Search

Background The aim of this study was to investigate the impact of anti-HBc (HBcAb) positivity on the progression of liver fibrosis (Fibrosis-4 score >3.25) in the Italian cohort of HIV-infected individuals naïve to antiretroviral treatment (ICONA). Methods All patients with FIB-4 Results Patients who were HBcAb+/HCV-/HBs antigen (HBsAg)- and HCV+/HBcAb+/HBsAg- or HBsAg+/HBcAb+/HCV- had CD4+ cell counts below the nadir and significantly higher prevalence of AIDS diagnosis at baseline than the other groups (P < .0001). A Cox regression model adjusted for age, HIV transmission mode, country of birth, and alcohol consumption showed a higher relative risk (HR) of progression to FIB-4 >3.25 in HCV+/HBcAb+/HBsAg- patients (HR, 7.2; 95% CI, 3 8–13.64). Conclusions HBcAb+ contributes to liver damage in HIV+/HCV+/HBcAb+/HBsAg- subjects. A careful monitoring for signs of previous HBV infection is needed in this kind of patients.

Osteomyelitis is a relatively understudied disease with no standardized and evidence-based approach to treatment. We aimed to evaluate a cohort of patients with osteomyelitis, comparing the outcomes between intravenous (IV) and oral treatment.We performed an observational retrospective study on osteomyelitis cases in adult patients seen for care between 2017 and 2019. We collected information on patient characteristics, microbiological etiology, infection treatment, and outcome. In addition, we divided osteomyelitis cases by antibiotic regimens [oral (OTG) vs. intravenous±oral (ITG)] and therapy durations to evaluate outcomes differences.A total of 235 episodes of osteomyelitis were evaluated, with a higher prevalence in male gender. Staphylococci, especially S. aureus, were the most common strains. Out of the 235 evaluated episodes, we selected 142 cases. Of these, 75 were treated with OTG and 67 with ITG. Gram-positive bacteria were the most frequent aetiological agents, with 81 isolates (61.8%). Full recovery was observed in 79 (55.6%) cases; of these, 36 (53.7%) were in the ITG and 43 (57.3%) in the OTG (p = 0.666). At the logistic regression, a polymicrobial infection [OR 4.16 (95%CI 1.28-13.4), p = 0.017] and a less than six weeks treatment duration [OR 4.24 (95%CI 1.38-5.43) p = 0.004] were significantly associated with a higher risk of treatment failure.Our study suggests that oral treatment efficacy is comparable to ITG therapy for osteomyelitis, confirming the most recent evidence suggesting that oral therapy is non-inferior to intravenous therapy to treat osteomyelitis.

Lung transplantation can improve the survival of patients with severe chronic pulmonary disorders. However, the short- and long-term risk of infections can increase morbidity and mortality rates. A non-systematic review was performed to provide the most updated information on pathogen, host, and environment-related factors associated with the occurrence of bacterial, fungal, and viral infections as well as the most appropriate therapeutic options. Bacterial infections account for about 50% of all infectious diseases in lung transplanted patients, while viruses represent the second cause of infection accounting for one third of all infections. Almost 10% of patients develop invasive fungal infections during the first year after lung transplant. Pre-transplantation comorbidities, disruption of physical barriers during the surgery, and exposure to nosocomial pathogens during the hospital stay are directly associated with the occurrence of life-threatening infections. Empiric antimicrobial treatment after the assessment of individual risk factors, local epidemiology of drug-resistant pathogens and possible drug-drug interactions can improve the clinical outcomes.

Since December 2019, when the first SARS-CoV2 infections have been reported, the number of cases has increased exponentially. In our University Hospital Unit, the first patient with COVID-19 was admitted on the 8th of March 2020. We aimed to investigate the predictors of death among inpatients with COVID-19.We performed a retrospective, monocentric study, consecutively enrolling patients with SARS-CoV2 infection. Clinical, laboratory, and radiological data were collected from the 8th of March to the 8th of April 2020. We aimed to describe the most frequent clinical and laboratory features and predictors of death among patients admitted to our Unit.87 patients were enrolled, 56 (64.4%) were male, with a median age of 72 (IQR 62.5-83.5) years. The majority of our population had at least one comorbidity in their medical anamnesis. Hypertension and cardiovascular disease were the most frequent, followed by obesity. Eighty (92%) patients had at least one symptom, whereas 7 (8%) were asymptomatic. The most common symptoms were fever and dyspnoea. Overall, 53 patients had lung disease confirmed at CT scan (60.9%). Twenty-five (28.7%) deaths occurred. Statistically significant predictors of death at multivariate analysis were lymphocytes count900 cells/mm3, moderate ARDS, and lack of compliance at baseline.This is the first Italian experience available. Our results seem to be in line with international literature. As highlighted by our data, more studies are needed to investigate the role of lymphocytes subsets, CT scan values. Furthermore, therapy choice and timing in this challenging setting should be urgently investigated in randomized clinical trials.

