Global characteristics and outcomes of SARS-CoV-2 infection in children and adolescents with cancer (GRCCC): a cohort study

Background: Previous studies have shown that children and adolescents with COVID-19 generally have mild disease. Children and adolescents with cancer, however, can have severe disease when infected with respiratory viruses. In this study, we aimed to understand the clinical course and outcomes of SARS-CoV-2 infection in children and adolescents with cancer. Methods: We did a cohort study with data from 131 institutions in 45 countries. We created the Global Registry of COVID-19 in Childhood Cancer to capture de-identified data pertaining to laboratory-confirmed SARS-CoV-2 infections in children and adolescents (<19 years) with cancer or having received a haematopoietic stem-cell transplantation. There were no centre-specific exclusion criteria. The registry was disseminated through professional networks through email and conferences and health-care providers were invited to submit all qualifying cases. Data for demographics, oncological diagnosis, clinical course, and cancer therapy details were collected. Primary outcomes were disease severity and modification to cancer-directed therapy. The registry remains open to data collection. Findings: Of 1520 submitted episodes, 1500 patients were included in the study between April 15, 2020, and Feb 1, 2021. 1319 patients had complete 30-day follow-up. 259 (19·9%) of 1301 patients had a severe or critical infection, and 50 (3·8%) of 1319 died with the cause attributed to COVID-19 infection. Modifications to cancer-directed therapy occurred in 609 (55·8%) of 1092 patients receiving active oncological treatment. Multivariable analysis revealed several factors associated with severe or critical illness, including World Bank low-income or lower-middle-income (odds ratio [OR] 5·8 [95% CI 3·8–8·8]; p<0·0001) and upper-middle-income (1·6 [1·2–2·2]; p=0·0024) country status; age 15–18 years (1·6 [1·1–2·2]; p=0·013); absolute lymphocyte count of 300 or less cells per mm3 (2·5 [1·8–3·4]; p<0·0001), absolute neutrophil count of 500 or less cells per mm3 (1·8 [1·3–2·4]; p=0·0001), and intensive treatment (1·8 [1·3–2·3]; p=0·0005). Factors associated with treatment modification included upper-middle-income country status (OR 0·5 [95% CI 0·3–0·7]; p=0·0004), primary diagnosis of other haematological malignancies (0·5 [0·3–0·8]; p=0·0088), the presence of one of more COVID-19 symptoms at the time of presentation (1·8 [1·3–2·4]; p=0·0002), and the presence of one or more comorbidities (1·6 [1·1–2·3]; p=0·020). Interpretation: In this global cohort of children and adolescents with cancer and COVID-19, severe and critical illness occurred in one fifth of patients and deaths occurred in a higher proportion than is reported in the literature in the general paediatric population. Additionally, we found that variables associated with treatment modification were not the same as those associated with greater disease severity. These data could inform clinical practice guidelines and raise awareness globally that children and adolescents with cancer are at high-risk of developing severe COVID-19 illness. Funding: American Lebanese Syrian Associated Charities and the National Cancer Institute.Fil: Mukkada, Sheena. St Jude Children's Research Hospital; Estados UnidosFil: Bhakta, Nickhill. St Jude Children's Research Hospital; Estados UnidosFil: Chantada, Guillermo Luis. Hospital Sant Joan de Déu Barcelona; España. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Chen, Yichen. St Jude Children's Research Hospital; Estados UnidosFil: Vedaraju, Yuvanesh. St Jude Children's Research Hospital; Estados UnidosFil: Faughnan, Lane. St Jude Children's Research Hospital; Estados UnidosFil: Homsi, Maysam R. St Jude Children's Research Hospital; Estados UnidosFil: Muniz Talavera, Hilmarie. St Jude Children's Research Hospital; Estados UnidosFil: Ranadive, Radhikesh. St Jude Children's Research Hospital; Estados UnidosFil: Metzger, Monika. St Jude Children's Research Hospital; Estados UnidosFil: Friedrich, Paola. St Jude Children's Research Hospital; Estados UnidosFil: Agulnik, Asya. St Jude Children's Research Hospital; Estados UnidosFil: Jeha, Sima. St Jude Children's Research Hospital; Estados UnidosFil: Lam, Catherine G.. St Jude Children's Research Hospital; Estados UnidosFil: Dalvi, Rashmi. Bombay Hospital And Medical Research Centre; IndiaFil: Hessissen, Laila. Universite Mohammed V. Rabat; Otros paises de ÁfricaFil: Moreira, Daniela. St Jude Children's Research Hospital; Estados UnidosFil: Santana, Victor M. St Jude Children's Research Hospital; Estados UnidosFil: Sullivan, Michael. University of Melbourne; AustraliaFil: Bouffet, Eric. University Of Toronto. Hospital For Sick Children; CanadáFil: Caniza, Miguela A.. St Jude Children's Research Hospital; Estados UnidosFil: Devidas, Meenakshi. St Jude Children's Research Hospital; Estados UnidosFil: Pritchard Jones, Kathy. UCL Great Ormond Street Institute of Child Health; Reino UnidoFil: Rodriguez Galindo, Carlos. St Jude Children's Research Hospital; Estados Unido

