Incidence and risk factors of bacterial sepsis and invasive fungal infection in neonates and infants requiring major surgery: an Italian multicentre prospective study.

BACKGROUND: Limited data are currently available on the incidence rates and risk factors for bacterial sepsis and invasive fungal infections (IFIs) among neonates and infants undergoing major surgery. AIM: To assess the incidence of bacterial sepsis and IFI, fungal colonization, risk factors for sepsis, and mortality in neonates and infants aged <3 months undergoing major surgery. METHODS: A multicentre prospective study was conducted involving 13 level-3 neonatal intensive care units in Italy, enrolling all infants aged ≤3 months undergoing major surgery. FINDINGS: From 2018 to 2021, 541 patients were enrolled. During hospitalization, 248 patients had a bacterial infection, and 23 patients had a fungal infection. Eighty-four patients were colonized by fungal strains. Overall, in-hospital mortality was 2.8%, but this was higher in infected than in uninfected infants (P = 0.034). In multivariate analysis, antibiotic exposure before surgery, ultrasound-guided or surgical placement of vascular catheters, vascular catheterization duration, and gestational age ≤28 weeks were all associated with bacterial sepsis. The risk of IFI was markedly higher in colonized infants (odds ratio (OR): 8.20; P < 0.001) and was linearly associated with the duration of vascular catheterization. Fungal colonization in infants with abdominal surgery increased the probability of IFI 11-fold (OR: 11.1; P < 0.001). CONCLUSION: Preventive strategies such as early removal of vascular catheters and the fluconazole prophylaxis should be considered to prevent bacterial and fungal sepsis in infants undergoing abdominal surgery, and even more so in those with fungal colonization.

Morquio A syndrome due to maternal uniparental isodisomy of the telomeric end of chromosome 16.

Morquio A syndrome (MPS IVA) is a recessive lysosomal storage disorder (LSD) caused by mutations in the GALNS gene leading to the deficiency of lysosomal enzyme N-acetylgalactosamine-6-sulfate sulfatase (GALNS). Patients show a broad spectrum of phenotypes ranging from classical severe type to mild forms. Classical forms are characterized by severe bone dysplasia and usually normal intelligence. So far, more than 170 unique mutations have been identified in the GALNS gene of MPS IVA patients. We report on a Morquio A patient with a classical phenotype who was found to be homozygous for a missense mutation (c.236 G>A; p.Cys79Tyr) in the GALNS gene. This alteration affects the highly conserved p.Cys79 that is transformed into formylglycine, the catalytic residue of the active site. The mutation was present in the proband's mother, but not in the father, whose paternity was confirmed by microsatellite analysis. In order to test the hypothesis of maternal uniparental disomy (UPD), we investigated the segregation of sixteen microsatellite markers from chromosome 16. The results showed a condition of maternal UPD due to an error in meiosis I. Maternal isodisomy of the 16q24 region led to homozygosity for the GALNS mutant allele, causing the patient's disease. These findings allow to add for the first time the LSD Morquio A syndrome to the list of conditions that can be caused by UPD. The possibility of UPD is relevant when giving genetic counseling to couples since the recurrent risk in future pregnancies is dramatically reduced.

Reader variability in reporting breast imaging according to BI-RADS assessment categories (the Florence experience).

The inter- and intraobserver agreement (K statistic) in reporting according to BI-RADS assessment categories was tested on 12 dedicated breast radiologists, with little prior working knowledge of BI-RADS, reading a set of 50 lesions (29 malignant, 21 benign). Intraobserver agreement (four categories: R2, R3, R4, R5) was fair (0.21-0.40), moderate (0.41-0.60), substantial (0.61-0.80) or almost perfect (>0.80) for one, two, five or four radiologists, or (six categories: R2, R3, R4a, R4b, R4c, R5) fair, moderate, substantial or almost perfect for three, three, three or three radiologists, respectively. Interobserver agreement (four categories) was fair, moderate or substantial for three, six, or three radiologists, or (six categories) slight, fair or moderate for one, six, or five radiologists. Major disagreement occurred for intermediate categories (R3=0.12, R4=0.25, R4a=0.08, R4b=0.07, R4c=0.10). We found insufficient intra- and interobserver consistency of breast radiologists in reporting BI-RADS assessment categories. Although training may improve these results, simpler alternative reporting methods (systems), focused on clinical decision-making, should be explored.

