Central nervous system involvement in pediatric acute lymphoblastic leukemia detected by 8-color flow cytometry: a prospective study

Introduction Acute lymphoblastic leukemia (ALL) may involve central nervous system (CNS) in 3-6% of pediatric patients. Conventional cytology (CC) of cerebrospinal fluid (CSF), together with cell count, is the current standard test to define CNS infiltration, although sensitivity and specificity are low. Flow cytometry (FC) can identify blasts in CSF samples that are negative for cytology with higher sensitivity and specificity. Clinical significance of this occult CNS involvement in children with ALL is still not clearly understood. The aim of this work is to explore the frequency of CNS involvement by FC analysis of CSF at diagnosis and at each lumbar puncture during therapy in primary and relapsed ALL. Moreover, we want to study prospectively its clinical significance in comparison with cytology and cell count. Patient and methods From 12.09.2013 to 12.09.2016 we included all consecutive patients (aged 1-18 years) with Philadelphia negative ALL and with ALL isolated bone marrow (iBM) relapse diagnosed at our Institution. Parent’s informed consent was acquired and the study was approved by the local ethical committee. Treatment schedule and definition of CNS involvement were as per AIEOP-BFM ALL 2009 Protocol. Relapsed patients were mainly treated according to AIEOP ALL REC 2003 protocol. At each time point of intrathecal therapy, CSF was collected and analyzed within 24 hours by cell count, cytology and 8-color FC (precursor-B or T lineage panel). A tiny cluster of events with immunophenotype compatible with blasts at diagnosis was considered positive by FC (FC+). Results Eighty-seven patients with primary diagnosis of ALL were included in the study, 1050 CSF samples were analyzed. At diagnosis, there were 34 (39%) samples that were positive by FC, 5 were also CC+. FC+ patients were mainly T-ALL, with higher peripheral blast percentage and high-risk features. Relapse incidence and mortality were not different between FC+ and FC- groups at diagnosis. During ALL treatment, other 37 samples belonging to 19 patients resulted positive by FC only. Comparison between FC+ patients during treatment and FC- did not result in significantly different outcome. Thirteen patients affected by iBM relapsed were included and 109 CSF samples analyzed for this cohort. At relapse, 7 patients were positive by FC (53.8%), none by CC. Characteristics of FC+ patients and FC- did not differ. Mortality and relapse incidence did not show any significan difference between the two groups. During relapse treatment, other 20 samples were FC+. In total 6 relapsed patients presented ≥2 FC+ samples during therapy, this group presented a higher incidence of subsequent relapses compared to FC- patients (83.3% vs 20%, p 0.04). Conclusion Our data demonstrated that CNS involvement detected by FC is a frequent finding in pediatric ALL at diagnosis and at relapse. The clinical significance is probably linked to the persistent CSF positivity rather than to the single sample positivity. Actual frontline treatment protocols seem to be able to control CNS submicroscopic leukemia. In relapsed ALL patients, persistent CSF positivity may be a sign of a more resistant disease and a negative prognostic factor. A larger group of patients and a longer follow up are needed to confirm our observations

"Delirium Day": A nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool

Background: To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. Methods: This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. Results: The mean sample age was 82.0 ± 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. Conclusions: Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys

Evidence for Sub-Haplogroup H5 of Mitochondrial DNA as a Risk Factor for Late Onset Alzheimer's Disease

BACKGROUND: Alzheimer's Disease (AD) is the most common neurodegenerative disease and the leading cause of dementia among senile subjects. It has been proposed that AD can be caused by defects in mitochondrial oxidative phosphorylation. Given the fundamental contribution of the mitochondrial genome (mtDNA) for the respiratory chain, there have been a number of studies investigating the association between mtDNA inherited variants and multifactorial diseases, however no general consensus has been reached yet on the correlation between mtDNA haplogroups and AD. METHODOLOGY/PRINCIPAL FINDINGS: We applied for the first time a high resolution analysis (sequencing of displacement loop and restriction analysis of specific markers in the coding region of mtDNA) to investigate the possible association between mtDNA-inherited sequence variation and AD in 936 AD patients and 776 cognitively assessed normal controls from central and northern Italy. Among over 40 mtDNA sub-haplogroups analysed, we found that sub-haplogroup H5 is a risk factor for AD (OR=1.85, 95% CI:1.04-3.23) in particular for females (OR=2.19, 95% CI:1.06-4.51) and independently from the APOE genotype. Multivariate logistic regression revealed an interaction between H5 and age. When the whole sample is considered, the H5a subgroup of molecules, harboring the 4336 transition in the tRNAGln gene, already associated to AD in early studies, was about threefold more represented in AD patients than in controls (2.0% vs 0.8%; p=0.031), and it might account for the increased frequency of H5 in AD patients (4.2% vs 2.3%). The complete re-sequencing of the 56 mtDNAs belonging to H5 revealed that AD patients showed a trend towards a higher number (p=0.052) of sporadic mutations in tRNA and rRNA genes when compared with controls. CONCLUSIONS: Our results indicate that high resolution analysis of inherited mtDNA sequence variation can help in identifying both ancient polymorphisms defining sub-haplogroups and the accumulation of sporadic mutations associated with complex traits such as AD

