Prospective external validation of IOTA methods for classifying adnexal masses and retrospective assessment of two-step strategy using benign descriptors and ADNEX: a Portuguese multicenter study

OBJECTIVE

This study aimed to externally and prospectively validate the International Ovarian Tumor Analysis (IOTA) Simple Rules (SRs), Logistic Regression model 2 (LR2) and Assessment of Different NEoplasias in the adneXa (ADNEX) in a Portuguese population, comparing them with operator subjective assessment (SA), Risk-of-Malignancy Index (RMI), as well as with each other. This study also aimed to retrospectively validate IOTA two-step strategy, using modified benign descriptors (MBDs) followed by the application of ADNEX in cases where MBDs were not applicable (MBDs + ADNEX).

METHODS

In this multicenter diagnostic accuracy study, conducted between January 2016 and December 2021, three tertiary referral centers prospectively included consecutive patients with ultrasound diagnosis of at least one adnexal tumor who underwent surgery. All ultrasound assessments were performed by level II or III sonologists with IOTA certification. Patient clinical data and serum cancer antigen (CA125) levels were collected from the hospital databases. Each adnexal mass was classified as benign or malignant using SA, RMI, IOTA SRs, LR2 and ADNEX (with and without CA125). The reference standard was histopathological diagnosis. In the second phase, all adnexal tumors were retrospectively classified using the two-step strategy (MBDs + ADNEX). The sensitivity, specificity, positive (PPV) and negative predictive value (NPV), positive (LR+) and negative likelihood ratio (LR-) as well as overall accuracy were determined for SA, RMI, IOTA SRs, LR2, ADNEX and two-step strategy (MBDs + ADNEX). Receiver-operator characteristic curves were constructed and corresponding areas under the curve (AUC) determined for RMI, LR2 and ADNEX and two-step strategy (MBDs + ADNEX). The ADNEX calibration plots were constructed and estimated by LOESS smoother.

RESULTS

Of the 571 included patients, 428 had benign disease, 42 borderline ovarian tumors, 93 primary invasive adnexal cancers and 8 metastatic tumors in adnexa (malignancy prevalence: 25.0%). The operator SA had an overall sensitivity of 97.9% and a specificity of 83.6% for distinguishing between benign and malignant lesions. RMI showed high specificity (95.6%) but very low sensitivity (58.7%), with an AUC of 0.913. The IOTA SRs were applicable in 80.0% of patients, with a sensitivity of 94.8% and a specificity of 98.6%. LR2 revealed a sensitivity of 84.6%, a specificity of 86.9% and an AUC of 0.939, at the malignancy risk cut-off of 10%. At the same cut-off, ADNEX with and without CA125 had a sensitivity of 95.8% and 98.6%, respectively, and a specificity of 82.5% and 79.7%, respectively. The AUC of ADNEX with vs. without CA125 was 0.962 vs. 0.960. The ADNEX model provided heterogeneous results in distinguishing between benign and different subtypes of malignancy, with the highest AUC (0.991) for discriminating benign masses from primary adnexal cancer stage II-IV, and the lowest AUC (0.696) for distinguishing primary adnexal cancer stage I and metastatic lesion in adnexa. The ADNEX calibration plots suggested an underestimation of the predicted risk in relation with the observed proportion of malignancies. The MBDs were applicable in 26.3% of cases (150/571 tumors, none of which were malignant). Similar to the ADNEX model applied in all patients, the two-step strategy using ADNEX in the second step only, with and without CA125, had an AUC of 0.964 and 0.961, respectively.

CONCLUSIONS

Our results showed a good to excellent performance of the IOTA methods in the studied Portuguese population, outperforming RMI. ADNEX was superior in accuracy, but interpretation of its ability to distinguish malignant subtypes was fundamentally limited not only by sample size but also by large differences in the prevalence of tumor subtypes. The IOTA MBDs have been shown to be reliable in identifying benign disease. The two-step strategy based on the application of MBDs, followed by the ADNEX model if MBDs are not applicable, has proven to be suitable for daily practice circumventing the need to use electronic support in all patients. This article is protected by copyright. All rights reserved.

Niti-S Esophageal Mega-Stent: An Emerging Endoscopic Tool with Different Applications in the Management of Surgical Anastomotic Leaks

Introduction

Anastomotic leak (AL) is a dangerous complication in the early postoperative period after total gastrectomy or esophagectomy being associated with high mortality. Self-expandable metal stents (SEMS) play a significant role in AL management. Only one case report described the use of Mega-Stent in AL setting. The authors report a two-case series with different applications of a Niti-S esophageal Mega-Stent in AL management.

Case Report

Case 1 is a 67-year-old male who underwent an esophagectomy due to a squamous cell carcinoma of the distal esophagus. The early postoperative period was complicated with AL and gastropleural fistula. Initially, an OTSC was deployed in the dehiscence but failed to resolve AL. The esophageal Mega-Stent was further placed in-between the esophagus and the bulbus. Post-stenting contrast studies confirmed no further AL.Case 2 is an 86-year-old woman who underwent total gastrectomy with roux-en-y esophagojejunostomy due to a gastric adenocarcinoma, complicated with AL. A partially covered metal stent (PCMS) was placed to cover the anastomosis. Computed tomography confirmed leakage persistence and a second PCMS was deployed, resolving the AL. Several weeks later, both PCMSs presented ingrowth from granulation tissue. An esophageal Mega-Stent was placed (stent-in-stent technique) and 2 weeks later, all stents were removed, with no AL recurrence.

Discussion/Conclusion

SEMS placement for AL is a safe, well-established therapeutic technique. Limitations include stent migration and incomplete cover of large AL. Mega-Stent can be an emerging tool for endoscopic AL management.

