Low-count monoclonal B-cell lymphocytosis persists after seven years of follow up and is associated with a poorer outcome

Low-count monoclonal B-cell lymphocytosis is defined by the presence of very low numbers of circulating clonal B cells, usually phenotypically similar to chronic lymphocytic leukemia cells, whose biological and clinical significance remains elusive. Herein, we re-evaluated 65/91 low-count monoclonal B-cell lymphocytosis cases (54 chronic lymphocytic leukemia-like and 11 non-chronic lymphocytic leukemia-like) followed-up for a median of seven years, using high-sensitivity flow cytometry and interphase fluorescence in situ hybridization. Overall, the clone size significantly increased in 69% of low-count monoclonal B-cell lymphocytosis cases, but only one subject progressed to high-count monoclonal B-cell lymphocytosis. In parallel, the frequency of cytogenetic alterations increased over time (32% vs. 61% of cases, respectively). The absolute number of the major T-cell and natural killer cell populations also increased, but only among chronic lymphocytic leukemia-like cases with increased clone size vs. age- and sex-matched controls. Although progression to chronic lymphocytic leukemia was not observed, the overall survival of low-count monoclonal B-cell lymphocytosis individuals was significantly reduced vs. non-monoclonal B-cell lymphocytosis controls (P=0.03) plus the general population from the same region (P≤0.001), particularly among females (P=0.01); infection and cancer were the main causes of death in low-count monoclonal B-cell lymphocytosis. In summary, despite the fact that mid-term progression from low-count monoclonal B-cell lymphocytosis to high-count monoclonal B-cell lymphocytosis and chronic lymphocytic leukemia appears to be unlikely, these clones persist at increased numbers, usually carrying more genetic alterations, and might thus be a marker of an impaired immune system indirectly associated with a poorer outcome, particularly among females.This work was supported by the RD06/0020/0035 and RD12/0036/0048 grants from Red Temática de Investigación Cooperativa en Cáncer (RTICC), Instituto de Salud Carlos III, Ministerio de Economía y Competitividad, (Madrid, Spain and FONDOS FEDER); CB16/12/00400 grant (CIBERONC, Instituto de Salud Carlos III, Ministerio de Economía y Competitividad, (Madrid, Spain and FONDOS FEDER); the FIS PI06/0824-FEDER, PS09/02430-FEDER, PI12/00905- FEDER, DTS15/00119-FEDER, PI16/00787-FEDER and PI17/00399-FEDER grants, from the Fondo de Investigación Sanitaria of Instituto de Salud Carlos III; the GRS206/A/08 grant, (Ayuda al Grupo GR37 de Excelencia, SAN/1778/2009) from the Gerencia Regional de Salud (Consejería de Educación and Consejería de Sanidad of Castilla y León, Valladolid, Spain) and the SA079U14 grant (Consejería de Educación and Consejería de Sanidad of Castilla y León, Valladolid, Spain). ML Gutiérrez is supported by grant PTA2014-09963-I from the Instituto de Salud Carlos III

Residual normal B-cell profiles in monoclonal B-cell lymphocytosis versus chronic lymphocytic leukemia

