Relative frequency of genomic mutations in SARS-CoV-2 recovered from southern Brazilian cases of COVID-19 through the Gamma, Delta and Omicron waves

The presence of different mutations in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) genome can be related to changes in coronavirus disease (COVID-19) infection. Besides, these viral alterations associated with factors such as massive number of positive cases, vaccination and reinfections can be important in the viral evolution process. As well as, mutations found at low frequencies may have a more neutral action and consequently be less inclined to negative selection, facilitating their spread through the population. Related to that, we aimed to present mutations that are possibly relevant in the process of viral evolution found in 115 SARS-CoV-2 sequences from samples of individuals residing in the metropolitan region of Porto Alegre in the state of Rio Grande do Sul, Brazil. The genome from clinical samples was sequenced using High-Throughput Sequencing (HTS) and analyzed using a workflow to map reads and find variations/SNPs. The samples were separated into 3 groups considering the sample lineage. Of the total number of analyzed sequences, 35 were from the Gamma lineage, 35 from Delta and 45 from Omicron. Amino acid changes present in frequencies lower than 80% of the reads in the sequences were evaluated. 11 common mutations among the samples were found in the Gamma lineage, 1 in the ORF1ab gene, 7 in the S gene, 2 in the ORF6 gene and 1 in the ORF7a gene. While in the Delta lineage, a total of 11 mutations distributed in the ORF1ab, S, ORF7a and N genes, 2, 7, 1 and 1 mutation were found in each gene, respectively. And finally, in the Omicron, 16 mutations were identified, 2 in the ORF1ab gene, 12 in the S gene and 2 in the M gene. In conclusion, we emphasize that genomic surveillance can be a useful tool to assess how mutations play a key role in virus adaptation, and its process of susceptibility to new hosts showing the possible signs of viral evolution.

Diversity of Omicron sublineages and clinical characteristics in hospitalized patients in the southernmost state of Brazil

BACKGROUND

Omicron has become the dominant variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) since first reported in November 2021. From the initially detected Wuhan lineage, sublineages BA.2, BA.4, BA.5, BQ, XAG, and XBB have emerged over time and are dominant in many countries. Therefore, the aim is to evaluate which variants are circulating and the clinical characteristics of inpatients infected with the Omicron variant.

METHODS

This retrospective cohort study selected hospitalized patients admitted with respiratory symptoms to a hospital in the state of Rio Grande do Sul, Brazil, between June and July 2022. SARS-CoV-2 results were analyzed together with clinical outcomes and vaccination status. A viral genome library was prepared and forwarded to the Illumina MiSeq Platform for sequencing.

RESULTS

In total, 37 genomes were sequenced. Concerning the Omicron sublineages, our study detected: BA.1 (21 K), BA.2 (21 L), BA.4 (22A), BA.5 (22B), BA.2.12.1 (22C), BQ.1 (22E), XBB (22F), and XAG recombinant. Omicron BA.5 (30%), BA.2 (19%), and BQ.1 (19%) were the most frequent sublineages, respectively. In total, 38% of patients present hypertension, and the most common symptoms were coughing (62%). Analyzing the COVID-19 vaccination, 30% of patients were fully vaccinated, 49% had a partial vaccination status, and 21% were unvaccinated (no dose).

CONCLUSIONS

BA.5 was the most prevalent sublineage in our study and surpassed the predominance of BA.2, as reported by the national genomic surveillance program. BQ.1 was diagnosed earlier in this study than it was officially reported in the state. Current data have demonstrated that the Omicron variant causes less severe infections, with the high rate of transmissibility and mutational landscape causing the rapid emergence of new sublineages.

DENV-1 genotype V linked to the 2022 dengue epidemic in Southern Brazil

Even though Brazil is a country where the dengue virus (DENV) is endemic, until recently, Southern states did not have significant viral circulation, such as Rio Grande do Sul (RS), and some municipalities were even considered dengue-free. During 2022, these places have shown a sharp increase in the incidence of the disease, apparently following a worldwide growth pattern. Therefore, in this study, we monitor and characterize the genetic diversity of DENV circulating in southern Brazil through next-generation sequencing during an outbreak in 2022. We generated 70 DENV-1 genome sequences, all characterized as genotype V, divided into two clade clusters in the L1 lineage. Furthermore, unique mutations have been described in each clade of L1 lineage. Our results are essential in managing outbreaks since these data provide important information during the emergence of DENV circulation in RS. Since the south of Brazil has a lower viral circulation when compared to other Brazilian states, RS still lacks data that can help in understanding the transmission, dissemination, and evolution of the dengue virus. Hence, genomic surveillance efforts are essential to increase the accuracy of preventive actions and to control viral dissemination.