The role of arbitration of discordant reports at double reading of screening mammograms.

OBJECTIVE: To asses the effectiveness of arbitration of discordant double readings in mammography screening. DESIGN: A retrospective study of 1217 consecutive arbitrations. SETTING: A subset of discordant double readings from the Florence screening programme underwent arbitration by a third reader. RESULTS: Positive arbitration of 1217 discordant double readings prompted assessment in 476 cases (39.2%), detecting 30 cancers (6.3%). Of 741 negative arbitrations (60.8%), 311 have been followed up thus far, and two cancers (0.64%) occurred in the site previously suspected at one of the two independent readings. Arbitration had a sensitivity of 86.3% and a negative predictive value of 99.3%. Arbitration reduced the overall referral rates from 3.82% to 2.59% (relative decrease 32.1%). Due to false-negative arbitration, cancers detected per 1000 women screened would decrease from 4.58 to 4.50 (relative decrease 1.7%). For every cancer missed due to false-negative arbitration, 151 unnecessary recalls and 21,248 euro would have been saved, whereas the saved cost per screened woman due to arbitration was 1.72 euro. DISCUSSION: Arbitration of discordant double reading would substantially reduce referral rates with a limited reduction in cancer detection rate, and may be recommended as a routine procedure. Greater benefit from arbitration might be expected in the presence of high referral rates at independent double reading, a common scenario in a newly implemented service screening.

Categorizing breast mammographic density: intra- and interobserver reproducibility of BI-RADS density categories.

The inter- and intraobserver agreement (kappa-statistic) in reporting according to Breast Imaging Reporting and Data System (BI-RADS((R))) breast density categories was tested in 12 dedicated breast radiologists reading a digitized set of 100 two-view mammograms. Average intraobserver agreement was substantial (kappa=0.71, range 0.32-0.88) on a four-grade scale (D1/D2/D3/D4) and almost perfect (kappa=0.81, range 0.62-1.00) on a two-grade scale (D1-2/D3-4). Average interobserver agreement was moderate (kappa=0.54, range 0.02-0.77) on a four-grade scale and substantial (kappa=0.71, range 0.31-0.88) on a two-grade scale. Major disagreement was found for intermediate categories (D2=0.25, D3=0.28). Categorization of breast density according to BI-RADS is feasible and consistency is good within readers and reasonable between readers. Interobserver inconsistency does occur, and checking the adoption of proper criteria through a proficiency test and appropriate training might be useful. As inconsistency is probably due to erroneous perception of classification criteria, standard sets of reference images should be made available for training.

Second reading of screening mammograms increases cancer detection and recall rates. Results in the Florence screening programme.

OBJECTIVE: To assess double reading effectiveness in mammography screening. DESIGN: Retrospective study of 177,631 consecutive mammograms double read during 1998-2003. SETTING: The Florence screening programme, involving 11 trained radiologists. Abnormalities reported by at least one reader prompted assessment. RESULTS: The referral rate was 2.89% for the first reader, 3.15% for the second reader, and 3.59% for either reader. Of 713 total cancers detected, 43 were suspected only by the second reader (6.4% relative, 0.024% increase in absolute detection rate) and had a lower stage compared to the first reader (pTis-pT1b = 65.7 versus 52.0%): 41 were reviewed and classified (error type) as "minimal sign" in six, and "screening error" in 35 cases, or as BI-RADS 3 in one, 4a in 20, 4b in 13, and 4c in three cases. The second reading cost was 2.70 per woman examined, or 11,168 per additional cancer detected (versus 11,585 at a single reading). DISCUSSION: Second reading is effective in detecting a limited number of additional cancer cases. Tumour stage (one-third over 1 cm in diameter) and review findings (high rate of "screening errors" and BI-RADS R4b-c categories) suggest that second reading detects small "difficult cases" as well as larger cancers missed due to fatigue or loss of attention. Second reading reduces screening specificity to a minor extent, and since cancer detection at second reading seems cost-effective the procedure is recommendable in routine practice.

