patients

BACKGROUND

Chronic spontaneous urticaria (CSU) is defined as spontaneous occurrence of wheals and/or angioedema for ≥6 weeks. Omalizumab is a monoclonal anti-IgE antibody effective in refractory CSU, but its mechanism of action and markers predictive of response remain not completely defined.

OBJECTIVES

To correlate baseline levels of two proposed biomarkers, total IgE (bIgE) and d-dimer (bd-dimer), and clinical parameters to omalizumab response and to relapses after drug withdrawal.

METHODS

In this retrospective Italian multicentre study, clinical data were collected in 470 CSU patients, and bIgE and bd-dimer were measured in 340 and 342 patients, respectively. Disease activity was determined by Urticaria Activity Score 7 (UAS7) at week 1 and 12 after omalizumab starting. Relapses were evaluated during a 2- and 3-month interval after a first and a second course of treatment, respectively.

RESULTS

bIgE correlated to a good response to omalizumab since levels were significantly higher in responders than non-responders (P = 0.0002). Conversely, bd-dimer did not correlate to response. There was no correlation between both bIgE and d-dimer and either first or second relapse. Disease duration was significantly longer in patients who experienced either first or second relapse (P < 0.0001 and P = 0.0105, respectively), while baseline UAS7 correlated only to first relapse (P = 0.0023).

CONCLUSIONS

Our study confirms bIgE as a reliable biomarker predicting response to omalizumab in CSU, while it does not support the usefulness of bd-dimer unlike previous findings. CSU duration before omalizumab and baseline UAS7 may be clinical markers of relapse risk.

Kikuchi-Fujimoto disease: a clinicopathologic update

Kikuchi-Fujmoto disease (KFD), also known as "histiocytic necrotizing lymphadenitis", is a rare lymphadenitis of unknown origin, but with an excellent prognosis. It is more common in Asia, but isolated cases are also reported in America, Africa and Europe. The disease can have an acute or subacute course, usually develops in 1 to 3 weeks, with spontaneous resolution in 1-4 months. The main clinical sign is cervical lymphadenopathy, especially in the posterior cervical triangle with bulky and painful lymph nodes, usually affecting only one side; rare cases of generalized lymphadenopathy can be seen. This common clinical presentation can also be accompanied by nausea, vomiting, weight loss, weakness, headache and arthralgia. An extranodal extension of the disease, including involvement of skin, eye, and bone marrow localizations, has been rarely described. Most patients have leukopenia or neutropenia with a relative leukocytosis. At an ultrasound exploration of the affected lymph nodes, a hypoechoic aspect can be seen, with an external, thick and irregular hyperechoic ring. As there are no specific tests for KFD, the final diagnosis is histologically-based from lymph node excisional biopsy. Histological examination shows paracortical foci of coagulative necrosis containing karyorrhectic debris, which are surrounded by numerous CD68+/myeloperoxidase (MPO)+ histiocytes, CD68+/CD123+ plasmacytoid dendritic cells, and a minority of small- to large-sized CD8+lymphocytes and immunoblasts. Differential diagnosis mainly includes systemic lupus erithematous (SLE)-related lymphadenopathy and large cell lymphoma. The histological absence of neutrophils, plasmacells, as well as hematoxylin bodies, is a feature which argues against the diagnosis of SLE. In addition, the absence of auto-antibodies and anti-nuclear antibodies is useful in ruling out an autoimmune disorder. Early diagnosis of KFD is crucial to prevent the patients undergo extensive investigations related to suspected malignant lymphomas or other diseases.