Global characteristics and outcomes of SARS-CoV-2 infection in children and adolescents with cancer (GRCCC): a cohort study

Background: Previous studies have shown that children and adolescents with COVID-19 generally have mild disease. Children and adolescents with cancer, however, can have severe disease when infected with respiratory viruses. In this study, we aimed to understand the clinical course and outcomes of SARS-CoV-2 infection in children and adolescents with cancer. Methods: We did a cohort study with data from 131 institutions in 45 countries. We created the Global Registry of COVID-19 in Childhood Cancer to capture de-identified data pertaining to laboratory-confirmed SARS-CoV-2 infections in children and adolescents (<19 years) with cancer or having received a haematopoietic stem-cell transplantation. There were no centre-specific exclusion criteria. The registry was disseminated through professional networks through email and conferences and health-care providers were invited to submit all qualifying cases. Data for demographics, oncological diagnosis, clinical course, and cancer therapy details were collected. Primary outcomes were disease severity and modification to cancer-directed therapy. The registry remains open to data collection. Findings: Of 1520 submitted episodes, 1500 patients were included in the study between April 15, 2020, and Feb 1, 2021. 1319 patients had complete 30-day follow-up. 259 (19·9%) of 1301 patients had a severe or critical infection, and 50 (3·8%) of 1319 died with the cause attributed to COVID-19 infection. Modifications to cancer-directed therapy occurred in 609 (55·8%) of 1092 patients receiving active oncological treatment. Multivariable analysis revealed several factors associated with severe or critical illness, including World Bank low-income or lower-middle-income (odds ratio [OR] 5·8 [95% CI 3·8–8·8]; p<0·0001) and upper-middle-income (1·6 [1·2–2·2]; p=0·0024) country status; age 15–18 years (1·6 [1·1–2·2]; p=0·013); absolute lymphocyte count of 300 or less cells per mm3 (2·5 [1·8–3·4]; p<0·0001), absolute neutrophil count of 500 or less cells per mm3 (1·8 [1·3–2·4]; p=0·0001), and intensive treatment (1·8 [1·3–2·3]; p=0·0005). Factors associated with treatment modification included upper-middle-income country status (OR 0·5 [95% CI 0·3–0·7]; p=0·0004), primary diagnosis of other haematological malignancies (0·5 [0·3–0·8]; p=0·0088), the presence of one of more COVID-19 symptoms at the time of presentation (1·8 [1·3–2·4]; p=0·0002), and the presence of one or more comorbidities (1·6 [1·1–2·3]; p=0·020). Interpretation: In this global cohort of children and adolescents with cancer and COVID-19, severe and critical illness occurred in one fifth of patients and deaths occurred in a higher proportion than is reported in the literature in the general paediatric population. Additionally, we found that variables associated with treatment modification were not the same as those associated with greater disease severity. These data could inform clinical practice guidelines and raise awareness globally that children and adolescents with cancer are at high-risk of developing severe COVID-19 illness. Funding: American Lebanese Syrian Associated Charities and the National Cancer Institute.Fil: Mukkada, Sheena. St Jude Children's Research Hospital; Estados UnidosFil: Bhakta, Nickhill. St Jude Children's Research Hospital; Estados UnidosFil: Chantada, Guillermo Luis. Hospital Sant Joan de Déu Barcelona; España. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Chen, Yichen. St Jude Children's Research Hospital; Estados UnidosFil: Vedaraju, Yuvanesh. St Jude Children's Research Hospital; Estados UnidosFil: Faughnan, Lane. St Jude Children's Research Hospital; Estados UnidosFil: Homsi, Maysam R. St Jude Children's Research Hospital; Estados UnidosFil: Muniz Talavera, Hilmarie. St Jude Children's Research Hospital; Estados UnidosFil: Ranadive, Radhikesh. St Jude Children's Research Hospital; Estados UnidosFil: Metzger, Monika. St Jude Children's Research Hospital; Estados UnidosFil: Friedrich, Paola. St Jude Children's Research Hospital; Estados UnidosFil: Agulnik, Asya. St Jude Children's Research Hospital; Estados UnidosFil: Jeha, Sima. St Jude Children's Research Hospital; Estados UnidosFil: Lam, Catherine G.. St Jude Children's Research Hospital; Estados UnidosFil: Dalvi, Rashmi. Bombay Hospital And Medical Research Centre; IndiaFil: Hessissen, Laila. Universite Mohammed V. Rabat; Otros paises de ÁfricaFil: Moreira, Daniela. St Jude Children's Research Hospital; Estados UnidosFil: Santana, Victor M. St Jude Children's Research Hospital; Estados UnidosFil: Sullivan, Michael. University of Melbourne; AustraliaFil: Bouffet, Eric. University Of Toronto. Hospital For Sick Children; CanadáFil: Caniza, Miguela A.. St Jude Children's Research Hospital; Estados UnidosFil: Devidas, Meenakshi. St Jude Children's Research Hospital; Estados UnidosFil: Pritchard Jones, Kathy. UCL Great Ormond Street Institute of Child Health; Reino UnidoFil: Rodriguez Galindo, Carlos. St Jude Children's Research Hospital; Estados Unido

