IKZF1plus is a frequent biomarker of adverse prognosis in Mexican pediatric patients with B-acute lymphoblastic leukemia

Background

Recurrent genetic alterations contributing to leukemogenesis have been identified in pediatric B-cell Acute Lymphoblastic Leukemia (B-ALL), and some are useful for refining classification, prognosis, and treatment selection. IKZF1plus is a complex biomarker associated with a poor prognosis. It is characterized by IKZF1 deletion coexisting with PAX5, CDKN2A/2B, or PAR1 region deletions. The mutational spectrum and clinical impact of these alterations have scarcely been explored in Mexican pediatric patients with B-ALL. Here, we report the frequency of the IKZF1plus profile and the mutational spectrum of IKZF1, PAX5, CDKN2A/2B, and ERG genes and evaluate their impact on overall survival (OS) in a group of patients with B-ALL.

Methods

A total of 206 pediatric patients with de novo B-ALL were included. DNA was obtained from bone marrow samples at diagnosis before treatment initiation. A custom-designed next-generation sequencing panel was used for mutational analysis. Kaplan-Meier analysis was used for OS estimation.

Results

We identified the IKZF1plus profile in 21.8% of patients, which was higher than that previously reported in other studies. A significantly older age (p=0.04), a trend toward high-risk stratification (p=0.06), and a decrease in 5-year Overall Survival (OS) (p=0.009) were observed, although heterogeneous treatment protocols in our cohort would have impacted OS. A mutation frequency higher than that reported was found for IKZF1 (35.9%) and CDKN2A/2B (35.9%) but lower for PAX5 (26.6%). IKZF1MUT group was older at diagnosis (p=0.0002), and most of them were classified as high-risk (73.8%, p=0.02), while patients with CDKN2A/2BMUT had a higher leukocyte count (p=0.01) and a tendency toward a higher percentage of blasts (98.6%, >50% blasts, p=0.05) than the non-mutated patients. A decrease in OS was found in IKZF1MUT and CDKN2A/2BMUT patients, but the significance was lost after IKZF1plus was removed.

Discussion

Our findings demonstrated that Mexican patients with B-ALL have a higher prevalence of genetic markers associated with poor outcomes. Incorporating genomic methodologies into the diagnostic process, a significant unmet need in low- and mid-income countries, will allow a comprehensive identification of relevant alterations, improving disease classification, treatment selection, and the general outcome.

A protective maternal nutrient concomitant intake associated with acute leukemia might be modified by sex, in children under 2 years

Introduction

Maternal dietary consumption during pregnancy has been inconclusively associated with acute leukemia (AL) in infants, probably because epidemiological evidence has emerged mainly from the analysis of one-by-one nutrient, which is not a real-life scenario. Our objective was to evaluate the association between AL in Mexican children under 2 years of age and their mothers' nutrients concomitant intake during pregnancy, as well as to explore whether there are differences between girls and boys.

Methods

We conducted a study of 110 cases of AL and 252 hospital-based controls in the Mexico City Metropolitan area from 2010 to 2019. We obtained information on maternal intake of 32 nutrients by a food frequency questionnaire and used weighted quantile sum regression to identify nutrient concomitant intakes.

Results

We found a concomitant intake of nutrients negatively associated with AL (OR 0.17; CI95% 0.03,0.88) only among girls; and we did not find a nutrient concomitant intake positively associated with AL.

Discussion

This is the first study that suggests nutrients that have been individually associated with AL are not necessarily the same in the presence of other nutrients (concomitant intake); as well as that maternal diet might reduce AL risk only in girls.

A NK Cell Odyssey: From Bench to Therapeutics Against Hematological Malignancies

In 1975 two independent groups noticed the presence of immune cells with a unique ability to recognize and eliminate transformed hematopoietic cells without any prior sensitization or expansion of specific clones. Since then, NK cells have been the axis of thousands of studies that have resulted until June 2021, in more than 70 000 publications indexed in PubMed. As result of this work, which include approaches in vitro, in vivo, and in natura, it has been possible to appreciate the role played by the NK cells, not only as effectors against specific pathogens, but also as regulators of the immune response. Recent advances have revealed previous unidentified attributes of NK cells including the ability to adapt to new conditions under the context of chronic infections, or their ability to develop some memory-like characteristics. In this review, we will discuss significant findings that have rule our understanding of the NK cell biology, the developing of these findings into new concepts in immunology, and how these conceptual platforms are being used in the design of strategies for cancer immunotherapy.

