Use of a high-risk human papillomavirus DNA test as the primary test in a cervical cancer screening programme: a population-based cohort study.

OBJECTIVE: To present the results of the first 2 years of a human papillomavirus (HPV) test-based screening programme outside the research context. DESIGN: Population-based cohort study. SETTING: A cervical service screening programme in Italy. POPULATION: Women aged 25-64 years invited to screening from April 2009 to April 2011. METHODS: Eligible women were invited to undergo an HPV test: those with a negative HPV test went on to the next screening episode; those with a positive HPV went on to triage with a Pap smear. Women with positive cytology (i.e. positive for atypical squamous cells of undetermined significance or worse, ASC-US+) were referred to colposcopy, whereas those with negative cytology were referred to repeat HPV testing 1 year later. MAIN OUTCOME MEASURES: Participation rate, positivity at HPV and at triage, referral rate to colposcopy, positive predictive value for cervical intraepithelial neoplasia grade 2+ (CIN2+) at colposcopy, and detection rate for CIN2+. RESULTS: Participation increased compared with the previous Pap programme (60.6 versus 43.9%). The HPV positivity rate was 7.0; 39.6% of Pap smears were scored as positive, and therefore 2.8% of the women screened were referred for immediate colposcopy. The compliance of women who scored positive for HPV and negative for Pap for repeat HPV testing at 12 months was 78.6%, and the HPV positivity rate was 56.6%. The overall referral rate to colposcopy was 4.6%. The overall detection rate for CIN2+ was 4.5 versus 1.5% of the Pap programme (25-34 years, 8.2%; 35+ years, 3.6%). CONCLUSIONS: Compared with the traditional Pap test, the HPV programme recorded a higher response to invitation and an increased DR for CIN2+. The most critical aspects were the reading of cytology in women that were positive for HPV and the increased workload at colposcopy.

Abnormal platelet trace amine profiles in migraine with and without aura.

Trace amines, including tyramine, octopamine and synephrine, are closely related to classic biogenic amines. In one study, where these substances were found elevated in plasma of migraineurs, it was hypothesized that trace amine metabolism is deranged in migraine. To confirm these findings, we studied, using a multichannel electrochemical high-performance liquid chromatography system, the concentrations of trace amines in platelets of migraine without aura (MoA) and migraine with aura (MA) patients in headache-free period, compared with controls. Platelet concentrations of trace amines, although elevated in both migraine types, showed a different profile in MoA and MA. Octopamine was significantly higher in MoA sufferers (0.69 +/- 0.43 ng/10(8) platelets) compared with both control subjects (0.22 +/- 0.16 ng/10(8) platelets) and MA patients (0.39 +/- 0.37 ng/10(8) platelets). Synephrine was significantly higher in MA patients (0.72 +/- 0.44 ng/10(8) platelets) with respect to both controls (0.33 +/- 0.25 ng/10(8) platelets) and MoA sufferers (0.37 +/- 0.29 ng/10(8) platelets). These results strengthen the hypothesis that tyrosine metabolism is deranged in migraine and may participate in its pathophysiology.

[Two cases of small bowel ischemia due to unusual cause]. / Ischemia intestinale da cause inusuali. Presentazione di due casi.

The authors report 2 cases of small bowel ischemia due to unusual cause. In both cases, vasculopathy was the cause of ischemia, but with a different etiology. In the first case, a mesenteric inflammatory veno-occlusive disease, with striking features of extensive phlebitis and venulitis affecting the veins of the small intestine and mesentery, without arterial involvement of this district was observed and histological examination showed inflammatory lymphocytic infiltrates and myointimal hyperplasia of the veins. The second case affected by intestinal ischemia from secondary and multiple cholesterol embolism, the histological examination showed inflammatory infiltrates with (lymphocytes and granulocytes) in the vessels of submucosal mesenteric area, by loose intimal fibrosis incorporating cholesterol clefts. Both patients required surgical exploration with resection of ischemic bowel. In the second case laparoscopy was the initial approach which allowed to identify the extension of ischemia with special regard to the perforation. The ultimate diagnosis is possible only with histological examination. Clinically, patients show the general signs of intestinal ischemia with pain, vomiting and bloody diarrhea. Prognosis depends on the extension of the lesions and the early surgical treatment.

[Thoracic lymphadenopathy due to vascular transformation of lymph node sinuses associated with upper limb edema in a chronic hemodialysis patient with congestive heart failure]. / Linfoadenopatia toracica da trasformazione vascolare dei seni linfonodali associata con edema dell'arto superiore in un paziente in emodialisi con insufficienza cardiaca congestizia.

