Infodemic management for public health practitioners: landscape analysis and practical tools

Issue

Infodemics (i.e., overflow of information in physical and digital spaces that makes it difficult for people to make good health decisions) can undermine emergency response, but capacity for infodemic management has been limited in countries thus far. Specifically, there is a need to build capacities in the field with practical and scalable tools.

Description of the problem

WHO has developed tools and trainings to quickly build and enhance infodemic management (IM) capacity at the country-level, such as tools for rapid generation of IM insights and a framework for conducting landscape analyses to establish sustainable IM capacities. These were developed in collaboration with multidisciplinary experts who provided feedback. We sought to create tools that can be a basis for introducing evidence-generation in health information systems to inform emergency preparedness and response, and mainstream methods into routine infodemic diagnostics activities.

Results

The tools and trainings provide a comprehensive framework for diagnosing and addressing infodemics, such as a public health taxonomy to guide digital intelligence analysis and integrated analysis methods for generation of actionable insights. Additionally, the landscape analysis framework outlines steps for assessing strategic needs and assets for routinizing IM functions as part of existing public health systems and programs.

Lessons

The tools and trainings will be deployed in the field to evaluate utility. Feedback from users in the global WHO infodemic manager community will be systematically captured.

Key messages

• Field responders need practical tools and trainings that guide quick infodemic response during health emergencies.

• These tools and trainings can be used to diagnose and intervene on infodemics, even in settings where infodemic insights units are not yet established.

Nickel and cadmium tissue bioaccumulation and blood parameters in Chelon auratus and Mugil cephalus from Anzali free zone in the south Caspian Sea (Iran) and Faro Lake (Italy): A comparative analysis

BACKGROUND

Analysis of heavy metal concentrations in fish blood is a valuable tool in environmental pollution monitoring. Among different type of fish, detritivorous fish are a very good indicator for monitoring pollution and environmental stress, along with hematological studies, which are an important indicator in eco-toxicological and biological studies.

AIM

The aim of this study was to evaluate the influence of environment on bioaccumulation of Ni and Cd and on blood parameters in Chelon auratus and Mugil cephalus (a detritivorous fish which is widely distributed in the world) captured in Caspian Sea and Faro Lake.

METHODS

For the research blood and tissues samples were collected from 40 mullets (20 Mugil cephalus from Italy and 20 Chelon auratus from Iran) in 2019. The hematological (white blood cell, WBC; red blood cell, RBC; thrombocyte count, TC; hematocrit, Hct; hemoglobin concentration, Hb; mean corpuscular volume, MCV; mean corpuscular hemoglobin, MCH and mean corpuscular hemoglobin concentration, MCHC) and biochemical parameters (aspartate aminotransferase, AST; alanine aminotransferase, ALT; alkaline phosphatase, ALP; lactate dehydrogenase, LDH and creatine phosphokinase, CPK were assessed.

RESULTS

Although the concentration of Ni and Cd in the muscle of fish have no significant health risks and were low in both regions, the most elevated concentration was found in the liver of Caspian Sea mullet. In all cases, the results obtained for all biochemical and most hematological parameters of individual Faro Lake, were considerably lower than the Caspian Sea, demonstrating that habitats and environmental conditions affect the blood metabolites.

CONCLUSIONS

The results of this study show that these measurements can be used as criteria for the quantitative evaluation of fish /health and provide information on the extent of potential poisoning and the risks posed to the populations and fisheries.

Design and structural bioinformatic analysis of polypeptide antigens useful for the SRLV serodiagnosis

Due to their intrinsic genetic, structural and phenotypic variability the Lentiviruses, and specifically small ruminant lentiviruses (SRLV), are considered viral quasispecies with a population structure that consists of extremely large numbers of variant genomes, termed mutant spectra or mutant cloud. Immunoenzymatic tests for SRLVs are available but the dynamic heterogeneity of the virus makes the development of a diagnostic "golden standard" extremely difficult. The ELISA reported in the literature have been obtained using proteins derived from a single strain or they are multi-strain based assay that may increase the sensitivity of the serological diagnosis. Hundreds of SRLV protein sequences derived from different viral strains are deposited in GenBank. The aim of this study is to verify if the database can be exploited with the help of bioinformatics in order to have a more systematic approach in the design of a set of representative protein antigens useful in the SRLV serodiagnosis. Clustering, molecular modelling, molecular dynamics, epitope predictions and aggregative/solubility predictions were the main bioinformatic tools used. This approach led to the design of SRLV antigenic proteins that were expressed by recombinant DNA technology using synthetic genes, analyzed by CD spectroscopy, tested by ELISA and preliminarily compared to currently commercially available detection kits.

Assessment of total (anti)oxidant status in goat kids

The redox potential of goat serum was assessed by different spectrophotometric assays. Among them, three methods are commonly applied for the evaluation of the oxidative (reactive oxygen metabolites, ROMs, and total oxidant status, TOS) and nitrosative (NO ⚫ metabolites, NO x ) stress, and four methods for the evaluation of the antioxidant status: the total antioxidant capacity (TAC) based on the ferric reducing ability of plasma (FRAP), the total antioxidant activity (TAA) based on the reduction of the coloured ABTS ⚫ + radical cation, the free radical scavenging activity (FRSA) based on the reduction of the purple DPPH ⚫ , and the total thiol levels (TTLs) based on their interaction with DTNB to form a highly coloured anion. Besides, myeloperoxidase (MPO) and ceruloplasmin oxidase (CP) activities were also assessed. Except for TAA, analytical data showed a great inter-individual variation for both oxidant and antioxidant assays. ROMs were strongly correlated with CP, while TOS with MPO and TAC. Furthermore, a tendency between TOS and FRSA was shown. NO x was correlated with TAC and TAA, and a tendency with TOS was shown. No correlations appeared among the antioxidant assays, even if a tendency between TAC and TAA was evidenced, but TAC was correlated with MPO activity. The observed correlation between ROMs and CP is discussed as a possible analytical interference. The absence of correlation among the antioxidant biomarkers suggests the simultaneous use of a panel of tests to verify any changes in the redox balance, mainly in livestock in which reference values for each biomarker are lacking.

