Pitfalls in anticoagulant-related nephropathy.

Anticoagulant-related nephropathy (ARN) is a rare but important disease and often misdiagnosed. The hallmark of the diagnosis is acute kidney injury (AKI) superimposed on preexisting kidney disease due to anticoagulation-induced glomerular hemorrhage with histologic features of widespread tubular obstruction by red blood cells and red cell casts. As ARN is a diagnosis of exclusion only proven by renal biopsy, the diagnosis is often unlikely to be confirmed histologically because of fear of biopsy-related bleeding during anticoagulant therapy. Given the large differential diagnosis in AKI, diagnosing ARN remains a challenge for clinicians. A case report and the pitfalls related to diagnosis and management will be discussed in this paper.

AI-enhanced simultaneous multiparametric 18F-FDG PET/MRI for accurate breast cancer diagnosis.

PURPOSE: To assess whether a radiomics and machine learning (ML) model combining quantitative parameters and radiomics features extracted from simultaneous multiparametric 18F-FDG PET/MRI can discriminate between benign and malignant breast lesions. METHODS: A population of 102 patients with 120 breast lesions (101 malignant and 19 benign) detected on ultrasound and/or mammography was prospectively enrolled. All patients underwent hybrid 18F-FDG PET/MRI for diagnostic purposes. Quantitative parameters were extracted from DCE (MTT, VD, PF), DW (mean ADC of breast lesions and contralateral breast parenchyma), PET (SUVmax, SUVmean, and SUVminimum of breast lesions, as well as SUVmean of the contralateral breast parenchyma), and T2-weighted images. Radiomics features were extracted from DCE, T2-weighted, ADC, and PET images. Different diagnostic models were developed using a fine Gaussian support vector machine algorithm which explored different combinations of quantitative parameters and radiomics features to obtain the highest accuracy in discriminating between benign and malignant breast lesions using fivefold cross-validation. The performance of the best radiomics and ML model was compared with that of expert reader review using McNemar's test. RESULTS: Eight radiomics models were developed. The integrated model combining MTT and ADC with radiomics features extracted from PET and ADC images obtained the highest accuracy for breast cancer diagnosis (AUC 0.983), although its accuracy was not significantly higher than that of expert reader review (AUC 0.868) (p = 0.508). CONCLUSION: A radiomics and ML model combining quantitative parameters and radiomics features extracted from simultaneous multiparametric 18F-FDG PET/MRI images can accurately discriminate between benign and malignant breast lesions.

Acute environmental temperature variation affects brain protein expression, anxiety and explorative behaviour in adult zebrafish.

This study investigated the effect of 4-d acute thermal treatments at 18 °C, 26 °C (control) and 34 °C on the nervous system of adult zebrafish (Danio rerio) using a multidisciplinary approach based on behavioural tests and brain proteomic analysis. The behavioural variations induced by thermal treatment were investigated using five different tests, the novel tank diving, light and dark preference, social preference, mirror biting, and Y-Maze tests, which are standard paradigms specifically tailored for zebrafish to assess their anxiety-like behaviour, boldness, social preference, aggressiveness, and explorative behaviour, respectively. Proteomic data revealed that several proteins involved in energy metabolism, messenger RNA translation, protein synthesis, folding and degradation, cytoskeleton organisation and synaptic vesiculation are regulated differently at extreme temperatures. The results showed that anxiety-like behaviours increase in zebrafish at 18 °C compared to those at 26 °C or 34 °C, whereas anxiety-related protein signalling pathways are downregulated. Moreover, treatments at both 18 °C and 34 °C affect the exploratory behaviour that appears not to be modulated by past experiences, suggesting the impairment of fish cognitive abilities. This study is the continuation of our previous work on the effect of 21-d chronic treatment at the same constant temperature level and will enable the comparison of acute and chronic treatment effects on the nervous system function in adult zebrafish.

US and MR imaging findings to detect placental adhesion spectrum (PAS) in patients with placenta previa: a comparative systematic study.

