Evidence-based malaria control in Timor Leste from 2006 to 2012.

BACKGROUND: Malaria has been a major public health problem in the newly established Democratic Republic of Timor Leste with over 200,000 cases being reported in 2006 and 2007. The National Malaria Control Programme (NMCP) was established in 2003. The progress made in malaria control in Timor Leste is reported. METHODS: Records maintained at the NMCP, the district health services, the Health Information and Management System, the National Laboratory on malaria diagnosis and entomological data of the NMCP were reviewed. RESULTS: There has been a 97% decrease in the reported malaria incidence from 2006 (223,002 cases) to 2012 (6,202 cases). 185,106 clinical cases reported in 2006 decreased to 2,016 in 2012 with introduction and expansion of malaria microscopy services and introduction of monovalent RDTs in 2008 and bivalent RDTs in 2010 in all parts of the country. The National Treatment Guidelines using ACT as the first-line treatment for Plasmodium falciparum infections and introduction of monovalent RDTs, led to a 42% and a 33% decrease from 2007 to 2008 in reported clinical and total malaria cases, respectively. LLINs were distributed initially to pregnant females and children under five and later per every two persons living in high-risk areas (based on microstratification at sub-district level). IRS was carried out in three districts in 2010 and extended to six districts in 2012. Anopheles barbirostris and Anopheles subpictus have been incriminated as malaria vectors. A National Laboratory, which routinely cross checks blood smears for quality assurance of microscopy was established. Malaria focal points at regional, district and sub district level, entomology surveillance staff, monitoring and evaluation officers, and quality control technicians were appointed to strengthen malaria control activities at all levels in the country. CONCLUSION: The 97% decrease in the incidence of malaria in Timor Leste is due to application of evidence-based malaria control methods that included enhancing improved quality surveillance, early diagnosis and prompt treatment of cases with effective anti-malarials, targeted vector control, human resource development and deployment, commitment of staff, GFATM funding and technical assistance from WHO.

Assessment of Nutritional Status in Sri Lankan Children: Validity of Current Anthropometry Cutoffs?

Despite socioeconomic improvement, undernutrition rates stagnate in Sri Lanka, while a slow rise in obesity and noncommunicable diseases (NCD) is seen. Inability to improve undernutrition and detection of NCD could be due to overdiagnosing stunting/wasting and underdiagnosing overweight/obesity. Obesity, being a risk factor for NCDs, needs correct tools for early diagnosis. Although body mass index (BMI) is a commonly used surrogate index, the validity of universal cutoffs is questioned. Evidence shows that body composition varies with ethnic origin and cutoff value reflecting fat mass (FM) varies in different ethnic groups. This study was conducted in 12 788, 5- to 15-year-old children from 8 schools in Negombo, Sri Lanka, to identify the validity of current anthropometric cutoffs. Obesity prevalence identified by body fat content was high. International BMI cutoffs had high specificity but varied sensitivity. Locally developed BMI cutoffs had high sensitivity and specificity. Validity of internationally developed anthropometric cutoffs in South Asian children is unsatisfactory; hence, locally/regionally developed anthropometric tools should be used for screening of obesity.

Interleukin 4 inhibits in vitro proliferation of leukemic and normal human B cell precursors.

In the present study, we have investigated the effects of IL-4 on the proliferation and differentiation of leukemic and normal human B cell precursors (BCP). We have demonstrated that IL-4 significantly inhibited spontaneous [3H]thymidine ([3H]-TdR) incorporation by leukemic blasts from some B lineage acute lymphoblastic leukemia (BCP-ALL) patients (8 of 14). Furthermore, IL-4 was found to suppress the spontaneous and factor-dependent (IL-7 and IL-3) proliferation of normal BCP (CD10+ surface [s] IgM- cells) isolated from fetal bone marrow. Maximum growth inhibition of either leukemic or normal BCP was reached at low IL-4 concentrations (10 U/ml), and the effect was specifically neutralized by anti-IL-4 antibody. IL-4 was further found to induce the expression of CD20 antigen on BCP-ALL cells from a number of the cases examined (5 of 8), but in contrast to leukemic cells, IL-4 failed to induce CD20 antigen on normal BCP. Finally, IL-4 was found to induce neither the expression of cytoplasmic mu chain, nor the appearance of sIgM+ cells in cultures of normal or leukemic BCP. Our data indicate that IL-4 has the potential to inhibit cell proliferation in leukemic and normal human B lymphopoiesis but is unable to drive the transition from BCP to mature B cells.