Impact of hospital characteristics on implementation of a Pediatric Early Warning System in resource-limited cancer hospitals

BackgroundPediatric Early Warning Systems (PEWS) aid in identification of deterioration in hospitalized children with cancer but are underutilized in resource-limited settings. Proyecto EVAT is a multicenter quality improvement (QI) collaborative in Latin America to implement PEWS. This study investigates the relationship between hospital characteristics and time required for PEWS implementation.MethodsThis convergent mixed-methods study included 23 Proyecto EVAT childhood cancer centers; 5 hospitals representing quick and slow implementers were selected for qualitative analysis. Semi-structured interviews were conducted with 71 stakeholders involved in PEWS implementation. Interviews were recorded, transcribed and translated to English, then coded using a priori and novel codes. Thematic content analysis explored the impact of hospital characteristics and QI experience on time required for PEWS implementation and was supplemented by quantitative analysis exploring the relationship between hospital characteristics and implementation time.ResultsIn both quantitative and qualitative analysis, material and human resources to support PEWS significantly impacted time to implementation. Lack of resources produced various obstacles that extended time necessary for centers to achieve successful implementation. Hospital characteristics, such as funding structure and type, influenced PEWS implementation time by determining their resource-availability. Prior hospital or implementation leader experience with QI, however, helped facilitate implementation by assisting implementers predict and overcome resource-related challenges.ConclusionsHospital characteristics impact time required to implement PEWS in resource-limited childhood cancer centers; however, prior QI experience helps anticipate and adapt to resource challenges and more quickly implement PEWS. QI training should be a component of strategies to scale-up use of evidence-based interventions like PEWS in resource-limited settings