Completeness of notifications of accidents involving venomous animals in the Information System for Notifiable Diseases: a descriptive study, Brazil, 2007-2019

OBJECTIVE

to describe the completeness of notifications of accidents involving venomous animals held on the Notifiable Health Conditions Information System (SINAN), in Brazil and its macro-regions, from 2007 to 2019.

METHODS

we analyzed essential and non-mandatory fields for snakebite, spider bite and scorpion sting notifications, considering the following completeness categories: Excellent (≤5.0% incompleteness), Good (5.0% to 10.0%), Regular (10.0% to 20.0%), Poor (20.0% to ≤50.0%) and Very Poor (>50.0%). Proportional change in completeness between 2007 and 2019 was estimated.

RESULTS

1,871,462 notifications were investigated. The "localized manifestations", "systemic manifestations", "case classification", "case progression" and "zone of occurrence" fields had excellent or good completeness. Completeness was regular or poor for the "schooling" and "race/color" fields. The "occupation" field was predominantly poorly or very poorly filled in. There was a proportional worsening in completeness (PC<0) in most regions for the "zone of occurrence", "case progression" and "schooling" fields.

CONCLUSION

completeness of most fields improved, although socioeconomic and occupational fields require more attention.

Long-Term Intestinal Failure and Home Parenteral Support: A Single Center Experience

<b><i>Introduction:</i></b> Home parenteral nutrition (HPN) and/or home parenteral hydration (HPH) are the gold-standard treatment for patients with long-term intestinal failure (IF). The authors aimed to assess the impact of HPN/HPH on nutritional status and survival of long-term IF patients, as well as HPN/HPH-related complications. <b><i>Methods:</i></b> This was a retrospective study including IF patients under HPN/HPH followed in a single large tertiary Portuguese hospital. The data collected included demographics, underlying conditions, anatomical characteristics, type and duration of parenteral support, IF functional, pathophysiological, and clinical classifications, body mass index (BMI) at the beginning and end of follow-up, complications/hospitalizations, current patient status (deceased, alive with HPN/HPH, and alive without HPN/HPH), and cause of death. Survival after HPN/HPH beginning, until death or August 2021, was recorded in months. <b><i>Results:</i></b> Overall 13 patients were included (53.9% female, mean age 63.46 years), and 84.6% of patients presented type III IF and 15.4% type II. Short bowel syndrome caused 76.9% of IF. Nine patients received HPN and 4 HPH. Eight patients (61.5%) were underweight at the beginning of HPN/HPH. At the end of follow-up, 4 patients were alive without HPN/HPH, 4 maintained HPN/HPH, and 5 died. All patients improved their BMI (mean initial BMI 18.9 vs. 23.5 at the end, <i>p</i> &#x3c; 0.001). Eight patients (61.5%) were hospitalized due to catheter-related complications, mainly infectious (mean hospitalization episodes 2.25, mean hospital stay of 24.5 days). No deaths were related to HPN/HPH. <b><i>Conclusion:</i></b> HPN/HPH significantly improved IF patients’ BMI. HPN/HPH-related hospitalizations were common, however causing no deaths, reinforcing that HPN/HPH is an adequate and safe therapy for long-term IF patients.

NOBLADS-External Validation of a Risk Scoring System for Severe Acute Lower Gastrointestinal Bleeding

BACKGROUND

Acute lower gastrointestinal bleeding is a common cause of hospital admission. NOBLADS is a lower gastrointestinal bleeding clinical risk score.

OBJECTIVE

This study aimed to externally validate NOBLADS in predicting severe acute lower gastrointestinal bleeding and clinical outcome.

DESIGN

Observational retrospective study.

SETTING

This study was performed in a single large tertiary hospital.

PATIENTS

Patients who were admitted with acute lower gastrointestinal bleeding during a 15-month period and underwent endoscopic evaluation were included. Patients with chronic lower gastrointestinal bleeding or acute lower gastrointestinal bleeding who were admitted for other conditions were excluded.

MAIN OUTCOME MEASURES

Primary outcome was acute severe lower gastrointestinal bleeding (classified as severe if requires transfusion of >2 units of packed red blood cells and/or produces a >20% hematocrit fall). Secondary outcomes: red blood cells requirement, therapeutic intervention and hospital stay duration. NOBLADS score was applied to all patients. Its accuracy to predict acute severe bleeding and secondary outcomes were studied using receiver operating characteristic analysis.

RESULTS

A total of 173 patients (50.3% males, age 69 ± 17 years) were included. The most common lower gastrointestinal bleeding etiologies were diverticular bleeding (18.5%) and ischemic colitis (15.6%). Fifty patients (28.9%) presented criteria for severe bleeding and 33 patients required instrumental intervention: endoscopic (n = 28), surgical (n = 4), and radiologic (n = 1) therapy. NOBLADS score was significantly different according with acute lower gastrointestinal bleeding causes (p < 0.001) and accurately predicted severe bleeding (area under the receiver operating characteristic curve 0.923 ± 0.018 (p < 0.001)). NOBLADS ≥2 detected acute severe lower gastrointestinal bleeding with 100% sensitivity/62.4% specificity, identifying the need for higher red blood cells requirement (3.6 vs 0.08, p < 0.001), therapeutic intervention (38% vs 13%, p < 0.001), and longer hospital stay (12.8 vs 3 days, p < 0.001).

LIMITATIONS

Unicenter retrospective study; number of unprepared sigmoidoscopies/left side colonoscopies; comparison between NOBLADS and other scoring systems was not performed.

CONCLUSION

NOBLADS is a practical, highly accurate tool and predicts the need of in-hospital management, early colonoscopy, red blood cells transfusion, and longer hospital stay in patients admitted with acute lower gastrointestinal bleeding. See Video Abstract at http://links.lww.com/DCR/B748.NOBLADS: VALIDACIÓN EXTERNA DE UN SISTEMA DE PUNTUACIÓN DE RIESGO PARA HEMORRAGIA DIGESTIVA BAJA AGUDA GRAVE.