PURPOSE: To compare the performance US and MR in identifying placental adhesion spectrum (PAS) in placenta previa (PP) and to establish a potential method of image interpretation. METHODS: US and MR examinations of 51 patients with PP were selected. The presence of imaging signs commonly used to detect PAS was assessed. Penalized logistic regression was performed considering histology as standard of reference; only signs statistically significant (p < 0.05) were considered for ROC and multivariate analysis. The probability of PAS according to the presence of US and/or MR signs was then assessed. RESULTS: At univariate analysis, loss of retroplacental clear space, myometrial thinning (MT) and placenta lacunar spaces on US, intraplacental dark bands (IDBs), focal interruption of myometrial border (FIMB) and abnormal vascularity (AV) on MR were statistically significant (p < 0.01). Three diagnostic methods for PAS were then developed for both US and MR when at least one (Method 1), two (Method 2) or three (Method 3) imaging signs occurred, respectively. Method 2 for MR showed a significantly (p < 0.05) higher accuracy (91%) compared to the other methods. When MR IDBs and AV as well as IDBs and FIMB were present in combination with US MT the probability of PAS increased from 75 to 90% and from 80 to 91%, respectively. CONCLUSION: MR demonstrated a higher diagnostic accuracy than US to detect PAS. However, since the combination of MR and US signs could improve the probability to detect PAS, a complementary diagnostic role of these techniques could be considered.

Conservative surgical treatment in rectal cancer after complete pathological response to neoadjuvant treatment. Prospective observational study.

In 2012 we started a prospective observational study at San Giovanni Addolorata Hospital in Rome for patients with rectal cancer with complete response to neoadjuvant therapy (nCRT). In our, IRB approved protocol, patients are evaluated at time 0 by physical, endoscopic, pathological and radiological examinations. 6 weeks after completion of nCRT they are re-evaluated. In case of persistence or progression of disease patients undergo surgery with Total Mesorectal Excision. In case of complete or major clinical response they are re-evaluated at 12 weeks and subjected to transanal surgical excision to confirm complete pathological response (pCR). If tumor is found in the transanal excision specimen the patient is operated upon whereas patients with pCR are followed up at 3 months interval.

Diagnostic accuracy of magnetic resonance imaging in assessing placental adhesion disorder in patients with placenta previa: Correlation with histological findings.

OBJECTIVE: To evaluate MRI accuracy in assessing placental adhesion disorders (PAD) in patients with placenta previa correlating imaging results with histological findings. MATERIALS AND METHODS: Sixty-one patients who underwent abdomino-pelvic magnetic resonance imaging (MRI) for ultrasound suspicion of PAD were prospectively evaluated. T1- and T2-weighted images, with and without fat suppression, were obtained in the three conventional planes using a 1.5 T MRI scanner. MRI accuracy to evaluate the presence of PAD was assessed on the basis of the occurrence of the following abnormal MRI signs: 1) intraplacental dark bands; 2) focal interruption of myometrial border; 3) intraplacental abnormal vascularity; 4) uterine bulging; 5) tenting of the bladder and/or 6) direct visualization of adjacent tissues invasion only in case of percretism. Imaging results were classified as suggestive or not of PAD using histological data as standard of reference; two methods of imaging analysis were used represented by the presence of at least one (Method A) or two (Method B) abnormal MRI signs; the correlation between the presence of each abnormal MRI sign of PAD and the corresponding histological finding was also assessed. RESULTS: The accuracy, as the area under the receiver operating characteristic curve, was significantly (p = 0.001) higher for Method B (0.92, C.I. 95%: 0.82-0.97) compared to Method A (0.764, C.I. 95%: 0.64-0.86). Among the abnormal MRI signs, intraplacental dark bands and focal interruption of myometrial border were those highly correlated with histological proof of PAD (ρ > 0.71, p < 0.001, for both); as result, a modified version of Method B (Method C) was identified considering as criterion for PAD the combined presence of the two abnormal MRI signs highly correlated with histologically proven PAD; however, the accuracy of Method C was significantly (p = 0.005) lower (0.80, C.I. 95%: 0.67-0.89) than Method B and comparable to Method A. CONCLUSIONS: MRI is a useful imaging technique to assess PAD in patients with placenta previa; in particular, the presence of at least two among all the abnormal MRI signs represents the most accurate criterion (Method B) to identify PAD. Although intraplacental dark bands and focal interruption of myometrial border showed the highest correlation with histological proof of PAD as well as this association was the most frequent in PAD, the combination of these latter MRI signs along with other abnormal signs should be considered diagnostic for PAD.

Neurologic Wilson disease: case series on a diagnostic and therapeutic emergency.