Erectile dysfunction in 1050 men following extended (18 cores) vs saturation (28 cores) vs saturation plus MRI-targeted prostate biopsy (32 cores)

Erectile dysfunction (ED) following transperineal prostate biopsy (TPB) was prospectively evaluated. From January 2011 to January 2014, 1050 patients were submitted to TPB: 18 core (extended TPB) in 610 cases, 28 core (saturation TPB) in 360 cases and 32 core (saturation plus magnetic resonance imaging (MRI) targeted TPB) in 210 cases. The indications for biopsy were increasing prostate-specific antigen (PSA) or PSA>10 ng ml(-1). All patients were prospectively evaluated with the 5-item version of the International Index of Erectile Function (IIEF-5) at time zero and at 1, 3 and 6 months from TPB. Prostate cancer was diagnosed in 385/1050 (36.6%) patients; 560 men (350 vs 110 vs 100) having benign histology and normal sexual activity also completed the study. Overall, IEEF-5 score at time zero and at 1, 3 and 6 months did not significantly worsen (P>0.05); in detail, at 1 month from biopsy 15 extended TPB (4.2%) vs 7 saturation TPB (6.4%) vs 7 saturation plus MRI targeted TPB (7%) men referred mild ED that disappeared after 3 months. Irrespective of method (18 vs 28 vs 32 core) TPB did not significantly worsen erectile function at 3-6 months from the procedure.

Morphological features of naevoid melanoma: results of a multicentre study of the International Dermoscopy Society

BACKGROUND

Naevoid melanoma (NeM), a rare variant of melanoma, can be difficult to detect as its clinical and histopathological morphology can simulate a naevus.

OBJECTIVES

To describe the clinical and dermoscopic features associated with NeM.

METHODS

Lesions with a histopathological diagnosis of NeM were collected via an e-mail request sent to all members of the International Dermoscopy Society. All lesions were histopathologically reviewed and only lesions fulfilling a set of predefined histopathological criteria were included in the study and analysed for their clinical and dermoscopic features.

RESULTS

Twenty-seven of 58 cases (47%) fulfilled the predefined histopathological criteria for NeM and were included in the study. Clinically, 16 of the 27 NeMs presented as a nodular lesion (59%), eight (30%) as plaque type and three (11%) as papular. Analysis of the global dermoscopic pattern identified three types of NeM. The first were naevus-like tumours (n = 13, 48%), typified by a papillomatous surface resembling a dermal naevus. In these lesions local dermoscopic features included irregular dots/globules (46%), multiple milia-like cysts (38%) and atypical vascular structures (46%). The second type were amelanotic tumours (n = 8, 30%), typified by an atypical vascular pattern (75%). The third type consisted of tumours displaying a multicomponent pattern (n = 4, 15%), characterized by classical local melanoma-specific criteria. Two lesions (7%) were classified as mixed-pattern tumours as they did not manifest any of the aforementioned patterns.

CONCLUSIONS

While NeMs may be clinically difficult to differentiate from naevi, any papillomatous lesion displaying dermoscopically atypical vessels and/or irregular dots/globules should prompt consideration for the possible diagnosis of NeM.

Reflectance confocal microscopy as a second-level examination in skin oncology improves diagnostic accuracy and saves unnecessary excisions: a longitudinal prospective study

BACKGROUND

Dermatoscopy increases both the sensitivity and specificity of melanoma diagnosis. Reflectance confocal microscopy (RCM) is a noninvasive technique that complements dermatoscopy in the evaluation of equivocal lesions at cellular resolution.

OBJECTIVES

To determine prospectively the potential impact of confocal microscopy when implemented in a routine melanoma diagnosis workflow.

METHODS

Patients referred to a single melanoma clinic were consecutively enrolled. At dermatoscopy, patients were referred to one of the following pathways: (i) no further examination or (ii) RCM examination. On examination atypical lesion(s) were referred for either (a) RCM documentation (lesions with consistent suspicious clinical/dermatoscopic criteria, already qualified and scheduled for surgical excision) or (b) RCM consultation for equivocal lesions, where RCM diagnosis would determine lesion definite outcome (excision or digital follow-up).

RESULTS

Reflectance confocal microscopy examination was performed for 41% of 1005 patients enrolled. In two-thirds of these cases RCM influenced the lesion outcome. The systematic application of RCM for equivocal lesions saved over 50% of benign lesions from unnecessary excision. The number needed to excise a melanoma was 6·8 with RCM examination, compared with a hypothetical 14·6 without RCM evaluation.