First Search for Dyons with the Full MoEDAL Trapping Detector in 13 TeV pp Collisions

The MoEDAL trapping detector consists of approximately 800 kg of aluminum volumes. It was exposed during run 2 of the LHC program to 6.46  fb^{-1} of 13 TeV proton-proton collisions at the LHCb interaction point. Evidence for dyons (particles with electric and magnetic charge) captured in the trapping detector was sought by passing the aluminum volumes comprising the detector through a superconducting quantum interference device (SQUID) magnetometer. The presence of a trapped dyon would be signaled by a persistent current induced in the SQUID magnetometer. On the basis of a Drell-Yan production model, we exclude dyons with a magnetic charge ranging up to five Dirac charges (5g_{D}) and an electric charge up to 200 times the fundamental electric charge for mass limits in the range 870-3120 GeV and also monopoles with magnetic charge up to and including 5g_{D} with mass limits in the range 870-2040 GeV.

Assessment of Total Antioxidant Capacity in Serum of Heathy and Stressed Hens

Simple Summary

In living organisms, the antioxidant defense system serves to counteract reactive oxygen (ROS) and nitrogen (RNS) species, thereby protecting cellular targets against their oxidative damage; it includes a combination of different substances of endogenous or exogenous origin. Several methods were developed to assess the overall antioxidant capacity or the precise determination of individual key antioxidants. In the present study, the total antioxidant capacity (TAC) in healthy and dexamethasone-stressed hen serum was measured by applying four different spectrophotometric methods intended for both clinical and research studies, which could be automated on clinical auto-analyzers, thus allowing rapid and not expensive data collections. TAC values assessed by all four methods did not change throughout the experimental period in the control group, whereas significant changes were shown by all adopted assays in the stressed group, with some remarkable differences, probably due to the different contribution in each assay of the various antioxidant substances present in the samples. Therefore, when TAC evaluation is necessary to verify if animals are experiencing oxidative stress (OS) or to evaluate possible benefits from an antioxidant-enriched diet, TAC assessment should involve multiple assays, due to the different analytical technologies on which their assessments are based.

Abstract

Total antioxidant capacity (TAC) in healthy and dexamethasone-stressed hens was measured by applying four different spectrophotometric methods—the ferric reducing ability (FRAP) assay, the 2,2′-azino-bis (3-ethylbenzotiazoline-6-sulphonic acid) (ABTS) radical cation decolorization assay, the free radical scavenging activity (FRSA), and the total thiol levels (TTL). TAC assessed by all four methods did not change throughout the experimental period in the control group, whereas significant changes were shown by all adopted assays in the stressed group with some remarkable differences. TAC increased in the stressed group when FRAP and ABTS assays were applied, while it was reduced when sera were assessed by FRSA and TTL assays. Furthermore, FRAP assay was the only test able to show a significant change in TAC immediately after the end of the induced stress. At the end of the experimental period, TAC assessed by ABTS and FRSA assays showed a complete recovery in the stressed group, whereas TAC assessed by FRAP and TTL assays still showed significant persistent differences when compared to the control group. The observed differences in TAC are discussed in the light of the different contribution in each assay of the various antioxidant substances present in the samples.

Patent ductus venosus and exercise related pulmonary hypertension: a case of a young adult with successful surgery closure

Abstract

The patent ductus venosus is an embryological portosystemic shunt that connects the umbilical vein to the inferior vena cava and it can be diagnosed incidentally or in subjects suffering from hepatic encephalopathy, hypoxemia or hypoglycaemia. Sometimes it can be found in patients with cardiac defects or hypoxia caused by pulmonary arteriovenous shunting.

Case presentation

A 34-year-old male patient was referred to our medical centre for further evaluation of abdominal pain and moderate exertional dyspnoea. An exercise stress echocardiogram was performed in order to understand the mechanism of the exertional dyspnoea. The test was interrupted due to dyspnoea and desaturation and an estimated pulmonary pressure value of 65 mmHg was detected. Exercise pulmonary hypertension (PH) seems to represent the hemodynamic manifestation of early pulmonary vascular disease, acting as a possible transitional phase anticipating resting PH.

An MRI of the abdomen showed the presence of a portosystemic shunt from a patent ductus venosus, associated with stenosis of the celiac tripod artery. A CT scan, of the pulmonary circulation, showed a normal pulmonary venous return,mediastinal vessel a normal pulmonary artery. Subsequently, taking into consideration the large size (> 25 mm) of the duct, treatment (closure) of the patent ductus venosus with the help of a detachable vascular plug device was not feasible and open surgery rather than a percutaneous invasive approach would be advisable.

Conclusion

Persistent ductus venous can lead to pulmonary arteriovenous shunt fistula and exercise related pulmonary hypertension. Percutaneous or surgical closure requires detailed planning and an anatomical and physiological evaluations.

Comparison of cheeses from goats fed 7 forages based on a new health index

This study proposed the General Health Index of Cheese (GHIC) as an indicator for the presence of health-promoting compounds in cheese and compared the antioxidant capacity and phenolic and fatty acid contents of cheeses from goats consuming 7 forage species. Ninety-one homogeneous Red Syrian goats were randomly assigned to 1 of 7 feeding treatments (Festuca arundinacea, Hordeum vulgare, Triticosecale, Pisum sativum, Trifolium alexandrinum, Vicia sativa, and Vicia faba minor). The housed goat groups received the scheduled forage ad libitum. Forage species affected the antioxidant capacity, the phenolic and fatty acid contents, the Health Promoting Index, and the GHIC. Trifolium alexandrinum, Triticosecale, and Hordeum vulgare showed a clear advantage in terms of beneficial fatty acids content in goat cheese. Cheese from the Triticosecale group also showed a high antioxidant capacity value even if its polyphenol content was intermediate compared with others. Trifolium alexandrinum and Triticosecale had the highest value of the new index GHIC. This comparison suggests that there are important differences in fatty acid profile and polyphenol content among cheeses from goats fed grasses and legumes commonly used in the Mediterranean area. In this first approach, GHIC index, which combines the positive components found in cheese, seems to be a useful tool to provide an indication concerning the general health value of the product.

