Colorectal cancer screening in LHU4 Chiavarese, Italy: ethical, methodological and outcome evaluations at the end of the first round.

UNLABELLED: INTRODUCTION. The screening programmes are very challenging from the ethical perspective, and their impact in terms of morbidity and mortality make secondary colorectal cancer prevention a valuable public health intervention. METHODS: The target population people aged 50-69 years receive an invitation card with a test-tube for the fecal occult blood test (FOBT) and an immunochemical test is used for fecal occult blood. Subjects positive to FOBT are invited to perform a gastroenterologic examination and a full colonoscopy. RESULTS: In the firt round of screening, 100% of the target population has been invited with an adhesion rate of 41.3%. A total of 1739 FOBT-positive subjects have been invited to the second level of the screening. 1429 of them have performed the gastroenterologic examination (83.9%). To date 956 full colonoscopies have been completed and the rate of subjects affected by carcinoma, malignant polyp and advanced adenoma has been equal to 23.5%. DISCUSSION: Thanks to the reminders already sent, an increasing compliance has been registered with an increased rate of subjects with a low schooling that have performed a FOBT test. With the aim to optimize all the operative aspects of the screening programme it is already ongoing a set of meetings between health workers of Local Health Unit 4 and General Practioners.

Torsión anexial y embarazo: resolución laparoscópica mínimamente invasiva, con entrada bajo visión directa / Adnexal cyst and pregnancy: laparoscopic management

Las masas anexiales durante el embarazo son de baja frecuencia, sin embargo tienen una alta probabilidad de complicarse, produciéndose torsión hasta en un 25 por ciento de ellas. Ante la necesidad de una resolución quirúrgica, debemos tener en cuanta los riesgos de desencadenar una pérdida fetal, como resultado de una cirugía muy invasiva. Gracias a los avances tecnológicos, el mayor conocimiento y manejo de anestesia durante el embarazo, la laparoscopia debería constituir la mejor vía para realizar estas cirugías. De esta forma, se aplican todos los principios de mínima invasión, facilitando un menor daño y rápida recuperación, con poca probabilidad de afectar el embarazo. Presentamos un caso de quiste anexial complicado con torsión, durante el segundo trimestre del embarazo, resuelto por medio de cirugía laparoscópica, con entrada bajo visión directa con cámara, para reducir la posibilidad de daño uterino.

The adnexal masses during pregnancy are of low frequency; nevertheless they have a high probability of complication. The torsion can be observed in a 25 percent of them. When they need surgery, we must be aware of the risks and morbidity imposed to the fetus and the patient. The technological advance and best knowledge of fetal physiology and hemodynamics plus anesthesia during the pregnancy, allow that laparoscopy constitutes the best via to perform this surgery. By the way, all principles of minor invasion are applied, with short hospital stay and lesser morbidity affecting the pregnancy. We present a case of a complicated adnexal cyst, with torsion, during the second trimester of the pregnancy. A laparoscopic surgery was performed, with entrance under direct camera vision, to reduce uterine damage.

Transfusión feto-fetal: resultado perinatal exitoso con cirugía endoscópica láser / Twin-twin transfusion: successful perinatal result with endoscopic laser surgery

Se presenta el caso de un embarazo gemelar monocorial-biamniótico complicado con transfusión feto-fetal que fue tratado exitosamente con cirugía endoscópica láser a las 21 semanas de gestación. Mediante esta técnica fue posible identificar y cauterizar las anastomosis arterio-venosas causantes de la enfermedad, permitiendo que el embarazo progresara hasta las 32 semanas, fecha en la cual se realizó operación cesárea debido a detención del crecimiento del feto donante. Ambos fetos sobrevivieron sin secuelas y con mínimo soporte neonatal.

[Hemorrhagic complications of oral anticoagulant therapy: results of a prospective multicenter study ISCOAT (Italian Study on Complications of Oral Anticoagulant Therapy)]. / Complicanze emorragiche della terapia anticoagulante orale: risultati dello studio prospettico multicentrico ISCOAT (Italian Study on Complications of Oral Anticoagulant Therapy).