© The Author(s) 2018.Chronic lymphocytic leukemia (CLL) is the most common adult leukemia in Western countries, which is characterized by the accumulation of mature CD5+/CD20lo/CD23+ clonal B-cells in peripheral blood (PB), bone marrow (BM), and other lymphoid tissues [1]. Currently, it is well-established that CLL is systematically preceded by a pre-leukemic stage, known as monoclonal B-cell lymphocytosis (MBL) [2]; MBL includes both low-count (MBLlo) and high-count MBL (MBLhi), depending on the number of PB clonal B-cells (70 y) [4, 5]. The biological and clinical significance of CLL-like clonal B-cells in PB of otherwise healthy individuals (MBLlo) has not been fully elucidated [6,7,8]. Recently, we have reported a very low rate of transformation of MBLlo to MBLhi/CLL, after 7 years of follow-up [8]. In contrast, we found a higher frequency of deaths in MBLlo subjects vs. age- and sex-matched non-MBL healthy adults from the same geographical area; among the former subjects, infection was an overrepresented cause of death (21% vs. 2%, respectively) [8]. This is in line with previous studies showing an ≈3-fold increased risk of infection in both MBLhi and CLL patients, in whom infections also represent a major cause of death [9, 10].This work was supported by the RD06/0020/0035 and RD12/0036/0048 grants from Red Temática de Investigación Cooperativa en Cáncer (RTICC), Instituto de Salud Carlos III, Ministerio de Economía y Competitividad, (Madrid, Spain and FONDOS FEDER); CB16/12/00400 and CB16/12/00233 grants, CIBERONC, Instituto de Salud Carlos III, Ministerio de Economía y Competitividad, (Madrid, Spain and FONDOS FEDER); the FIS PI06/0824-FEDER, PS09/02430-FEDER, PI12/00905-FEDER, DTS15/00119-FEDER, and PI17/00399-FEDER grants, from the Fondo de Investigación Sanitaria of Instituto de Salud Carlos III; the GRS206/A/08 grant (Ayuda al Grupo GR37 de Excelencia, SAN/1778/2009) from the Gerencia Regional de Salud (Consejería de Educación and Consejería de Sanidad of Castilla y León, Valladolid, Spain). MLG is supported by grant PTA2014-09963-I from the Instituto de Salud Carlos III and AR-C is supported by grant CB16/12/00400, Instituto de Salud Carlos III, Ministerio de Economía y Competitividad

Host virus and pneumococcus-specific immune responses in high-count monoclonal B-cell lymphocytosis and chronic lymphocytic leukemia: implications for disease progression

[EN]Patients diagnosed with chronic lymphocytic leukemia (CLL) display a high incidence of infections due to an associated immunodeficiency that includes hypogammaglobulinemia. A higher risk of infections has also been recently reported for high-count monoclonal B-cell lymphocytosis, while no information is available in low-count monoclonal B-cell lymphocytosis. Here, we evaluated the status of the humoral immune system in patients with chronic lymphocytic leukemia (n=58), as well as in low- (n=71) and high- (n=29) count monoclonal B-cell lymphocytosis versus healthy donors (n=91). Total free plasma immunoglobulin titers and specific levels of antibodies against cytomegalovirus, Epstein-Barr virus, influenza and S.pneumoniae were measured by nephelometry and ELISA-based techniques, respectively. Overall, our results show that both CLL and high-count monoclonal B-cell lymphocytosis patients, but not low-count monoclonal B-cell lymphocytosis subjects, present with relatively high levels of antibodies specific for the latent viruses investigated, associated with progressively lower levels of S.pneumoniae-specific immunoglobulins

Common Infectious Agents and Monoclonal B-cell Lymphocytosis: A Cross-sectional Epidemiological Study Among Healthy Adults

Background: Risk factors associated with monoclonal B-cell lymphocytosis (MBL), a potential precursor of chronic lymphocytic leukaemia (CLL), remain unknown. Methods: Using a cross-sectional study design, we investigated demographic, medical and behavioural risk factors associated with MBL. "Low-count" MBL (cases) were defined as individuals with very low median absolute count of clonal B-cells, identified from screening of healthy individuals and the remainder classified as controls. 452 individuals completed a questionnaire with their general practitioner, both blind to the MBL status of the subject. Odds ratios (OR) and 95% confidence interval (CI) for MBL were estimated by means of unconditional logistic regression adjusted for confounding factors. Results: MBL were detected in 72/452 subjects (16%). Increasing age was strongly associated with MBL (P-trend<0.001). MBL was significantly less common among individuals vaccinated against pneumococcal or influenza (OR 0.49, 95% confidence interval (CI): 0.25 to 0.95; P-value = 0.03 and OR: 0.52, 95% CI: 0.29 to 0.93, P-value = 0.03, respectively). Albeit based on small numbers, cases were more likely to report infectious diseases among their children, respiratory disease among their siblings and personal history of pneumonia and meningitis. No other distinguishing epidemiological features were identified except for family history of cancer and an inverse relationship with diabetes treatment. All associations described above were retained after restricting the analysis to CLL-like MBL. Conclusion: Overall, these findings suggest that exposure to infectious agents leading to serious clinical manifestations in the patient or its surroundings may trigger immune events leading to MBL. This exploratory study provides initial insights and directions for future research related to MBL, a potential precursor of chronic lymphocytic leukaemia. Further work is warranted to confirm these findings