ANTECEDENTES

La hemorragia digestiva baja aguda es causa común de admisión hospitalaria. NOBLADS es una puntuación de riesgo clínico de hemorragia gastrointestinal baja.

OBJETIVO

Este estudio tuvo como objetivo validar externamente NOBLADS en la predicción de hemorragia digestiva baja aguda grave y sus resultados clínicos.

DISEO

Estudio observacional retrospectivo.

AJUSTE

Realizado en un gran hospital terciario.

PACIENTES

Se incluyeron todas aquellas personas ingresados con hemorragia digestiva baja aguda durante un período de 15 meses y que fueron sometidos a evaluación endoscópica. Se excluyó la hemorragia digestiva baja crónica o la hemorragia digestiva baja aguda en pacientes ingresados por otras afecciones.

PRINCIPALES MEDIDAS DE RESULTADO

El resultado pricipal fue la hemorragia digestiva baja grave aguda (clasificada como grave si requiere >2 transfusiones de glóbulos rojos y / o produce una caída del hematocrit >20%). Las medidas de resultados secundarias fueron: requerimiento de glóbulos rojos, intervención terapéutica y duración de la estancia hospitalaria. Se aplicó la puntuación NOBLADS a todos los pacientes. Se estudió su precisión para predecir la hemorragia aguda grave y los resultados secundarios mediante análisis ROC.

RESULTADOS

Se incluyeron 173 pacientes (50,3% varones, edad 69 ± 17 años). La etiología de hemorragia digestiva baja más frecuentes fueron: la hemorragia de orígen diverticular (18,5%) y la colitis isquémica (15,6%). 50 pacientes (28,9%) presentaron criterios de sangrado severo y 33 pacientes requirieron intervención instrumental: terapia endoscópica (n = 28), quirúrgica (n = 4), radiológica (n = 1). La puntuación NOBLADS fue significativamente diferente según las causas de hemorragia digestiva baja aguda (p <0,001), siendo precisa para predecir hemorragia grave (AUC 0,923 ± 0,018 (p <0,001). NOBLADS ≥2 detectó hemorragia digestiva baja aguda grave con 100% de sensibilidad / 62,4 % de especificidad, identificando la necesidad de mayor requerimiento de glóbulos rojos (3.6 vs 0.08, p <0.001), intervención terapéutica (38% vs 13%, p <0.001) y estadía hospitalaria más prolongada (12.8 vs 3 días, p <0.001).

LIMITACIONES

Estudio retrospectivo Unicentrico; número de sigmoidoscopias / colonoscopias del lado izquierdo no preparadas; no se realizó comparación entre NOBLADS y otros sistemas de puntuación.

CONCLUSIN

NOBLADS es una herramienta práctica y altamente precisa que predice la necesidad de manejo hospitalario, colonoscopia precoz, transfusión de glóbulos rojos y estadía hospitalaria más prolongada en pacientes ingresados con hemorragia digestiva baja aguda. Consulte Video Resumen en http://links.lww.com/DCR/B748. (Traducción-Dr. Xavier Delgadillo).

Multiple bezoars causing small bowel obstruction: a unique case of resolution with upper and low GI endoscopy

Reports of obstructing foreign bodies in the small bowel are rare and the majority describe surgical resolution. We report a case of successful endoscopic treatment of small bowel obstruction (SBO) caused by multiple bezoars. A 92-year-old woman presented to the emergency department with a history of persistent vomiting. Computed tomography (CT) showed gastric distension and an intraluminal ovaloid foreign body with heterogenous density in the second portion of the duodenum, suggestive of bezoar.

Histologic Features of Colon Biopsies (Geboes Score) Associated With Progression of Ulcerative Colitis for the First 36 Months After Biopsy

BACKGROUND & AIMS

In addition to findings from endoscopy, histologic features of colon biopsies have been associated with outcomes of patients with ulcerative colitis (UC). We investigated associations between Geboes scores (a system to quantify structural changes and inflammatory activity in colon biopsies) and UC progression, and the time period over which this association is valid.

METHODS

We analyzed data from 399 asymptomatic patients with UC enrolled in the ACERTIVE study, followed at 13 inflammatory bowel disease (IBD) centers in Portugal through 31 December 2019. Blood and stool samples were collected and analyzed, and all patients underwent sigmoidoscopy within 24 h of sample collection. We assessed baseline endoscopic status (Mayo endoscopic subscore), histologic features of 2 sigmoid and 2 rectal biopsies (Geboes score), and concentration of fecal calprotectin (FC). The primary outcome was UC progression (surgical, pharmacologic, and clinical events). We generated survival curves for 36 months or less and more than 36 months after biopsy according to Geboes score using the Kaplan-Meier method and compared findings with those from a log rank test. Cox regression was adjusted for Mayo endoscopic subscore, Geboes score, and level of FC; results were expressed as adjusted hazard ratios (HR) with 95% CIs.

RESULTS

Patients with Geboes scores >2B.0, Geboes scores >3.0, or Geboes scores >4.0 had a higher frequency of, and a shorter time to UC progression, than patients with Geboes scores ≤2B.0, Geboes scores ≤3.0, or Geboes score ≤4.0 (P < .001). Disease progression occurred earlier in patients with Geboes scores >2B.0, Geboes scores >3.0, or Geboes scores >4.0 compared with patients with Geboes scores ≤2B.0 (HR, 2.021; 95% CI, 1.158-3.526), Geboes scores ≤3.0 (HR, 2.007; 95% CI, 1.139-3.534), or Geboes scores ≤4.0 (HR, 2.349; 95% CI, 1.269-4.349), respectively, in the first 36 months after biopsy. Similar results were found for patients with concentrations of FC below 150 μg/g.