BACKGROUND: To assess the incidence of bleeding complications during oral anticoagulant therapy (OAT) in a population of patients representative of daily practice in Italian anticoagulation clinics. DESIGN: prospective, inception-cohort, multicentre. SETTING: Thirty-four anticoagulation clinics federated in the Italian Federation of Anticoagulation Clinics. PATIENTS: 2745 consecutive patients, included from beginning of their first OAT course. Most patients were aged between 60 and 79 y (57.8%), with 8% being > or = 80 y. Venous thromboembolism was the most frequent indication for OAT (one third of all the patients), followed by non ischemic heart disease which mainly included atrial fibrillation (16.8% of patients). Warfarin (in 63.8% of patients) and acenocoumarol were the only anticoagulant drugs used. The targeted anticoagulation intensity was low (INR < or = 2.8) in 71% of patients and high (INR > 2.8) in the remainder. OUTCOMES: Fatal, major and minor bleeding events. Thrombotic events were also recorded, though not analyzed in the present report. FINDINGS: During the 2011 patient-years (pt-y) of follow-up, 153 bleeding complications (7.6% pt-y) were recorded--5 fatal (all cerebral haemorrhages, 0.25% pt-y), 23 major (1.1% pt-y) and 125 minor (6.2% pt-y). The rate of events did not vary according to sex, coumarin type, size of enrolling centre or targeted therapeutic range; it was higher in older patients (10.5% pt-y in those aged > or = 70 y, relative risk--RR--1.75, p < 0.001), in cases where indication for anti-coagulant treatment was peripheral and/or cerebrovascular disease (12.5% pt-y; RR 1.80, p < 0.01) and during the first 90 days of treatment (11% pt-y, RR 1.75, p < 0.001). One fifth of bleeding events occurred at a very low anticoagulation intensity (INR < 2; the category rate being 7.7% pt-y); the rate was 4.8% pt-y in the 2.0-2.9 INR category, reaching 9.5% pt-y, 40.5% pt-y and 200% pt-y in the 3-4.4, 4.5-6.9 and > or = 7 INR categories respectively (RR for INR levels > 4.5 = 7.91, p < 0.0001). CONCLUSIONS: The overall rate of bleeding events recorded in the present study was much lower than that recorded in other (including recent) observational and experimental studies. The risk of bleeding increased in the following cases: age > 70 y; arterial vascular disease as indication for OAT; first 3 months of treatment; INR values > or = 4.5. OAT has become safer in recent years, particularly if monitored in special anticoagulation clinics. Caution should be exercised when prescribing OAT in elderly patients and the intensity anticoagulation levels should be closely monitored to minimize incidental periods of overanticoagulation.

Thrombotic events during oral anticoagulant treatment: results of the inception-cohort, prospective, collaborative ISCOAT study: ISCOAT study group (Italian Study on Complications of Oral Anticoagulant Therapy).

The paper reports on rate and type of thrombotic events occurring during the observational, prospective, inception-cohort, multicenter ISCOAT study. 2,745 unselected, daily practice patients, consecutively referring to 34 Italian anticoagulation clinics to monitor the oral anticoagulant treatment, were included in the study from beginning of their first anticoagulant course. During a total follow-up of 2,011 patient-years of treatment 70 thrombotic events (3.5 per 100 patient years) were recorded in 67 patients: 20 fatal (1%), 39 major (1.9%) and 11 minor (0.6%). 34/70 events occurred within the first 90 days of treatment (relative risk - at multivariate analysis - of < or =90 days vs. >90 = 20.6, C.I. 12.7-33.5; p <0.0001). The risk was higher in patients aged > or =70 y (1.62, C.I. 1.0-2.61; p <0.05), and when indication for anticoagulant treatment was peripheral/cerebral arterial disease (1.84, C.I. 1.01-3.36; p <0.05). The frequency of thrombotic events was 17.5% when international normalised ratio (INR) levels were < 1.5, decreasing to 2.3% for INRs within the 2-2.99 category (relative risk of INRs <2.0 vs. > or =2 = 1.88, C.I. 1.16-3.07; p <0.05). The recorded rate of thrombotic events was lower than that reported in the few available studies. A greater risk should be expected during the first 90 days of treatment, when anticoagulation levels are <2.0 INR, in patients > 70 years and in those with cerebrovascular/peripheral arterial disease.