Central nervous system involvement in pediatric acute lymphoblastic leukemia detected by 8-color flow cytometry: a prospective study

Introduction Acute lymphoblastic leukemia (ALL) may involve central nervous system (CNS) in 3-6% of pediatric patients. Conventional cytology (CC) of cerebrospinal fluid (CSF), together with cell count, is the current standard test to define CNS infiltration, although sensitivity and specificity are low. Flow cytometry (FC) can identify blasts in CSF samples that are negative for cytology with higher sensitivity and specificity. Clinical significance of this occult CNS involvement in children with ALL is still not clearly understood. The aim of this work is to explore the frequency of CNS involvement by FC analysis of CSF at diagnosis and at each lumbar puncture during therapy in primary and relapsed ALL. Moreover, we want to study prospectively its clinical significance in comparison with cytology and cell count. Patient and methods From 12.09.2013 to 12.09.2016 we included all consecutive patients (aged 1-18 years) with Philadelphia negative ALL and with ALL isolated bone marrow (iBM) relapse diagnosed at our Institution. Parent’s informed consent was acquired and the study was approved by the local ethical committee. Treatment schedule and definition of CNS involvement were as per AIEOP-BFM ALL 2009 Protocol. Relapsed patients were mainly treated according to AIEOP ALL REC 2003 protocol. At each time point of intrathecal therapy, CSF was collected and analyzed within 24 hours by cell count, cytology and 8-color FC (precursor-B or T lineage panel). A tiny cluster of events with immunophenotype compatible with blasts at diagnosis was considered positive by FC (FC+). Results Eighty-seven patients with primary diagnosis of ALL were included in the study, 1050 CSF samples were analyzed. At diagnosis, there were 34 (39%) samples that were positive by FC, 5 were also CC+. FC+ patients were mainly T-ALL, with higher peripheral blast percentage and high-risk features. Relapse incidence and mortality were not different between FC+ and FC- groups at diagnosis. During ALL treatment, other 37 samples belonging to 19 patients resulted positive by FC only. Comparison between FC+ patients during treatment and FC- did not result in significantly different outcome. Thirteen patients affected by iBM relapsed were included and 109 CSF samples analyzed for this cohort. At relapse, 7 patients were positive by FC (53.8%), none by CC. Characteristics of FC+ patients and FC- did not differ. Mortality and relapse incidence did not show any significan difference between the two groups. During relapse treatment, other 20 samples were FC+. In total 6 relapsed patients presented ≥2 FC+ samples during therapy, this group presented a higher incidence of subsequent relapses compared to FC- patients (83.3% vs 20%, p 0.04). Conclusion Our data demonstrated that CNS involvement detected by FC is a frequent finding in pediatric ALL at diagnosis and at relapse. The clinical significance is probably linked to the persistent CSF positivity rather than to the single sample positivity. Actual frontline treatment protocols seem to be able to control CNS submicroscopic leukemia. In relapsed ALL patients, persistent CSF positivity may be a sign of a more resistant disease and a negative prognostic factor. A larger group of patients and a longer follow up are needed to confirm our observations.Introduzione La leucemia linfoblastica acuta (ALL) può coinvolgere il sistema nervoso centrale (CNS) in circa il 3-6% dei pazienti pediatrici. La citologia convenzionale (CC) su liquor cefalorachidiano (CSF), insieme alla conta cellulare, è la metodica standard per definire l’infiltrazione al CNS. Sensibilità e specificità di questa tecnica si sono però dimostrate scarse. La citofluorimetria (FC) è in grado di identificare blasti in campioni che sono negativi all’analisi citologica con maggior sensibilità e specificità. Il significato clinico di questo coinvolgimento occulto del CNS nei bambini affetti da ALL non è del tutto stato chiarito. Con questo lavoro ci prefiggiamo di valutare la frequenza del coinvolgimento CNS mediante analisi citofluorimetria del liquor dei pazienti pediatrici con ALL all’esordio e alla ricaduta. Inoltre vogliamo studiarne il significato clinico in un lavoro prospettico, paragonandolo alle metodiche standard. Pazienti e metodi Dal 12.09.2013 al 12.09.2016 abbiamo incluso consecutivamente tutti i pazienti di età 1-18 anni affetti da ALL (Philadelphia negativa) e ricaduta midollare isolata di ALL diagnosticati presso il nostro Centro. È stato acquisito il consenso informato dei genitori e lo studio è stato approvato dal comitato etico locale. Le modalità di trattamento e la definizione di coinvolgimento CNS sono riportate nel protocollo BFM-AIEOP ALL 2009. I pazienti con ricaduta sono stati trattati per la maggior parte secondo il protocollo AIEOP ALL REC 2003. I campioni di liquor sono stati raccolti ad ogni punto previsto per la somministrazione della terapia intratecale e sono stata analizzati entro 24 ore tramite conta cellulare, citologia e citofluorimetria a 8 colori (con pannelli specifici di linea B o T). In presenza di una popolazione di eventi raggruppati in un cluster con caratteristiche antigeniche e fisiche sovrapponibili alla popolazione dei blasti dell’esordio, il campione di liquor è stato classificato come positivo in citofluorimetria (FC +). Risultati Ottantasette pazienti affetti da ALL all’esordio sono stati inclusi nello studio, 1050 campioni di liquor sono stati analizzati. Alla diagnosi 34 (39%) campioni sono risultati positivi per FC, 5 di questi lo erano anche per CC. Il gruppo FC+ comprendeva soprattutto leucemie a fenotipo T, con più alta percentuale di blasti in periferico e caratteristiche di alto rischio. Tra i pazienti FC+ e quelli FC- alla diagnosi non è stata dimostrata differenza in termini di ricadute e mortalità. Durante il trattamento altri 37 campioni appartenenti a 19 pazienti sono risultati postivi solo in FC. La prognosi dei pazienti FC+ e quelli FC- durante il trattamento non è risultata significativamente diversa. Tredici pazienti affetti da ricaduta midollare isolata di ALL sono stati inclusi. Per questa coorte, i campioni di liquor analizzati sono stati in totale 109. Alla recidiva 7 pazienti sono risultati positivi in citofluorimetria (53.8%), nessuno alla citologia. Le caratteristiche dei pazienti del gruppo FC+ e di quello FC- sono risultate sovrapponibili. L’incidenza di ricadute e la mortalità tra i due gruppi non sono risultate diverse. Durante il trattamento della recidiva, 6 pazienti in totale hanno presentato ≥2 campioni FC+, questo gruppo ha mostrato un’incidenza di ricadute successive statisticamente più alta rispetto al gruppo FC- (83.3% vs 20%, p 0.04), la mortalità non è risultata diversa. Conclusioni I nostri dati dimostrano che il coinvolgimento del sistema nervoso centrale all’analisi citofluorimetrica è un reperto frequente nelle ALL pediatriche sia alla diagnosi che alla recidiva. Il significato clinico di tale dato è probabilmente legato alla persistenza della positività del liquor in CF, piuttosto che alla positività del singolo campione. Gli attuali protocolli di prima linea appaiono in grado di controllare questa infiltrazione sub-microscopica di malattia. Nei pazienti con recidiva, la persistente positività del liquor mediante FC potrebbe essere un segno di malattia resistente al trattamento ed un fattore prognostico negativo. E’ necessario uno studio su una coorte più ampia di pazienti ed un follow-up più prolungato per confermare la veridicità di tali osservazion