Defining the Role of the Mouse Jhy Gene in the Ependyma and Choroid Plexus

The cerebrospinal fluid (CSF) is produced by the choroid plexus and is contained within the brain ventricular system (Damkier et al., 2013). CSF flows from the lateral ventricles to the third ventricle, where it then enters the fourth ventricle through the cerebral aqueduct (Brinker et al., 2014). The composition of the CSF is derived from passive filtration of plasma and membrane secretion and it has three mains functions: 1) protect the brain by serving as a cushion against mechanical shock, 2) serve as a route for nutrient delivery and signaling factors, and 3) carry waste products and toxins away from the brain (Lun et al., 2015; Spector et al., 2015). CSF production and circulation should be carefully regulated to allow proper brain development (Gato et al., 2014; Mohammad Nabiuni, 2015). Increased CSF volume causes ventricular dilation and it can lead to the development of a neurological condition known as hydrocephalus. Congenital hydrocephalus is the most common form of the disease, which is present at birth and it affects 1-2/1000 children in the United States (Kahle et al., 2015). Hydrocephalus can result from abnormalities in the production, flow or absorption of the CSF, and if untreated it can lead to death. The ventricles of the brain are lined by a monolayer of ciliated squamous epithelia known as the ependymal cells. The ependyma carry motile cilia (9+2), which coordinately beat to produce a laminar flow and promote CSF circulation throughout the ventricles (Spassky, 2013). The choroid plexus is composed of a monolayer of modified ependymal cells though these cells have developed a unique polarization of membrane associated proteins, along with other secretory properties that allow choroid plexus (CP) cells to function in CSF secretion (Damkier et al., 2013; Dziegielewska et al., 2001). Hydrocephalus can result from the disruption of ependymal cells and/or the choroid plexus by the loss of CSF flow and CSF overproduction, respectively (Baas et al., 2006a; Banizs et al., 2005). Despite the undeniable importance of the ependyma and the CP in CSF homeostasis, the mechanisms and factors involved in their differentiation are largely unknown. The work presented here aimed to further characterize the structure and function of the ependymal cells and the specialized ependymal cells of the CP. The JhylacZ mouse line carries an insertional mutation in the Jhy gene (formerly 4931429I11Rik), and homozygous JhylacZ/lacZ mice develop a rapidly progressive juvenile hydrocephalus (Appelbe et al., 2013). Molecular analysis of the ependymal cells in JhylacZ/lacZ mice was performed using a cell-type specific marker approach to assess the expression of markers involved in vital cellular processes of these cells. JhylacZ/lacZ mice display abnormal ependymal cell differentiation with ventricular ependyma retaining an unorganized and multi-layered morphology, representative of immature ependymal cells. Morphological and molecular analysis of the ependyma demonstrated a delay rather than a block in differentiation. Additionally, JhylacZ/lacZ ependymal cells manifest disruptions in adherens junction formation. Ultrastructural analysis of postnatal JhylacZ/lacZ mice found abnormal organization of the motile cilia lining the lateral ventricles of the brain, structures believed to be required for proper CSF flow. JhylacZ/lacZ ependymal cells have defects in the polarized organization of the apically located cilia. The latter resulted in severely reduced motility, a likely cause for the development of hydrocephalus. A second Jhy mutant model (i.e. JhylacZNeo ) was generated upon the availability of Jhy targeted embryonic stem cells from the Knockout mouse consortium (KOMP). We sought to identify the role of Jhy in the specialized ependymal cells of the choroid plexus in the JhylacZNeo mouse line. Our analysis indicates that JhylacZNeo/lacZNeo develop early onset hydrocephalus, with mice rarely surviving past 3 weeks of age. JhylacZNeo/lacZNeo CP also displays disruptions in adherens junction formation, with abnormal localization of the key adherens junction protein, E-cadherin. TEM analysis of the CP in JhylacZNeo/lacZNeo demonstrated defects in ciliary ultrastructure, along with altered microvilli distribution. Together, this data identifies Jhy as a gene required for proper adherens junction formation and cilia ultrastructure, in the ependyma and the specialized ependyma of the choroid plexus

Ciliary abnormalities are more severe in the delayed <i>Jhy</i>^{<i>lacZ/lacZ</i>} dorsal ependymal cells.