Reinfection by SARS-CoV-2 by divergent Omicron sublineages, 16 days apart

Since the beginning of the SARS-CoV-2 pandemic, studies on the variants and sublineages stand out, mainly in the cases of reinfection in a short period. In this study, we describe a case of infection by BA.1.1 sublineage in an individual from Southern Brazil. The same patient acquired reinfection with sublineage BA.2 within 16 days after the first detection. The viral extraction and RT-qPCR were performed on the samples LMM72045 (collected in May 2022) and LMM72044 (collected in June 2022). After the confirmation of SARS-CoV-2 infection, we conducted the sequencing and viral genome analysis. This case of reinfection affected a 52-year-old male patient, without comorbidities, with three doses of vaccines against COVID-19, showing symptoms on May 19. These symptoms lasted for approximately six days. The patient returned to work activities on May 30. However, on June 4, the patient felt a new round of clinical signs that lasted for approximately seven days. Analysis of the viral genomes recovered from patients' clinical samples revealed that the two COVID-19 episodes were related to two divergent VOC Omicron sublineages, namely, BA.1.1 for the first round of symptoms and BA.2 for the second infection. Based on our findings, we can say that the present case of reinfection is the shortest described so far.

Prolonged SARS-CoV-2 Infection and Intra-Patient Viral Evolution in an Immunodeficient Child

BACKGROUND

With the progression of the Coronavirus disease pandemic, the number of mutations in the viral genome has increased, showing the adaptive evolution of severe acute respiratory syndrome coronavirus 2 in humans and intensification in transmissibility. Long-term infections also allow the development of viral diversity. In this study, we report the case of a child with severe combined immu presenting a prolonged severe acute respiratory syndrome coronavirus 2 infection. We aimed to analyze 3 naso-oropharyngeal swab samples collected between August and December 2021 to describe the amino acid changes present in the sequence reads that may have a role in the emergence of new viral variants.

METHODS

The whole genome from clinical samples was sequenced through high throughput sequencing and analyzed using a workflow to map reads and then find variations/single-nucleotide polymorphisms. In addition, the samples were isolated in cell culture, and a plaque forming units assay was performed, which indicates the presence of viable viral particles.

RESULTS

The results obtained showed that the virus present in all samples is infectious. Also, there were 20 common mutations among the 3 sequence reads, found in the ORF1ab and ORF10 proteins. As well, a considerable number of uncommon mutations were found.

CONCLUSIONS

In conclusion, we emphasize that genomic surveillance can be a useful tool to assess possible evolution signals in long-term patients.

Viral isolation allows characterization of early samples of SARS-CoV-2 lineage B1.1.33 with unique mutations (S: H655Y and T63N) circulating in Southern Brazil in 2020

Different approaches are in use to improve our knowledge about the causative agent of coronavirus disease (COVID-19). Cell culture-based methods are the better way to perform viral isolation, evaluate viral infectivity, and amplify the virus. Furthermore, next-generation sequencing (NGS) have been essential to analyze a complete genome and to describe new viral species and lineages that have arisen over time. Four naso-oropharyngeal swab samples, collected from April to July of 2020, were isolated and sequenced aiming to produce viral stocks and analyze the mutational profile of the found lineage. B.1.1.33 was the lineage detected in all sequences. Although the samples belong to the same lineage, it was possible to evaluate different mutations found including some that were first described in these sequences, like the S:H655Y and T63N. The results described here can help to elicit how the pandemic started to spread and how it has been evolving in south Brazil.

SARS-CoV-2 and COVID-19: A perspective from environmental virology

December 2019 marked the beginning of the current Coronavirus disease pandemic (COVID-19). Severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) was identified as the causative agent of a viral pneumonia outbreak in Wuhan, Hubei Province, China. The alarming spread levels and clinical severity elevated the status of COVID-19 to the global pandemic by the World Health Organization. In 6 months, more than 25 million cases of infected people and more than 890,000 deaths by COVID-19 had been reported worldwide. The main goal of this review is to shed light upon the current COVID-19 epidemic situation in Brazil with a health approach highlighting some unique environmental, animal and epidemiological aspects.

Quantitative microbial risk assessment of SARS-CoV-2 for workers in wastewater treatment plants

Faecal-oral transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is yet to be validated, but it is a critical issue and additional research is needed to elucidate the risks of the novel coronavirus in sanitation systems. This is the first study that investigates the potential health risks of SARS-CoV-2 in sewage to wastewater treatment plant (WWTP) workers. A quantitative microbial risk assessment (QMRA) is applied for three COVID-19 scenarios (moderate, aggressive and extreme) to study the effects of different stages of the pandemic in terms of percentage of infected population on the probability of infection to WWTP workers. A dose-response model for SARS-CoV-1 (as a surrogate pathogen) is assumed in the QMRA for SARS-CoV-2 using an exponential model with k = 4.1 × 10². Literature data are incorporated to inform assumptions for calculating the viral load, develop the model, and derive a tolerable infection risk. Results reveal that estimates of viral RNA in sewage at the entrance of WWTPs ranged from 4.14 × 10¹ to 5.23 × 10³ GC·mL^-1 (viable virus concentration from 0.04 to 5.23 PFU·mL^-1, respectively). In addition, estimated risks for the aggressive and extreme scenarios (2.6 × 10^-3 and 1.3 × 10^-2, respectively) were likely to be above the derived tolerable infection risk for SARS-CoV-2 of 5.5 × 10^-4 pppy, thus reinforcing the concern of sewage systems as a possible transmission pathway of SARS-CoV-2. These findings are helpful as an early health warning tool and in prioritizing upcoming risk management strategies, such as Emergency Response Plans (ERPs) for water and sanitation operators during the COVID-19 and future pandemics.