Prevalence and genotypes of the adenovirus infection as well detection of co-infection with bocavirus in Mexican immunosuppressed and non-immunosuppressed children with pneumonia

BACKGROUND

Adenovirus (AdV) causes respiratory infection; recent observations suggest that some subtypes have more ability to develop fatal disease. AdV infection has been associated with co-infection with human bocavirus (HBoV). We analysed the frequency of AdV infection, its subtypes and the presence of co-infection with HBoV, as well the clinical characteristics of such co-infection in Mexican paediatric immunosuppressed (IP) and non-immunosuppressed patients (non-IP) diagnosed with pneumonia.

METHODS

A total of 5185 nasopharyngeal swabs from two groups of children with pneumonia, one IP and the other non-IP, were analysed for the detection of AdV by immunofluorescence and confirmed by PCR and culture. HBoV was identified by PCR. Positive samples for AdV and AdV/HBoV were typed using PCR sequencing, the clinical characteristics of the AdV/HBoV co-infection were analysed.

RESULTS

Thirty-seven of the 5185 (0.71%) samples were positive for AdV, of those 27/37 (73%) were detected in non-IP and 10/37 (27%) in the IP group. Twelve were typed as follows: 9/12 (75%) as Species B1 subtype 3, of those 8/9 (88.9%) in non-IP and 1/9 in the IP group. One of twelve AdV2 subtype B11a was identified in one non-IP and the remaining two out of 12 successfully typed, were identified as Species C subtypes 2 and 6 in the group of non-IP. The presence of both AdV and HBoV1 in co-infection was observed in 2/37 (5.4%) non-IP with a syndrome like influenza.

CONCLUSIONS

In this 5 year analysis of samples from non-IP and IP hospitalized paediatric patients with a diagnosis of pneumonia, a low incidence of AdV was found. B1 was the most frequent subtype and frequently found in non-IP, and two cases of co-infection AdV/HBoV1 were detected in two non-IP with a influenza-like syndromes. This is the first report of HBoV and AdV co-infection in Mexico. The frequency of AdV and HBoV co-infection was lower than that reported in other populations.

Detection and gB genotyping of CMV in Mexican preterm infants in the context of maternal seropositivity

INTRODUCTION

Congenital (CI) and perinatal cytomegalovirus (CMV) infections (PI) can be linked to maternal CMV seropositivity, with fatal consequences in preterm newborns. GB genotyping has been used to analyze genotypic similarity in mothers and infants. The frequency of CMV infection in the context of maternal seropositivity and the viral gB genotypes as well as the genotypic similarity in mothers and preterm infants were investigated.

METHODOLOGY

Saliva samples and dry blood spots (DBS) were taken weekly from preterm newborns  from birth until the first month of life, and breast milk samples were taken from their mothers weekly during the first month of lactation. CMV IgG seroprevalence of the mothers and CI or PI in the infants were established. The gB status and genotypic similarities were established retrospectively in DBS and in the breast milk samples.

RESULTS

In total, 387 neonates and 375 mothers were enrolled. The maternal CMV-positive IgG serology was 97.3% (365/375). Neonatal CMV was found in 5.1% (20/387) of newborns, and one infant presented with CMV-compatible symptoms. CI was 2.5% and PI in the first month after birth was 11.8%. GB2 was the most prevalent genotype and was also the genotype preferentially transmitted to newborns by mothers with mixed infections.

CONCLUSIONS

CMV PI and CI in preterm infants from highly seropositive mothers was high, but the rate of symptomatic infection was low. The prevalent genotype was gB2, and this genotype was preferentially transmitted to newborns by mothers with mixed infections.

Promoting networks between evidence-based medicine and values-based medicine in continuing medical education

BACKGROUND

In recent years, medical practice has followed two different paradigms: evidence-based medicine (EBM) and values-based medicine (VBM). There is an urgent need to promote medical education that strengthens the relationship between these two paradigms. This work is designed to establish the foundations for a continuing medical education (CME) program aimed at encouraging the dialogue between EBM and VBM by determining the values relevant to everyday medical activities.