Wilson disease is a rare genetic disease causing pathologic deposition of copper in the liver, brain, cornea, kidney, and cardiac muscles. Presented are two cases of neurologic Wilson disease with progressive movement disorder and Kayser-Fleischer rings with low serum copper, low ceruloplasmin, and increased 24-hour urine copper against a background of normal transaminases. Cranial imaging revealed symmetric basal ganglia hyperintensities in T2/FLAIR. More often than not, these cases go unnoticed and misdiagnosed because of its rarity and varied presentation. Extensive workup is necessary to confirm the diagnosis. As for management, the earlier the intervention is initiated, the better prognosis would be for recovery. There are several treatment options which should be tailored to every patient with neurologic Wilson disease. Neurologic Wilson disease is considered as a copper toxicity; immediate diagnostic evaluation and early treatment initiation is a must.

La Enfermedad de Wilson es una enfermedad genética rara provocada por un depósito patológico de cobre en el hígado, cerebro, córnea, riñón y músculo cardíaco. Se presentan dos casos de Enfermedad de Wilson neurológica con trastorno progresivo del movimiento y anillos de Kayser-Fleischer con cobre y ceruloplasmina séricos bajos, y aumento de cobre en orina de 24 horas, con transaminasas normales. Las imágenes craneales revelan hiperintensidad simétrica en T2/FLAIR de los ganglios basales. Lo más frecuente es que estos casos pasen inadvertidos o no se realice el diagnóstico correcto debido a la rareza y variedad de sus presentaciones. Se require de un completo trabajo para poder precisar el diagnóstico. Respecto al manejo, cuanto antes se inicie la intervención, mejor será el pronóstico para la recuperación. Existen diversas opciones terapéuticas y deben adaptarse a cada paciente con Enfermedad de Wilson neurológica. La Enfermedad de Wilson neurológica se considera una toxicidad al cobre, por lo que es una necesidad la evaluación diagnóstica inmediata y el tratamiento precoz.

La maladie de Wilson est une maladie génétique rare qui provoque un dépôt de cuivre pathologique dans le foie, le cerveau, la cornée, le rein et le muscle cardiaque. Nous présentons deux cas de maladie de Wilson dans sa forme neurologique avec un trouble kinétique progressif et des anneaux de Kayser-Fleischer, avec une hypocuprémie, une hypocéruloplasminémie et une hypercuprurie des 24 h, les transaminases étant normales. L'IRM cérébrale montre des hypersignaux symétriques en FLAIR et T2 des ganglions de la base. Le plus souvent ces cas ne sont pas diagnostiqués et passent inaperçus en raison de la rareté et de la présentation variée de la maladie. Un bilan approfondi est nécessaire pour établir le diagnostic. De même que pour la prise en charge, plus tôt le traitement est instauré, meilleur est le pronostic de guérison. Plusieurs options de traitement sont disponibles qui doivent être adaptées à chaque patient atteint de la maladie de Wilson. La maladie de Wilson sous sa forme neurologique est considérée comme une toxicité au cuivre ; elle nécessite une évaluation diagnostique immédiate et un traitement précoce.

Immunohistochemical profile, pattern of recurrence, and time to progression of non-metastatic breast cancer patients of the Department of Health-Breast Cancer Medicines Access Program

BACKGROUND: Breast cancer remains to be the leading cause of malignancy among women and survival rates vary worldwide. Molecular and immunohistochemical (NC) profiling of breast cancer has emerged to improve treatment, which led to 6 different breast cancer subtypes luminal-A, luminal-B, Her-2 enriched, basal-like, daudin low, and normal breast. Essentially, this guides clinicians as to the choice of treatment and prognostication of disease. This study evaluates the characteristics of the different IHC subtypes of breast cancer among Filipinos as to pattern of recurrence and time to progression (TIP) within their 1st 2 years of follow-up.METHODS: This is a retrospective cohort study, approved by the University of the Philippines Manila Research Ethics Board (UPMREB). Study population included breast cancer patients enrolled in the DOH-BCMAP and managed at the medical oncology clinics of the Philippine General Hospital (PGH) and Jose R. Reyes Memorial Medical Center (JRRMMC) from 1 May 2011 to 31 December 2013. Patients' demographics, disease and treatment profile were gathered from the medical charts. Patients were grouped into 12 different IHC subtypes utilizing only IHC staining results of Her2neu, ER and PR. Disease progression/ relapse and time to progression (UP) were primary outcomes analyzed and compared between subtypes using SPSS.RESULTS: There were 368 eligible patients; 50% were >50 years old, 48% postmenopausal, 34% stage IIA, and 94% had invasive ductal carcinoma. About 88% completed their chemotherapy regimen, mostly AC-T. At 1 to 2 years follow-up, 18% had disease progression, mostly distant metastasis, with HER2neu(-)/ER(-)/PR(-), HER2(+), and HER2neu(-)/ER(+)/PR(+) subtypes having the most number of disease progression. The HER2neu(-)/ER(-)/PR(-) subtype had the shortest median TTP (11 months 9sd). HER2(+) subtype had median TTP of 14±8 sd, while HER2neu(-)/ER(+)/PR(+) had median TTP at 11.6±7.41 sd. The median TTPs among the different IHC subtypes were statistically comparable. CONCLUSION: Filipinas with non-metastatic breast cancer after surgery and mainly on adjuvant chemotherapy started to develop disease progression/ relapse within the first 2 years of follow-up; 82% had no relapse. At these early years of follow-up, the median TTPs among the different breast cancer IHC subtypes who went into relapse were comparable, although HER2neu(+) regardless of ER/PR subtype tended to have more disease progression, followed by HER2neu(-)/ ER(-)/ regardless of PR subtype, and then HER2neu(-)/ ER(+)/ regardless of PR subtype. IHC resultant HER2neu(+) regardless of ER/PR and HER2neu(-)/ER(-)/PR(-/+) subtypes can serve as early prognosticators of breast cancer relapse.  

