Effectiveness of a smartphone-based virtual reality intervention on balance and functional mobility in children with acute lymphoblastic leukemia: A pre-post experimental study.

BACKGROUND: The odds of survival of children with acute lymphoblastic leukemia (ALL) has increased markedly owing to a better understanding of pathogenesis, adoption of risk stratification therapy, and availability of newer therapeutic agents. These drugs, however, may affect balance and functional mobility, leading to activity restrictions. Virtual reality (VR) is a promising rehabilitation program for motor difficulties. The study, therefore, aimed to determine the effect of a smartphone-based VR intervention on balance and functional mobility in children with ALL. METHODS: The pre-post experimental study included 32 children with ALL between 4 and 18 years of age. They received smartphone-based VR intervention every day for a period of 2 weeks, with each session lasting for 30 minutes. Each session included five VR games that were played by the child for 5 minutes each, with 1 minute rest between the games. Pre- and post-intervention, balance and functional mobility were evaluated using the balance subset of Bruininks Oseretsky Test of Motor Proficiency, second edition (BOT-2) and the Timed Up and Go (TUG) test, respectively. RESULTS: Children with ALL demonstrated a significant improvement in balance post-intervention, with a mean difference of 2.22 ± 1.75 (P < 0.0001). Functional mobility improved with a mean difference of 1.12 ± 1.09 (P < 0.0001). There was an improvement of 8.04% and 11.04% in balance and functional mobility, respectively. CONCLUSION: The study concluded that a 2-week smartphone-based VR intervention is effective in improving balance and functional mobility in children with ALL.

ALL induction outcome: Real-world data from a pediatric oncology center in an LMIC setup with rural predominance.

BACKGROUND: Acute lymphoblastic leukemia (ALL) has survival rates of greater than 90% in developed nations. However, various sociodemographic factors adversely affect outcome rates in low- and middle-income countries (LMICs). OBJECTIVE: To study induction outcome of ALL and various factors affecting it. METHODS: This was a prospective cohort study which enrolled 86 children up to the age of 18 years with newly diagnosed ALL registered in newly established pediatric hematology and oncology division over the duration of 3 years. Sociodemographic and clinical data was collected. Outcome was assessed using morphological remission, minimal residual disease (MRD) and mortality rate. RESULTS: Of the 170 children with malignancies registered, 86 were ALL. Mean age was 7.09 ± 4.07 years and the M: F ratio of 1.32:1. Sixteen (38.09%) of them had severe acute malnutrition and another 16 (38.09%) had moderate acute malnutrition. Thirty (68.18%) children over 5 years were undernourished. Seventy-four (86.05%) were B-ALL and 12 (13.95%) T-ALL. In total, 28.77% had WBC counts greater than 50 × 109/L. t (12;21) was the most common cytogenetic abnormality. Majority (60.46%) of the patients belonged to lower socioeconomic status. Seventy-one (93.42%) patients completed induction of which 100% attained morphological remission and 64 (90.14%) were MRD negative. There were five mortalities, three (60%) due to sepsis and 2 (40%) due to hemophagocytic lymphohistiocytosis. Fifty (65.78%) children had morbidities during induction, febrile neutropenia being the commonest. CONCLUSIONS: Successful induction outcome rates at par with high-income countries can be achieved even in resource-limited settings of LMIC with support from government and NGOs. Decentralized cancer care centers can effectively pave the way in reducing cancer mortality in children of lower socioeconomic status residing in rural areas.

A Study of Factors Influencing Delayed Diagnosis in Pediatric Cancers: A Step Towards Better Outcomes-A Cross-sectional Study.

Annually, India contributes to one-fifth of newly diagnosed pediatric cancers worldwide. Poor outcome in India as compared with developed nations is mainly attributed to delayed diagnosis and study of factors influencing delay in diagnosis holds paramount importance in formulating strategies and counter-measures to improve survival. It was a cross-sectional study conducted on children diagnosed with malignancy at a tertiary care hospital. Diagnosis delay was defined and further divided into patient delay and physician delay. Various patient-related factors and socioeconomic factors that could affect diagnosis were studied. Statistical analysis included descriptive analysis, Mann-Whitney U test, Kruskal-Wallis test, and multivariate linear regression. Of 185 patients enrolled, median diagnosis delay, patient delay, and physician delays were 59, 30, and 7 days respectively. Median diagnosis delay was significantly higher in younger children, children of illiterate parents, and low income. Median diagnosis delay in children presenting to a general practitioner (9 [4 to 29] days) was higher than those presenting to a pediatrician (5.5 [2 to 18] days). Sex, occupation of parents, and distance from oncology center did not affect time for diagnosis. We concluded that augmentation of the parent's attitudes, increased awareness, and decentralization of specialized pediatric care to rural areas can significantly reduce mortality from, otherwise, curable malignancies.