Magnetic Monopole Search with the Full MoEDAL Trapping Detector in 13 TeV pp Collisions Interpreted in Photon-Fusion and Drell-Yan Production

MoEDAL is designed to identify new physics in the form of stable or pseudostable highly ionizing particles produced in high-energy Large Hadron Collider (LHC) collisions. Here we update our previous search for magnetic monopoles in Run 2 using the full trapping detector with almost four times more material and almost twice more integrated luminosity. For the first time at the LHC, the data were interpreted in terms of photon-fusion monopole direct production in addition to the Drell-Yan-like mechanism. The MoEDAL trapping detector, consisting of 794 kg of aluminum samples installed in the forward and lateral regions, was exposed to 4.0  fb^{-1} of 13 TeV proton-proton collisions at the LHCb interaction point and analyzed by searching for induced persistent currents after passage through a superconducting magnetometer. Magnetic charges equal to or above the Dirac charge are excluded in all samples. Monopole spins 0, ½, and 1 are considered and both velocity-independent and-dependent couplings are assumed. This search provides the best current laboratory constraints for monopoles with magnetic charges ranging from two to five times the Dirac charge.

Abdominal pain and internal hernias after Roux-en-Y Gastric Bypass: are we dealing with the tip of an iceberg?

Background:

Abdominal pain is the most frequent cause of hospital admission after Roux-en-y gastric bypass (RYGB). Among numerous possible underlying causes, internal hernias represent one of the most peculiar and insidious conditions, setting challenging diagnostic and therapeutic problems for the surgeon. The aim of this study is to analyze aspecific abdominal pain incidence and characteristics after RYGB, discriminating peculiar aspects suggestive of internal hernias.

Methods:

13 patients submitted to internal hernia repair after laparoscopic antecolic RYGB and a group of 49 controls (non-complicated RYGB) have been assessed using a specific questionnaire. Overall aspecific abdominal pain incidence and characteristics have been analysed. Typical pain traits and predisposing conditions for internal hernias have been investigated.

Results:

33% of controls reported aspecific abdominal pain after RYGB, mainly early postprandial, deep, remittent, colicky, located in the upper left abdomen. 77% of the case patients reported prodromal episodes of pain similar to the controls. The only significant differences between prodromal and acute episodes were pain intensity and quality (continuous). Excess weight lost at 3 months significantly correlated with internal hernia occurrence (p: 0.002). Conclusions: Based on abdominal pain characteristics, we can reasonably postulate the presence of remittent bowel torsions (remittent internal hernia) in many patients after antecolic RYGB, only occasionally complicating. Therapeutic management of these cases remains controversial, being laparoscopic exploration a reasonable option when symptomatology is suggestive.(www.actabiomedica.it)

Natural antibodies and their relationship with total immunoglobulins and acquired antibody response in goat kid (Capra hircus, L. 1758) serum

Natural antibodies (NAb) are antibodies that can bind to a particular antigen without any apparent antigenic stimulation. In this paper, a careful analysis has been carried out on NAb levels in goat kid serum; possible correlations with the total immunoglobulin (tot-Ig) levels and specific antibody (SpAb) response were considered. Twenty randomly chosen kids were submitted to a first blood sampling (day 0). After 60 and 100 days, new blood samplings were carried out in the same animals. On day 0, after blood collection, all animals were immunized with a commercial vaccine; the immunization was repeated 30 days apart. Some exogenous antigens were tested to verify their immunoreactivity to NAb. Among them, the synthetic hapten 2,4,6-trinitrophenyl (TNP) conjugated with bovine serum albumin, resulted as the antigen with the higher immunoreactivity to NAb. Tot-Ig levels increased over time (p < 0.001). On the contrary, NAb levels, both IgG- and IgM-isotypes, significantly decreased during the experimental period (p < 0.001 and <0.05, respectively). Linear regression analyses showed a high correlation between IgM-NAb and tot-IgM levels (p < 0.001) at all the evaluated sampling times. However, a significant correlation between IgG-NAb and IgM-NAb was found only at the 1^st (p < 0.01) and at the 2^nd sampling (p < 0.05). No significant correlations were found between SpAb response and the other assessed humoral immune parameters. The obtained results are discussed in the light of the possible use of NAb assessment for the evaluation of the immune system activity in goat.

Abstract P4-16-04: Oral ibandronate for osteopenic breast cancer patients receiving adjuvant aromatase inhibitors: secondary 5-year survival outcomes analysis of the single-center phase 2 BONADIUV trial

Background. Several randomized trials demonstrated aromatase inhibitors (AI) superiority in terms of disease-free survival (DFS) compared to tamoxifen treatment for postmenopausal hormone receptor-positive breast cancer (BC) patients. Anyway, AI toxicity profile is a concern due to estrogen suppression. Pivotal trials demonstrated a significant bone mineral density (BMD) loss due to AI, with a consistent 5-year risk of bone fractures, thus impacting on patients' quality of life. Bisphosphonates represent an effective treatment in postmenopausal osteoporosis fractures prevention. However, an adequate patient's selection for adjuvant bisphosphonates treatment during AI endocrine therapy is still a challenge. Final results of BONADIUV trial presented at San Antonio Breast cancer Symposium in 2016 showed that treatment with ibandronate, as compared to placebo, significantly improved BMD change in osteopenic women treated with adjuvant AI, and consistently protected patients' bone loss. We present the secondary 5-year analysis on survival outcomes of the trial.

Patients and methods. The BONADIUV trial is a single-blind, randomized, placebo-controlled phase 2 study designed to evaluate the impact of ibandronate treatment on BMD in osteopenic women taking AI. Between January 2011 and May 2014, 171 osteopenic patients (lumbar spine [LS] and/or trochanter -1&lt; T-score &lt;-2.5), were randomized in a 1:1 ratio to receive either placebo or oral monthly ibandronate (150 mg). Treatment duration was 2 years, with 6-months evaluation. Primary endpoint was the mean BMD difference between the two arms at a 2-year follow up. Secondary analysis on survival outcomes (overall survival [OS] and invasive DFS [iDFS]) have been performed at 5-year median follow-up time. ClinicalTrials.gov identifier: NCT02616744.