Bleeding complications of oral anticoagulant treatment: an inception-cohort, prospective collaborative study (ISCOAT). Italian Study on Complications of Oral Anticoagulant Therapy.

BACKGROUND: Bleeding is the most serious complication of the use of oral anticoagulation in the prevention and treatment of thromoboembolic complications. We studied the frequency of bleeding complications in outpatients treated routinely in anticoagulation clinics. METHODS: In a prospective cohort from thirty-four Italian anticoagulation clinics, 2745 consecutive patients were studied from the start of their oral anticoagulation (warfarin in 64%, acenocourmarol in the rest). The target anticoagulation-intensity was low (international normalised ratio [INR] < or = 2.8) in 71% of the patients and high (> 2.8) in the remainder. We recorded demographic details and the main indication for treatment and, every 3-4 months, INR and outcome events. Such events included all complications (bleeding, thrombosis, other), although only bleeding events are reported here, and deaths. We divided bleeding into major and minor categories. FINDINGS: 43% of the patients were women. Nearly three-fifths of the patients were aged 60-79; 8% were over 80. The main indication for treatment was venous thrombolism (33%), followed by non-ischaemic heart disease (17%). Mean follow-up was 267 days. Over 2011 patient-years of follow-up, 153 bleeding complications occurred (7.6 per 100 patient-years). 5 were fatal (all cerebral haemorrhages, 0.25 per 100 patient-years), 23 were major (1.1), and 125 were minor (6.2). The rate of events was similar between sexes, coumarin type, size of enrolling centre, and target INR. The rate was higher in older patients: 10.5 per 100 patient-years in those aged 70 or over, 6.0 in those aged under 70 (relative risk 1.75, 95% Cl 1.29-2.39, p < 0.001). The rate was also higher when the indication was peripheral and/or cerebrovascular disease than venous thromboembolism plus other indications (12.5 vs 6.0 per 100 patient-years) (1.80, 1.2-2.7, p < 0.01), and during the first 90 days of treatment compared with later (11.0 vs 6.3, 1.75, 1.27-2.44, p < 0.001). A fifth of the bleeding events occurred at low anticoagulation intensity (INR < 2, rate 7.7 per 100 patient-years of follow-up). The rates were 4.8, 9.5, 40.5, and 200 at INRs 2.0-2.9, 3-4.4, 4.5-6.9, and over 7, respectively (relative risks for INR > 4.5, 7.91, 5.44-11.5, p < 0.0001). INTERPRETATION: We saw fewer bleeding events than those recorded in other observational and experimental studies. Oral anticoagulation has become safer in recent years, especially if monitored in anticoagulation clinics. Caution is required in elderly patients and anticoagulation intensity should be closely monitored to reduce periods of overdosing.

[Automated blood cell measurements: a comparison between the Bayer H2 and the Abbott Cell-Dyn 3500]. / L'esame emocromocitometrico in automazione: confronto tra Bayer H2 e Abbott Cell-Dyn 3500.