Quantitative microbial risk assessment of SARS-CoV-2 for workers in wastewater treatment plants

Faecal-oral transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is yet to be validated, but it is a critical issue and additional research is needed to elucidate the risks of the novel coronavirus in sanitation systems. This is the first study that investigates the potential health risks of SARS-CoV-2 in sewage to wastewater treatment plant (WWTP) workers. A quantitative microbial risk assessment (QMRA) is applied for three COVID-19 scenarios (moderate, aggressive and extreme) to study the effects of different stages of the pandemic in terms of percentage of infected population on the probability of infection to WWTP workers. A dose-response model for SARS-CoV-1 (as a surrogate pathogen) is assumed in the QMRA for SARS-CoV-2 using an exponential model with k = 4.1 × 10². Literature data are incorporated to inform assumptions for calculating the viral load, develop the model, and derive a tolerable infection risk. Results reveal that estimates of viral RNA in sewage at the entrance of WWTPs ranged from 4.14 × 10¹ to 5.23 × 10³ GC·mL^-1 (viable virus concentration from 0.04 to 5.23 PFU·mL^-1, respectively). In addition, estimated risks for the aggressive and extreme scenarios (2.6 × 10^-3 and 1.3 × 10^-2, respectively) were likely to be above the derived tolerable infection risk for SARS-CoV-2 of 5.5 × 10^-4 pppy, thus reinforcing the concern of sewage systems as a possible transmission pathway of SARS-CoV-2. These findings are helpful as an early health warning tool and in prioritizing upcoming risk management strategies, such as Emergency Response Plans (ERPs) for water and sanitation operators during the COVID-19 and future pandemics.

Detection, Quantification, and Microbial Risk Assessment of Group A Rotavirus in Rivers from Uruguay

The aim of this study was to detect, quantify, and assess the risk of infection and illness for Group A Rotavirus (RVA) in the watersheds of the Santa Lucia and Uruguay rivers in Uruguay. Monthly sampling was carried out for one year in six sites in the watershed of the Santa Lucía River and four in the Uruguay River. All the collection sites are used for recreational activities. Viral concentration was performed with the adsorption-elution method, and detection and quantification of RVA was carried out by TaqMan quantitative PCR (qPCR). Quantitative microbial risk assessment was applied to estimate the daily and annual risk of RVA infection, as well as the daily risk of illness considering direct exposure through recreational activity. RVA was detected in 42% (20/48) of the analyzed samples in the Uruguay River and 40% (29/72) in the Santa Lucía River. The virus was present in all the analyzed points in both watersheds. A pattern of seasonality, characterized by a higher detection frequency of the virus during coldest month of the year, was observed in both basins. The mean concentration for RVA was 1.3 × 10⁵ genomic copies/L. The microbiological risk assessment shows that Santa Lucía watershed presented the highest daily risk of infection (6.41E-01) and illness (3.20E-01) estimated for the point downstream of Florida City; meanwhile for Uruguay River, the highest probabilities of infection (6.82E-01) and illness (3.41E-01) were estimated for the collection site for drinking water intake in Salto city. These results suggest that RVA contamination of these important rivers negatively impact on their microbiological quality since they are used for recreation and drinking water intake, demonstrating that the disposal of waste from cities located in their riverside confers a constant threat of infection for the general population, especially for children.

Human mastadenovirus in water, sediment, sea surface microlayer, and bivalve mollusk from southern Brazilian beaches

Anthropogenic contamination of beaches in the south of Brazil was assessed by detection of Escherichia coli, human mastadenovirus species C (HAdV-C) and F (HAdV-F) and hepatitis E virus (HEV). Sampling was carried out in October (2016), and in January, April and July (2017). Water, sediment, sea surface microlayer (SML), bivalves, and air sentinel samples were evaluated. Quantitative microbiological risk assessment (QMRA) was used to estimate the probability of swimmer infection. HAdV-C was present in 26% of the samples, for both qPCR and viral isolation. The highest rates of detection in genomic copies (GC) were in water (2.42E+10 GC/L), SML (2.08E+10 GC/L), sediment (3.82E+08 GC/g) and bivalves (3.91E+07 GC/g). QMRA estimated daily and annual risks with a maximum value (9.99E-01) in almost all of the samples. Viable HAdV-C was often detected in the SML, pointing that this is a source of infection for people bathing in these waters.

'Don't put your head under water': enteric viruses in Brazilian recreational waters

Like in many other countries, virologic analyses are not routinely performed in Brazil in monitoring water quality for recreational purposes. We surveyed current research regarding viral contamination of recreational water environments in Brazil. Among the enteric viruses studied in Brazilian recreational waters, we highlight adenoviruses, rotaviruses, enteroviruses and noroviruses. Although there has been relatively little research on outbreaks related to bathing in recreational water environments in Brazil, noroviruses and adenoviruses are the viruses that are most often related to outbreaks. Better surveillance of the occurrence of enteric viruses in water could improve the assessment of risk to human health as well as indicate the sources of contamination and thus demonstrate the importance of adequate environmental sanitation.