BACKGROUND: Vascular transformation of lymph node sinuses (VTLS) is a rare disorder characterized by transformation of lymph node sinuses into endothelium-lined capillary-like channels. This phenomenon was originally discovered by accident whilst examining regional lymph nodes draining cancer. However, it has been found in association with other conditions associated with lympho venous congestion and distension, such as congestive heart failure (CHF) or even lymphoadenopathy alone. CASE REPORT: We describe the clinical case of a male dialysis patient with CHF (secondary to ischemic-hypertensive cardiac failure) who developed gross edema of the upper left limb on the arteriovenous fistula (AVF) side. Edema appeared within a month after carotid endoarteriectomy following approximately twenty years of chronic hemodialysis. Doppler ultrasound with other investigations showed that subclavian and upper cava veins were patent, but revealed many enlarged lymph nodes in the upper left thorax and in the left axilla. Suspicion of lymphoproliferative disease or metastatic involvement was raised and a lymph node biopsy was performed, revealing VTLS. Bone marrow biopsy and abdominal tomographies showed no mass or a proliferative disorder. Based on a hypothesis of an association between upper limb edema and ipsilateral AVF, the AVF was tied. The upper limb edema decreased dramatically within weeks, whilst RRT was continued by means of a central venous catheter. However, a few months later the patient's condition worsened; he developed relapsing pleural effusions and eventually died. Post-mortem examination revealed severe ischemic-calcific cardiopathy and showed that major thoracic and brachial vessels were patent whilst most thoracic and hilar lymph nodes showed VTLS and fibrosis. CONCLUSIONS: We believe that in our patient CHF was the primary cause of thoracic adenomegaly and that CHF, together with venous hypertension at the left fistula's arm, caused ipsilateral limb edema. Thus, adenomegaly due to VTLS could represent an accompanying feature even in upper limb edema in chronic hemodialysis patients. To our knowledge, this is the first report of such an association. In our patient months were "lost" because we thought that limb edema was secondary to the adenomegaly. It is important that clinicians working in dialysis units are aware that when upper limb edema is present, adenomegaly might just be an accompanying symptom, especially in case of concomitant diagnosis of CHF.

Alpha-fetoprotein production by pancreatic tumors exhibiting acinar cell differentiation: study of five cases, one arising in a mediastinal teratoma.

Five cases of pancreatic neoplasms accompanied by production of alpha-fetoprotein (AFP) and serum elevation of this marker are presented, and the better-documented cases of this phenomenon from the literature are reviewed. Four of the cases originated in the orthotopic pancreas, whereas the fifth arose in the pancreatic component of a mediastinal teratoma. The patients were children or young adults. AFP production in pancreatic tumors is closely linked to acinar differentiation, most cases representing either pancreatoblastoma or acinar cell carcinoma. The distinction between these 2 tumors may be difficult because of the many morphologic and immunohistochemical features they share.

[Primitive malignant melanoma of the base of the tongue]. / Melanoma maligno primitivo della base lingua.

Although the incidence of malignant cutaneous melanoma has doubled each decade since the early 1960s, the mucous counterpart is still rare, representing 1.4% of all melanomas in caucasian patients. In the oral cavity this incidence is even higher, ranging from 0.2% to 8.0% of all melanomas. However, it is unusual for the primary location to be in the tongue and only 25 such cases have been reported in the literature. In 1974, Conley, reviewing 52 melanomas of the mucous membranes of the head and neck, observed that "it is curious that no melanomas occurred in the tongue". The prognosis for mucosal melanomas is clearly worse than for cutaneous melanoma, with most authors reporting a 5-year survival rate of 10-25%. It is not clear whether mucosal melanomas are biologically more aggressive than their cutaneous counterparts or if prognosis is simply related to the fact that they are normally more advanced at the time of diagnosis. In fact, it is clear that the etiologic and pathogenetic basis for the origin of mucosal melanomas, as well as of their treatment and prognosis, is not understood nearly as well as that of cutaneous melanomas. Historically, cutaneous melanoma has been characterized as radio-resistant, although recent observations regarding the radiobiological and clinical responses have prompted investigators to re-evaluate the role of radiotherapy in localized mucosal melanoma. The authors report a primary malignant melanoma of the tongue base, heavily pigmented, rather bulky and nodular, approximately 0.4 cm in size, very similar to one of the varices usually encountered in this portion of the tongue. The patient came to the authors' observation complaining of peripheral vertigo. The melanoma was suspected due to a pulmonary metastasis observed in a routine chest X-ray and after a thorough search for the possible primary neoplasm. Because of widespread metastases, the patient was not treated with radio or chemotherapy and died 8 weeks after surgical ablation of the primary lesion. As observed by Batsakis, at least 25% of mucosal melanomas are clinically identical to innocent lesions. For this reason, the authors stress the importance of taking into consideration the possibility of mucosal melanoma in the differential diagnosis of head and neck neoplasms and of being suspicious of lesions which appear clinically insignificant.

[Metastasis in the frontal sinus from a clear cell renal carcinoma: description of a case and literature review]. / Metástasis en el seno frontal de carcinoma renal de células claras: descripción de un caso y revisión de la literatura.

The present paper reports a case of metastasis of renal adenocarcinoma in the frontal sinus in absence of symptoms related to the primary localization. The patient's advanced age and the extent of the tumor contraindicated any treatment and the decrease occurred six months after the diagnosis was reached. The authors point out that before an expansive lesion of nasal cavity and paranasal sinuses whose cytological examination is negative for squamous carcinoma, a metastasis from a renal or genito-urinary carcinoma should be suspected.