Practice parameters for the diagnosis and treatment of anal intraepithelial neoplasia (AIN) on behalf of the Italian Society of Colorectal Surgery (SICCR).

Squamous cell carcinoma (SCC) of the anus is a human papilloma virus (HPV) related malignancy that is preceded by anal intraepithelial neoplasia (AIN) making this cancer, at least theoretically, a preventable disease. In the past 10 years the diagnosis, management and nomenclature of AIN has dramatically changed. Increased life expectancy in human immunodeficiency virus (HIV) positive patients due to highly active antiretroviral therapy (HAART) has caused an increase in the incidence of SCC of the anus. While many experts recommend screening and treatment of anal high-grade squamous intraepithelial lesion (HSIL), there is no consensus on the optimal management these lesions. Therefore, there is a need to review the current evidence on diagnosis and treatment of AIN and formulate recommendations to guide management. Surgeons who are members of the Italian Society of Colorectal Surgery (SICCR) with a recognized interest in AIN were invited to contribute on various topics after a comprehensive literature search. Levels of evidence were classified using the Oxford Centre for Evidence-based Medicine of 2009 and the strength of recommendation was graded according to the United States (US) preventive services task force. These recommendations are among the few entirely dedicated only to the precursors of SCC of the anus and provide an evidence-based summary of the current knowledge about the management of AIN that will serve as a reference for clinicians involved in the treatment of patients at risk for anal cancer.

Short-term additional enfuvirtide therapy is associated with a greater immunological recovery in HIV very late presenters: a controlled pilot study.

OBJECTIVES: To evaluate whether the addition of enfuvirtide to standard highly active antiretroviral therapy (HAART) could confer immunovirological benefits in human immunodeficiency virus (HIV)-infected very late presenters. The current study is an open comparative therapeutic trial of standard protease inhibitor (PI)-based HAART ± additional enfuvirtide in treatment-naïve deeply immunologically impaired HIV-positive patients. METHODS: Very late presenters (CD4 <50/mm(3)), without tuberculosis and neoplasms, were alternatively allocated to two nucleoside reverse transcriptase inhibitors (NRTIs) and lopinavir/ritonavir without (control arm, CO) or with (ENF arm) enfuvirtide 90 mg bid. Enfuvirtide was administered until the achievement of viral load <50 copies/ml and for at least 24 weeks. The primary objective was the magnitude of CD4+ cell recovery at 6 months. HIV RNA was intensively monitored in the first month, and, thereafter, monthly, as for CD4+ cell count and percentage, clinical data, and plasma drug concentrations. RESULTS: Of 22 enrolled patients (11 per arm), 19 completed the study (10 in the ENF arm). Baseline CD4+ cell counts and % were comparable, with 20 CD4+/mm(3) (12-37) and a percentage of 3.3 (1.7-7.1) in the ENF arm, and 16 CD4+/mm(3) (9-29) and a percentage of 3.1 (2.3-3.8) in the CO arm, respectively. The baseline viral load was also comparable between the two arms, with 5.77 log10 (5.42-6) and 5.39 log10 (5.06-6) in the ENF and CO arms, respectively. Enfuvirtide recipients had higher CD4+ percentage at week 8 (7.6 vs. 3.6%, p = 0.02) and at week 24 (10.7 vs. 5.9%, p = 0.02), and a greater CD4+ increase at week 24 (207 vs. 134 cells/mm(3), p = 0.04), with 70% of enfuvirtide intakers versus 12.5% of controls who achieved a CD4+ cell count >200/mm(3) (p = 0.01). At 48 weeks, patients in the ENF arm had CD4+ cell counts higher than controls (251 vs. 153cells/mm(3), p = 0.04) and were also found to be faster in reaching a CD4 cell count over 200/mm(3): 18 (8-24) versus 48 (36-108) weeks (p = 0.01). Viral load decay at week 4 was greater in the ENF arm (-3 vs. -2.2 log, p = 0.04), while the proportion of patients with viral load <50 copies/ml at week 24 was comparable. CONCLUSIONS: In this pilot study, the addition of enfuvirtide to a lopinavir-based HAART was shown to be associated with a significantly faster and greater immunological recovery in newly discovered HIV-positive patients with very low CD4+ cell counts. Induction strategies using an enfuvirtide-based approach in such subjects warrant further investigation.

Immunostimulation to reduce recurrence after surgery for anal condyloma acuminata: a prospective randomized controlled trial.