Temporal dynamics of Human mastadenovirus species in cases of respiratory illness in southern Brazil

Human mastadenovirus (HAdV) genus is related to several diseases, among them upper and lower respiratory tract illness. HAdV species B, C, D, and E are mainly associated with respiratory infections. The goal of this work was to identify the HAdV species associated with respiratory infections in hospitalized patients from southern Brazil. Samples were collected from 1996 to 2004 and 2011 to 2017. During this period, 28,524 samples were collected, and 9983 were positive for respiratory viruses, being 435 for HAdV. From these 435 samples, 57 were selected for characterization of HAdV species. For screening the presence of HAdV, a partial sequence of the DNA polymerase gene (DNApol gene) was amplified by nested PCR. Partial nucleotide sequencing was performed in positive samples, and HAdV (DNApol gene) was detected in 53 samples: species B (28; 49.1%), C (16; 28.0%), D (2; 3.5%), E (5; 8.7%), and untyped (2; 3.5%). Specie D was found only in 2017 and specie E in 2011 and 2012. The age of the patients ranged from < 1 to 81 years old, and 62.3% were male. No relationship between gender or age and identified HAdV species were observed. In addition, in the period of 2013-2017, 18 samples from patients who died were analyzed: 11 were related to species B, 4 to C, and 2 to D and 1 remained untyped. Circulation of HAdV species D and E varied over the years, but species B and C were present throughout the evaluated period. In addition, respiratory infections by HAdV affect elderly and children mainly.

Microbial risk assessment in recreational freshwaters from southern Brazil

In this study, total coliforms (TC), Escherichia coli, enterovirus (EV), rotavirus (RV), and human mastadenovirus species C and F (HAdV-C and HAdV-F) were evaluated in water samples from Belo Stream. For HAdV-C and F, the infectivity was assessed by integrated cell culture quantitative real-time polymerase chain reaction (ICC-qPCR). Samples were collected monthly (May/2015 to April/2016) at four sites. Viral analyses were performed for both ultracentrifuge-concentrated and unconcentrated samples. For site P4 (used for recreational purposes), QMRA was applied to estimate health risks associated with exposure to E. coli and HAdV-C and F. TC and E. coli were present throughout the collection period. EV and RV were not detected. HAdV-C were present in 8.51% (1.89E + 06 to 2.28E + 07 GC (Genomic Copies)/L) and 21.27% (2.36E + 05 to 1.29E + 07 GC/L) for unconcentrated and concentrated samples, respectively. For HAdV-F were 12.76% (2.77E + 07 to 3.31E + 08 GC/L) and 48.93% (1.10E + 05 to 4.50E + 08 GC/L) for unconcentrated and concentrated samples, respectively. For unconcentrated samples, infectivity for HAdV-C was detected in 37.20% (1st ICC-qPCR) and 25.58% (2nd ICC-qPCR). For HAdV-F, infectivity was detected in 6.97% (1st ICC-qPCR) and 6.97% (2nd ICC-qPCR). For concentrated samples, HAdV-C infectious was observed in 17.02% (1st ICC-qPCR) and in 8.51% (2nd ICC-qPCR). For HAdV-F, were present in 8.51% for both 1st and 2nd ICC-qPCR. Statistical analyzes showed significant difference between the collection sites when analyzed the molecular data of HAdV-F, data of TC and E. coli. Correlation tests showed direct correlation between HAdV-F with E. coli and TC. E. coli concentrations translated to the lowest estimates of infection risks (8.58E-05 to 2.17E-03). HAdV-F concentrations were associated with the highest infection risks at 9.99E-01 and for group C, 1.29E-01 to 9.99E-01. These results show that commonly used bacterial indicators for water quality may not infer health risks associated with viruses in recreational freshwaters.

Caffeine levels as a predictor of Human mastadenovirus presence in surface waters-a case study in the Sinos River basin-Brazil

The presence of caffeine in environmental water samples is almost entirely human-related, given that there are virtually no industrial or agricultural releases. Caffeine has already been proposed as an anthropogenic marker for wastewater contamination of surface waters. The aim of this study was to evaluate if caffeine concentrations in water can be a predictor of virological and bacteriological contamination. Water samples were taken at three sampling sites from urban water streams from the hydrographic basin of the Sinos River (Brazil) monthly in the period of May 9th, 2016 to April 11th, 2017 (n = 36). Concentrations of Human mastadenovirus (HAdV-F and HAdV-C), fecal coliforms, and caffeine were measured in all collected samples. Concentrations of caffeine in water were strongly correlated with HAdV-F (r_s = 0.704, p = 0.000). This study, for the first time, characterized caffeine concentrations in water as predictors of virus presence, with cut-off values presenting 92.9% specificity and 95.5% sensitivity for HAdV-F and 66.7% specificity and 80% sensitivity for HAdV-C. Considering its marked chemical stability and ease of quantification, caffeine concentrations can be used as a comprehensive marker of human contamination of water resources, also being predictive of bacteriological and virological concentrations.