CONCLUSIONS

Reflectance confocal microscopy as a second-level examination to dermatoscopy proved to be highly accurate in diagnosis and reduced the number of unnecessary excisions. Improved accuracy, considering that RCM enabled the detection of the six melanomas (2%) in the group of 308 lesions eligible for follow-up, also minimizes the risk of referring a melanoma to digital dermatoscopy monitoring, and potentially losing the patient to follow-up.

Model-based control of plasma glycemia: Tests on populations of virtual patients

Closed-loop devices delivering medical treatments in an automatic fashion clearly require a thorough preliminary phase according to which the proposed control law is tested and validated as realistically as possible, before arranging in vivo experiments in a clinical setting. The present note develops a virtual environment aiming to validate a recently proposed model-based glucose control law on a solid simulation framework. From a theoretical viewpoint, the artificial pancreas has been designed by suitably exploiting a minimal set of delay differential equations modeling the glucose-insulin regulatory system; on the other hand, the validation platform makes use of a different, multi-compartmental model to build up a population of virtual patients. Simulations are carried out by properly addressing the available technological limits and the unavoidable uncertainties in real-time continuous glucose sensors as well as possible malfunctioning on the insulin delivery devices. The results show the robustness of the proposed control law that turns out to be efficient and extremely safe on a heterogenous population of virtual patients.

First survey of endoparasites in pet ferrets in Italy

Endoparasites are infrequently reported in ferrets. A cross-sectional survey was conducted to determine the prevalence of intestinal parasites in pet ferrets in southern Italy. Fresh fecal samples were randomly collected from 50 ferrets housed in pet shops or privately owned. All fecal samples were processed using the FLOTAC pellet technique to identify and count helminthic eggs/larvae and protozoan cysts/oocysts. In addition, the samples were analyzed also by the Remel XpectGiardia/Cryptosporidium immunoassay. Intestinal parasites were detected in 15 out of 50 ferrets (30%). Eggs of ancylostomids were found in 28.0% (14/50) of the animals and oocysts of Sarcocystis were detected in one ferret (2.0%). None of the samples was positive for Cryptosporidium or Giardia. To the authors' knowledge, this is the first report of sarcosporidiosis in a pet ferret in Italy.

Carcinosarcoma of the Female Urethra

Carcinosarcoma is a rare malignant tumor with a biphasic morphology characterized by the presence of a malignant epithelial and mesenchymal component. It has been reported in many organs, including the genitourinary tract. We describe a case of a 47-year-old woman admitted to our hospital for history of recurrent urinary tract infection, dysuria and discharge of bloody fluid from the urethra at the end of urination. A tender palpable mass under the anterior vaginal wall was found and pathological examination showed a urethral carcinosarcoma. The histopathogenetic hypothesis and clinical management were considered in this report.

Poly (ADP-ribose) polymerase 1 protein expression in normal and neoplastic prostatic tissue

A genetic background has been implicated in the development of prostate cancer. Protein microarrays have enabled the identification of proteins, some of which associated with apoptosis, that may play a role in the development of such a tumor. Inhibition of apoptosis is a co-factor that contributes to the onset and progression of prostate cancer, though the molecular mechanisms are not entirely understood. Poly (ADP-ribose) polymerase 1 (PARP-1) gene is required for translocation of the apoptosis-inducing factor (AIF) from the mitochondria to the nucleus. Hence, it is involved in programmed cell death. Different PARP-1 gene expression has been observed in various tumors such as glioblastoma, lung, ovarian, endometrial, and skin cancers. We evaluated the expression of PARP-1 protein in prostatic cancer and normal prostate tissues by immunohistochemistry in 40 men with prostate cancer and in 37 normal men. Positive nuclear PARP-1 staining was found in all samples (normal prostate and prostate cancer tissues). No cytoplasmic staining was observed in any sample. PARP-1-positive cells resulted significantly higher in patients with prostate carcinoma compared with controls (P<0.001). PARP-1 over-expression in prostate cancer tissue compared with normal prostate suggests a greater activity of PARP-1 in these tumors. These findings suggest that PARP-1 expression in prostate cancer is an attempt to trigger apoptosis in this type of tumor similarly to what reported in other cancers.