METHODS

A quasi-experimental, observational, comparative, prospective and qualitative study was conducted by analyzing through a concurrent triangulation strategy the correlation between healthcare personnel-patient relationship, healthcare personnel's life history, and ethical judgments regarding dilemmas that arise in daily clinical practice.In 2009, healthcare personnel working in Mexico were invited to participate in a free, online clinical ethics course. Each participant responded to a set of online survey instruments before and after the CME program. Face-to-face semi-structured interviews were conducted with healthcare personnel, focusing on their views and representations of clinical practice.

RESULTS

The healthcare personnel's core values were honesty and respect. There were significant differences in the clinical practice axiology before and after the course (P <0.001); notably, autonomy climbed from the 10th (order mean (OM) = 8.00) to the 3rd position (OM = 5.86). In ethical discernment, the CME program had an impact on autonomy (P ≤0.0001). Utilitarian autonomy was reinforced in the participants (P ≤0.0001). Regarding work values, significant differences due to the CME intervention were found in openness to change (OC) (P <0.000), self-transcendence (ST) (P <0.001), and self-enhancement (SE) (P <0.019). Predominant values in life history, ethical discernment and healthcare personnel-patient relation were beneficence, respect and compassion, respectively.

CONCLUSIONS

The healthcare personnel participating in a CME intervention in clinical ethics improved high-order values: Openness to change (OC) and Self Transcendence (ST), which are essential to fulfilling the healing ends of medicine. The CME intervention strengthened the role of educators and advisors with respect to healthcare personnel. The ethical values developed by healthcare professionals arise from their life history and their professional formation.

Incidence of cancer in children residing in ten jurisdictions of the Mexican Republic: importance of the Cancer registry (a population-based study)

BACKGROUND

In 1996, Mexico started to register cases of childhood cancer. Here, we describe the incidence of cancer in children, residing in ten Mexican jurisdictions, who were treated by the Instituto Mexicano del Seguro Social (IMSS).

METHODS

New cases of childhood cancer, which were registered prospectively in nine principal Medical Centers of IMSS during the periods 1998-2000 (five jurisdictions) and 1996-2002 (five jurisdictions), were analyzed. Personnel were specifically trained to register, capture, and encode information. For each of these jurisdictions, the frequency, average annual age-standardized incidence (AAS) and average annual incidence per period by sex and, age, were calculated (rates per 1,000,000 children/years).

RESULTS

In total 2,615 new cases of cancer were registered, with the male/female ratio generally >1, but in some tumors there were more cases in females (retinoblastoma, germ cells tumors). The principal groups of neoplasms in seven jurisdictions were leukemias, central nervous system tumors (CNS tumors), and lymphomas, and the combined frequency for these three groups was 62.6 to 77.2%. Most frequently found (five jurisdictions) was the North American-European pattern (leukemias-CNS tumors-lymphomas). Eight jurisdictions had AAS within the range reported in the world literature. The highest incidence was found for children underless than five year of age. In eight jurisdictions, leukemia had high incidence (>50). The AAS of lymphomas was between 1.9 to 28.6. Chiapas and Guerrero had the highest AAS of CNS tumors (31.9 and 30.3, respectively). The frequency and incidence of neuroblastoma was low. Chiapas had the highest incidence of retinoblastoma (21.8). Germ-cell tumors had high incidence.

CONCLUSION

The North American-European pattern of cancers was the principal one found; the overall incidence was within the range reported worldwide. In general but particularly in two jurisdictions (Yucatán and Chiapas), it will be necessary to carry out studies concerning the causes of cancer in children. Due to the little that is known about the incidence of cancer in Mexican children, it will be necessary to develop a national program to establish a cancer registry for the whole of the country.

KIR gene in ethnic and Mestizo populations from Mexico

Killer cell immunoglobulin-like receptors are characterized by their great diversity of genes and alleles. Population studies have identified the presence of a broad variety of genotypes. In Mexico, there are diverse ethnic groups representing 9% of the total population and the rest is composed of Mestizos with a more varied biology. For the purpose of this study, genotyping was performed in Mestizos, in Mexico City inhabitants, and in three ethnic groups. The frequencies of genes KIR2DL2, 2DL5, 2DS1-3, 2DS5, and 3DS1 showed a greater variability in the groups studied. A total of 12 different genotypes were identified, the higher number for the Mestizos and the lower number for the Tarahumaras. Genotype 1 was found at a greater frequency in all the groups, except for the Tarahumaras, in which genotype 4 was more frequent. The frequency of genotypes 4 and 8 in Mexicans was higher than that for other populations analyzed. By subtyping of KIR3DL1, 3DL2, 2DL1, and 2DL3, two B haplotypes were identified in families; both were absent in Caucasian families. Our results indicated a greater diversity of genes in the Mestizos group than in the ethnic groups.