CONCLUSIONS

We found histologic features of colon biopsies (Geboes score) to be an independent risk factor for progression of UC in the first 36 months after biopsy.

A Unique Case of Recurrent Upper Gastrointestinal Bleeding Caused by Two Metachronous Dieulafoy's Lesions: The Role of EUS Evaluation

Introduction

Dieulafoy's lesion (DL) is a rare but important cause of acute, severe, life-threatening, and recurrent upper gastrointestinal bleeding (UGIB). It is frequently difficult to diagnose DL with upper GI endoscopy (UGIE), and endoscopic ultrasonography (EUS) may be valuable. There are only 2 reported bleeding cases caused by two synchronous DL but no reported cases of two metachronous DL.

Case Report

A 28-year-old healthy male presented with acute severe UGIB. UGIE was inconclusive. Systematic EUS mapping identified a gastric DL. After several attempts of EUS-guided hemostasis, DL was marked using a through-the-scope clip and the patient underwent successful transcatheter arterial embolization (TAE). Three years later, a new severe UGIB episode was caused by a second gastric DL in a different location, which was identified and marked by EUS and further successfully treated through TAE. The patient maintained follow-up without evidence of further bleeding.

Discussion/Conclusion

The authors report a unique case of severe, recurrent UGIB caused by two metachronous gastric DL lesions. The importance of systematic EUS scanning for diagnosis, treatment, and follow-up of DL is emphasized, as well as the potential influence in the outcome of other techniques like angiographic embolization.

Histological Inflammation in the Endoscopically Uninflamed Mucosa is Associated With Worse Outcomes in Limited Ulcerative Colitis

BACKGROUND

The Montreal classification categorizes patients with ulcerative colitis (UC) based on their macroscopic disease extent. Independent of endoscopic extent, biopsies through all colonic segments should be retrieved during index colonoscopy. However, the prognostic value of histological inflammation at diagnosis in the inflamed and uninflamed regions of the colon has never been assessed.

METHODS

This was a multicenter retrospective cohort study of newly diagnosed patients with treatment-naïve proctitis and left-sided UC. Biopsies from at least 2 colonic segments (endoscopically inflamed and uninflamed mucosa) were retrieved and reviewed by 2 pathologists. Histological features in the endoscopically inflamed and uninflamed mucosa were scored using the Nancy score. The primary outcomes were disease complications (proximal disease extension, need for hospitalization or colectomy) and higher therapeutic requirements (need for steroids or for therapy escalation).

RESULTS

Overall, 93 treatment-naïve patients were included, with a median follow-up of 44 months (range, 2-329). The prevalence of any histological inflammation above the endoscopic margin was 71%. Proximal disease extension was more frequent in patients with histological inflammation in the endoscopically uninflamed mucosa at diagnosis (21.5% vs 3.4%, P = 0.04). Histological involvement above the endoscopic margin was the only predictor associated with an earlier need for therapy escalation (adjusted hazard ratio, 3.69; 95% confidence interval, 1.05-13.0); P = 0.04) and disease complications (adjusted hazard ratio, 4.79; 95% confidence interval, 1.10-20.9; P = 0.04).

CONCLUSIONS

The presence of histological inflammation in the endoscopically uninflamed mucosa at the time of diagnosis was associated with worse outcomes in limited UC.

Digestive Oncology in the COVID-19 Pandemic Era

Introduction

Since the rise of the COVID-19 pandemic there has been widespread concern regarding the possible delay in the diagnosis/treatment of cancer patients. We aimed to assess the impact of the COVID-19 pandemic on the diagnosis, treatment, and outcome of patients with digestive cancer.

Methods

This was a retrospective study including patients with an inaugural digestive cancer diagnosis discussed for the first time at our center during the weekly digestive oncology reunion (DOR) meeting. The study group was enlisted from March to August 2020, and a control group was sourced from the equivalent period of 2018. Patients with a previous digestive cancer diagnosis/discussion in the DOR were excluded. The following data were collected: demographics, referral origin, tumor staging, first DOR discussion timing, treatment, and outcome.

Results

A total of 235 patients were included: 107 in the study group (65.4% male, mean age 71.59 years); 128 in the control group (54.7% male, mean age 68.16 years). The mean number of clinical discussions per week was higher in 2018 (13.65 vs. 10.67, p = 0.040), without a difference in the mean number of patients discussed for the first time (inaugural diagnosis) between groups (p = 0.670). In the 2020 study group, more patients were referred to DOR from the emergency room (ER), fewer from the outpatient clinic/hospital wards (p < 0.001), and more were referred after urgent surgery (p = 0.022). There was no difference in the mean waiting time from diagnosis to first DOR discussion (p = 0.087). Tumor staging in colorectal, gastric, and esophageal cancer was not significantly different between the groups (p = 0897, p = 0.168, and p = 0.717). More patients in the study group presented with stage IV pancreatic cancer (p = 0.043). There was no difference in the time span from DOR until the beginning of neoadjuvant chemotherapy (p = 0.680) or elective surgery (p = 0.198), or from surgery until adjuvant chemotherapy (p = 0.396). Also, there was no difference in 30-day mortality from the first DOR date between the groups (p = 0.742).

Conclusion

During the COVID-19 era there was a reduced number of clinical discussions in the DOR, but the number of debated patients with an inaugural digestive cancer diagnosis was similar. In the study group more patients were referred to DOR from the ER, and were referred after urgent surgery, suggesting a delayed demand for clinical attention. Study group patients were not significantly affected by the pandemic regarding timely DOR discussion, beginning of treatment, or 30-day mortality, reflecting the maintenance of the quality of care for digestive cancer patients.