Gross Cystic Disease Fluid Protein-15(GCDFP-15)/Prolactin-Inducible Protein (PIP) as Functional Salivary Biomarker for Primary Sjögren's Syndrome

Background

Gross cystic disease fluid protein-15(GCDFP-15)/prolactin-inducible protein (PIP) is a secretory acinar glycoprotein of 14 KDa which we have recently described as significantly lower in salivary samples of patients with primary Sjögren’s syndrome (pSS) in comparison to healthy volunteers by proteomic analysis.

Aims of the study

(1) to validate our previous data on the decrease of GCDFP-15/PIP protein in a larger number of subjects with pSS (2) to integrate the proteomic results with complementary immunoassays in order better clarify the pathophysiological relevance of GCDFP-15/PIP in pSS exocrinopathy (3) to assess both the glandular expression of the GCDFP-15/PIP and the levels of glandular GCDFP-15/PIP mRNA in the patients’ minor salivary gland (MSG) biopsies in order to verify whether the observed reduction of GCDFP-15/PIP in saliva may be related to a decrease in the protein production.

Patients and methods

A total of 123 salivary samples from patients affected by pSS, no-SS sicca syndrome and sex- age-matched healthy volunteers were analyzed by different proteomic techniques (SELDI-TOF-MS, 2DE, MALDI-TOF-MS). The expression of GCDFP-15/PIP was then validated by western blot analysis. Real Time PCR and immunohistochemistry for GCDFP-15/PIP in the minor salivary glands (MSG) biopsies were then carried out.

Results

By using complementary proteomic analysis we found that a putative peak of 16547 m/z was among the best independent biomarkers for pSS able to discriminate between patients and healthy controls with a sensitivity of 96 % and a specificity of 70%, with a global cross validated error of 29%. We identified the peak as the GCDFP-15/PIP protein and verified that the intensity of GCDFP-15/PIP was significantly lower in pSS patients when compared to both no-SS sicca subjects and healthy controls (p<0.0001). GCDFP-15/PIP expression also correlated with both the salivary flow rate (r=0.312, p=0.023) and MSG biopsies focus score (r=−0.377, p=0.04). Finally, immunohistochemistry confirmed that GCDFP-15/PIP staining was faint in mucus acini and Real Time PCR showed that GCDFP-15/PIP mRNA was significantly lower in pSS patients when compared to both no-SS sicca subjects and healthy controls (p=0.023) thus supporting the hypothesis that the observed reduction of GCDFP-15/PIP in pSS saliva may be related to a decrease in the protein production.

Conclusion

In this study by different complementary-omic techniques we confirmed the potential role of GCDFP-15/PIP as a novel biomarker for pSS. This finding might also be functionally important as GCDFP-15/PIP has previously been shown to bind to Aquaporin 5 (AQP5), a salivary gland water channel, critical to saliva formation that is known to be downregulated in pSS. It is likely that exploring the GCDFP-15/PIP/AQP5 axis will help better understand the mechanism of salivary gland dysfunction in pSS.

Serum trace elements and risk of malnutrition in institutionalised elderly

OBJECTIVE

The objective of this work is to evaluate the association between Selenium (Se)-, Copper (Cu)- and Zinc (Zn)-circulating concentrations and indicators of nutritional status.

SUBJECTS/METHODS

This study enroled 428 institutionalised elderly. The diagnostic tools used are a form to collect data regarding gender, age, duration of stay in nursing home, number of prescribed drugs, chronic diseases, Mini Nutritional Assessment (MNA), anthropometric measurements, albumin, transferrin and serum concentrations of Se, Cu and Zn. The collected data were analysed with descriptive assessments of the differences χ(2), Student's t-test and analysis of variance. Multivariate linear regression were performed to evaluate the association between the concentrations of each trace elements and the other variables.

RESULTS

The study population was represented by 327 women and 101 men, of whom 13.8% were 65-75 years old and 47.4% were older than 85 years. According to the MNA score, 58.4% were at risk of malnutrition and 21.3% were malnourished. The results show a significant reduction in the average concentrations of Se and Zn in women when the nutritional status gets worse. The same trend, although not statistically significant, is also observed in men. In both genders, the Cu concentration does not show a statistically significant association with nutritional status. Multivariate linear regression show some positive or negative associations.