<p>Scanning electron microscopy of lateral ventricle medial wall at P10 in <i>Jhy</i>^<i>+/+</i> (A, B) and <i>Jhy</i>^{<i>lacZ/lacZ</i>} (C, D). <i>Jhy</i>^<i>+/+</i> dorsal (A) and ventral (B) ependymal cells carry apical tufts of elongated cilia with a consistent orientation. In <i>Jhy</i>^{<i>lacZ/lacZ</i>} mice, both dorsal (C) and ventral (D) cells have fewer, disorganized cilia, with areas where cells have no cilia at all (C, asterisk). Dorsal cells were typically more severely affected than were ventral cells in <i>Jhy</i>^{<i>lacZ/lacZ</i>} brains. Scale bars: 20μm (A-D).</p

The mouse <i>Jhy</i> gene regulates ependymal cell differentiation and ciliogenesis

<div><p>During the first postnatal week of mouse development, radial glial cells lining the ventricles of the brain differentiate into ependymal cells, undergoing a morphological change from pseudostratified cuboidal cells to a flattened monolayer. Concomitant with this change, multiple motile cilia are generated and aligned on each nascent ependymal cell. Proper ependymal cell development is crucial to forming the brain tissue:CSF barrier, and to the establishment of ciliary CSF flow, but the mechanisms that regulate this differentiation event are poorly understood. The <i>Jhy</i>^<i>lacZ</i> mouse line carries an insertional mutation in the <i>Jhy</i> gene (formerly <i>4931429I11Rik</i>), and homozygous <i>Jhy</i>^{<i>lacZ/lacZ</i>} mice develop a rapidly progressive juvenile hydrocephalus, with defects in ependymal cilia morphology and ultrastructure. Here we show that beyond just defective motile cilia, <i>Jhy</i>^{<i>lacZ/lacZ</i>} mice display abnormal ependymal cell differentiation. Ventricular ependyma in <i>Jhy</i>^{<i>lacZ/lacZ</i>} mice retain an unorganized and multi-layered morphology, representative of undifferentiated ependymal (radial glial) cells, and they show altered expression of differentiation markers. Most <i>Jhy</i>^{<i>lacZ/lacZ</i>} ependymal cells do eventually acquire some differentiated ependymal characteristics, suggesting a delay, rather than a block, in the differentiation process, but ciliogenesis remains perturbed. <i>Jhy</i>^{<i>lacZ/lacZ</i>} ependymal cells also manifest disruptions in adherens junction formation, with altered N-cadherin localization, and have defects in the polarized organization of the apical motile cilia that do form. Functional studies showed that cilia of <i>Jhy</i>^{<i>lacZ/lacZ</i>} mice have severely reduced motility, a potential cause for the development of hydrocephalus. This work shows that JHY does not only control ciliogenesis, but is a crucial component of the ependymal differentiation process, with ciliary defects likely a consequence of altered ependymal differentiation.</p></div

Abnormal N-cadherin and β-catenin localization in <i>Jhy</i>^{<i>lacZ/lacZ</i>} ependymal cells.

<p>In P10 <i>Jhy</i>^<i>+/+</i> medial wall ependymal cells, N-cadherin (A, E) and β-catenin (C, G) expression in dorsal (A, C) and ventral (E, G) regions localize to the adherens junctions at the apicolateral cell borders (inset in A, C). A schematic of a typical cell in panel A (marked by an orange star) is provided for orientation. In this schematic, the apical cell membrane is indicated by a dotted red line, the basal membrane by a blue line, and the lateral membranes by yellow lines. In <i>Jhy</i>^{<i>lacZ/lacZ</i>} ependyma, dorsal cells showed mislocalization of N-cadherin and β-catenin (B, D), with both proteins found throughout the basolateral cell membrane (inset in B, D). Some <i>Jhy</i>^{<i>lacZ/lacZ</i>} dorsal cells also contained large cytoplasmic inclusions that were positive for N-cadherin (inset in B). Some <i>Jhy</i>^{<i>lacZ/lacZ</i>} ventral cells display proper apicolateral N-cadherin localization (inset in F, asterisk), while other cells mislocalize N-cadherin throughout the lateral walls (inset in F, arrowhead). All ventral cells in <i>Jhy</i>^{<i>lacZ/lacZ</i>} showed mislocalization of β-catenin throughout the basolateral membranes (H). (I-J) Quantification of the percentage of cells displaying normal (black bar) and aberrant (grey bar) localization of N-cadherin (I) and β–catenin (J) in <i>Jhy</i>^<i>+/+</i> and <i>Jhy</i>^{<i>lacZ/lacZ</i>} medial wall ependymal cells. **, p≤0.01; ***, p≤0.001. DAPI is depicted in blue, the boxed region in each large image shows the region of the inset. CP, choroid plexus; MW, medial wall; LW, lateral wall; LV, lateral ventricle. Scale bars: 20μm bar in F (A, B, E, F); 10μm bar in H (C, D, G, H).</p

Ventromedial ependymal cells progressively acquire differentiated ependymal characteristics.