Low-count monoclonal B-cell lymphocytosis persists after seven years of follow up and is associated with a poorer outcome

[EN]Low-count monoclonal B-cell lymphocytosis is defined by the presence of very low numbers of circulating clonal B cells, usually phenotypically similar to chronic lymphocytic leukemia cells, whose biological and clinical significance remains elusive. Herein, we re-evaluated 65/91 low-count monoclonal B-cell lymphocytosis cases (54 chronic lymphocytic leukemia-like and 11 non-chronic lymphocytic leukemialike) followed-up for a median of seven years, using high-sensitivity flow cytometry and interphase fluorescence in situ hybridization. Overall, the clone size significantly increased in 69% of low-count monoclonal B-cell lymphocytosis cases, but only one subject progressed to high-count monoclonal B-cell lymphocytosis. In parallel, the frequency of cytogenetic alterations increased over time (32% vs. 61% of cases, respectively). The absolute number of the major T-cell and natural killer cell populations also increased, but only among chronic lymphocytic leukemia-like cases with increased clone size vs. age- and sex-matched controls. Although progression to chronic lymphocytic leukemia was not observed, the overall survival of low-count monoclonal B-cell lymphocytosis individuals was significantly reduced vs. non-monoclonal Bcell lymphocytosis controls (P=0.03) plus the general population from the same region (P≤0.001), particularly among females (P=0.01); infection and cancer were the main causes of death in low-count monoclonal B-cell lymphocytosis. In summary, despite the fact that mid-term progression from low-count monoclonal B-cell lymphocytosis to high-count monoclonal B-cell lymphocytosis and chronic lymphocytic leukemia appears to be unlikely, these clones persist at increased numbers, usually carrying more genetic alterations, and might thus be a marker of an impaired immune system indirectly associated with a poorer outcome, particularly among females

Effectiveness of an intervention for improving drug prescription in primary care patients with multimorbidity and polypharmacy:Study protocol of a cluster randomized clinical trial (Multi-PAP project)

This study was funded by the Fondo de Investigaciones Sanitarias ISCIII (Grant Numbers PI15/00276, PI15/00572, PI15/00996), REDISSEC (Project Numbers RD12/0001/0012, RD16/0001/0005), and the European Regional Development Fund ("A way to build Europe").Background: Multimorbidity is associated with negative effects both on people's health and on healthcare systems. A key problem linked to multimorbidity is polypharmacy, which in turn is associated with increased risk of partly preventable adverse effects, including mortality. The Ariadne principles describe a model of care based on a thorough assessment of diseases, treatments (and potential interactions), clinical status, context and preferences of patients with multimorbidity, with the aim of prioritizing and sharing realistic treatment goals that guide an individualized management. The aim of this study is to evaluate the effectiveness of a complex intervention that implements the Ariadne principles in a population of young-old patients with multimorbidity and polypharmacy. The intervention seeks to improve the appropriateness of prescribing in primary care (PC), as measured by the medication appropriateness index (MAI) score at 6 and 12months, as compared with usual care. Methods/Design: Design:pragmatic cluster randomized clinical trial. Unit of randomization: family physician (FP). Unit of analysis: patient. Scope: PC health centres in three autonomous communities: Aragon, Madrid, and Andalusia (Spain). Population: patients aged 65-74years with multimorbidity (≥3 chronic diseases) and polypharmacy (≥5 drugs prescribed in ≥3months). Sample size: n=400 (200 per study arm). Intervention: complex intervention based on the implementation of the Ariadne principles with two components: (1) FP training and (2) FP-patient interview. Outcomes: MAI score, health services use, quality of life (Euroqol 5D-5L), pharmacotherapy and adherence to treatment (Morisky-Green, Haynes-Sackett), and clinical and socio-demographic variables. Statistical analysis: primary outcome is the difference in MAI score between T0 and T1 and corresponding 95% confidence interval. Adjustment for confounding factors will be performed by multilevel analysis. All analyses will be carried out in accordance with the intention-to-treat principle. Discussion: It is essential to provide evidence concerning interventions on PC patients with polypharmacy and multimorbidity, conducted in the context of routine clinical practice, and involving young-old patients with significant potential for preventing negative health outcomes. Trial registration: Clinicaltrials.gov, NCT02866799Publisher PDFPeer reviewe