CONCLUSIONS

Our study seems to confirm the association between Se and nutritional status, as well as with some blood chemistry parameters. The length of institutionalisation seems to be an independent predictor of Se concentration.

Comparison of colonoscopy and fecal occult blood testing as a first-line screening of colonic lesions in patients with newly diagnosed acromegaly

CONTENT

Patients with acromegaly have frequently colonic neoplasms; however, how acromegalic patients should be screened for colonic lesions is still unsettled.

AIMS

To compare fecal occult blood testing (FOBT) and colonoscopy in the screening program of patients with acromegaly.

DESIGN

Colonoscopy and FOBT were performed at the first diagnosis of acromegaly.

SETTING

Tertiary University center.

PATIENTS

Eighty-five consecutive patients with untreated active acromegaly submitted to colonoscopy and FOBT.

RESULTS

FOBT, which was positive in 16 (18.8%) out of 85 patients, identified 2 patients with colonic adenocarcinoma and 2 with adenoma; the remaining 12 patients had no detectable colonic lesions. Colonoscopy revealed colonic lesions in 29 patients: 3 (3.5%) cancers, 11 (12.9%) adenomas, and 15 (17.6%) hyperplastic polyps. The remaining 56 acromegalic patients had no detectable lesions. A patient with cancer and 9 patients with adenoma were missed if screened only by FOBT.

CONCLUSIONS

Colonoscopy is superior to FOBT in detecting colonic lesions at the first diagnosis of acromegaly.

The clinical course of pulmonary embolism patients anticoagulated for 1 year: results of a prospective, observational, cohort study

BACKGROUND

Few studies have examined the clinical course of pulmonary embolism (PE) in patients anticoagulated continuously for 1 year.

OBJECTIVE

We sought to determine the incidence of death, recurrent PE and bleeding during anticoagulation in the first year after acute PE, and to assess associated risk factors.

METHODS

All consecutive PE patients who were referred to our center in Pisa, Italy between 2001 and 2005 received a conventional initial treatment, followed by vitamin K antagonists [international normalized ratio (INR), 2.0-3.0] for 1 year. They were followed-up at scheduled times at the study center. The development of recurrent PE was objectively documented and recorded.

RESULTS

Out of 497 patients, 48 (9.6%) developed recurrent PE, which was fatal in 36. Of these 48 events, 39 occurred within 10 days of diagnosis and only two patients had a non-fatal recurrent PE between 6 and 12 months. Risk factors associated with the risk for overall recurrent PE were persistent severe dyspnoea (P = 0.007), a high perfusion defect score index (PDI) (P = 0.003) and cardiopulmonary co-morbidities (P = 0.005). Unprovoked presentation (P = 0.030), persistent severe dyspnoea (P = 0.011) and a high PDI (P = 0.001) predicted the risk for fatal PE. Overall bleeding incidence was 3.4%, no cases of bleeding occurred between 180 and 360 days post-diagnosis.

CONCLUSIONS

In spite of conventional anticoagulation, a proportion of patients with PE experience both a fatal and non-fatal recurrent embolism within the first year. The large majority of these occur within the days proceeding diagnosis, with only a small minority occurring in the last 6 months. No bleeding was observed after 6 months. Therefore, prolonging anticoagulation for 1 year represents both a safe and effective treatment.

Primary high grade sarcoma of the specialised prostatic stroma: a case report with clinico-pathological considerations

Malignant tumours of the prostate other than carcinomas are rare. One such malignant tumours arising from the specialised stromal tissue of the prostate is stromal prostatic sarcoma (namely low-grade and high-grade). Herein, we report the clinico-pathological features of a high grade stromal sarcoma of the prostate occurring in a 65-year-old man who presented for urinary obstructive symptoms. The clinical picture suggested a benign prostatic hyperplasia, and surgery consisting in a transcapsular adenomectomy was performed. Following a pathological diagnosis of high grade prostatic stromal sarcoma, a radical cystoprostatectomy and bilateral pelvic node dissection was performed showing residual high grade stromal sarcoma of the prostate and incidental in situ urothelial carcinoma of the bladder. No further medical treatments were planned. One year after surgery the patient is well with no evidence of local disease or distant metastases.