Impact of histopathological profile on disease progression of breast cancer patients during the 1st 1-2 years follow-up: Evidence from the Philippine DOH-Breast Cancer Medicine Access Program

INTRODUCTION: Current international consensus confirms that certain histopathologic factors such as tumor morphology, histologic grade and presence of lymphovascular invasion are correlated with prognosis. This retrospective cohort study evaluated the correlation between histopathologic profile and time to disease progression (UP) within the first 1-2 years follow-up of Filipino Stage I-Ill early breast cancer patients.METHODS: This is a retrospective cohort study which included breast cancer patients enrolled in the Department of Health¬Breast Cancer Medicine Access Program (DOH-BCMAP) at the medical oncology clinics of two tertiary hospitals in Manila. Clinical and histopathologic factors were gathered from patient records, and the patients were grouped according to the modified St. Gallen definition of risk categories for patients with breast cancer. Kaplan-Meier survival analysis determined the average UP as well as progression-free survival (PFS). Multivariate logistic regression determined factors contributing to disease progression.RESULTS AND CONCLUSION: Of the 326 patients enrolled in this study, 18% showed progression, with a median HP of 14 months. UP was comparable among the low-, intermediate- and high-risk groups. PFS during the 1st 1-2 years follow-up was estimated to be at 78% for the high-risk group, 83% for the intermediate-risk group, and 86% for the low-risk group. During this 1st 1-2 years follow-up, no studied factors of interest were shown to be significantly correlated with outcome among this predominantly intermediate to high risk for recurrence breast cancer patients. Follow-up of this patients up to 5 or more years would define sustained gains from the DOH-BCMAP.

The effect of DOH-PCSI patient navigation access program for breast cancer on quality of care at the Medical Oncology Clinic at the Philippine General Hospital: The 1st 6 months

INTRODUCTION: Cost has become a limiting factor for indigent breast cancer patients at the Philippine General Hospital (PGH). The Department of Health-Philippine Cancer Society Inc (DOH¬PCSI) Access Program for Breast Cancer Medicine provided free chemotherapy through a patient navigation system in PGH starting January 2012 to improve breast cancer treatment quality. This study looked into the differences of quality care in the non-metastatic setting among enrolled patients in the first 6 months compared to patients outside of the program from 2011-2012.METHODS: This retrospective cohort used follow-up rates and 19 quality care indicators linked to improved outcomes to look into quality of care among patients who were enrolled (n=58) and those who were not (n=118 for 2011 and 2012). Subgroup analyses compared patients in the program and those who were not included in the same period (n=28). Another analysis compared 2011 patients (n= 90) with those in 2012 (n=86). Z¬test for the difference of proportions was done.RESULTS: Attrition rate decreased from 62% in 2011 to 18% in 2012 (pConclusion. The DOH-PCSI Access Program for Breast Cancer Medicine program improved care among breast cancer patients in PGH, noted as early as within its first six months.

Adenocarcinomas of appendix: a rare tumor. Two case reports.