AIM: Human papillomavirus is the most common cause of sexually transmitted disease. It is associated with immunosuppression and shows a marked tendency to recur. We investigated a natural immunostimulant aimed to reduce recurrence. METHOD: A randomized controlled study was carried out including 261 patients allocated to surgical excision alone (control group; n = 122) and surgical excision plus postoperative immunostimulation for 30 days with a natural product (STET; study group; n = 139). Patients with HIV positivity were excluded. All patients gave fully informed consent. RESULTS: The patients were followed for 6 months after surgery. Recurrence occurred in 7.2% (10/139) in the study group and in 27.1% (33/122) in the control group (P < 0.0001). There were no significant differences in the sex, sexual orientation, number of lesions, time to diagnosis and treatment or localization of lesions in the two groups. CONCLUSIONS: Immunostimulation using a natural product significantly reduced the incidence of recurrence of anal condylomata in patients undergoing surgical excision.

Performance and costs of a rapid syphilis test in an urban population at high risk for sexually transmitted infections.

INTRODUCTION: Rapid syphilis screening could facilitate case-identification in populations at high risk for sexually transmitted infections (STI). The aim of this study was to compare the performance and the cost-effectiveness of a rapid immunochromatography syphilis test with a traditional ELISA screening test in patients with suspected infectious syphilis or patients at high risk for STI/syphilis. METHODS: Consecutive patients attending a STI clinic cosensually underwent serological testing with two different tests. Sensitivity, specficity, Positive Predictive Values, Negative Predictive Values and effectiveness of the two tests were evaluated with respect to definitive diagnosis. RESULTS: In our population, the immunochromatography essay (Abbott Determine Syphilis TP) had a sensitivity of 95.0% (95% CI 88.7-97.8) and a specificity of 97.7% (95% CI 94.7-99.0). The ELISA test had a sensitivity of 95.0% (95% CI 88.8-97.9) and a specificity of 97.2% (95% CI 94.1-98.7). The Positive Predictive Value for ELISA was 94.1% (95% CI 87.6-97.3) and 95.0% (95% CI 88.7-97.8) for the rapid test. The Negative Predictive Value was 97.7% (95% CI 94.7-99) for both ELISA and the rapid tests. The cost-effectiveness analysis showed that the rapid test was less expensive than ELISA (EUR 26.46 vs EUR 40.57) and yielded a similar number of right diagnoses. CONCLUSIONS: The Abbott Determine Syphilis TP test is an accurate, easy and inexpensive test that could facilitate the rapid detection of syphilis in high-risk urban patients.

Culture proven Legionella pneumophila pneumonia in a HIV-infected patient: case report and review.

We report the first culture proven case of Legionella pneumonia in a HIV-positive patient in Italy. The laboratory diagnosis was obtained by isolation of Legionella pneumophila serogroup 1, serology, urinary antigen detection and PCR. Culture first allowed diagnosis of the infection, that probably would have been unrecognized. Since Legionellosis in HIV-positive patients with respiratory symptoms is rare and difficult to confirm, we strongly suggest that all available laboratory tests, and particularly culture, should be performed. A review of literature on culture proven cases is also provided.

[HHV-8 infection. Update on pathogenesis and epidemiology]. / Infezione da HHV-8. Attualità su patogenesi ed epidemiologia.

HHV-8 (Human Herpesvirus 8) is a human lymphotropic and transforming virus closely associated to the development of Kaposis's sarcoma, Castleman's disease and Primary Effusion Lymphoma among immunosuppressed patients. Prevalence of infection varies according to different geographic area and to ethnic group or to risk factors. No effective treatments are available at present.

The Karpas AIDS Cell Test compared with an enzyme-linked immunosorbent assay for detecting antibody to the human immunodeficiency viruses (HIV-I and HIV-2).

We have compared the Karpas AIDS Cell Test for antibodies to the human immunodeficiency viruses (HIV) with a commercial enzyme-linked immunosorbent assay (ELISA) (Organon Teknika) by testing serum samples from 324 intravenous drug abusers in Turin. The cell test was found to be more sensitive and as specific as the ELISA with the serum samples from the drug abusers. In Lisbon, 30 samples were tested on slides containing cells infected with HIV-1 and/or HIV-2. All 15 samples, which were positive for HIV-2 alone (in the HIV-2 Elavia test and by the Western blotting technique), were also positive in the Karpas AIDS test. In contrast, only one of the 15 samples (7%) gave a positive reading in the ELISA for HIV-1. Results of 30 samples tested in Turin and Lisbon by the Western blotting technique agreed closely with those obtained with the Karpas AIDS Cell Test. We were also able to show that the entire test can be performed at room temperature and completed within 1 hour. Moreover, the cell test requires minimal skill and simple equipment and is inexpensive. It also includes non-infected cells as a control and the specificity of positive samples may be verified with a bench microscope. Furthermore, this test which detects antibodies to both HIV-1 and HIV-2 allows rapid typing of the infecting strain.