Florence-Sydney Breast Biopsy Study: sensitivity of ultrasound-guided versus freehand fine needle biopsy of palpable breast cancer.

BACKGROUND: Fine needle aspiration biopsy (FNAB) is widely used in the diagnosis of breast cancer. It is unknown whether, for palpable cancers, ultrasound-guided FNAB is more accurate than freehand FNAB, and practice varies between physicians, services and countries. METHODS: From consecutive women attending a major cancer centre in Florence, we prospectively recruited subjects who had a definitely palpable lump which was solid on ultrasound and suspicious of malignancy (n = 102). All subjects were investigated using both ultrasound-guided and freehand FNAB (one aspirate with each method). Radiologists skilled in both sampling techniques performed all clinical examinations and aspirations, and for each subject the same radiologist obtained both FNAB samples. Sequence of aspiration method was randomised. Cytological interpretation was blinded to method of sampling. Comparative sensitivity (and insufficiency) for FNAB using the two methods was calculated in all cancers (n = 97). RESULTS: Ultrasound-guided FNAB resulted in 13.6% (5-22%) less insufficient aspirates than freehand FNAB (chi2 = 7.58; p = 0.006). When insufficient aspirates are included and considered as negative, ultrasound-guided FNAB has a 14.6% (5.8-23%) or a 16.5% (7.6-25.4%) significantly better sensitivity than freehand FNAB (for cytology 3-5 positive or cytology 4-5 positive respectively). When insufficient aspirates are excluded from the analysis, ultrasound-guided FNAB has a 1.4% (-1.2 to 3.9%) or a 2.6% (-2.5 to 7.8%) higher sensitivity than freehand FNAB (for cytology 3-5 positive or cytology 4-5 positive respectively) but this difference in the sensitivity of the two methods is not statistically significant. CONCLUSION: Our data suggest that ultrasound-guided FNAB has better sensitivity than freehand FNAB in palpable breast cancer, which is predominantly an effect of a significant reduction in insufficient aspirates, but in part an effect of 'upgrading' cytological classification of cancers.

The role of H2O2 in the platelet-derived growth factor-induced transcription of the gamma-glutamylcysteine synthetase heavy subunit.

This study demonstrates that platelet-derived growth factor (PDGF) increases transcription of the gamma-glutamylcysteine synthetase (GCS) heavy subunit (GCS-HS) in NIH 3T3 fibroblasts via H2O2 and activation of protein kinase C (PKC). The data obtained using catalase, H2O2, phorbol-12-myristate 13-acetate (PMA) or a specific inhibitor of PKC demonstrate the possibility of a PDGF up-regulation pathway of GCS synthesis. Moreover, since PDGF mitogenic activity takes place through PKC activation and sphingosine-1-phosphate (S1P) production, the involvement of sphingosine kinase activity in the PDGF effect was also investigated. No clear direct relationship emerged between S1P production and any PDGF- or H2O2-induced increase in the GCS-HS mRNA level. However, for the first time, in S1P-stimulated NIH 3T3 cells, increased levels of GCS-HS mRNA were shown to be related to increases in the reduced glutathione synthesis rate similar to those obtained after PMA and PDGF stimulation.

Early and late (ten years) experience with circular stapler hemorrhoidectomy.