Assessment of diversity of adenovirus DNA polymerase gene in recreational waters facilitated by ultracentrifugal concentration

Adenoviruses (AdV) are related to respiratory and gastrointestinal diseases in animals and human beings. Their wide genetic diversity in water bodies and their resistance to environmental conditions allow the use of AdV as a reliable marker for detection of fecal contamination. In this work, the diversity of AdV along Belo Stream - in the city of Caxias do Sul, Rio Grande do Sul, Brazil - was evaluated. Samples were compared in both concentrated and unconcentrated forms. The identification of different AdV species was performed by amplifying a partial sequence of the DNA polymerase gene. AdV was detected in 24 out of 55 concentrated samples (43.6%) and the following species were identified: human adenovirus (HAdV) species C (4/55; 7.2%), D (6/55; 10.9%), E (2/55; 3.6%), and F (9/55; 16.3%). AdV related to other mammalian hosts, such as bovine adenovirus (1/55, 1.8%) and murine adenovirus (2/55, 3.6%), have also been identified; 23.6% (13/55) of the unconcentrated samples were positive, and identified as HAdV species C (6/55, 10.9%), D (1/55, 1.8%), and F (6/55, 10.9%). Results obtained evidenced the presence and the great diversity of AdV, mainly of human origin, circulating in Belo Stream. As expected, the concentration step performed helped to detect AdV in more samples.

Enteric viruses and adenovirus diversity in waters from 2016 Olympic venues

Rio de Janeiro's inner and coastal waters are heavily impacted by human sewage pollution for decades. Enteric viruses, including human adenoviruses (HAdV), human enterovirus (EV), group A rotavirus (RV) and hepatitis A virus (HAV) are more likely to be found in contaminated surface waters. The present work aimed to assess the frequency and loads of EV, HAdV-C and -F species, RV and HAV in sand and water samples from venues used during the 2016 Summer Olympics and by tourists attending the event. Sixteen monthly collections were carried out from March 2015 to July 2016 in 12 different sites from Rio de Janeiro, Brazil. Total and thermotolerant coliform counting was performed along molecular detection of virus was performed using quantitative polymerase chain reaction (qPCR). Analyses of all samples were further investigated by integrated cell culture PCR to check about the presence of HAdV infectious virus particles. The results show that 95.9% of water samples showed contamination with at least one type of virus. Regarding the viruses individually (% for water and sand respectively): HAdV-C (93.1%-57.8%), HAdV-F (25.3%-0%), RV (12.3%-4.4%), EV (26.7%-8.8%) and HAV (0%). The viral loads ranged from 10³gc/L up to 10⁹gc/L (water), and 10³gc/g to 10⁶gc/g (sand). In the phylogenetic tree, were classified into four main clusters, referring to species C, D, F and BAdV. And up to 90% of sites studied presented at least once presence of infectious HAdV-C. The most contaminated points were the Rodrigo de Freitas Lagoon, where Olympic rowing took place, and the Marina da Glória, the starting point for the sailing races, demonstrating serious problem of fecal contamination of water resources and threatens the health of Olympic athletes, tourists and residents.

The European Innovation Partnership on Active and Healthy Ageing Synergies: Protocol for a Prospective Observational Study to Measure the Impact of a Community-Based Program on Prevention and Mitigation of Frailty (ICP - PMF) in Community-Dwelling Older Adults

Aim of this paper is to describe the protocol of the study "Impact of a Community-based Program on Prevention and Mitigation of Frailty in community-dwelling older adults" developed in the framework of the European Innovation Partnership on Active and Healthy Ageing. This proposal has been developed by the Partnership Action groups on frailty, fall prevention and polypharmacy in older. The proposal wants to assess the impact of community-based programs aimed to counteract three main outcomes related to frailty: hospitalization, institutionalization and death. Bringing together researchers from seven European countries, the proposal aims to achieve the critical mass and the geographical extension enough to provide information useful to all older European citizens. An observational study will be carried out to calculate the incidence of the different outcomes in relation to the various interventions that will be assessed; results will be compared with data coming from already established national, regional and local dataset using the observed/expected approach. The sample will be made up by at least 2000 citizens for each outcome. All the citizens will be assessed at the baseline with two multidimensional questionnaires: the RISC questionnaire and the Short Functional Geriatric Evaluation questionnaire. The outcomes will be assessed every six-twelve months.

Abstract P3-12-07: Dose delays, dose reductions, and relative dose intensity in early stage breast cancer patients receiving (neo)adjuvant chemotherapy in community oncology practices

Background: Neutropenic complications, such as febrile neutropenia (FN), often necessitate delays or reductions in doses of myelosuppressive chemotherapy. The resulting reduced relative dose intensity (RDI) may lead to poorer disease-free survival and overall survival among patients with early stage (stage I-IIIA) breast cancer (ESBC) (Chirivella, 2009; Wildiers, 2011).

Methods: Using the McKesson Specialty Health/US Oncology iKnowMed™ HER database, we retrospectively identified the first course of (neo)adjuvant chemotherapy received by female adult patients with ESBC who initiated treatment from 1/1/2007-3/31/2011. We then assigned patients to chemotherapy cohorts (standard regimens described in the NCCN breast cancer guidelines or in published phase 3 trials) based on chemotherapy agents received in cycle 1 and planned regimen information in the database. Only standard regimen cohorts containing ≥100 patients were included in this study. For each standard regimen cohort, we estimated the following statistics: the proportion of patients receiving colony-stimulating factor (CSF) prophylaxis in the first 5 days of cycle 1; mean RDI; and the incidences of reduced RDI (&lt;85% over the course), dose delays (≥7 days in any cycle of the course), and dose reductions (≥15% in any cycle of the course) relative to the corresponding standard regimens. We conducted similar analyses of patient subgroups based on patient age and body surface area (BSA) at the time chemotherapy was initiated.