Correlation and Regression Analysis Applied for Types and Number of Blood Transfusions Versus Transfusions Induced ADR Among Pediatric Haemato-Oncology and Thalassemia Patients.

Introduction: Blood transfusion is a remedial intercession and a fundamental fragment of Current medical services framework. As indicated by the WHO the bonding is an action of moving blood or blood-items taken from a giver into the vasculature and in this manner the flowing blood of the recipient, done by embeddings an IV Needle/Catheter in the patient and followed by use of blood or the blood-items. In any case, the dangers of non-irresistible difficulties have gotten more obvious. These nonirresistible complexities called as adverse transfusion reactions (ATRs) can either be intense in nature or follow a postponed course. Transfusion reaction is any unanticipated impact that happens in a patient during or subsequent to accepting blood and the blood-items. These can be agreed as intense transfusion responses, happening inside 24 hours of transfusion and deferred bonding responses happens inside the space of days or long periods of bonding. Intense and moderate responses can be additionally classified as insusceptible interceded and non-immune-intervened. Methodology: The prospective and observational study was carried at Department of Pediatric Oncology & Thalassemia unit for a period of 6 months. The population required for the study includes patients undergoing blood transfusions. Results: In study data out of 83 units, 61 units of PCV was transfused (73.49%), 6 units of Platelet was transfused (7.22%), 14 units of Whole Blood was transfused (16.86%), 1 units of Fresh Frozen Plasma was transfused (1.20%), and 1 units of RBC was transfused (1.20%). The chance of an ADR occurrence with every transfusion is 0.4. The P value is less than .05 so it is statically significant. It is positively correlated, having a high impact on the number of transfusion and rate of incidence of ADR. Conclusion: While a Blood transfusion is given for unavoidable situation the important factors to be kept under consideration are ADR following transfusion which can be the common complication observed. The study also concludes that the rate of incidence of ADR is increased significantly as the number of transfusion increases.

Clinical, laboratory, and mutational profile of children with glucose phosphate isomerase deficiency: a single centre report.

Glucose phosphate isomerase (GPI) deficiency is an autosomal recessive condition with mutations in the GPI gene on chromosome 19q13.1. Patients present with congenital non-spherocytic hemolytic anemia, and occasionally intellectual disability. In this study, we describe the clinical, hematological and biochemical parameters in the largest single-center cohort consisting of 17 GPI-deficient cases. Demographic and clinical data were noted, and red cell enzyme activity levels were estimated. Mutation analysis was done by single-stranded-conformation polymorphism, restriction-fragment length polymorphism and Sanger's sequencing of exon 12 of the GPI gene. The male-to-female ratio was 0.7:1, median age at diagnosis was 5.0 years, 82.3% of patients had severe neonatal jaundice, and 13.3% had subtle neurological manifestations. Median Hb and MCV levels were 6.3 g/dl and 130.2 fl. Splenectomized patients required fewer transfusions. Sixteen of 17 patients had the pathogenic c.1040G > A (p.Arg347His) homozygous mutation in exon12 of the GPI gene, and one had the pathogenic c.1414C > T(p.Arg472Cys) homozygous mutation in exon 16. In summary, we report that neonatal jaundice, macrocytosis and high prevalence of p.Arg347His variant were predominant in GPI deficiency with prominent lack of neurological manifestations, and we emphasize the benefits of splenectomy and the need for genetic counseling.

Rare hereditary nonspherocytic hemolytic anemia caused by a novel homozygous mutation, c.301C > A, (Q101K), in the AK1 gene in an Indian family.

BACKGROUND: Adenylate kinase (AK) deficiency is a rare red cell enzymopathy associated with moderate to severe congenital nonspherocytic hemolytic anemia, along with mental and psychomotor retardation (in exceptional cases). Only ten mutations have been detected in the AK1 gene to date. In this study, we aimed to diagnose the unexplained issue of haemolytic anaemia and offer antenatal screening to the family. METHODS: Genomic DNA was isolated from whole blood by a standard protocol. Targeted next-generation sequencing (t-NGS) was performed to identify pathogenic variants in the patient and control samples. A chronic villus sample was collected at 11 weeks of gestation from the mother, and molecular testing was performed. Genetic confirmation was concluded by Sanger DNA sequencing. Bioinformatics tools predicted the pathogenicity of the variant. RESULTS: t-NGS revealed a homozygous variant (c.301C > A, p. Gln101Lys) in the AK1 gene in the patient and heterozygosity in the fetus and parental samples. The prediction tools SIFT, Polyphen2, Provean, PMUT, Mutation taster, and Mutation Assessor, confirmed the damaging effect of the variant on the AK1 protein structure CONCLUSION: We have presented a novel mutation in the AK1 gene (p. Gln101Lys) associated with adenylate kinase deficiency. It is the first prenatal diagnosis of AK deficiency in India, where heterogeneity is exceptionally high.