[Consistency and validity of the evaluation of the clinical chart]

OBJECTIVE

Assess the degree of external consistency and validity of the EXP CLIN instrument has for measuring the quality information contained in medical charts.

MATERIAL AND METHODS

In a transverse comparative study, two hundred and twelve clinical charts were randomly selected belonging to patients seen at a pediatric hospital. The charts were assessed using the EXP-CLIN for phases: 1) internal assessment: by hospital personnel of the pediatric hospital, and, II) external assessment: by personnel from other hospitals. The results were analyzed using the concordance method.

RESULTS

The concordance percentages were found to be 76% for medical charts and medical notes related with the process of diagnosis-treatment, as well as the general characteristics of the clinical chart. The concordance percentages average was 88%, supporting the idea that when the EXP-CLIN instrument is applied twice to the same chart, good concordance is obtained between the two measures.

CONCLUSIONS

Given that the application of the instrument documented a good level of external consistency, its use is justified for assessing the quality of the information contained in the charts of the patients seen at our unit.

[Lipid profile in healthy newborn infants and its correlation with maternal lipid levels]

OBJECTIVE

To determine serum levels of lipid, cholesterol, triglycerides and lipoproteins in newborns and their mothers and to know the association between them.

MATERIAL AND METHODS

Blood samples were taken from 200 newborns and from their mothers, and analyzed for lipid, cholesterol, triglyceride and lipoprotein content in an autoanalyzer. Data were analyzed with the Epi Info 6 program. Central tendency measurements, variance analysis and Pearson correlation coefficient were obtained.

RESULTS

Average lipid levels in newborn blood samples was 625.2 +/- 130, 158.8 +/- 44 mg/dl of cholesterol, 136.9 +/- 97 mg/dl of triglycerides, 70.5 +/- 23.9 mg/dl LDL, 52.7 +/- 14 mg/dl HDL and 26.5 +/- 15.5 mg/dl VLDL.

CONCLUSIONS

Newborn cholesterol levels were similar to values reported by Alpers and higher than levels published by the American Committee of Pediatric Biochemistry in USA. An association between levels in mothers and their children was found.

[Classification by levels of clinico-epidemiological research designs]

The objective was to identify the characteristics of epidemiologic designs enabling their classification. A critical review of the literature in the clinical epidemiologic area was done to establish the main differences between designs. A meeting with experts to discuss this controversial topic and obtain criteria by consensus was organized. We propose an integral classification based on levels with two fundamental shafts: intervention and explanatory reasoning.

Nutritional state alterations in children with acute lymphoblastic leukemia during induction and consolidation of chemotherapy

The objective of the study was to determine if children with high risk acute lymphoblastic leukemia (ALL) exhibit higher frequency of alterations in nutritional state during the phases of induction and consolidation of chemotherapy than children with low risk ALL, based on the arm muscle area. The design was concurrent comparative cohorts. It was performed at pediatric hematology service of the Hospital General del Centro Médico Nacional "La Raza" and hematology service of the Hospital de Pediatría del Centro Médico Nacional "Siglo XXI". One hundred-five patients were incorporated into the study: 53 with high risk (HR) ALL and 52 with low risk (LR) ALL. Basal measurements of arm circumference and tricipital skinfold were surveyed monthly (for 3 months) by standardized personnel. Altered nutritional state during follow-up was defined as the loss of 10% or more of the arm muscular area (AMA) measured at diagnosis. Statistics of proportion analysis with a significance level of 0.05 and relative risk (RR) with confidence intervals (CI) were calculated. In the first month the RR was 0.77 (CI 0.31-1.87); the LR group was the most affected. In the second month the RR was 7.31 (CI 1.41-38.03); the most affected group was the HR. In the third month the RR was 1.77 (CI 0.60-4.92); the HR group was the most affected. High-risk patients show a higher frequency of nutritional state alterations reflected in AMA during the second month after diagnosis. This may be caused by the more aggressive chemotherapy received by these patients.