Results:

Study results by standard regimen cohortStandard regimen cohortNAge, mean (SD)CSF prophylaxis in cycle 1,%Mean RDI,% (SE)RDI &lt;85%,%Dose delay ≥7 days,%Dose reduction ≥15%,%TC (4-cycle)3,41457.4 (11.0)50.789.6 (0.3)19.524.623.0TAC1,56750.6 (9.7)91.885.7 (0.5)27.136.234.8Dose-dense AC→Q2W paclitaxel1,27150.9 (10.3)89.193.5 (0.2)15.738.227.1TC (6-cycle)1,18057.3 (11.0)49.983.9 (0.6)34.440.741.7TCH1,13854.2 (11.5)55.679.4 (0.7)43.445.458.5AC→QW paclitaxel42153.9 (11.3)28.390.3 (0.5)21.957.046.6Dose-dense AC40451.9 (10.5)86.180.7 (1.1)42.344.838.4Dose-dense AC→QW paclitaxel38050.5 (10.2)92.191.1 (0.5)25.359.540.5AC39555.4 (11.1)30.482.9 (1.1)33.938.533.2AC→Q3W paclitaxel16655.7 (10.8)38.690.0 (0.7)28.350.644.0AC→docetaxel13456.0 (10.5)33.684.4 (0.9)44.854.576.1TC: docetaxel, cyclophosphamide; TAC: docetaxel, doxorubicin, cyclophosphamide; AC: doxorubicin, cyclophosphamide; TCH: docetaxel, carboplatin, trastuzumab; QW/Q2W/Q3W: every 1/2/3 week(s)

Discussion: Chemotherapy dose delays, dose reductions, and reduced RDI were common in patients with ESBC treated in community oncology practices and their frequencies were higher in older patients and in patients with BSA &gt;2 m2. Further research should evaluate the impact of these factors on patient outcomes.

Study results by patient subgroupSubgroupNMean RDI,% (SE)RDI &lt;85%,%Dose delay ≥7 days,%Dose reduction ≥15%,%Age &lt;503,67788.6 (0.3)23.634.231.2Age 50-644,70487.6 (0.2)25.835.534.0Age 65-741,68784.7 (0.5)32.039.740.5Age ≥7540279.4 (1.2)42.046.549.2BSA ≤2 m28,62787.8 (0.2)25.335.833.5BSA &gt;2 m21,84384.5 (0.4)33.237.639.8

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-12-07.

Laparoscopic repair for recurrent incisional hernias: a single institute experience of 10 years

PURPOSE

The treatment of recurrent incisional hernias (RIH) has been associated with unsatisfactory postoperative (PO) morbidity and high failure rates. The aim of this study is to retrospectively investigate our single-center experience of laparoscopic repair (LR) for RIH.

METHODS

The case records of 69 patients with RIH who underwent LR in our institution between January 2002 and November 2011 were reviewed. The operative technique has been standardized and provides onlay placement of an ePTFE mesh fixed with titanium tacks. Patients' demographic data and comorbidities, intraoperative course, PO complications and recurrences at follow-up were systematically collected and analyzed. The influence of defect's size and obesity variables on clinical outcomes was also investigated.

RESULTS

The mean operative time was 147.6 ± 71.2 min and mean hospital stay was 5.8 ± 1.8 days. No conversion occurred while five intraoperative complications (7.2 %) were recorded: three bowel injuries treated by laparoscopic sutures, one omentum bleeding and one epigastric vessel lesion. PO mortality was null, while overall morbidity was 13 % (9 patients) with a prevalence of seroma lasting over 8 weeks in six patients (8.7 %). Along a mean follow-up of 41 months (range 6-119), recurrence rate was 5.7 % (4 patients). Univariate analysis for width of defects and BMI showed no significant influence on patients' outcomes.

CONCLUSIONS

Surgical treatment for RIH remains controversial because of lack in literature of specific studies on this topic. Morbid obesity and large defects have been often associated with technical difficulties and worse results. Our 10 years' experience with LR provided satisfactory results in terms of PO morbidity and recurrence rate, despite any kind of patient selection.

Multifocal, multicentric and contralateral breast cancers: breast MR imaging in the preoperative evaluation of patients with newly diagnosed breast cancer

PURPOSE

This study was done to verify the usefulness of preoperative breast magnetic resonance (MR) imaging in patients with newly diagnosed breast cancer.

MATERIALS AND METHODS

A retrospective analysis of 291 patients with invasive breast cancer newly diagnosed with conventional breast imaging (mammography and ultrasound) was performed. All patients underwent MR imaging prior to surgery. The MR imaging detection rate of additional malignant cancers occult to mammography and ultrasound was calculated. Data were analysed with Fisher's exact test (p<0.05) according to the following parameters: histopathological features of the index tumour (histological type and size) and mammographic density [according to the Breast Imaging Reporting and Data System (BI-RADS) classification from 1 fatty to 4 dense). The gold standard was the histological examination on the surgical specimen.