<p>H&E staining of coronal sections of P5 (A, G), P10 (C, I) and P14 (E, K) <i>Jhy</i>^<i>+/+</i> and <i>Jhy</i>^{<i>lacZ/lacZ</i>} lateral ventricles. <i>Jhy</i>^<i>+/+</i> medial wall ependymal cells at P5 (A, inset B), P10 (C, inset D) and P14 (E, inset F) display differentiated characteristics in both dorsal and ventral regions. The boxed region in each large image shows the area of the inset, the dotted line in F indicates the medial ependymal cell layer. <i>Jhy</i>^{<i>lacZ/lacZ</i>} dorsal cells remain undifferentiated at P5 (G, inset H), P10 (I), and P14 (K, inset M). <i>Jhy</i>^{<i>lacZ/lacZ</i>} ventral cells progressively acquire a differentiated appearance (inset J, L), with the differentiated (bracketed) region advancing dorsally (G, I, K). CP, choroid plexus; MW, medial wall; LW, lateral wall; LV, lateral ventricle. Scale bars: 100μm (A-M).</p

Delayed <i>Jhy</i>^{<i>lacZ/lacZ</i>} ependymal cells express FOXJ1 normally.

<p>IF analysis of P5 lateral ventricle medial wall sections from <i>Jhy</i>^<i>+/+</i> (A-F) and <i>Jhy</i>^{<i>lacZ/lacZ</i>} (G-L) mice for expression of Vimentin (pink) and FOXJ1 (green). <i>Jhy</i>^<i>+/+</i> dorsal (A-C) and ventral (D-F) cells express the differentiated ependymal markers Vimentin and FOXJ1. In <i>Jhy</i>^{<i>lacZ/lacZ</i>} brains, both undifferentiated-appearing dorsal (G-I) and differentiated-appearing ventral (J-L) cells express Vimentin and FOXJ1. (M-N) Quantification of the percentage of cells positive for FoxJ1 dorsally (M) and ventrally (N) in <i>Jhy</i>^<i>+/+</i> (black bar) and <i>Jhy</i>^{<i>lacZ/lacZ</i>} (grey bar) mice. The boxed region in each large image shows the region of the inset. CP, choroid plexus; MW, medial wall; LW, lateral wall; LV, lateral ventricle. Scale bars: 50μm (A-L).</p

Delayed differentiation of medial ventricular wall ependymal cells in <i>Jhy</i>^{<i>lacZ/lacZ</i>} mice.

<p>(A, B) IF detection of S-100β in P5 coronal sections from <i>Jhy</i>^<i>+/+</i> (A) and <i>Jhy</i>^{<i>lacZ/lacZ</i>} (B) brains. The boxed region in each large image shows the region of the inset, and the white bracket denotes the width of the cell layers marked by S-100β expression. A) <i>Jhy</i>^<i>+/+</i> medial wall cells display a flattened, single cell-layered differentiated ependyma, while B) <i>Jhy</i>^{<i>lacZ/lacZ</i>} medial wall cells retain a pseudostratified undifferentiated appearance. (C) Schematic of lateral ventricle showing regions designated as medial wall and lateral wall, dorsal and ventral. (D-G) H&E staining of sections of P5 <i>Jhy</i>^<i>+/+</i> (D, E) and <i>Jhy</i>^{<i>lacZ/lacZ</i>} (F, G) lateral ventricle medial ependymal walls. <i>Jhy</i>^<i>+/+</i> ependyma has a differentiated appearance in both dorsal and ventral regions (D, E), while <i>Jhy</i>^{<i>lacZ/lacZ</i>} remains undifferentiated dorsally, but is largely differentiated ventrally (F, G). MW, medial wall; LW, lateral wall; LV, lateral ventricle; D, dorsal; V, ventral; L, lateral. Scale bars: 50μm (A-B); 20μm (D-G).</p