PURPOSE: We present a retrospective clinical study concerning the preliminary experience with the circular stapler in the treatment of hemorrhoids. Early results, complications, and long-term follow-up are revisited. METHODS: Fifty-six consecutive patients with second-, third-, and fourth-degree hemorrhoids were included in the study. Data about operation, early postoperative results, and follow-up at one, two, and four weeks were collected. Patients were also contacted by phone after a long-term follow-up (mean, 33 (range, 5-120) months). RESULTS: Every operation attempted was successfully terminated. The length of the operation was less than 15 minutes. No major bleeding or anastomotic disruption occurred. Six patients (13 percent) who underwent spinal or epidural anesthesia had urinary retention. One patient (1.7 percent) had minor bleeding, and four patients (7.1 percent) experienced transient edema of the anastomotic ring after the operation. None needed further treatments. The mean analgesic requirement was 1.4 (range, zero to eight) ketorolac 30-mg injections; 23 patients (41 percent) received no analgesics, and seven patients (12 percent) required a single extra dose of opiates (10 mg morphine cloridrate). Length of hospital stay was between 0 and 11 (mean, 2.7) days, but 20 patients (35 percent) received an additional operation for coexisting surgical disease. At one week, almost all patients experienced little pain at digital inspection and little bleeding after defecations. No anastomotic leakage, wound infection, or healing delay was found. Three patients (5.3 percent) experienced wound edema and pain during defecation. Two weeks later, one patient (1.7 percent) suffered from painful defecation and ten patients (17 percent) reported minor bleeding, but all returned to normal activities. No pain during defecation, bleeding, stenosis, soiling, incontinence, or other anal symptoms were found at one month after the operation, and all patients were well. All patients were contacted by phone 5 to 120 (mean, 33) months later, and all were pleased with the results of this procedure. There were no symptomatic recurrences. DISCUSSION: Our study confirms the feasibility of circular stapler hemorrhoidectomy in the treatment of hemorrhoids. Complications and postoperative pain were minimal. There were no recurrences during long-term follow-up. CONCLUSION: Mechanical hemorrhoidectomy is a promising new option in the treatment of all patients eligible for a surgical approach.

[Assessment of diagnostic accuracy of mammography carried out for secondary prevention. Results of a test with a sample caseload conducted by 75 Italian radiologists]. / Valutazione dell'accuratezza diagnostica nella mammografia eseguita con fini di prevenzione secondaria. Risultati di una prova su casistica campione sostenuta da 75 radiologi italiani.

PURPOSE: To report the results of a test performed by 75 volunteer radiologists involved in screening program in Italy. MATERIAL AND METHODS: The test includes 12 screening detected cancers and 6 cancers (4 screening detected and 2 interval lesions) with minimal signs at review of a previous negative mammogram. Data on previous experience in mammography (years of activity, years of screening activity, total number of mammograms read and number of mammograms read per year) were also collected. RESULTS: Standards for passing the test were at least 83.3% for sensitivity for screening detected cancers and at most 30% for recall rate among negative cases. Mean sensitivity was 83.9% (median 83.3%, range 50-100%) and mean recall rate was 16.3 (median 14.4%, range 3.8-42.4%). In all, 44 radiologists (58.7%) passed the test. On average 1.4 of 6 cancers with minimal signs were correctly identified. According to readers' experience (at least 5 years in mammographic activity, at least 3 years in screening mammography, at least 10,000 total mammograms read, at least 5,000 per year) radiologists were classified as expert (13) or not (62): no difference in test performance was observed between the two groups. The only significant association occurred for years of mammographic activity and sensitivity. DISCUSSION AND CONCLUSIONS: Test results suggest the need for proper training of radiologists prior to involvement in a screening program. Seeding proficiency tests with cancers with minimal signs was of no benefit as far as evaluation is concerned.

GSH role on platelet-derived growth factor receptor tyrosine phosphorylation induced by H2O2.

This study, conducted on NIH3T3 cells, demonstrates that GSH depletion obtained by buthionine sulfoximine (BSO) treatment does not affect platelet-derived growth-factor receptor (PDGFr) autophosphorylation or cell protein phosphorylation induced by exogenous addition of H2O2, while it does decrease tyrosine phosphorylation obtained by PDGF stimulation. This last effect seems due to the lack of H2O2 generation; for the first time a relation between intracellular GSH content and H2O2 production induced by PDGF has been demonstrated. Therefore, changes of GSH levels can affect the early events of the PDGFr signal pathways by redox regulation. It has also demonstrated that in NIH3T3 cells, H2O2 can directly activate tyrosine phosphorylation by a reversible effect with the involvement of SH-group. This H2O2 effect is increased by vanadate and by GSH depleting agent, diethylmaleate, which unlike BSO is able to produce H2O2 as the current study shows.