Isolated local recurrence of renal neoplasm with caval involvement 16 years after radical nephrectomy

OBJECTIVE

To report a case of local recurrence 16 years after radical nephrectomy; to analyse literature data concerning, treatment and prognosis.

METHODS/RESULTS

We report a case of local recurence associated with caval trombosis who was underwent an en-bloc resection of vena cava along with pericaval lesion and caval replacement with PTFE prosthesis. The Authors reviewed and analysed literature data.

CONCLUSIONS

Local recurrence after radical nephrectomy is rare as it is reported only in 2-4% of patients. This condition is even rarer beyond 10 years especially if associated with caval trombosis. A case of isolated local recurrence of renal cell carcinoma with caval involvement 16 years after radical nephrectomy is described herein. To the best of our knowledge, this is the first case reported in literature. This case highlights the opportunity of a periodic checkup of patients submitted to radical nephrectomy, even many years after surgery.

Incidence of Prostate Cancer in Sicily: Results of a Multicenter Case-Findings Protocol

OBJECTIVE

To establish the incidence of prostate cancer (PCa) in Sicily in patients who entered an early detection protocol.

METHODS

From February 2002 to February 2004, 16,298 subjects aged 40-75 entered the protocol. Patients with suspicious DRE, PSA>10 ng/ml, PSA<or=2.5 ng/ml, from 2.6 to 4 ng/ml or from 4.1 to 10 ng/ml with F/T PSA of <or=15%, <or=20% and <or=25% respectively underwent needle biopsy according to an extensive protocol.

RESULTS

3266 patients were eligible for biopsy; PSA was <or=4 in 12.7% and <or=10 ng/ml in 63.9% of patients. A PCa was found in 1171 cases (36.9%) with a relationship between PCa incidence and PSA and age respectively (chi2-test, p<0.0001); 51.8% of patients with PCa had a PSA<10 and 8.8% a PSA<4 ng/ml; 49% were clinically staged as T1c. The estimated odds ratios for each age group showed increased risk for PCa in the fourth decade with PSA between 2.6 and 4 ng/ml (12.5 times higher) and in the fifth decade with PSA between 4.1 and 10 ng/ml (6.2 times higher).

CONCLUSIONS

Age and serum PSA levels are the major risk factors for PCa. On their basis it is possible to modulate the most suitable timing for early diagnosis in individual patients.

Prediction by quantitative histology of pathological stage in prostate cancer

AIMS

To find a predictor of extraprostatic extension in clinically localized prostate cancer (PCa), pre-operative ultrasound-guided prostate needle biopsies and clinico-pathological data were reviewed.

METHODS

One hundred and eighty-three consecutive patients who underwent radical retropubic prostatectomy for clinical T1-T2 PCa and serum PSA <10 ng/ml were reviewed. Pre-operative biopsy was performed according to an extended protocol and whole-mount prostatectomy specimens were processed. The following biopsy variables were categorized to this analysis: Gleason score (< or =6, >6), TPC (< or =20%; >20%), GPC (< or =50%; >50%), cancer-positive cores (< or =2; >2), cancer-positive cores in both lateral portions (yes; no), PCa (monolateral; bilateral).

RESULTS

Only 60/183 specimens showed an organ-confined PCa; the remaining ones showed pT3a in 57 cases, pT3b in 11 and pT3 with positive surgical margins in 55. A locally advanced PCa was found in 60.2 and 76.8% of T1c and T2 clinical stage, respectively. The positive predictive value and negative predictive value of biopsy findings to predict a locally advanced PCa was 89.9 and 75%, respectively. All biopsy variables associations were statistically significant; however, among these variables (non-categorized), in multivariate logistic regression analysis, only GPC was significantly associated with pathologic stage (odds ratio estimate was 1.075, 95% CI: 1.053-1.098).

CONCLUSIONS

Quantitative histology, especially GPC, seems to be helpful for pre-operative staging of PCa in patients with T1c-T2 clinical stage and PSA < 10 ng/ml.