B-cell maturation stages of Burkitt's lymphoma cell lines according to Epstein-Barr virus status and type of chromosome translocation.

This study addressed the possible relationship between B-cell maturation stage of Burkitt's lymphoma (BL) cell lines and Epstein-Barr virus (EBV) status, ethnic group, or type of chromosome translocation. Fifty-seven cell lines obtained at the International Agency for Research on Cancer from 51 patients were studied. Cytogenetic analyses of 54 cells lines were available. Cell size, surface immunoglobulins (sIgs), cytoplasmic immunoglobulins (cIgs), mouse red blood cell receptors, and reactivity with various monoclonal antibodies were assessed. Immunoglobulin (Ig) class secretions were measured in the supernatant of 2- and 5-day cultures from 33 cell lines, with the use of a sensitive enzyme-linked immunosorbent assay technique. From this study, BL appears to cover a broad range of the B-cell differentiation sequence, since the following Ig phenotypes were observed: null cells (sIg-, cIg-), large pre-B-cells (intracytoplasmic mu-chains), small B-cells (sIg+, cIg-), and various types of secreting B-cells (sIg+, cIg+). Among the latter, various patterns of cIg could be defined (perinuclear, paranuclear, and vesicular). B-cell maturation stages were correlated with the amount of secreted Ig. In sIg+ cell lines, different classes of Ig were found: 35 IgM, 10 IgM plus IgD, 4 IgG, and 1 IgA. None of the different monoclonal antibodies used was specific to a precise stage of maturation. The stages of maturation were correlated with neither the type of chromosome translocations of BL nor the presence of EBV genome, but the most immature cell lines were all EBV positive and most of them originated from African patients. In contrast with acute lymphoblastic leukemia, the common acute lymphocytic leukemia antigen (CD10) was expressed on nearly all BL cell lines of intermediate maturation stages but only on half of the pre-B ones. In addition, none of the cell lines tested was found to react with CD5 antibodies, which recognize most of the chronic lymphocytic leukemia of the same stage of maturation as that in the B-lymphocyte lineage.

Proliferation of MIELIKI a novel t(7;9) early pre-B acute lymphoblastic leukemia cell line is inhibited concomitantly by IL-4 and IL-7.

The present study describes a novel cell line, MIELIKI, established from bone marrow of a pediatric patient with B lineage acute lymphoblastic leukemia (ALL) at diagnosis. The MIELIKI cell line displays an early pre-B cell phenotype (CD10+, CD19+, CD20+, CD34-, Cmu-, sIg-) with rearrangements on both Ig heavy chain and k light chain alleles, and carries an unfrequent t(7;9) chromosomal translocation identical to the freshly isolated leukemic blasts. The proliferation of MIELIKI cells was abrogated by IL-4 and by IL-7, as measured by DNA replication and viable cell recovery. The effects of IL-4 and IL-7 were mediated, respectively, through the CDw124 and CDw127 IL-4 and IL-7 receptor components. Growth inhibition by IL-4 was not mediated by soluble factors released by MIELIKI cells in response to IL-4, suggesting the existence of an intrinsic negative signaling pathway. Finally, neither IL-4 nor IL-7 were found to induce maturation of MIELIKI into cells expressing cytoplasmic or surface membrane mu chain. The present cell line should constitute a useful model of t(7;9) early pre-B ALL and allow investigation of the relationship between IL-4 and IL-7 negative signaling in leukemic B cell ontogeny.

Enhanced expression of p16ink4a is associated with a poor prognosis in childhood acute lymphoblastic leukemia.