RESULTS

MR imaging identified 40 mammographically and sonographically occult malignant lesions other than the index cancer in 27/291 patients (9%). These additional cancers were located in the same quadrant as the index cancer in 13 women (4%), in a different quadrant in 12 (4%) and in the contralateral breast in the remaining two (1%). The cancer detection rate in the subgroup of index cancers with lobular histological type was 25%, significantly higher (p=0.03) than the detection rate of 11% recorded in the subgroup of ductal cancers. The cancer detection rate in the subgroup of index cancers >2 cm was 27%, significantly higher (p=0.001) than the rate of 8% found in the subgroup of index cancers <2 cm. Mammographic density was not correlated (p=0.48) with MR detection of additional cancer, with 14% of additional malignancies being detected in both dense and fatty breasts.

CONCLUSIONS

In patients with newly diagnosed invasive breast cancer, preoperative MR imaging is useful for detecting additional synchronous malignancies that are not detected on conventional breast imaging. The cancer detection rate is 9%. The use of preoperative MR imaging as an adjunct to conventional breast imaging in women with an infiltrating lobular index cancer and an index cancer >2 cm is especially beneficial.

Autoimmune pancreatitis: imaging findings on contrast-enhanced MR, MRCP and dynamic secretin-enhanced MRCP

PURPOSE

This study retrospectively determined magnetic resonance (MR), MR cholangiopancreatography (MRCP) and secretin-MRCP findings in patients with autoimmune pancreatitis (AIP).

MATERIALS AND METHODS

The MR examinations of 28 patients with histopathologically proven AIP were reviewed. In 14 cases, secretin-enhanced MRCP was performed. The observers evaluated pancreatic parenchymal enlargement, signal intensity abnormalities, enhancement, vascular involvement, bile-duct diameter and main pancreatic duct (MPD) narrowing (diffuse/focal/segmental). After secretin administration, the presence of the "duct-penetrating" sign was evaluated.

RESULTS

MR imaging showed diffuse pancreatic enlargement in 8/28(29%) cases, focal pancreatic enlargement in 16/28 (57%) cases and no enlargement in 4/28 (14%) cases. The alteration of pancreatic signal intensity was diffuse in 8/28 (29%) cases (eight diffuse AIP) and focal in 20/28 (71%) cases (20 focal AIP). Delayed pancreatic enhancement was present in all AIP, with peripheral rim of enhancement in 8/28 (29%) AIP (1/8 diffuse, 7/20 focal); vascular encasement was present in 7/28 (25%) AIP (1/8 diffuse, 6/20 focal); distal common bile duct narrowing was present in 12/28(43%) AIP (5/8 diffuse, 7/20 focal). MRCP showed MPD narrowing in 17/28 (61%) AIP (4/8 diffuse, 15/20 focal), MPD dilation in 8/28(29%) AIP (3/8 diffuse, 5/20 focal) and normal MPD in 1/8 diffuse AIP. Secretin-MRCP showed the duct-penetrating sign in 6/14(43%) AIP (one diffuse AIP with MPD segmental narrowing, five focal AIP with MPD focal narrowing), demonstrating integrity of the MPD.

CONCLUSIONS

Delayed enhancement and MPD stenosis are suggestive for AIP on MR and MRCP imaging. Secretin-enhanced MRCP is a problem-solving tool in the differential diagnosis between focal AIP and ductal adenocarcinoma.

Combined radiofrequency and kyphoplasty in painful osteolytic metastases to vertebral bodies

PURPOSE

The aim of this study was to assess retrospectively the safety and efficacy of combined radiofrequency (RF) and kyphoplasty (KP) in managing painful osteolytic metastases to vertebral bodies resistant to conservative treatments.

MATERIALS AND METHODS

Eleven patients (9 women and 2 men; mean age 68 years; age range 58-82) with painful osteolytic vertebral body metastases unresponsive to conservative treatments underwent RF combined with KP under general anaesthesia. Primary neoplasms were kidney carcinoma (n=1), breast carcinoma (n=1), thyroid carcinoma (n=2) and multiple myeloma (n=7). Lesion levels were cervical (n=1), thoracic (n=9) and lumbar (n=1). Combined RF and KP was well-tolerated by all patients. The procedures were performed using fluoroscopic guidance and intraoperative neurophysiology monitoring. Pain relief with the visual analogue scale (VAS) pain score and analgesic consumption were evaluated before and after treatment.

RESULTS

No complication occurred. In one case, we observed an asymptomatic cement leakage. Pain significantly decreased after treatment: the mean VAS pain score before treatment was 8 (range 7-10) vs. 1.8 (range 0-3) and 1.9 (range 1-3), respectively, 72 h and 6 weeks after the treatment. Analgesic reduction was achieved in all patients.

CONCLUSIONS

RF combined with KP represents a potential alternative method for palliation of painful spinal osteolytic metastases in selected patients. The procedures are safe and provide pain relief with bone augmentation and improvement in quality of life.

Natural orifices transluminal endoscopic surgery (NOTES): an overview of technical challenges and complications of transgastric procedures in anesthetized pigs

AIM

Natural orifice transluminal endoscopic surgery (NOTES) is a new reality that is progressively gaining popularity in the scientific community. The aim of this study was to report the authors' experience with various peroral transgastric procedures performed on the porcine model. The technical difficulties and challenges that arose were also analyzed.