Results. At the database cutoff time for the present analysis on May 4, 2018, median follow up was 63.3 months (mean 61.2; range 2.7-87.3) for whole series, 64.9 months (range 33.8-84.0) for the placebo arm, and 62.2 months (range 24.2-87.3) for the ibandronate arm. Ten patients in the placebo group and 17 patients in the ibandronate group withdrew the allocated arm before any follow up data collection, and so were excluded from the analysis, performed on 144 patients (72 patients per arm). At the database cutoff time, the OS rate was 97.2% in the placebo group and 100% in the ibandronate arm. We observed four loco-regional relapse (three in the placebo arm, one in the ibandronate arm; p=0.33), three distant metastases (none in the placebo arm, three in the ibandronate arm; p=0.075), and three contralateral BC (one in the placebo arm, two in the ibandronate arm; p=0.65). The number of iDFS events did not differ between groups: four in the placebo group and six in the ibandronate group (p=0.56). Up to data cutoff, two deaths have occurred; none in the placebo arm and two in the ibandronate arm (p=0.15). The OS rate did not differ between arms.

Conclusions. The secondary analysis of survival outcomes showed no difference between arms in terms of OS and iDFS rates. Further large investigations and mature follow-up from the published ones are awaited.

Citation Format: Meattini I, Scotti V, Desideri I, Saieva C, Visani L, Salvestrini V, Cecchini S, De Feo ML, Mariotti M, Olmetto E, Delli Paoli C, Francolini G, Bernini M, Orzalesi L, Sanchez L, Nori J, Bianchi S, Livi L. Oral ibandronate for osteopenic breast cancer patients receiving adjuvant aromatase inhibitors: secondary 5-year survival outcomes analysis of the single-center phase 2 BONADIUV trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-16-04.

Megarectosigmoid in anorectal malformations: the role of laparoscopic resection

Surgical treatment for anorectal malformations may lead to chronic constipation or stool incontinence. The first condition is mostly linked to an abnormal dilation of rectum and sigma and it is primarily managed with medical therapy (laxatives, diet and enemas). When medical therapy fails to improve the symptoms, a surgical resection of the dilated colon is advocated. When performing the procedure it is mandatory to consider all the previous operations the patient undergone. We present a laparoscopic left emicolectomy for an extremely dilated megarectosimoid after posterior sagittal anorectoplasty in childhood for a recto-urethral fistula.

Resolution of late-onset heart and liver failures after reversion of jejuno-ileal bypass: a case report

OBJECTIVES

Jejuno-ileal bypass (JIB) was a kind of bariatric surgery performed from 1960s to 1980s, able to induce sustainable weight loss by creating a surgical short bowel syndrome.

MATERIALS AND METHODS

We report a case of an octogenarian woman who underwent in the early eighties this kind of surgery with consequent 40 kg weight loss. After 27 years, she first developed a reversible metabolic cardiomyopathy that began with signs and symptoms of heart failure. Thereafter, she was diagnosed with severe intractable liver insufficiency.

RESULTS

Despite her old age, the patient underwent reversal of JIB with consequent early improvement of hepatic function.

CONCLUSIONS

This case demonstrate that in case of long-term and life-threatening complications, it is possible to successfully reverse JIB surgery after upto 30 years. The hypothesis on pathophysiology of heart and liver insufficiency are discussed.

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.

Determinants of Non-Attendance to Mammographic Screening. Analysis of a Population Sample of the Screening Program in the District of Florence

The characteristics associated with non-attendance to mammographic breast cancer screening were studied by interviewing a random sample (213 attenders, 121 non-attenders in the 1989 screening) of residents in one of the municipalities of the Florence District Program, where screening has been ongoing since 1970. The overall attendance rate was 60%, and it was dependent on age (40–49 years, 66.5%; 50–59 years, 62.5%; 60–70 years, 55.5%), whereas a significant association with socio-economic status, educational level and health-behavior reported in other programs was not confirmed in the study. This finding suggests that determinants of non-attendance may vary and should be evaluated in each local setting. The belief that screening is useless, fear of cancer being detected, postponement and laziness were the most common motivations of refusal stated by non-attenders, and such a negative attitude towards screening was rather strong since most non-attenders stated they would not like to be informed or stimulated to attend future screenings. Rapid improvement of attendance rates in such a context might be achieved only by putting special pressure on women aimed to change their negative attitude towards screening and their opinion about the benefits of early breast cancer detection. This might be regarded as unacceptable and however would involve high costs and a major organization effort.

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.

Attendance to a Screening Program for Cervical Cancer in the City of Florence

The study was aimed to assess: a) the proportion of true refusers among non-attenders resulting from residents and screening database matching, b) the typology of refusers compared to attenders, and c) the reasons for non-attendance as stated by refusers. Three hundred and forty-one non-attenders according to computer-produced lists were interviewed: 29 were not evaluable, 148 had had a Pap test, 18 had not attended for valid reasons, and 146 were true refusers; 94 refusers accepted the interview as far a points b) and c) were concerned. Ninety-four attenders, matched by age and residence, were interviewed for comparison. Attendance at private laboratories or incorrect identification of subjects on the screening record accounted for 45 % or 55 % of misclassified cases, respectively. The adjusted true refusal rate in the last 10 years was 18.1 % compared to a computer-assessed non-attendance rate of 40.7 %. Refusal was significantly associated to socioeconomic status (geographic origin, working activity and educational level of both women and husbands), whereas no significant association was observed for sexual history (deliveries, age at first sexual relation, number of partners) or health-related behavior. Attendance and counseling at the gynecologist's office were strongly associated to attendance, and gynecologists should be stimulated to promote opportunistic screening. The belief that screening is useless in the absence of symptoms, the fear of cancer being detected, postponement or laziness were the reasons for non-attendance stated by 80% of refusers. Improving knowledge about the purpose of the Pap test should be the main goal of any action aimed to improve screening attendance.

Risk of Endometrial Cancer in Breast Cancer Patients under Long-Term Adjuvant Treatment with Tamoxifen

Aims

To evaluate the relative risk of endometrial cancer with respect to the expected underlying incidence in breast cancer patients undergoing long-term adjuvant tamoxifen therapy.