Expression of nm23 gene in gastric cancer is associated with a poor 5-year survival.

The nm23 gene is thought to play a role as an inhibitor of metastatic progression in several human cancers and its down-regulation has been associated with increased metastasis and reduced survival in some studies, though not in others. To better investigate the role of nm23 in gastric cancer (GC), the expression and prognostic impact of this gene was examined in 107 radically operated GC patients in a high risk area. The expression of nm23 was determined immunohistochemically by using the rabbit antibody anti-human nm23 protein. The expression of nm23 was detected in 40.2% (n = 43) of 107 gastric tumours and correlated with a poorer clinical outcome. In a survival analysis at 5 years, patients with nm23-positive tumours had significantly worse prognosis than patients (n = 64) with nm23-negative tumours (p < 0.05). The prognostic significance of nm23 expression was confirmed by multivariate analysis including terms for tumour stage and lymph node involvement. Our results suggest that the expression of the nm23 gene in gastric carcinoma is significantly related to tumour progression and poor prognosis at 5 years.

[Surgical treatment of thyroid microcarcinoma]. / Trattamento chirurgico dei microcarcinomi tiroidei.

Thyroid microcarcinoma is nowaday defined as a tumor of one centimeter or less in the maximum diameter. It occurs in less than five per cent of all thyroid carcinomas. In personal experience four thyroid microcarcinomas have been found in specimens from 121 thyroidectomies and have been retrospectively reviewed clinical data and the long term follow-up of the patients. Total thyroidectomies nor prophylactic lymphadenectomies were never performed. All patients at present are well. Our purpose was to focus on the current surgical treatment of microcarcinoma. Many hypotheses are done to explain pathogenesis and fairly good prognosis of thyroid microcarcinomas, without univocal conclusions. Almost all authors agree that microcarcinoma of the thyroid gland is a low-aggressive tumor, with good biological behaviour, but the therapeutic strategies are not codified yet. Particularly, doubt still exists about the choice between total thyroidectomy and more conservative procedure, and lymphadenectomy, especially when tumor is found in specimens after surgery for benign disease. In conclusion, in our opinion conservative management is the best choice, provided that the patient is included in a correct long-term follow-up.

[Radiologic analysis of interval cancers in the screening program called Florence Woman Project]. / Analisi radiologica dei carcinomi di intervallo nel programma di screening Progetto Firenze Donna.

PURPOSE: The aim of the present study was to provide data on interval cancer incidence after the first round of the screening program in the city of Florence, and to provide and discuss the results of the review of previous screening mammograms. MATERIAL AND METHODS: The screening program "Progetto Firenze Donna" involves all women age 50 to 69 years resident in the city of Florence. In the interval from the end of the first and the start of the second screening round 51 interval cancers were identified, of which 41 were available for radiological review. Films were reviewed by expert screening radiologists, not involved in the program and blinded to the final diagnosis, according to the review criteria recommended by the UK Guidelines for radiologists (blind and informed review). RESULTS: Sensitivity (screening errors/total) was different among blind reviewers (reader A = 7.3%, reader B = 14.6%), as well as specificity which shows an inverse pattern (reader A = 98.4%, reader B = 97.6%). Informed review classified 5 cases as "screening error" (12.2%), 11 as "minimal sign" (26.8%) and 25 as "occult" (61%). Informed review classified a higher proportion of cases as "minimal sign" (minimal abnormalities are better perceived with the knowledge of the site and the pattern of subsequent cancer). DISCUSSION AND CONCLUSIONS: Analysis of interval cancers is fundamental for the quality control of a screening program. According to this experience, informed review tends to overestimate "minimal signs" in the cancer site and should not be used (or "minimal signs" should be anyhow assumed as negative). Identification of interval cases as "minimal signs" may be influenced by individual variability. Standard criteria should be adopted to identify and review/classify interval cancers to allow comparisons between different programs.

Glutathione transport system in NIH3t3 fibroblasts.