Abstract P1-18-05: Management of bone marrow involvement in advanced breast cancer: Retrospective multicenter cohort study

Background: Optimal management of bone marrow metastasis (BMM) in advanced breast cancer (ABC) remains unknown. Associated severe cytopenias often urge treatment, but they are also a challenging factor for delivering chemotherapy (CT). Since BMM in ABC is infrequent, available data are scarce.

Aim: Clinical and prognostic characterization of ABC patients with BMM and its management; evaluation of the effectiveness of treating BMM with more myelosuppressive CT regimen (that we hypothesized that could be more active in the BMM) Vs. less myelosuppressive regimen.

Methods: Retrospective cohort study of patients with pathological confirmation of BMM (positive myelogram or osteomedullary biopsy) between Jan'2010 and Dec'2016 in the two major Portuguese cancer centers. Patients with diagnosis of a second carcinoma or active hemato-oncological condition within 5 years before BMM were excluded. We considered the more myelosuppressive regimens those with &gt; 5% risk of febrile neutropenia according to Truong et al 2015(1). Kaplan-Meier and log-rank methodology were used to estimate survival and Cox regression to identify the covariates with independent prognostic value. Statistical level of significance was 5%.

Results: We included 74 patients: 74% with disease stage I-III at presentation, 74% ductal and 12% lobular invasive carcinomas, 58% grade 2 and 27% grade 3, 80% hormone receptor + / HER2-, 4% HER2+ and 12% triple negative (TN). Median time from ABC diagnosis to BMM was 10 months (IQR 2-36), synchronous in 34%. At diagnosis of BMM, median age was 57 years-old (IQR 47-65), 57% were post-menopausal, 97% had bone metastasis, 50% had visceral metastasis, 53% performed ≥ 2 previous palliative systemic treatments and 53% were exposed to bisphosphonates. The most frequent immunohistochemistry change in BMM biopsy was the loss of progesterone receptor expression (37%). Bicytopenia (anemia/thrombocytopenia) was the trigger for BMM investigation in 69% of cases, with grade 3-4 anemia in 16% and grade 3-4 thrombocytopenia in 26%. Median survival after BMM diagnosis was 5 months (95% CI, 3-11); overall survival at 12 and 24 months were 35% (CI 26-48%) and 24% (CI 15-36%), respectively. First treatment after BMM was CT in 58% (median survival, 11 months) and endocrine therapy in 14% (median survival, 3 months). An anti-HER2 regimen was used in 4% and 22% did not receive any treatment after BMM. On multivariate analysis, TN subtype (HR 4.02, CI 1.46-11.01), thrombocytopenia (G0 reference; G1-2: HR 2.47, CI 1.11-5.56; G3-4: HR 4.89, CI 1.85-12.91) and ≥ 2 palliative systemic treatments (HR 2.77, CI 1.46-5.27) were associated with worse prognosis. Within those treated with CT, there was a trend for a deleterious survival effect of more myelosuppressive regimens (HR 2.19, CI 0.94-5.09; 5 months Vs. 14 months, n=31), after controlling for subtype, number of previous regimens and thrombocytopenia.

Conclusion: BMM was not a late event in ABC disease course and had worse prognosis in multi-treated patients, in TN subtype and in the presence of thrombocytopenia. No benefit was shown with the use of more myelosuppressive CT regimens.

(1)Truong J et al, Ann Oncol. 2016 Apr;27(4):608-18.

Citation Format: Martins-Branco D, Ferreira SC, Pereira I, André S, Varelas A, Leal C, Esteves S, Abreu MH, Sousa S, Moreira A, Brito M. Management of bone marrow involvement in advanced breast cancer: Retrospective multicenter cohort study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-18-05.

Successful Treatment of Strongyloides stercoralis Hyperinfection in a Kidney Transplant Recipient: Case Report

Strongyloides stercoralis (SS) can cause hyperinfection and disseminated infection in immunosuppressed individuals, with risk of mortality. We report the case of a cadaveric kidney transplant recipient who developed gastrointestinal symptoms and eosinophilia, approximately 3 months after transplantation. Stool examination and esophagogastroduodenoscopy with biopsies were positive for SS larvae. The patient was started on oral ivermectin and immunosuppression was reduced, but still the clinical picture got worse with metabolic ileus and respiratory symptoms, with the need for administration of subcutaneous ivermectin and combined therapy with albendazol. The patient survived and graft function was preserved. The patient was unlikely to be the source of infection. We also present a review of cases of SS infection in kidney transplant recipients.

Suppression of tumor-derived Semaphorin 7A and genetic ablation of host-derived Semaphorin 7A impairs tumor progression in a murine model of advanced breast carcinoma

Solid tumors can generate a plethora of neurogenesis-related molecules that enhance their growth and metastasis. Among them, we have identified axonal guidance molecule Semaphorin 7A (SEMA7A) in breast cancer. The goal of this study was to determine the therapeutic effect of suppressing SEMA7A levels in the 4T1 murine model of advanced breast carcinoma. We used anti-SEMA7A short hairpin RNA (shRNA) to gene silence SEMA7A in 4T1 mammary tumor cells. When implanted into the mammary fat pads of syngeneic mice, SEMA7A shRNA-expressing 4T1 tumors exhibited decreased growth rates, deferred metastasis and reduced mortality. In vitro, SEMA7A shRNA-expressing 4T1 cells had weakened proliferative, migratory and invasive abilities, and decreased levels of mesenchymal factors. Atomic force microscopy studies showed that SEMA7A shRNA-expressing 4T1 cells had an increase in cell stiffness that corresponded with their decreased malignant potential. Genetic ablation of host-derived SEMA7A further enhanced the antitumor effects of SEMA7A shRNA gene silencing in 4T1 cells. Our preclinical findings demonstrate a critical role for SEMA7A in mediating mammary tumor progression.