The purpose of the present review is an update on the diagnosis of prosthetic valve endocarditis (PVE), evaluating the additional value of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) to the standard modified DUKE criteria on which for a long time is based the diagnostic strategy of the disease.We did a comprehensive research on the studies reported in the literature and regarding the employment of 18F-FDG PET/CT in the early diagnosis of PVE in patients with suspected disease. Scientific databases have been examined such as Medline and PubMed, followed by a review of citations and reference lists. The research included the following terms: infective endocarditis, prosthetic heart valve and cardiac valve replacement infections, 18F-FDG PET/CT and endocarditis.The recent studies reported in the literature on the PVE diagnostic approaches showed elevated sensitivity and specificity values of 18F-FDG PET/CT ranging from 73 to 96.6% and from 80 to 94%, respectively, reducing the number of misdiagnosed patients. The usefulness of the radioisotopic procedure is even more important when the other diagnostic conventional diagnostic tools, such as echocardiography, are inconclusive or negative in patients in whom the diagnosis of PVE is definitively ascertained. However, false negative and positive results of 18F-FDG PET/CT were also ascertained in some studies interfering with image interpretation even if such limitation can be reduced with an adequate patient preparation, with a better knowledge of clinical course of the disease, of the treatment in progress and of the different technical aspects of the method.In different studies reported in the literature, 18F-FDG PET/CT proved to improve the diagnostic accuracy of the conventional modified DUKE criteria in patients with suspected IE, and in particular with PVE, giving the highest diagnostic performance and providing additional diagnostic benefits. Thus, the radioisotopic hybrid procedure should be included in the diagnostic protocol of PVE as complementary tool to modified DUKE criteria. Finally, the usefulness of 18F-FDG PET/CT in monitoring the response to antibiotic therapy, although the few data reported in the literature are encouraging, needs more numerous studies and with a major number of cases.

We investigated 99mTc-tetrofosmin scintigraphy in 27 patients with Kaposi’s sarcoma: 20 had classic (CK), 5 AIDS-associated (AK) and 2 transplantation-associated (TK) variants. Twenty-three patients had clinically evident cutaneous and/or mucosal lesions, 9 of them with associated sarcomatous lymphadenopathy; 2 TK patients had only lymph nodes or other extracutaneous Kaposi sites. Both planar and SPECT 99mTc-tetrofosmin scintigraphies were performed in all cases and neck pinhole (P)-SPECT in selected patients. 99mTc-tetrofosmin uptake was observed in 88% of patients with clinically evident cutaneous and/or extracutaneous Kaposi lesions. Scintigraphy gave additional information on cutaneous lesion extent, particularly SPECT regarding deep invasion and subclinical sites in some cases. However, scintigraphy was less sensitive in the detection of small, isolated and scattered lesions. SPECT/P-SPECT were positive in 8/8 patients with sarcomatous lymph nodes, planar imaging in 5/8, ultrasonography in 7/8, while all procedures were negative in 6 other patients with reactive or HIV infection lymph nodes. SPECT demonstrated lymphadenopathy remission in 1 TK patient after immunosuppressive therapy modification and, like planar imaging, ascertained an associated lymphoma with 67Ga-citrate combined. 99mTc-tetrofosmin scintigraphy, especially SPECT, can be useful both in the detection and staging of Kaposi sarcoma lesions as a complementary tool to clinical and other conventional diagnostic methods.

Percent free prostate-specific antigen (PSA) is a promising tool for prostate cancer (CaP) diagnosis. However, its diagnostic performances have not yet been established. The present study was carried out with the aim of evaluating percent free PSA in the most favourable analytical conditions.Eighty-eight patients affected by newly diagnosed, untreated, primary CaP, and 169 cases with biopsy-confirmed, untreated, benign prostatic hypertrophy (BPH) were prospectively enrolled. Abbott AxSYM total and free PSA were measured by the same technician using the same instrument and the same reagent batch.Percent free PSA was more effective than total PSA in differential diagnosis between CaP and BPH in every evaluated dose range of total PSA. In cases with total PSA4 microg/l, percent free PSA could have reduced by about 50% the rate of unnecessary biopsies with a probably still acceptable 93% cancer detection rate. The likelihood of CaP after the determination of percent free PSA was in fact higher than 50% using cut-off points which provide low sensitivity values (i.e. 58% in men aged 50-59 years).Percent free PSA is superior to total PSA in distinguishing primary CaP from BPH in patients with total PSA between 2 and 30 microg/l and in reducing the rate of unnecessary biopsies in men with total PSA higher than 4 microg/l. However, percent free PSA should be cautiously interpreted in decision making in individual patients since post-test probability is relatively low in men aged 50-70 years.