Current status of umbilical cord blood transplantation in children

The first umbilical cord blood (UCB) transplantation was performed 30 years ago. UCB transplantation (UCBT) is now widely used in children with malignant and non-malignant disorders who lack a matched family donor. UCBT affords a lower incidence of graft-versus-host disease compared to alternative stem cell sources, but also presents a slower immune recovery and a high risk of infections if serotherapy is not omitted or targeted within the conditioning regimen. The selection of UCB units with high cell content and good human leucocyte antigen match is essential to improve the outcome. Techniques, such as double UCBT, ex vivo stem cell expansion and intra-bone injection of UCB, have improved cord blood engraftment, but clinical benefit remains to be demonstrated. Cell therapies derived from UCB are under evaluation as potential novel strategies to reduce relapse and viral infections following transplantation. In recent years, improvements within haploidentical transplantation have reduced the overall use of UCBT as an alternative stem cell source; however, each may have its relative merits and disadvantages and tailored use of these alternative stem cell sources may be the optimal approach

Radon-enriched hot spring water therapy for upper and lower respiratory tract inflammation

Background Radon-222-enriched hot spring therapy, which is characterized by a safe level of radioactivity, is used for the treatment of rheumatic disorders, and its efficacy has already been studied in several clinical trials. Radon-water inhalation therapy for the treatment of upper and lower airway inflammatory diseases is used in many hot springs centers. However, its application has not been reviewed to date. Methods We systematically searched the PubMed and Scopus databases for clinical trials published in the last 20 years in which objective parameters of upper and lower airway function had been tested before and after radon-enriched inhalation treatment. Results Four prospective studies were found: 1 asthma trial, 1 placebo-controlled chronic rhinosinusitis trial, 1 upper respiratory tract inflammation with nasal obstruction trial, and 1 case-control allergic rhinitis trial. Patients were treated with nasal inhalations of radon-enriched water for 12 to 28 days and were assessed at baseline and after therapy. After 2 weeks of treatment, nasal resistance decreased, flow increased, mucociliary clearance was enhanced, ciliated-to-muciparous cell ratio increased, and %FEV1 increased in asthmatic patients. Conclusion Radon-enriched inhalation therapy improves objective indicators of nasal function in allergic rhinitis and chronic rhinosinusitis, and causes relief of pulmonary obstruction in asthma

Leczenie inhalacyjne wodą termalną wzbogaconą w radon zapaleń górnych i dolnych dróg oddechowych

Wstęp: Terapia wodą mineralną wzbogaconą w radon 222, charakteryzująca się bezpiecznym poziomem radioaktywności, stosowana jest w leczeniu zaburzeń reumatycznych, a jej skuteczność została już potwierdzona w kilku badaniach klinicznych. Terapia chorób zapalnych górnych i dolnych dróg oddechowych wodami radonowymi funkcjonuje w wielu ośrodkach dysponujących gorącymi źródłami, a do chwili obecnej nie powstał przegląd dotyczący ich zastosowania. Metody: Dokonano przeglądu systematycznego w bazach danych PubMed i Scopus w odniesieniu do badań klinicznych opublikowanych w ciągu ostatnich 20 lat, w których porównywano obiektywne parametry czynności górnego i dolnego odcinka dróg oddechowych, przed i po leczeniu inhalacyjnym wodą wzbogaconą radonem. Wyniki: Znaleziono cztery prospektywne badania: jedno badanie dotyczące leczenia astmy oskrzelowej, jedno badanie kontrolowane placebo dotyczące przewlekłego zapalenia zatok przynosowych, jedno badanie odnoszące się do stanów zapalnych górnych dróg oddechowych z niedrożnością nosa oraz jedno badanie kliniczno-kontrolne dotyczące alergicznego nieżytu nosa. Pacjenci byli leczeni za pomocą inhalacji przez nos wody wzbogaconej w radon przez okres od 12 do 28 dni oraz oceniani na początku badania i po zakończeniu terapii. Po 2 tygodniach leczenia zmniejszyły się wartości oporów dróg nosowych, zwiększyły się wartości przepływów, poprawił się klirens śluzowo-rzęskowy, zwiększył się stosunek liczby komórek rzęskowych do śluzowych, wzrosła wartość procentowa FEV1 u pacjentów z astmą. Wnioski: Terapia inhalacyjna wodą termalną wzbogaconą w radon prowadzi do istotnej poprawy obiektywnych wskaźników funkcji nosa w alergicznym nieżycie nosa i przewlekłym zapaleniu nosa i zatok przynosowych oraz zmniejsza obturację płuc w astmie