The First Report of Tomato spotted wilt virus on Gerbera and Chrysanthemun in Venezuela

Gerbera (Gerbera jamesonii) and Chrysanthemum (family Asteraceae) are two of the top 10 cut flowers of the world, with great commercial value. Since 1998, Venezuela began a floral industry to produce and export fresh cut gerbera and chrysanthemum, with 40% of nurseries concentrated in Altos Mirandinos (Miranda State, north central region of the country). For the past 2 years, greenhouse-grown gerbera and chrysanthemum have been observed displaying symptoms resembling those associated with tospoviruses. Symptomatic plants showed concentric rings, irregular chlorotic blotches, and deformation on leaves. Disease incidence was estimated at 30%. Mechanical inoculation with extracts of symptomatic leaves reproduced the typical concentric ring symptoms on indicator plants Arachis hypogaea L. cv. San Martín, Capsicum chinense, and G. jamesonii 6 to 15 days after inoculation. In initial tests, leaves from each 30 symptomatic gerbera and chrysanthemum species from several greenhouse facilities in Altos Mirandinos reacted positively when tested by DAS-ELISA with polyclonal antisera (ATCC, Rockville, MD) raised against Tomato spotted wilt virus (TSWV). Total RNA was extracted with the RNeasy Plant Mini kit (QIAGEN, Hilden, Germany) from two gerbera and two chrysanthemum ELISA-positive samples. The TSWV coat protein gene was amplified by conventional reverse transcription (RT)-PCR using primers CP1 TSWV (TTAACTTACAGCTGCTTT) and CP2 TSWV (CAAAGCATATAAGAACTT) (1). A single DNA product of ~823 bp was amplified from all samples. RT-PCR products were directly sequenced in both orientations and sequences were deposited in GenBank (Accession Nos. KF146700 and KF146701 derived from chrysanthemum, KF146702 and KF146703 derived from gerbera). The resulting sequences showed over 99% identity with each other. and were found to be closely related (over 99%) with TSWV isolates deposited in GenBank originating from different hosts from France (FR693058, FR693055), Montenegro (GU339506, GU339508, GU355940), Italy (HQ830187), New Zealand (KC494501), South Korea (KC261967), and the United States (AY744476). To our knowledge, this is the first confirmed report of TSWV infecting gerbera and chrysanthemum in Venezuela. The relatively widespread occurrence of TSWV in Miranda State underscores the need for systematic surveys to assess its incidence and impact on ornamental crops so that appropriate management tactics can be developed. Reference: (1) R. A. Mumford et al. J. Virol. Methods 57:109, 1996.

[Ectrodactyly of the foot]

BACKGROUND

Ectrodactyly is a congenital malformation characterized by the presence of clefts in the feet accompanied by aplasia and hypoplasia of the phalanges and metatarsals. It is a rare genetic disorder with an incidence of 1:90,000-100,000 live births and it is not linked to sex. Its genetic pattern is autosomal dominant with a variable genetic penetrance. Clinical diagnosis is made at birth, however it can be prenatal through ultrasound during the first trimester. Management of ectrodactyly includes both surgical and non-surgical treatment.

METHODS

We reviewed the archive of medical histories from January 2005 to January 2010, we included all patients with an ectrodactyly diagnosis. We found two patients who were treated surgically and were followed-up for three years.

RESULTS

The long term evolution was favorable, allowing the patient to wear shoes and walk. There were no recurrences or complications observed. The final results were good according to the Tani et al scale.

DISCUSSION

According to our medium and long term results in the management of these two cases of ectrodactyly, we recommend the combination of conservative orthopedic treatment as preparation for surgery and the final resolution with closure of the cleft. The surgical treatment performed and appropriate postoperative management allowed the patient to wear shoes, to improve function and appearance in both cases.

Assessment of genotoxic effects in nurses handling cytostatic drugs

Several antineoplastic drugs have been classified as carcinogens by the International Agency for Research on Cancer (IARC) on the basis of epidemiological findings, animal carcinogenicity data, and outcomes of in vitro genotoxicity studies. 5-Fluorouracil (5-FU), which is easily absorbed through the skin, is the most frequently used antineoplastic agent in Portuguese hospitals and therefore may be used as an indicator of surface contamination. The aims of the present investigation were to (1) examine surface contamination by 5-FU and (2) assess the genotoxic risk using cytokinesis-block micronucleus assay in nurses from two Portuguese hospitals. The study consisted of 2 groups: 27 nurses occupationally exposed to cytostatic agents (cases) and 111 unexposed individuals (controls). Peripheral blood lymphocytes (PBL) were collected in order to measure micronuclei (MN) in both groups. Hospital B showed a higher numerical level of contamination but not significantly different from Hospital A. However; Hospital A presented the highest value of contamination and also a higher proportion of contaminated samples. The mean frequency of MN was significantly higher in exposed workers compared with controls. No significant differences were found among MN levels between the two hospitals. The analysis of confounding factors showed that age is a significant variable in MN frequency occurrence. Data suggest that there is a potential genotoxic damage related to occupational exposure to cytostatic drugs in oncology nurses.

Abstract P3-09-05: Febrile neutropenia in FEC-D regimen for early stage breast cancer, is there a place for G-CSF primary prophylaxis?

Background:

Febrile neutropenia (FN) is a major toxicity of anthracycline-taxane based chemotherapy, which is actually the most active cytotoxic combination for breast cancer treatment. The standard and widely adopted FEC-D regimen reported initially a favorable toxicity profile, with a global and Docetaxel FN rate of 11.2% and 7.4% respectively.

FEC-D has not been commonly considered by guidelines (ASCO, ESMO, EORTC and NCCN) a high risk FN regimen (FN risk ≥20%), and G-CSF primary prophylaxis is therefore not systematically recommended. We aimed to analyze the incidence and severity of FN in FEC-D in our Center.