The percent free PSA value is a promising diagnostic tool for prostate cancer. However, its actual role has not yet been established because of the widely diverging sensitivity and specificity values. This could depend at least in part on analytical difficulties, since the free PSA concentration is much lower than that of total PSA. The present investigation was designed to evaluate the diagnostic performance of the percent free PSA in the most favorable analytical conditions. Materials and methods 81 patients affected by newly diagnosed, untreated primary prostate cancer (CaP) and 239 patients with untreated benign prostatic hyperplasia (BPH) were prospectively enrolled. Hybritech total and free PSA were measured by the same technician using the same reagent batch. Results The percent free PSA was not significantly associated with age, tumor stage, gland volume, Gleason score, and total PSA, nor was it significantly affected by concomitant prostatic complications either in CaP or BPH. Percent free PSA was more effective than total PSA in the differential diagnosis between CaP and BPH in every evaluated dose range of total PSA. Percent free PSA determination could have reduced the rate of unnecessary biopsies in cases with total PSA ≥ 4 ng/mL and ≥ 10 ng/mL (avoided biopsies 61% and 63%, respectively). The post-test probability of the disease, which represents the proportion of patients with a positive percent free PSA value who have the disease, was, however, relatively low in younger patients with total PSA within the normal range. Conclusions The diagnostic performance of the percent free PSA value is enhanced when the methodological variability is reduced, particularly in men with low total PSA. Percent free PSA is superior to total PSA in distinguishing primary CaP from BPH in patients with total PSA between 2 and 30 ng/mL. The percent free PSA value is effective in reducing the rate of unnecessary biopsies in men with total PSA higher than 4 or 10 ng/mL. However, due to its relatively low post-test probability, the percent free PSA value should be interpreted with caution in the decision-making related to individual patients and should be used in association with clinical and instrumental evaluation of the patient.

63 CORRELATION OF EARLY DETECTION OF HCV NS3-RESISTANCE AND VIROLOGICAL FAILURE IN PATIENTS TREATED WITH TRIPLE THERAPY INCLUDING TELAPREVIR OR BOCEPREVIR V. Cento, V.C. Di Maio, D. Di Paolo, F. De Luca, V. Micheli, M. Tontodonati, M.C. Bellocchi, L. Carioti, D. Armenia, F. De Leonardis, F.P. Antonucci, G. Madeddu, C. Magni, C. Sarrecchia, S. Babudieri, G. Parruti, M. Angelico, G. Rizzardini, C.F. Perno, F. Ceccherini-Silberstein. University of Rome Tor Vergata, University Hospital of Rome Tor Vergata, Roma, Hospital Sacco of Milan, Milan, Infectious Disease Clinic of Chieti, Chieti, University of Sassari, Sassari, Pescara General Hospital, Pescara, Italy E-mail: ceccherini@med.uniroma2.it

The SimulTRAC FT4/TSH kit (Becton Dickinson), allowing a simultaneous determination of free thyroxine (FT4) and thyrotropin (TSH), was assessed in terms of analytical quality and clinical performance. The results of a multicenter trial were included in this study to obtain a more complete and reliable information. The current validation procedures (ie evaluation of analytical imprecision and sensitivity, between-kit comparison of estimates and--limited to TSH--check of response linearity on dilution) demonstrated quite acceptable analytical characteristics for both the FT4 and the TSH tests. The diagnostic sensitivity and predictive value were derived for separate and combined tests from a relatively large number of cases (ie 401 euthyroids, 127 overt and 48 subclinical hypothyroids, 205 overt and 80 compensated hyperthyroids). The TSH test proved more effective than FT4 in discriminating both overt and subclinical dysfunctions, and, in this respect, the test association was found to add a little advantage--if any. However, the extension of the concepts of diagnostic efficiency to any combination of test results--favoured by their production in a single assay--provides a basis to establish diagnostic protocols and to predict costs and benefits of medical actions.