METHODS

Ten anesthetized pigs, divided into an acute (3) and a survival group (7) underwent the following procedures using a double channel endoscope: peritoneoscopy (10), cholecystectomy (6),splenectomy (3), and gastrojejunostomy (3).

RESULTS

All the procedures were completed successfully. There was one complication related to the gastric wall incision. In the survival experiment group all pigs (4) submitted to biliare procedures made an uncomplicated recovery after a follow-up period of 2 weeks. Gastrojejunostomies (3) were instead graved by one technical failure (anastomosis disruption at post-mortem examination) and one case of mortality (premature euthanasia for evidences of sepsis). Complete gastric cleansing was impossible to achieve and overinflation was a common problem. The creation of gastro-enteric anastomoses was technically difficult with the current available devices.

CONCLUSION

Transgastric endoscopic surgery is technically feasible in a porcine model. A new instrumentation is needed and could strongly help to overcome the technical difficulties highlighted. More extensive animal studies are mandatory in order to evaluate the benefits and the limitations of this new technique.

Assessment of pelvic endometriosis: correlation of US and MRI with laparoscopic findings

PURPOSE

The purpose of this study was to evaluate the contribution of ultrasound (US) and magnetic resonance (MR) imaging in the diagnosis and local staging of endometriosis by comparing results with laparoscopic findings.

MATERIALS AND METHODS

We evaluated 36 consecutive women with suspected or clinically diagnosed endometriosis. Thirty-two out of 36 patients met the following inclusion criteria: transabdominal and endocavitary (US) examination and MR imaging, followed by laparoscopy performed within 2 weeks. US and MR findings were classified based on location, number and morphology (small nodules, large nodules, laminar lesions, cystic lesions, complex lesions, adhesions, cul-de-sac obliteration).

RESULTS

Laparoscopy, considered the gold standard, identified 143 lesions in 32 patients. US detected 101 lesions, and MR detected 92 lesions, which were subsequently divided by morphologic appearance. Sensitivity and specificity of the two imaging techniques in the recognition of the different locations were 58% and 25%, respectively, for US and 56% and 50%, respectively, for MR imaging. Results of the two techniques in the different locations examined were similar, with the exception of lesions in the rectovaginal septum, which were better detected by US, and for adhesions and cul-de-sac obliteration, which were more easily detected by MR.

CONCLUSIONS

Both US and MR are accurate in the diagnosis of endometriosis. There are no significant differences in staging of pelvic endometriosis between US and MR. US examination is the primary evaluation in cases of suspected disease and for the rectovaginal septum. MR examination is recommended for correct classification in doubtful cases and in cases of suspected extrapelvic lesions and adhesions.

Branch duct IPMTs: value of cross-sectional imaging in the assessment of biological behavior and follow-up

Branch duct intraductal papillary mucinous tumors (IPMTs) are increasingly being described and represent a challenge for the physician. Recent imaging modalities, especially computed tomography and magnetic resonance, allow for a correct diagnosis, but IPMTs can manifest with different degrees of cellular atypia so it is very important to be able to establish the biological behavior of the lesion. Sixty-five patients were included in this study: 29 of them underwent surgery, and the other 36 were followed with cross-sectional imaging. Among patients who underwent surgery, 11 had benign lesions and 18 had malignant lesions. Overall sensitivity, specificity, and accuracy in the diagnosis of malignancy for all the cross-sectional imaging techniques were 61%, 81%, and 69%, respectively. Among patients who were followed and had a magnetic resonance cholangiopancreatographic diagnosis of branch duct IPMT with imaging features indicative of benignity, only two showed modifications over the follow-up period. Even considering some important biases (small number of patients and relatively short follow-up), interesting conclusions can be drawn: the imaging diagnosis of malignancy can be trusted, whereas that of benignity cannot be relied upon, but if the signs of malignancy are absent, the slow growth of the lesions justifies watchful follow-up in the correct clinical setting.

[Determination of bone mineral content and correlations with calciotropic hormones in periodic hemodialysis patients]

The investigation on several forms of uremic osteodystrophy by means of bone mineral content (BMC) measurement led to contradictory conclusions. BMC in 27 patients on periodical hemodialysis treatment was measured correlating it to the seric levels of Ca, P, Mg, alkaline phosphatase (AP), calcitonin (Ct), osteocalcin (BGP), intact parathormone (PTHi), c-terminal and mean molecule PTH. Patients on dialysis treatment from a long period of time showed high AP and low BMC levels. This correlation proved significant just for the values recorded at a third distal site of radius. Patients with BMC under the normal range showed higher BGP levels and a longer period of dialytic treatment than those presenting normal BMC. The former showed a Ct inverse correlation as to age and mineralization indexes. Higher values of Ct and BMC have been reported in males rather than in females. Hence BMC is not suited to investigate different kinds of uremic osteodystrophy. Seric PTH dosage is certainly best fitted to discriminate patients affected with hyperparathyroidism from those with low turnover osteodystrophy. BMC determination is a valid support to evaluate the bone mineral loss in patients on haemodialysis treatment. It significatively correlates to the duration of the dialytic treatment; it is higher in female than in male population; it mainly affects cortical components rather than trabecular ones and is related to a seric Ct decrease.