Primary Adenocarcinomas of the appendix are rare tumor. Most commonly diagnosis was made after surgical pocedure of appendicectomy for suspect acute appendicitis and the pathology report confirms appendiceal neoplasm. Laboratory exams and imaging show low sensibility and specificity for preoperative diagnosis. We report two cases of primary mucinous adenocarcinoma in caucasian men misdiagnosed as having acute appendicitis. Appendicectomy was done and excised appendix was sent for histopathological examination. Mucinous Adenocarcinoma of the appendix was confirmed after histopathological examination. Right hemicolectomy, peritonectomy and Intraoperative Hyperthermic Chemotherapy were done as a second stage procedure. The surgical treatment of these neoplasms depends from the histological stage and local presentation. Cytoreductive surgery associated with Intraoperative Hyperthermic Chemotherapy show best results in advanced cases.

Laparoscopic management of left paraduodenal hernia. Case report and review of literature.

We report a rare case of left paraduodenal hernia in patient with symptoms of abdominal subobstruction treated successful with laparoscopic management in urgent situation that have reduced the length of stay and postoperative pain. Internal hernia is only 1% of the causes of abdominal obstruction and the left paraduodenal hernia about 50% of them; it is a congenital defect that derive from malrotation and abnormal mesenteric adhesion. The modern imaging techniques help for the correct diagnosis despite difficult identification of the pathology for the various clinical presentation. The treatment of choice is the surgical intervention; the laparoscopic approach is rarely described in literature but it can reduce the morbidity, postoperative pain and the length of hospital stay.

Is HE4 serum level a valid screening test in women candidates for kidney transplant? A case report and a review of literature.

While studying a candidate for kidney transplant it is essential to exclude active malignant diseases. Serum biomarkers help to exclude specific cancers. Tumor markers are proteins secreted by neoplastic cells that can mark their activities. HE4 is a new tumor marker used in ovarian cancer. It is an epithelium protein that appears overexpressed in ovarian cancer, but it is also present in other normal human tissues. Often in patients with kidney failure serum biomarkers are increased compared to healthy people. We report a case of a Caucasian woman suffering from kidney failure examined by our team to be included on the kidney transplantation list. Patient had a known pelvic mass. Determination of serum biomarkers, CA125 and HE4, was performed to exclude pelvic tumor, and we found high levels of HE4 with normal levels of CA125. A new transvaginal ultrasound was performed on the patient and it showed a pelvic mass near the left ovary. This mass resulted bigger than in the previous ultrasound, performed about a month before. We decided to perform a pelvic CT for improved diagnostic accuracy. The reports of this exam showed that the mass was a hematoma correlated with a previous knee prosthetic surgery. Even tough many serum biomarkers are higher in patients with renal failure, there is no study to demonstrate that HE4 blood levels are modified in these patients. This case report shows how HE4 can be elevated in people in hemodialysis in a benign situation, also in a pelvic mass not from the genital tract. There is no similar case described in literature.

Inhibitory effect of Quassia amara Linn. crude bark extract on Entamoeba histolytica in vitro

BACKGROUND: Entamoeba histolytica is an important etiologic agent of diarrhea. Globally, it is estimated to infect 40 to 50 million people and cause 40,000 to 100,000 deaths per year. Metronidazole is effective but can cause adverse reactions in certain individuals. In search of alternatives, traditional medicinal plants are being studied. Several plants in Family Simaroubaceae have shown anti-amoebic activity. Quassia amara, a member of this family has not been tested.OBJECTIVE: To determine the effect of Q. amara crude extract on Entamoeba histolytica in vitro.METHODS: Initial testing of 104 µg/ml ethanolic bark extract was performed. Counts were made after 72 hours. Three trials in triplicates were performed.Nine (9) dilutions of extract were then tested (18.8 to 5,00 µg/ml). Test tubes were checked for viable amoeba after 24-hour and 72-hour incubation. Minimum inhibitory concentrations (MIC) were determined for the two incubation periods. At least two trials in triplicates for each dilution were performed. metronidazole served as positive control.RESULTS: At 104 µg/ml incubated for 72 hours, no viable amoeba was obtained and counted. The MIC after 24 hours was 5,000 µg/ml, while the MIC at 72 hours was 37.5 µg/ml.CONCLUSION: Q. amara crude extract has inhibitory effects on E. histolycain vitro.

Abdominal emergency in elderly: a case of small bowel obstruction and ischemia caused by bulky IA ovarian cancer.