In 24 patients affected with post-traumatic reflex sympathetic dystrophy syndrome (RSDS) with upper limb involvement following humeral fractures, bone mineral density (BMD, mg/cm2) was measured by means of dual-photon absorptiometry in the distal radius of both the affected and the normal contralateral limbs. Subsequently, all patients underwent dynamic and static scintigraphic exams after i.v. injection of 99mTc-MDP (20 mCi), with gamma camera collimator centered in both limbs. BMD values were significantly lower in the affected sides than in the normal contralateral ones. Time-activity curves with MDP showed increased flow in the involved limbs. Significant increase in blood pool and in bone uptake was also observed. After carbocalcitonin treatment (80 U/q.d. i.m. in 12 cases and 40 U/q.d. i.m. in the other 12 cases for a month) all the patients presented improved clinical symptoms and significant increase in BMD, that was restored to normal values in 7 of the patients who had a longer treatment (40 U/q.d. i.m. for 2 months). Both local blood flow and bone uptake in the affected side significantly decreased after carbocalcitonin therapy while bone avidity index increased in those patients in whom this parameter had been measured. Our results confirm the usefulness of radioisotopic procedures in post-traumatic RSDS for both diagnosis (by demonstrating increased local blood flow and early bone demineralization) and monitoring response to treatment with carbocalcitonin, which seems to play an important role in this condition.

The authors report on their experience with liver hemangioma (LH) diagnosis by means of a simplified method--that is, the simultaneous, in vivo, double labelling of liver reticuloendothelial system (RES) and of red blood cells (RBC) by 99mTc. Twenty-eight patients with US diagnosis of suspected LH and 15 controls were examined after sequential iv injection of SnCl2, of 99mTc-mucolloid albumin and, after liver scintigraphy, of 99mTc-pertechnetate to conclude in vivo RBC labelling. All patients underwent CT and, if necessary, CT-guided biopsy. Focal colloid defects filled after RBC labelling were shown in 20/22 patients with unquestionable LH. No colloid defects were shown in 6/28 cases (expansive process). 15/15 controls showed unchanged non-filling defects after double labelling. Finally, the authors point out that, in the diagnosis of LH, sequential double labelling of liver RES and RBC appears to be a quicker scintigraphic technique than conventional ones. Moreover, this technique has the same high specificity and sensitivity as more time-consuming ones.

Sonographic images of liver hemangioma are not specific. Causal detection imposes further investigations (angiography, CT, NMR) which are not always practicable. 99mTc-red blood cells study after 99mTc colloid liver scintigraphy has been already proposed. Ten patients with hepatic hemangiomas were evaluated by simplified, simultaneous in vivo double labelling of the reticuloendothelial system and red blood cells by means of successive i.v. injections of SnCl2, 99mTc colloid albumin and 99mTc-pertechnetate. Focal colloid defects filled with the labelled RBC were revealed in 9/10 liver hemangiomas. Angioscintigraphy showed decreased perfusion and RBC scintigraphy an increased blood volume in the focal colloid defects due to the hemangiomas.

The LeVeen peritoneovenous shunt (PVS) was investigated in 40 cirrhotic patients with refractory ascites. Five millicuries of Tc-99m-tagged human albumin microspheres (15-36 microns) were injected into the peritoneal cavity between the umbilicus and the left anterior superior iliac spine. The radiotracer was always detectable by scintigram in the lungs when the shunt was patent. In case of malfunction, by contrast, the radioactivity was either restricted to the venous tube or confined below the diaphragm for at least 4 hr. In the presence of complete obstruction, whereas the tube was not visualized after peritoneal injection, it was outlined by direct injection of 2 mCi of Tc-99m albumin microspheres into its subcutaneous tract, where it crossed the 12th rib, immediately above the valve. This technique sufficed to establish whether the site of obstruction was at the valve or in the tubing itself. In one patient, poor visualization of the tube and a delayed image of the lungs was caused by partial occlusion of the valve with fibrinoid debris. This radiotracer method proved simple, quick, and led to an immediate selective replacement when the shunt was not patent. Therefore, the use of this test is recommended for a definitive diagnosis, since there were neither false negatives nor false positives. No complications such as embolism or bacterial infection were encountered with Tc-99m human albumin microspheres, which are excellent tracers.

10 patients with clinical and histopathological evidence of Kaposi’s sarcoma were evaluated with 99Tcm-pertechnetate and 67Ga-citrate scintigraphs. Combined studies using these radionuclides are useful aids in investigating, detecting and following-up Kaposi’s sarcoma and any associated lymphoma or other malignancies.