The current study characterizes a mediated transport for GSH uptake in murine fibroblasts NIH3T3. The presence of GSH mediated transport is indicated by the behaviour of GSH uptake time-course, as well as by kinetic saturation and the specific inhibition of the initial rate of GSH transport. Moreover, a concentrative GSH uptake has been measured, whose driving force may be due to a change of membrane potential and the direct involvement of ATP. Hyperbolic kinetic saturation shows a single mediated transport with high affinity for GSH (Km = 0.209 +/- 0.03 mM). High specificity of this GSH transporter for the entire structure of GSH is also demonstrated. To summarize, GSH uptake into NIH3T3 cells occurs by an active transport system and shows characteristics similar to ATP-dependent mechanisms previously identified in hepatocyte membranes. Moreover, a possible physiological role of this GSH transporter related to NIH3T3 cell proliferation has been hypothesized.

Sphingosine 1-phosphate induces arachidonic acid mobilization in A549 human lung adenocarcinoma cells.

In the present paper, the effect of sphingosine 1-phosphate (Sph-1-P) on arachidonic acid mobilization in A549 human lung adenocarcinoma cells was investigated. Sph-1-P provoked a rapid and relevant release of arachidonic acid which was similar to that elicited by bradykinin, well-known pro-inflammatory agonist. The Sph-1-P-induced release of arachidonic acid involved Ca(2+)-independent phospholipase A(2) (iPLA2) activity, as suggested by the dose-dependent inhibition exerted by the rather specific inhibitor bromoenol lactone. The Sph-1-P-induced release of arachidonic acid was pertussis toxin-sensitive, pointing at a receptor-mediated mechanism, which involves heterotrimeric Gi proteins. The action of Sph-1-P was totally dependent on protein kinase C (PKC) catalytic activity and seemed to involve agonist-stimulated phospholipase D (PLD) activity. This study represents the first evidence for Sph-1-P-induced release of arachidonic acid which occurs through a specific signaling pathway involving Gi protein-coupled receptor(s), PKC, PLD and iPLA2 activities.

Proficiency test for screening mammography: results for 117 volunteer Italian radiologists.

OBJECTIVE: To analyse the performance of a large sample of Italian radiologists undergoing a proficiency test for screening mammography. DESIGN: Evaluation of performance indicators according to reference standards determined by a panel of experts (sensitivity (reference standard > or = 80%), recall rate (reference standard < or = 15%)). SETTING: 117 Italian radiologists of varying experience (years of practice 0.5-18, average 5.9; mammograms read 500-51,000, average 13,000), all currently reporting clinical mammography and planning to take part in screening in the near future. RESULTS: Eighty four of 117 (72%) radiologists reached the standard for sensitivity, 88 (75%) reached the standard for recall rate, and only 59 (50%) reached both standards and passed the proficiency test. The probability of passing the test was significantly correlated with mammographic practice (p = 0.015), mammograms read (p = 0.024), and mammograms read/year (p = 0.043). DISCUSSION: The performance of a large sample of Italian radiologists currently reporting clinical mammography was disappointing, indicating the need for proper training of at least 50% of the tested subjects. When implementing organised screening the health authority should set up a proper process for training and accrediting radiologists, and a proficiency test should be part of such a process.

[Ileal duplication in adults. A very rare nosological entity]. / La duplicazione ileale dell'adulto. Una rarissima entità nosologica.

The report presents a rare case of intestinal duplication in a 43-year old female. Intestinal duplication is a rare congenital malformation and is extremely exceptional in adults. A lot of etiopathogenic theories have been advanced to explain this malformation that can occur anywhere along the alimentary tract, even if the ileum remains the most common. It may be cystic or tubular. An important aspect of mucosal histology is the possibility of gastric heterotopy, conditioning a particular treatment. The literature shows 14 cases with clinical very different presentations and instrumental exams were rarely helpful for correct diagnosis. Treatment of choice is surgical complete resection of the duplication. When contiguous structures are involved intestinal bypass or Roux-on-Y anastomosis may be necessary with mandatory stripping of the mucosa when heterotopic gastric mucosa is present in order to prevent the risk of gastrointestinal haemorrhage or malignant transformation, an event possible in about 25% of the cases reported in the literature.