Methods

A total of 1010 postmenopausal breast cancer patients receiving adjuvant tamoxifen and with a first negative endometrial ultrasonography (cutoff for abnormal endometrial thickness >5 mm) were followed by annual transvaginal ultrasonography. Abnormal endometrial thickness prompted an outpatient endometrial biopsy or curettage under anesthesia in the case of cervical stenosis and increasing endometrial thickness. The standardized incidence ratio (SIR) with respect to underlying incidence was determined.

Results

A total of 1,010 eligible subjects who had been receiving tamoxifen for an average of 51 months were enrolled and followed for a total of 2,361 patient-years between January 1993 and December 1996. Five cases of endometrial cancer were observed in the study period: 1 was detected at screening, and 4 were diagnosed for vaginal bleeding in the interval between screening examinations. SIR was 4.0 (95% confidence interval, 1.39.4) and increased to 4.8 (CI, 1.6-10.5) when the single cancer detected at first screening was considered as incident.

Conclusions

This study adds evidence to the hypothesis that long-term tamoxifen treatment may be responsible for a relevant increase in the risk of developing endometrial cancer. Surveillance based on endometrial ultrasonography was poorly sensitive, but the favorable stage at diagnosis of screen-detected or interval endometrial cancers does not support a more aggressive screening approach.

Evaluation of the Sensitivity of Cervicography in a Consecutive Colposcopic Series

Cervicography was performed in 606 women referred for colposcopy. Cervigrams were blindly reviewed by two independent readers. The positivity rate at cervicography was high (operator A = 50 %, B = 58.8 %). The sensitivity for papillomavirus infection (HPV)/cervical intraepithelial neoplasia I (CIN I) (n = 141) was 79.4 % for operator A and 80.8 % for operator B. The sensitivity for CIN II or more severe lesions (n = 22) was 95.2 % and 90.5 % for operators A and B, respectively. The positive predictive value for HPV/CIN I or CIN II, or more severe lesions was 36.9 % and 6.9 % for operator A and 32.1 % and 5.3 % for operator B, respectively. Interobserver variability was acceptable (kappa = 0.62). Cervicography suspected 27 HPV/CIN I, 1 CIN II and 1 CIN III which showed no cytologic abnormalities. This study confirms that cervicography has a good sensitivity for cervical lesions, but it is based on a selected series, not representative of a screening condition. The combination of cervicography and cytology in screening is presently under evaluation in a prospecitve study of screened women.

Trends in the Prevalence of Cervical Intraepithelial Neoplasia Grade 3 in the District of Florence, Italy

Aims and background

The objective of this study was to investigate the detection rate of cervical intraepithelial neoplasia grade III (CIN 3) in previously unscreened women, in order to reveal trends over time in the prevalence of CIN 3 in the District of Florence, where a population-based screening for cervical cancer has been going on since 1973.

Study design

We considered the women, recorded in the computerized archives of CSPO, who had had no pap test for at least 10 years. Trends of CIN 3 (histologically proven) were analyzed within age groups; the effect of age, cohort and period were considered by means of a Poisson regression model.

Results

A total of 648 cases of histologically proven CIN 3 were detected in the study period. The detection rates of CIN 3 increased steadly within age groups over birth cohort and calendar period simultaneously. The Poisson regression analysis showed that only the model with age + time trend was statistically significant.

Conclusions

Although several biases should be taken into account, the analysis seemed to indicate a real increase in CIN 3 prevalence. An increase in frequency of precancerous lesions for cervical cancer in more recent birth cohorts supports the need to keep screening coverage and efficiency as high as possible.

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.

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.

Hysteroscopy and Endometrial Cancer Diagnosis: A Review of 2007 Consecutive Examinations in Self-Referred Patients

The authors reviewed 2007 consecutive outpatient hysteroscopies performed in self-referred women to assess the detection rate of uterine cancer and the validity of different selection criteria for hysteroscopy. Thirty cases of uterine cancer (29 endometrial, 1 carcinosarcoma) were detected. Abnormal uterine bleeding was the indication most commonly associated with cancer (26 of 30 cases, cancer detection rate = 2.1 %), whereas the presence of cervical polyps had no predictive value. Patients age was correlated to cancer detection rate, and the investigation of uterine cancer under the age of 45 was poorly cost effective. Hysteroscopy and endometrial biopsy, performed by Permacurette or Novak curette immediately after hysteroscopy, missed respectively 8 and 2 of 30 cancers. Hysteroscopy should be employed in combination with endometrial biopsy as a standard outpatient investigation whenever endometrial cancer is suspected. These procedures are safe and accurate and rule out more aggressive and costly procedures, such as dilatation and curettage, in most cases.

« 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.

Comparing two Modalities of Management of Women with Cytologic Evidence of Squamous Or Glandular Atypia: Early Repeat Cytology or Colposcopy

Early repeat cytology is recommended in most screening programs for cervical cancer in subjects with squamous or glandular abnormalities not amounting to neoplasia (atypical squamous cells of undetermined significance, ASCUS), but immediate colposcopy is also recommended in some countries, especially those where there is easy access to colposcopic facilities. We evaluated the cost-effectiveness of the two procedures in a prospective study of women with cytologic ASCUS, invited to cytocolposcopic assessment after 6 months. Colposcopy-directed biopsy was assumed as the gold standard, and the accuracy of colposcopy at 6 months was assumed to be equal to that of immediate colposcopy. Out of 874 compilers, punch biopsy was performed in 303 cases (34.7%), and 19 CIN2+ lesions were detected (CIN2 = 12, CIN3 = 6, microinvasive carcinoma = 1). Detecting 13 CIN2+ lesions at colposcopy required 874 colposcopies and 303 directed biopsies: the cost per CIN2+ lesion detected with the procedure was 2,749 US$. Detecting 15 CIN2+ lesions at repeat cytology required 874 cytologic examinations, 137 colposcopies, 64 directed biopsies, and 6 diagnostic large-loop resections, the latter being performed in subjects with high-grade squamous intraepithelial lesion and less severe lesions at punch biopsy: the cost per CIN2+ lesion detected with the procedure was 1,961 US$. The policy of repeat smear was more cost-effective than immediate colposcopy. According to such results, the protocol of the Florence screening program has been modified since October 1996.