Programa Curricular de Educación Básica Alternativa. Ciclos Inicial - Intermedio 2019

El programa curricular de EBA forma parte del Currículo Nacional de Educación Básica y su finalidad es contribuir con orientaciones específicas que permitan concretar la propuesta pedagógica del CNEB. Además, se constituye como el documento orientador para la toma de decisiones pedagógicas a nivel regional, local e institucional. El programa curricular de EBA para los ciclos inicial e intermedio se ha estructurado en dos partes: la primera, contiene los aspectos generales como el perfil de egreso, las características de los estudiantes, las características de la modalidad, los enfoques transversales; asimismo, las orientaciones para la planificación y la evaluación, orientaciones para el desarrollo de los aprendizajes, la tutoría y orientación educativa, y los espacios educativos. En la segunda parte, se presentan las competencias organizadas en las áreas curriculares, así como, los desempeños que se alinean a los niveles de los estándares prescritos para los ciclos de la modalidad

Programa curricular de Educación Básica Alternativa : ciclos Inicial - Intermedio

La Constitución Política del Perú establece que la educación es un derecho fundamental de la persona y de la sociedad. El Estado garantiza el ejercicio del derecho a una educación integral y de calidad para todos y la universalización de la Educación Básica. La Ley General de Educación Nº 28044, en un esfuerzo de transformación estructural del sistema educativo nacional, institucionaliza la Educación Básica Alternativa (EBA) como modalidad equivalente a la Educación Básica Regular en calidad y logros de aprendizaje; enfatiza la preparación para el trabajo y el desarrollo de capacidades empresariales de los estudiantes. La EBA se organiza flexiblemente en función de las necesidades y demandas específicas de los estudiantes, que por diversas razones no accedieron o no culminaron la Educación Básica Regular y necesitan compatibilizar el trabajo con el estudio. Asimismo, admite el reconocimiento de sus trayectorias educativas y experiencias de vida. Así, como la existencia de otros espacios educativos en la comunidad, que fortalecen los aprendizajes de los estudiantes y son reconocidos a través de mecanismos adecuados de convalidación, revalidación o evaluación de ubicación, según normatividad vigente. El Currículo es la base de la política pedagógica nacional y es elaborada por el Ministerio de Educación (Minedu). Mediante Resolución Ministerial Nº 281-2016-MINEDU, modificada por Resolución Ministerial Nº 159-2017-MINEDU, se aprueba el Currículo Nacional de la Educación Básica (CNEB) que establece los aprendizajes que se espera logren los estudiantes como resultado de su formación básica en concordancia con los fines y principios de la Educación Peruana, el Proyecto Educativo Nacional y los objetivos de la Educación Básica

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CLL-like B-lymphocytes are systematically present at very low numbers in peripheral blood of healthy adults

[EN] Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in the Western world. The disease is typically diagnosed in adults >40 years old, who show an expansion (>5 × 109 cells per l) of clonal B-cells with a unique CD5+, CD23+, B-cell receptor (BCR)low immunophenotype in peripheral blood (PB) and bone marrow, frequently in association with involvement of other lymphoid tissues, disease symptoms and a heterogeneous clinical outcome. In parallel, monoclonal B-cell lymphocytosis (MBL), typically characterized by an expansion of clonal CLL-like B-cells (<5 × 109 cells per l), has been also frequently reported in otherwise asymptomatic subjects.1, 2 Increasing evidence suggests that this could represent a pre-leukemic condition, as CLL frequently develops in individuals with previous history of MBL, and MBL cases progress to CLL at a rate of 1% per year