INTRODUCTION: We have compared two hematologic analyzers, H2 (Bayer) and CELL DYN 3500 (Abbott). The protocol we used was able to evaluate the overall analytical quality, the effect of aging of the sample on the measured parameters, the quality of leucocytes differential count. Number and quality of information supplied for each sample by both analyzers were then taken in account. RESULTS: Excellent correlation for all measured parameters was found: only monocytes were, albeit modestly, overestimated by CELL DYN 3500 compared to H2. Ageing of sample and temperature of storage had a marked effect on CELL DYN's measurements, resulting in impaired recognition and classification of leucocytes, while the results for the other parameters were acceptable. Comparative evaluation of the differential count of leucocytes was made between the results of both analyzers and microscopic examination. While specificity, predictive value of negative results and quantity of false negative results were practically the same, sensitivity, predictive value of positive results and quantity of false positive results were better for H2 as compared to CELL DYN (87.1% vs 78.1%, 79.4% vs 65.8, 7 vs 13, respectively). The clinical utility of supplementary informations (alarms, flags, cytograms, etc.) yielded by the analyzers was relevant for H2 regarding the erythrocytes cytograms, for CELL-DYN 3500 regarding the application of the extended lyse program for lytic resistant RBCs and of the Vet Package. CONCLUSIONS: CELL DYN 3500 performance have on the whole confirmed the producer's claims, being of reliable use in the haematological screening on account of its simplicity and more than good overall analytical quality.

Relationship between HDL-cholesterol and apolipoprotein A1 and the severity of coronary artery disease.

INTRODUCTION: We investigated whether apolipoprotein A1 (ApoA1) could better identify patients with severe vessel damage than HDL-cholesterol in a population with recent acute myocardial infarction (AMI). METHODS: One hundred and forty-one male patients (mean age: 54.3 +/- 7.3 years) who had undergone coronary angiography within 3 weeks of an AMI were studied. Coronary angiography data were evaluated both anatomically (as single, double or multivessel disease) and by means of the Gensini score. The main lipid parameters were evaluated on admission to the Coronary Care Unit. RESULTS: ApoA1 and the ApoA1/ApoB ratio (A1/B) mean values were significantly (P < 0.05) different when patients were divided on the basis of HDL-cholesterol cut-off value (35.0 mg.dl-1); when divided on the basis of Gensini score (< or = 18 or > 18), there was a statistically significant difference for ApoA1 (P < 0.01), HDL-cholesterol and A1/B (P < 0.05): only this latter was able to discriminate between the two groups. The mean ApoA1 and A1/B (P < 0.01), Gensini score (P < 0.001) and total cholesterol/HDL-cholesterol (P < 0.05) values of patients in the single-vessel disease group differ from those both of double- and multivessel disease groups. A1/B is also able to discriminate between single- and double-vessel disease. DISCUSSION: Our results confirm that ApoA1 and ApoA1/ApoB ratio are better than HDL-cholesterol in assessing the severity of coronary damage.

[Abdominal tuberculosis in childhood: the clinical manifestations]. / Tuberculosis abdominal en la infancia: manifestaciones clíncas.

The authors reviewed the histories of 133 patients with abdominal tuberculosis in Instituto Nacional de Salud del Niño (Children's Hospital), Lima, Perú, between 1989 and 1991. We found morbidity higher in scholars (67.4%). Weight lost were present in all cases and malaise in 95.3%, abdominal distension in 83.72% and abdominal pain in 79.06%. Anaemia in 76.06%, ratio albumin/globulin were altered in 74.41% leukocytosis in 67.44%. Evidence of tuberculosis on chest X-ray were detected only in 62.5%.

[Determination of the pneumoconiosis hazard in the cork industry]. / Accertamento del rischio pneumoconiogeno nell'industria del sughero.

The AA. have carried out an epidemiological investigation in order to control the prevalence of chronic respiratory diseases on a group of 385 people working in several cork industries in North Sardinia. At the same time an environmental investigation has been carried out. Standard questionnaire (CECA questionnaire) for chronic bronchitis and pulmonary emphysema, standard chest X-ray film, spyrographic investigation, ECG and sputum analysis for acid resistent bacteria have been used for epidemiological investigation. Environmental dust concentration and individual dust exposure, environmental concentration of sulphur oxides, nitrogen oxides, carbon mono- and dioxide, ammonia nad microclimatic conditions have been studied. Examination of medical data shows only a low degree of respiratory pathology in contrast with results of other authors, probably because of different methods used for epidemiological investigation and data interpretation and because of different environmental and working conditions.