Cytologic Screening for Cervical Cancer in the Florence District

During the years 1970–1978, 213,575 women living in the Florence District had at least one cytologic smear. The overall incidence ratios were: dysplasia 1.09 ±, carcinoma «in situ » 1.25 ±, invasive carcinoma 1.01 ±. Age of the women attending the service, and incidence ratios according to age groups are examined. Incidence ratios in women who had previous negative smears are calculated; these values seem to fit well with a «false negative model». These results are compared with those reported by other authors, and indications for a new kind of program are suggested.

Colposcopy as a Primary Screening test for Cervical Cancer

Aim and background

To evaluate the cost effectiveness of screening by colposcopy compared to conventional cytology.

Methods

A prospective study was performed in the Florence District screening center on 3,000 consecutive women, self referring, who were examined by cytology and colposcopy in a blind fashion. Further assessment was based on cytologic report or on colposcopy-directed punch biopsy. Actual costs of the whole screening process were known. The cost effectiveness of different possible simulated screening scenarios was then determined.

Results

Overall, 18 high-grade lesions (CIN3 = 9, CIN2 = 9) were detected. Four different screening scenarios were compared, namely a) cytology alone, b) cytology + repeat smear for ASCUS (atypical squamous cells of undeterminate significance) cases, c) colposcopy + cytology for cases of condyloma at punch biopsy, and d) colposcopy alone. Although they had a higher cost per examined woman (a) = 17.98, b) = 19.40, c) = 23.86, d)= 22.10 US$), scenarios c) and d) had a higher relative sensitivity (a = 44.4, b = 61.1, c = 100, d = 88.8%) and a lower cost per high-grade lesion detected (a = 6,743, b = 5,291, c = 3,977, d = 4,144 US$).

Conclusions

Screening by colposcopy is a feasible procedure which is more sensitive and more cost effective than conventional cytologic screening. At least in those settings where access to cytopathology may be difficult, screening by colposcopy should be considered as a possible alternative.

Contribution of Cytology, Colposcopy, Target Biopsy and Conization to the Early Diagnosis of Precancerous and Cancerous Lesions of the Cervix Uteri

The study is based on. 334 cytologic suspect or positive women observed in the area of Florence. Cytologic diagnoses of dysplasia, carcinoma in situ (CIS), and invasive carcinoma are related to the histologic reports. To the same histologic reports are related the colposcopic aspects. Lastly, diagnoses made by target biopsy are compared with the final diagnoses made by cone biopsy. The 3 diagnostic methods and their diagnostic accuracy are then compared. As regards dysplasia, the diagnostic precision of cytology is 40.2% and for target biopsy is 76.9%. In the diagnosis of CIS, cytology shows a diagnostic accuracy (77.7%) that is a little lower than that of target biopsy (81.7%). In invasive carcinoma, cytology has a good diagnostic precision (88.2%), which becomes 100% if the diagnosis is made by target biopsy. The correlation between colposcopic aspects and histologic reports is not very reliable. We conclude that cytology is a valid test in an extensive mass screening, that colposcopy is essential to execute target biopsy, and that the latter is useful in defining dysplasia and invasive carcinoma diagnoses. On the contrary, in the case of CIS, target biopsy does not greatly increase cytology diagnostic precision.

Morphological Changes in the Carotid Artery Intima after Gastric Bypass for Morbid Obesity

BACKGROUND

Carotid intima-media thickness (C-IMT) can be considered as an early marker of atherosclerosis, thus representing a reliable cardiovascular risk predictor. Bariatric surgery decreases the burden of cardiovascular disease in obese patients through complex mechanisms, of which weight loss is merely the most evident epiphenomenon. The aim of this study is to evaluate C-IMT variations in patients undergoing Roux-en-Y gastric bypass (RYGB) and possible correlations with biometric parameters and cardiovascular risk factors.

METHODS

Thirty patients undergoing RYGB for morbid obesity were enrolled for carotid artery B-mode ultrasound evaluation before surgery and at 1-, 3-, 6-, and 12-month follow-up; C-IMT was recorded at three levels (bulb, common, and internal carotid). At each one of the follow-ups, biometric and serohematic parameters were also collected.

RESULTS

The 22 patients who completed the follow-up and were included in the study showed significant C-IMT reduction at all three levels at 12-month follow-up (p < 0.001). Along with a significant BMI reduction and diabetes/hypertension remission, we found a considerable decrease in total cholesterol (219 vs 164 mg/dl; p < 0.001) and uric acid (5.6 vs 4.5 mg/dl; p < 0.01) and a significant increase in HDL cholesterol (43.9vs59.2 mg/dl; p < 0.001). The data imply that the mean 10-year cardiovascular risk score drops by nearly 50 % (5.7 ± 5.6 vs. 2.9 ± 2.7 %, p < 0.001) according to Framingham cardiovascular risk stratification.

CONCLUSIONS

RYGB is associated with significant decrease in C-IMT at 1 year. Pathophysiologic processes underlying such a variation, probably involving lipid and urate metabolism and their correlation with cardiovascular risk reduction should be confirmed by long-term prospective trials.

Laparoscopic subtotal gastrectomy for the treatment of advanced gastric cancer: a comparison with open procedure at the beginning of the learning curve

BACKGROUND

In the last decades, after some initial concern, laparoscopic subtotal gastrectomy (LSG) is gaining popularity also for the treatment of advanced gastric cancer (AGC). The aim of this study is to compare a single surgeon initial experience on LSG and open subtotal gastrectomy in terms of surgical safety and radicality, postoperative recovery and midterm oncological outcomes.

METHODS

a case control study was conducted matching the first 13 LSG for AGC with 13 open procedures performed by the same surgeon. Operative and pathological data, postoperative parameters and midterm oncological outcomes were analyzed.

RESULTS

There was no significant difference in mortality (0%) and morbidity, while the laparoscopic approach allowed lower analgesic consumption and faster bowel movement recovery. Operation time was significantly higher in LSG patients (301.5 vs 232 min, p: 0.023), with an evident learning curve effect. Both groups had a high rate of adequate lymph node harvest, but the number was significantly higher in LSG group (p: 0.033). No significant difference in survival was registered. Multivariate analysis identified age at diagnosis, diffuse-type tumor, pN and LODDS as independent predictors of worse prognosis.