Bowel obstruction resulting from colorectal and ovarian cancer is a serious and distressing complication of these malignancies. This may be caused by diffuse peritoneal carcinomatosis, bulky masses filling the pelvis and abdomen or postoperative adhesions, and should be carefully worked out by pre-operative imaging. We report the case of a small bowel obstruction and intestinal ischemia caused by a bulky (20x40 cm in diameter) cystic ovarian neoplasm that was found to be a stage IA G2 cystadenocarcinoma, successfully managed by uterus-sparing surgery.

MBNL142 and MBNL143 gene isoforms, overexpressed in DM1-patient muscle, encode for nuclear proteins interacting with Src family kinases.

Myotonic dystrophy type-1 (DM1) is the most prevalent form of muscular dystrophy in adults. This disorder is an RNA-dominant disease, caused by expansion of a CTG repeat in the DMPK gene that leads to a misregulation in the alternative splicing of pre-mRNAs. The longer muscleblind-like-1 (MBNL1) transcripts containing exon 5 and the respective protein isoforms (MBNL142-43) were found to be overexpressed in DM1 muscle and localized exclusively in the nuclei. In vitro assays showed that MBNL142-43 bind the Src-homology 3 domain of Src family kinases (SFKs) via their proline-rich motifs, enhancing the SFK activity. Notably, this association was also confirmed in DM1 muscle and myotubes. The recovery, mediated by an siRNA target to Ex5-MBNL142-43, succeeded in reducing the nuclear localization of both Lyn and MBNL142-43 proteins and in decreasing the level of tyrosine phosphorylated proteins. Our results suggest an additional molecular mechanism in the DM1 pathogenesis, based on an altered phosphotyrosine signalling pathway.

Automated three-dimensional coded contrast imaging hysterosalpingo-contrast sonography: feasibility in office tubal patency testing.

OBJECTIVE: To evaluate the feasibility of transvaginal hysterosalpingo-contrast sonography (HyCoSy) with new automated three-dimensional coded contrast imaging (3D-CCI) software in the evaluation of tubal patency and visualization of tubal course. METHODS: Patients undergoing HyCoSy with automated 3D-CCI software were evaluated prospectively. First, to evaluate the feasibility of 3D visualization of tubal course, we performed consecutive volume acquisitions while injecting SonoVue contrast agent. We then performed conventional two-dimensional (2D) real-time HyCoSy to confirm tubal patency status by detection of saline and air bubbles moving through the Fallopian tubes and around the ovaries. We also evaluated visualization with CCI of the contrast agent around the ovaries, side effects and pain during and after the procedure, by visual analog scale (VAS) (ranging from 0 to 10, with 0 corresponding to no pain and 10 corresponding to maximum pain). RESULTS: A total of 126 patients (252 tubes) underwent 3D-CCI HyCoSy followed by 2D real-time HyCoSy. According to the final 2D real-time evaluation, bilateral tubal patency was observed in 111 patients, bilateral tubal occlusion in four patients and unilateral tubal patency in 11 patients. The concordance rate for tubal patency status between the first 3D volume acquisition and the final 2D real-time evaluation was 84% and that between the second 3D volume acquisition and the final 2D real-time evaluation was 97%. A pain score >5 on VAS was recorded in 58% of patients during the procedure, but a pain score ≤ 5 was recorded in 85.7% of patients immediately after the procedure. CONCLUSIONS: HyCoSy with automated 3D-CCI technology retains the advantages of conventional 2D HyCoSy while overcoming the disadvantages. 2D HyCoSy is highly observer-dependent and is only accurate in the hands of experienced investigators; by obtaining a volume of the uterus and tubes, automated 3D volume acquisition permits visualization of the tubes in the coronal view and of the tubal course in 3D space, and should allow less experienced operators to evaluate tubal patency status relatively easily.

Isolated pancreatic tuberculosis: a diagnostic challenge.

Abdominal tuberculosis is quite commonly found in miliary tuberculosis, especially in countries where TB is endemic, however the abdominal localization of tuberculosis in absence of disseminated disease is a rare condition and the involvement of the pancreas alone is extremely rare. Epidemiology of TB is changing in the latest years, often this illness is found in non-endemic regions and physicians are asked to interpret what happen when an old disease meets new diagnostic technologies. We describe the case of a young male admitted in our hospital for abdominal pain. Echotomography, CT scan and MRI showed a pancreatic mass suspected to be cancer and susceptible to surgical treatment, Endoscopic Ultrasound guided fine needle aspiration (FNA) showed isolated pancreatic tuberculosis.