Serum tissue polypeptide antigen (TPA) was measured by RIA in 151 female patients who had had mastectomies for breast cancer, in 30 patients with benign breast disease, and in 30 normal controls. The marker was elevated in 52 neoplastic patients (25 with metastases) and in six cases of benign breast disease. At the time of our observation 15 cancer patients were at stage I, 53 at stage II, 48 at stage III, and 35 at stage IV, the prevalence of high TPA values significantly correlated with staging gradually increasing from 0 to 71.4% from stage I to IV. In patients with breast cancer TPA was significantly higher in the subgroup with metastatic disease compared to patients with apparently inactive disease. Nineteen patients without (group A) and 35 with metastases (group B) were monitored with serial measurements of TPA for 8-24 months. Group B was receiving either hormone or chemotherapy. In 10 group A patients TPA was either higher or rose 1-7 months prior to the clinical detection of metastases. Twenty-two patients from Group B had disease progression: In 20 of them TPA rose further. The remaining 13 patients had an apparent disease regression, and in 11 instances TPA either fell or remained normal. Thus TPA can detect early recurrence of breast cancer before clinical and instrumental methods; moreover, it might prove important in evaluating tumor response to treatment and in follow-up of patients with metastatic disease. Finally, serial measurements of TPA could identify previous false-positive results, thus improving the specificity of the test.

The role of 131Cs scan in the preoperative diagnosis of cancer was evaluated in 355 patients with either cold or nonfunctioning thyroid nodules. Nodules were classified as positive, doubtful or negative by the pattern of isotope accumulation. Among 234 patients who underwent thyroidectomy, malignant lesions were found in 10.2 per cent of cases. All carcinomas but one found during surgery had been classified as positive by radiocesium scan and were considered as highly suspicious preoperatively; one carcinoma and two papillary adenomas had been classified doubtful and considered presumably malignant. False-positive nodules were found. However, we did not document histologically malignant lesions in nodules which were classified as negative by radiocesium uptake. The routine use of 131Cs scanning may be very useful in patients with cold or nonfunctioning thyroid nodules because of its high sensitivity in excluding malignant lesions.

Two new familial cases of Peutz-Jeghers syndrome are reported. The cases present a number of original aspects with regard to anomalous transmission of the defect, the common finding of a single ileal polyp and associated malformations in the first of the two cases. The clinical aspects of the disease are discussed together with the histology of the polyps in relation to their possibility or otherwise of degenerating. Finally, the various surgical techniques indicated for the treatment of this rare condition are examined.

The importance of a knowledge of the relations between recurrent nerve and inferior thyroid artery, in order to minimise the incidence of injuries to the nerve during thyroidectomy, is stressed. These relations are analysed from the anatomo-surgical standpoint, with particular emphasis on the great variability to which they are subject. It is concluded by asserting the utility of prior location of the recurrent nerve, with an indication of some basic concepts that must always be borne in mind when performing thyroid surgery.

Plasma and cerebrospinal fluid beta-endorphin concentrations were radioimmunologically assayed in dogs subjected to spinal cord ischemia induced by infrarenal aortic ligature and in control sham-operated dogs. Plasma beta-endorphin levels rose significantly following surgery in control dogs but were unaffected by spinal ischemia. On the other hand, a significant increase in cerebrospinal fluid beta-endorphin concentration occurred after spinal ischemia, while surgical stress had no significant effect. Thus, the origins of plasma and cerebrospinal fluid beta-endorphin may be different, with the former secreted from the hypophysis and the latter from nervous tissue. Observed changes in cerebrospinal fluid beta-endorphin concentration could be related to the ischemic lesion of nervous tissue while the changes in plasma levels may reflect general stressing factors such as the surgery in our experiments.

Serum carcinoembryonic antigen (CEA) was measured by double antibody radioimmunoassay technique in 95 normal subjects and in 258 patients with thyroid nodules. All the normal subjects and the patients with benign nodules had normal CEA values. Increased serum CEA levels (above 50 ng/ml) were found in all medullary and undifferentiated (giant cell) carcinomas. After surgery, the CEA fell within the normal range in the patients with medullary carcinoma. High levels of CEA were also present in 26% of differentiated carcinomas. A relationship between high CEA values and the presence of metastatic disease was not found. Measurement of serum carciniembryonic antigen may be useful in the preoperative diagnosis of cancer in patients with thyroid nodules.