CONCLUSIONS

LSG can be safely performed for the treatment of AGC, allowing faster postoperative recovery.

Surgical treatment of multiple sporadic colorectal carcinoma

Aim: Many aspects of the surgical management of multiple sporadic colorectal cancer syndrome, either synchronous and metachronous, remain to be cleared, in particular the prognostic influence of the extent of surgical resection. Method: A retrospective review was performed of patients diagnosed with multiple colorectal cancer from 1982 to May 2010. Clinical and pathologic data were collected and reviewed. Survival analysis was performed. Results: We identified 23 patients with multiple sporadic colorectal cancers, of which 8 had synchronous (SC) and 15 metachronous cancers (MC). Of the MC patients, 2 (13%) had the second cancer within 2 years, 4 (27%) in the time period of 2-5 years and 9 (60%) after 5 years. Twenty-one patients underwent multiple segmental resections; 2 patients underwent subtotal colectomy. The 5-year overall survival rate of SC and MC patients was 100% and 87% (p<0.001) respectively. The 5-year overall survival rate of multiple segmental resection patients and subtotal colectomy was 94% and 75% (p=0.655) respectively. Conclusion: Either synchronous and metachronous MSCRC patients showed good prognosis independently from to the extent of resection. Our results support a less aggressive biological behaviour allowing a more conservative management. Multiple segmental colorectal resections seem appropriate from an oncologic point of view in MSCRC patients. (www.actabiomedica.it)

Abstract P2-09-12: A single-blind, randomized, placebo-controlled phase II study to evaluate the impact of oral ibandronate on bone mineral density in osteopenic breast cancer patients receiving adjuvant aromatase inhibitors: Final results of the single-center BONADIUV trial

Background. Several randomized trials demonstrated aromatase inhibitors (AI) superiority in terms of disease-free survival compared to tamoxifen treatment for postmenopausal hormone receptor-positive breast cancer (BC) patients. Anyway AI toxicity profile due to estrogen suppression is a concern. Pivotal trials demonstrated a significant bone mineral density (BMD) loss due to AI, with a consistent risk of fractures, thus impacting on patients' quality of life.

Bisphosphonates represent an effective treatment in postmenopausal osteoporosis fractures prevention. Several studies demonstrated that upfront bisphosphonates therapy prevents bone loss in postmenopausal women receiving adjuvant AI for early-stage BC. However an adequate patients selection for adjuvant bisphosphonates treatment during AI endocrine therapy is still a challenge.

We present the final results of the BONADIUV trial, a single-blind, randomized, placebo-controlled phase 2 study designed to evaluate the impact of ibandronate treatment on BMD in osteopenic women taking AI.

Methods. Between January 2011 and May 2014, 561 patients underwent a baseline BMD assessment before starting AI as planned adjuvant treatment. Overall 171 osteopenic patients (lumbar spine [LS] and/or trochanter -1&lt; T-score &lt;-2.5), were randomized in a 1:1 ratio to receive either placebo or oral monthly ibandronate (150 mg). All patients receive oral supplementation of calcium and vitamin D3. Study duration was 2 years. Exclusion criteria were: premenopausal status at time of randomization; comorbidities with increased risk of osteoporosis; body mass index &lt;18; chronic use of steroids; previous use of bisphosphonates; psychiatric disorders. Primary endpoint was the mean BMD difference between the two arms at a 2-year follow up. ClinicalTrials.gov identifier: NCT02616744. A total of 72 patients per arm of treatment were needed to obtain an 85% statistical power in order to detect a 2% BMD mean difference between the two arms. Considering a 10% dropout, at least 158 patients were required.

Results. A total of 171 patients were randomized in the study. Overall 27 patients (15.8%) withdrew the protocol (17 ibandronate vs 10 placebo arm): the final analysis was performed on 144 patients (72 patients per arm). P-value from Wilcoxon test showed no significant difference between arms at baseline both for LS (p=0.94) and trochanter (p=0.83).

At 2-year, osteopenic patients treated with ibandronate gained +18.7% and +15.5% at the LS and trochanter BMD, respectively. Patients treated with placebo lost -13.3% at the LS, and gained +2.9% at the trochanter.

Trochanter p-value from covariance analysis showed a mean BMD change significantly in favor of ibandronate arm at 1-year (p=0.012), and borderline at 2-year (p=0.087). Concerning LS, the mean BMD change was significantly in favor of ibandronate arm both at 1-year (p=0.002) and 2-year (p&lt;0.0001).

Conclusions. Final results of our study showed that treatment with ibandronate, as compared to placebo, improved BMD change in osteopenic women treated with adjuvant AI, and consistently protected patients' bone loss.

Citation Format: Livi L, Saieva C, Desideri I, Scotti V, De Luca Cardillo C, Carta G, Cecchini S, Orzalesi L, Sanchez LJ, Casella D, Bernini M, Nori J, Bianchi S, De Feo ML, Meattini I. A single-blind, randomized, placebo-controlled phase II study to evaluate the impact of oral ibandronate on bone mineral density in osteopenic breast cancer patients receiving adjuvant aromatase inhibitors: Final results of the single-center BONADIUV trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-09-12.

Search for Magnetic Monopoles with the MoEDAL Forward Trapping Detector in 13 TeV Proton-Proton Collisions at the LHC

MoEDAL is designed to identify new physics in the form of long-lived highly ionizing particles produced in high-energy LHC collisions. Its arrays of plastic nuclear-track detectors and aluminium trapping volumes provide two independent passive detection techniques. We present here the results of a first search for magnetic monopole production in 13 TeV proton-proton collisions using the trapping technique, extending a previous publication with 8 TeV data during LHC Run 1. A total of 222 kg of MoEDAL trapping detector samples was exposed in the forward region and analyzed by searching for induced persistent currents after passage through a superconducting magnetometer. Magnetic charges exceeding half the Dirac charge are excluded in all samples and limits are placed for the first time on the production of magnetic monopoles in 13 TeV pp collisions. The search probes mass ranges previously inaccessible to collider experiments for up to five times the Dirac charge.