Methods:

Retrospective study to evaluate the incidence and severity of FN events in a cohort of women with breast cancer consecutively treated in our Center with adjuvant or neoadjuvant FEC-D regimen (5-FU 500 mg/m2, Epirubicin 100 mg/m2, Cyclophosphamide 500 mg/m2 - 3 cycles followed by Docetaxel 100 mg/m2 - 3 cycles). Patients (pts) on concomitant trastuzumab were excluded.

FN was defined as axillary temperature ≥38°C and absolute neutrophil count (ANC) &lt; 500/mm3.

Data is described as median and interquartile range (IQR) / range and association between variables was calculated using relative risk (RR).

Results:

Our cohort consisted of 189 pts treated with FEC-D, 56% adjuvant and 44% in the neoadjuvant setting. Median age was 61 years (IQR: 52-66). In 5% the stage was I, 50% II and in 45% III. Hormonal receptors and HER 2/neu were positive in 80% and 19% pts respectively.

Fifty-one pts (27%) developed at least one episode of FN, 7% (n = 13) during FEC and 21% (n = 40) during docetaxel administration.

There were a total of 61 FN episodes in the 1100 cycles of FEC-D administered (5.6%). The majority (n = 47; 77%) occurred during C4-C6 (Docetaxel cycles), with a predominance of FN events in C4 (46%). Median day of FN presentation was 11 for FEC and 8 for Docetaxel.

In 33 episodes (54.1%) FN resulted in hospital admission for a median duration of 5 days (range: 2-13). There were no deaths related to FN.

Ten pts delayed the subsequent cycle of chemotherapy, nine needed dose intensity reduction and five pts changed chemotherapy regimen, all due to Docetaxel related NF.

The risk of developing a FN episode was globally equal in pts &lt; and ≥ 65 years (RR = 1).

Discussion:

In contrast with the initial results reported for FEC-D, we found a substantial higher than expected rate of FN (&gt; 20%) during FEC-D Docetaxel cycles. Our Docetaxel FN rate is already in line with some other authors experience in out-of-trial patients.

FN had a significant impact on patients care and on healthcare system with hospital admittance and chemotherapy dose or regimen modification needed in approximately half of FN episodes.

Our results were practice-changing in our Center. We now recommend the use of G-CSF primary prophylaxis in all FEC-D pts from cycle 4 to 6.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-09-05.

Effectiveness of a myocardial infarction protocol in reducing door-to-ballon time

BACKGROUND

An adequate door-to-balloon time (<120 minutes) is the necessary condition for the efficacy of primary angioplasty in infarction to translate into effectiveness.

OBJECTIVE

To describe the effectiveness of a quality of care protocol in reducing the door-to-balloon time.

METHODS

Between May 2010 and August 2012, all individuals undergoing primary angioplasty in our hospital were analyzed. The door time was electronically recorded at the moment the patient took a number to be evaluated in the emergency room, which occurred prior to filling the check-in forms and to the triage. The balloon time was defined as the beginning of artery opening (introduction of the first device). The first 5 months of monitoring corresponded to the period of pre-implementation of the protocol. The protocol comprised the definition of a flowchart of actions from patient arrival at the hospital, the team's awareness raising in relation to the prioritization of time, and provision of a periodic feedback on the results and possible inadequacies.

RESULTS

A total of 50 individuals were assessed. They were divided into five groups of 10 sequential patients (one group pre- and four groups post-protocol). The door-to-balloon time regarding the 10 cases recorded before protocol implementation was 200 ± 77 minutes. After protocol implementation, there was a progressive reduction of the door-to-balloon time to 142±78 minutes in the first 10 patients, then to 150±50 minutes, 131±37 minutes and, finally, 116±29 minutes in the three sequential groups of 10 patients, respectively. Linear regression between sequential patients and the door-to-balloon time (r = - 0.41) showed a regression coefficient of - 1.74 minutes.

CONCLUSION

The protocol implementation proved effective in the reduction of the door-to-balloon time.

Relation of severe deficiency of vitamin D to cardiovascular mortality during acute coronary syndromes

Vitamin D deficiency is associated with risk for a first cardiovascular event in the general population, possibly because of inflammation, insulin resistance, and neurohumoral activation. However, its relation with outcomes in acute coronary syndromes has not been reported. To test the hypothesis that severe deficiency of vitamin D is independently associated with cardiovascular mortality during ACS, 206 patients admitted for unstable angina, non-ST-segment elevation myocardial infarction, or ST-segment elevation acute myocardial infarction had 25-hydroxyvitamin D serum levels measured at admission. Severe vitamin D deficiency was defined a priori as a value ≤10 ng/ml. The average concentration of vitamin D was 20 ± 8.2 ng/ml, and 10% of patients were severely deficient (95% confidence interval 6.6% to 15%). Cardiovascular mortality during hospitalization took place in 14 patients, an incidence of 6.8%. Patients with severe vitamin D deficiency had in-hospital cardiovascular mortality of 24%, significantly higher than the 4.9% observed in the remaining patients (relative risk 4.3, 95% confidence interval 1.8 to 10, p = 0.001). After adjustment for Global Registry of Acute Coronary Events (GRACE) score, Gensini angiographic score, and potential confounding variables, severe deficiency of vitamin D remained an independent predictor of in-hospital cardiovascular mortality (odds ratio 14, 95% confidence interval 1.2 to 158, p = 0.03). In conclusion, severe vitamin D deficiency is independently associated with in-hospital cardiovascular mortality in patients with acute coronary syndromes.

Protocol of orofacial myofunctional evaluation: validity and reliability

Short Communication selected from the Oral Presentations of the 56th Congress of the Groupèment International pour la Recherche Scientifique en Stomatologie et Odontologie, Peñafiel (Portugal) May 2012.