The Spectrum of Clinical, Immunological, and Molecular Findings in Familial Hemophagocytic Lymphohistiocytosis: Experience From India.

Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of immune dysregulation characterized by hyperactivation of the immune system, excessive cytokine secretion and severe systemic inflammation. HLH is classified as familial (FHL) when associated with mutations in PRF1, UNC13D, STX11, and STXBP2 genes. There is limited information available about the clinical and mutational spectrum of FHL patients in Indian population. This study is a retrospective analysis of 101 molecularly characterized FHL patients over the last 10 years from 20 different referral centers in India. FHL2 and FHL3 together accounted for 84% of cases of FHL in our cohort. Patients belonging to different FHL subtypes were indistinguishable based on clinical and biochemical parameters. However, flow cytometry-based assays viz. perforin expression and degranulation assay were found to be specific and sensitive in diagnosis and classification of FHL patients. Molecular characterization of respective genes revealed 76 different disease-causing mutations including 39 (51%) novel mutations in PRF1, UNC13D, STX11, and STXBP2 genes. Overall, survival was poor (28%) irrespective of the age of onset or the type of mutation in our cohort. Altogether, this article sheds light on the current scenario of FHL in India. Our data reveal a wide genetic heterogeneity of FHL in the Indian population and confirms the poor prognosis of FHL. This study also emphasizes that though mutational analysis is important for diagnostic confirmation of FHL, flow cytometry based assays help significantly in rapid diagnosis and functional validation of novel variants identified.

Clinical and Genetic Spectrum of a Large Cohort of Patients With Leukocyte Adhesion Deficiency Type 1 and 3: A Multicentric Study From India.

Leukocyte adhesion deficiency (LAD) syndrome is a group of inborn errors of immunity characterized by a defect in the cascade of the activation and adhesion leading to the failure of leukocyte to migrate to the site of tissue injury. Three different types of LAD have been described. The most common subtype is LAD type 1 (LAD1) caused due to defects in the ITGß2 gene. LAD type 2 (LAD2) is caused by mutations in the SLC35C1 gene leading to a generalized loss of expression of fucosylated glycans on the cell surface and LAD type 3 (LAD3) is caused by mutations in the FERMT3 gene resulting in platelet function defects along with immunodeficiency. There is a paucity of data available from India on LAD syndromes. The present study is a retrospective analysis of patients with LAD collated from 28 different centers across India. For LAD1, the diagnosis was based on clinical features and flow cytometric expression of CD18 on peripheral blood leukocytes and molecular confirmation by Sanger sequencing. For patients with LAD3 diagnosis was largely based on clinical manifestations and identification of the pathogenic mutation in the FERMT3 gene by next-generation Sequencing. Of the total 132 cases diagnosed with LAD, 127 were LAD1 and 5 were LAD3. The majority of our patients (83%) had CD18 expression less than 2% on neutrophils (LAD1°) and presented within the first three months of life with omphalitis, skin and soft tissue infections, delayed umbilical cord detachment, otitis media, and sepsis. The patients with CD18 expression of more than 30% (LAD1+) presented later in life with skin ulcers being the commonest manifestation. Bleeding manifestations were common in patients with LAD3. Persistent neutrophilic leukocytosis was the characteristic finding in all patients. 35 novel mutations were detected in the ITGß2 gene, and 4 novel mutations were detected in the FERMT3 gene. The study thus presents one of the largest cohorts of patients from India with LAD, focusing on clinical features, immunological characteristics, and molecular spectrum.

Glucose Phosphate Isomerase Deficiency: High Prevalence of p.Arg347His Mutation in Indian Population Associated with Severe Hereditary Non-Spherocytic Hemolytic Anemia Coupled with Neurological Dysfunction.