Laparoscopic subtotal gastrectomy for the treatment of advanced gastric cancer: a comparison with open procedure at the beginning of the learning curve

BACKGROUND

In the last decades, after some initial concern, laparoscopic subtotal gastrectomy (LSG) is gaining popularity also for the treatment of advanced gastric cancer (AGC). The aim of this study is to compare a single surgeon initial experience on LSG and open subtotal gastrectomy in terms of surgical safety and radicality, postoperative recovery and midterm oncological outcomes.

METHODS

a case control study was conducted matching the first 13 LSG for AGC with 13 open procedures performed by the same surgeon. Operative and pathological data, postoperative parameters and midterm oncological outcomes were analyzed.

RESULTS

There was no significant difference in mortality (0%) and morbidity, while the laparoscopic approach allowed lower analgesic consumption and faster bowel movement recovery. Operation time was significantly higher in LSG patients (301.5 vs 232 min, p: 0.023), with an evident learning curve effect. Both groups had a high rate of adequate lymph node harvest, but the number was significantly higher in LSG group (p: 0.033). No significant difference in survival was registered. Multivariate analysis identified age at diagnosis, diffuse-type tumor, pN and LODDS as independent predictors of worse prognosis.

CONCLUSIONS

LSG can be safely performed for the treatment of AGC, allowing faster postoperative recovery.

Kinetic activity, membrane mitochondrial potential, lipid peroxidation, intracellular pH and calcium of frozen/thawed bovine spermatozoa treated with metabolic enhancers

Owing to the progressive decline of sperm motility during storage there is a need to find substances capable of enhancing sperm energy metabolism and motility and/or preserving it from oxidative damage. The aim of this study was to evaluate in frozen/thawed bovine spermatozoa the effect of several compounds, such as myo-inositol, pentoxifylline, penicillamine + hypotaurine + epinephrine mixture (PHE), caffeine and coenzyme Q10+ zinc + d-aspartate mixture (CZA), on either kinetic or metabolic parameters. Sperm kinetics was evaluated by Sperm Class Analyser whereas specific fluorochromes were used to evaluated mitochondrial membrane potential (MMP), intracellular pH, intracellular calcium concentration and lipid peroxidation. Lipid peroxidation was also evaluated by TBARS analysis. Treatments significantly affected total and progressive motility with different dynamics in relation to the incubation time. After the first hour of incubation, CZA treatment produced the best performance in total and progressive sperm motility as well as in curvilinear velocity, average path velocity and amplitude of head displacement, whereas pentoxifylline stimulated the highest straight-line velocity. MMP showed higher values (p < 0.01) after treatment with pentoxifylline and PHE. Intracytoplasmic calcium concentration and lipid peroxidation were significantly (p < 0.05) affected by the incubation time rather than the treatments. Intracellular pH varied significantly (p < 0.01) in relation to either the incubation time or treatments. In particular, it showed a progressive increase throughout incubation with values in control group significantly higher than in myo-inositol, PHE, caffeine, pentoxifylline and CZA groups (7.37 ± 0.03 vs. 7.29 ± 0.03, 7.28 ± 0.03, 7.26 ± 0.03, 7.22 ± 0.03 and 7.00 ± 0.03, respectively; p < 0.01).; however, among treatments, CZA displayed the lowest values. Significant correlations were found between sperm kinetic and metabolic parameters. These findings provide new comparative information on the effects of putative metabolic enhancers on kinetics and metabolic activities of bovine spermatozoa. In this study, a rapid methodological approach for evaluating sperm quality is proposed.

Delayed onset infections after lower third molar germectomy could be related to the space distal to the second molar

The onset of delayed infection after lower third molar germectomy is influenced by the amount of distal space. This retrospective study aimed to determine whether the incidence of delayed onset infection is related to the space distal to the second molar. The ratio between the distal space and the crown width, measured according to the Ganss protocol on panoramic radiographs, was obtained for 218 surgical germectomies performed for orthodontic reasons in 134 patients. A delayed onset infection occurred following 20 germectomies at between 2 and 8 weeks after surgery; purulent exudates from the alveolus and swelling were present. In 16 of the 20 cases of infection, a Ganss ratio of <0.5 showed the almost complete absence of space distal to the second molar. This study found that the distal space was significantly and inversely correlated with delayed onset infection (P=0.004). From a clinical point of view, it is important for the surgeon to be aware that a higher Ganss ratio may indicate that a delayed onset infection is less likely to occur and that a lower Ganss ratio could indicate a greater likelihood of this type of infection, so that the patient can be properly informed.

Prognostic assessment of gastric cancer: retrospective analysis of two decades

BACKGROUND

Gastric cancer mortality rates have remained relatively unchanged over the past decades, in spite of progressive decrease in incidence. Nodal status represents a key factor for prognostic assessment, allowing a tailored-made adjuvant therapy for the patients. The aim of this study is to evaluate the prognostic influence of different nodal involvement indicators on the overall survival in a large series of patients submitted to gastrectomy at our Institution.

METHODS

we retrospectively collected data from 634 newly diagnosed patients with gastric cancer who underwent curative gastrectomy, with D1/D2 lymphadenectomy during the last 20 years. Prognostic values of age, histologic type, pN, nodal ratio (LNR) and log odds of positive lymph nodes (LODDS) of were analyzed.

RESULTS

The median overall survival was 40.2 +/-31 months. Multivariate analysis identified age at diagnosis, diffuse-type tumor, pN and LODDS as independent predictors of worse prognosis. Scatter plots of relationships between LODDS and LNR showed that LODDS seems to better assesses prognosis for patients at LNR stage 0 or 1.

CONCLUSIONS

Nodal involvement confirmed to be a strong indicator of prognosis. LODDS demonstrated a theoretical advantage over pN and LNR system allowing more accurate patients stratification, but our results have to be confirmed by further trials.

Cyst of the gastric wall arising from heterotopic pancreas: report of a case

Heterotopia of pancreatic tissue is a common developmental anomaly, affecting predominantly the gastrointestinal tract. The case of a symptomatic cyst arising from the posterior gastric wall in a 40-year-old man is presented, undergoing laparoscopic gastric wedge resection. Pathology report described a cyst of the gastric wall lined by ductal pancreatic epithelium.