Obstructive sleep apnea affects hospital outcomes of patients with non-ST-elevation acute coronary syndromes

STUDY OBJECTIVE

We aimed to test the hypothesis that clinically suspected obstructive sleep apnea (OSA) independently predicts worse in-hospital outcome in patients with non-ST elevation acute coronary syndromes.

DESIGN

At admission, individuals were evaluated for clinical probability of OSA by the Berlin Questionnaire. Primary cardiovascular endpoint was defined as the composite of death, nonfatal myocardial infarction, or refractory angina during hospitalization.

SETTING

Coronary care unit.

PATIENTS

There were 168 consecutive patients admitted with unstable angina or non-ST elevation acute myocardial infarction.

MEASUREMENTS AND RESULTS

During a median hospitalization of 8 days, the incidence of cardiovascular events was 13% (12 deaths, 4 nonfatal myocardial infarctions, and 6 refractory anginas.) Incidence of the primary endpoint was 18% in individuals with high probability of OSA, compared with no events in individuals with low probability (P = 0.002). After logistic regression adjustment for the Global Registry of Acute Coronary Events (GRACE) risk score, anatomic severity of coronary disease, and hospital treatment, probability of OSA remained an independent predictor of events (odds ratio [OR] = 3.4; 95% confidence interval [CI] = 1.3 - 9.0; P = 0.015). Prognostic discrimination of the GRACE score, measured by a C-statistic of 0.72 (95% CI = 0.59-0.85), was significantly improved to 0.82 (95% CI = 0.73-0.92) after inclusion of OSA probability in the predictive model (P = 0.03).

CONCLUSION

Considering the independent prognostic and incremental value of suspected OSA, this condition may represent an aggravating factor for patients with non-ST elevation acute coronary syndrome.

PDE4 control on cAMP/PKA compartmentation revealed by biosensor imaging in neurons

Electrophysiological recordings (using the slow-AHP potassium current) together with novel biosensor imaging methods (with AKAR and Epac sensors) were used in preparations of rodent brain slices to record PKA activation in real time and in individual neurons. The experiments revealed the propagation of the PKA signal from the membrane to the cytosol and eventually to the nucleus. The experiments show how the geometry of the neurons combined with phosphodiesterase activities (mostly rolipram-sensitive PDE4) contributes to a functional compartmentation of the cAMP in subcellular domains.

Accuracy of the GRACE and TIMI scores in predicting the angiographic severity of acute coronary syndrome

BACKGROUND

The accuracy of the GRACE and TIMI scores in predicting coronary disease extension in patients with non-ST-elevation acute coronary syndromes (ACS) has not been established.

OBJECTIVE

To assess the hypothesis that the GRACE and TIMI risk scores satisfactorily predict coronary disease extension in patients withnon-ST-elevation ACS undergoing coronary angiography.

METHODS

Individuals meeting the objective criteria for ACS and undergoing coronary angiography during hospitalization were consecutively assessed. Angiographic coronary disease was described as follows: quantification of coronary disease extension by using Gensini score; presence of any coronary artery obstruction (> 70% or > 50% when affecting left main coronary artery); and presence of severe disease (three-vessel disease or affecting the left main coronary artery).

RESULTS

Of 112 patients assessed, a positive correlation of the Gensini score was observed with the GRACE (p = 0.017) and TIMI (p = 0.02) scores, but that association was weak (r = 0.23 and r = 0.27; respectively). The GRACE score could predict neither obstructive coronary disease (area under the ROC curve = 0.57; 95% CI = 0.46 - 0.69), nor severe coronary disease (ROC = 0.59; 95% CI = 0.48 - 0.70). The TIMI score proved to be a modest predictor of coronary disease (ROC = 0.65; 95% CI = 0.55 - 0.76) and of severe coronary disease (ROC = 0.66; 95% CI = 0.56 - 0.76).

CONCLUSION

(1) There is a positive association between the values of the TIMI or GRACE scores and the extension of coronary artery disease in patients with ACS; (2) however, the degree of that association is not sufficient to make those scores accurate predictors of coronary angiography results.

Causality analysis of the relationship between bleeding and lethality in Acute Coronary Syndromes

BACKGROUND

Hemorrhagic events in Acute Coronary Syndromes (ACS) have been independently associated with death in international multicenter registries. However, that association has not been tested in Brazil and the true causal relationship between bleeding and death has not been completely shown.

OBJECTIVE

To test the following hypotheses: (1) major bleeding is an independent predictor of in-hospital death in ACS; (2) the relationship between those two endpoints is causal.

METHODS

This study included patients meeting predefined criteria of unstable angina, non-ST-segment elevation myocardial infarction or ST-segment elevation myocardial infarction. Major bleeding during hospitalization was defined according to the Bleeding Academic Research Consortium (types 3 or 5). Logistic regression and analysis of the sequence of events were used to assess the association between bleeding and death.

RESULTS

Of the 455 patients studied, 29 experienced major bleeding (6.4%; 95% CI = 4.3-9.0%). They had in-hospital mortality of 21%, as compared with 5.6% of those not experiencing bleeding (RR = 4.0; 95% CI = 1.8-9.1; P = 0.001). After adjusting for the propensity score, major bleeding remained as a predictor of in-hospital death (OR = 3.34; 95% CI = 1.2-9.5; P = 0.02). Of the 29 patients who experienced bleeding, six died. However, the detailed analysis of the sequence of events showed causal relationship only in one case.

CONCLUSION

(1) Major bleeding is an independent predictor of in-hospital death in ACS; (2) the role of bleeding as a risk marker overcomes that as a risk factor for death. This conclusion should be seen as a hypothesis generator to be confirmed by larger-sample studies.