OBJECTIVES: Glucose-6-phosphate isomerase (GPI) deficiency is an autosomal recessive genetic disorder causing hereditary non-spherocytic hemolytic anemia (HNSHA) coupled with a neurological disorder. The aim of this study was to identify GPI genetic defects in a cohort of Indian patients with HNSHA coupled with neurological dysfunction. METHODS: Thirty-five patients were screened for GPI deficiency in the HNSHA patient group; some were having neurological dysfunction. Enzyme activity was measured by spectrophotometric method. The genetic study was done by single-stranded conformation polymorphism (SSCP) analysis, restriction fragment length polymorphism (RFLP) analysis by the restriction enzyme AciI for p.Arg347His (p.R347H) and confirmation by Sanger's sequencing. RESULTS: Out of 35 patients, 15 showed 35% to 70% loss of GPI activity, leading to neurological problems with HNSHA. Genetic analysis of PCR products of exon 12 of the GPI gene showed altered mobility on SSCP gel. Sanger's sequencing revealed a homozygous c1040G > A mutation predicting a p.Arg347His replacement which abolishes AciI restriction site. The molecular modeling analysis suggests p.Arg347 is involved in dimerization of the enzyme. Also, this mutation generates a more labile enzyme which alters its three-dimensional structure and function. CONCLUSIONS: This report describes the high prevalence of p.Arg347His pathogenic variant identified in Indian GPI deficient patients with hemolytic anemia and neuromuscular impairment. It suggests that neuromuscular impairment with hemolytic anemia cases could be investigated for p.Arg347His pathogenic variant causing GPI deficiency because of neuroleukin activity present in the GPI monomer which has neuroleukin action at the same active site and generates neuromuscular problems as well as hemolytic anemia.

'Quality of Life' of Parents of Children Suffering from Pediatric Malignancies in a Low Income Setting.

OBJECTIVES: To evaluate the impact of pediatric malignancies on quality of life (QOL) and psychological status of parents and to correlate it with well-matched controls and socioeconomic status. METHODS: A prospective comparative cross-sectional study was conducted. Seventy parents of children diagnosed with pediatric malignancies within the last three months were enrolled in the study group (SG) and 50 matched parents of healthy children as the control group (CG). Assessment was done by WHOQOL-BREF questionnaire, Depression Anxiety Stress Score (DASS) scale and Kuppuswamy scale. Data analysis was done by using Statistical Package for social sciences (SPSS) version 20.0. p value <0.05 considered as significant. RESULTS: Mean score of QOL for SG in physical health domain (D1), psychological health (D2), social relationships (D3) and environment health (D4) was 48.64, 43.07, 47.36, and 40.58 respectively whereas that of CG was 79.38, 76.32, 80.58 and 72.86 respectively and the difference was statistically significant (p value <0.001). The environmental domain (D4) had the lowest mean score amongst all domains in the SG. QOL was maximally affected by the parameter sleep, depression, personal relationship and lack of information in the respective domains. Mean depression, anxiety and stress score of SG was 23.43, 20.33, 23.56 respectively whereas that of the CG was 7.1, 8.06 and 8.54 respectively and this was statistically significant (p value <0.001). The QOL of SG in D1 for the lower socioeconomic class was 48.86 and for the upper class was 63 and this difference was statistically significant (p value <0.015). Similarly in D2 and D4 the QOL scores went higher with the socioeconomic class and this was statistically significant (p value < 0.007 and p value <0.030 respectively). CONCLUSIONS: SG had poorer QOL and were significantly more depressed, anxious and stressed. It is concluded that effective interventions are needed to aid these families to improve outcomes by delivering the benefit of vastly improved therapeutic strategies in this field.

Human Leukocyte Antigen-B27: The Genetic Predisposition Leading to Reactive Arthritis during Induction Phase Chemotherapy for Acute Myeloid Leukemia.

We report a case of reactive arthritis (ReA) during induction phase chemotherapy of a 15-year-old male patient with acute myeloid leukemia (AML) M4 with inv(16), most probably due to a genetic predisposition of being human leukocyte antigen b27 (HLA-B27) positive. The episode of ReA recurred during consolidation therapy; however, the patient was asymptomatic after the completion of treatment. The link between HLA-B27 and a large family of inflammatory rheumatic diseases is a well-established fact, but interestingly, there is also a molecular link between HLA-B27 and hematological malignancies. This case brings to our notice, the common immunological, molecular, and microbiological link between AML, HLA-B27, and ReA. It also emphasizes the fact that clinicians should have a high index of suspicion of HLA-B27 positivity, if a case of AML develops arthritis during chemotherapy, since early introduction of immunosuppressive medications for arthritis may reduce morbidity and prevent delay in the administration of further chemotherapy cycles.

Juvenile granulosa cell tumor associated with Ollier disease.

Juvenile granulosa cell tumor (JGCT) is a rare neoplasm of childhood. Interestingly, it is known to be associated with Ollier disease, which is a rare bone disease characterized by multiple enchondromatosis. There is paucity of literature about the co-occurence of these two conditions. However, this association is noteworthy because these two conditions share a common pathogenesis. We report a case of JGCT in a 2.5-year-old female child in which multiple enchondromas mimicking bony metastasis were an incidental finding during routine workup for tumor staging, thus leading to a diagnosis of Ollier disease.