The tumor suppressor gene p16ink4a is homozygously deleted in numerous T as well as in some B lineage acute lymphoblastic leukemia (ALL). We therefore analyzed the clinical and biological implications of this feature by studying p16ink4a expression in 58 cases of childhood ALL. mRNA and protein were significantly correlated and both appeared more highly expressed in B than in T lineage ALLs: 13 out of the 15 T cell ALLs did not show any p16ink4a expression. The main result of this study is the strong prognostic value of p16ink4a expression. When stratifying the patients in three groups according to p16ink4a expression, we observed in univariate analysis: (1) the shortest disease-free survival for patients presenting a high p16ink4a level; (2) contrasting with the good prognosis in the group of patients expressing p16ink4a at low level; (3) while cases without any expression of the inhibitor were associated with a medium course of the disease (P=0.0165). This prognostic value was confirmed by the multivariate analysis showing therapeutic regimen and p16ink4a protein expression as the only variables retained in the model. A specific metabolic profile related to cellular survival and proliferation was observed in each of the three p16ink4a expression groups. Among the cell cycle-related proteins we analyzed, only p21waf1 bcl-2 and CDK4 were significantly and positively correlated to p16ink4a. Furthermore, CDK6 was also strongly expressed in the group of cases with high p16ink4a level. An enhancement of p16ink4a, p21waf1 and bcl-2 was previously described in prolonged cellular survival, while aging cells showed a decrease in CDK4 expression. The concomitant high expression of the oncogenic protein CDK4 (and of CDK6), we observed, may amplify the leukemic advantage of prolonged lifespan blast cells by favoring cell progression through G1 phase. These data suggest that at least two mechanisms may be associated in the oncogenesis of very aggressive ALLs, ie deregulation of cell multiplication and prolonged blast lifespan.

Characterization of a t(1;19) pre-B acute lymphoblastic leukemia (ALL) cell line which proliferates in response to IL-7.

The present study describes the establishment of the cell line Pre-Alp from the bone marrow of a pediatric patient with a t(1;19) pre-B acute lymphoblastic leukemia (ALL) at diagnosis. Proliferation of leukemic blasts was found to be initially dependent on the presence of autologous stromal cells. However, after five weeks of culture, the stromal cells were no longer necessary and cells began to grow autonomously, with a doubling time of approximately 24 hours. The established Pre-Alp cell line displays a pre-B cell phenotype (CD19+, CD10+, CD34-, c mu+, s mu-), with immunoglobulin (Ig) light chain DNA in germline configuration, and carries a (1;19)(p23;q13.3) chromosomal translocation identical to the freshly-isolated leukemic blasts. A unique feature of this cell line is represented by its ability to respond to interleukin 7 (IL-7). Thus, IL-7 enhances 3H-thymidine uptake by Pre-Alp cells in a dose-dependent manner, under conditions of low cell density and serum concentration, and increases cell recovery. Finally, Pre-Alp cells were found to remain at a pre-B stage even upon addition of various cytokines, which failed to induce a transition to surface Ig+ cells. The presently described cell line should constitute a useful model of t(1;19) pre-B ALL and permit the study of IL-7 dependent signal transduction in human pre-B cells.

Long-term results of three randomized trials (58831, 58832, 58881) in childhood acute lymphoblastic leukemia: a CLCG-EORTC report. Children Leukemia Cooperative Group.

We present here the long-term results of three randomized clinical trials conducted on children with newly diagnosed acute lymphoblastic leukemia (ALL) between 1983 and 1998 by the Children Leukemia Cooperative Group (CLCG) from EORTC. In study 58831/32, the overall event-free survival (EFS) rates (+/- s.e.) at 6 and 10 years were 66% +/- 1.8% and 65% +/- 1.8%, respectively, and the risk of isolated central nervous system (CNS) relapse was 6% +/- 1% and 7% +/- 1%, respectively. In patients with a standard risk of relapse the omission of cyclophosphamide had no adverse effect on disease-free survival rates at 10 years (trial 58831). In medium- and high-risk patients the omission of radiotherapy did not increase the risk of CNS or systemic relapse (trial 58832). In study 58881 (1989-1998) the overall EFS rate at 8 years was 68.4% +/- 1.2% and the risk of isolated CNS relapse was 4.2%+/-0.5%. In this trial which adressed three randomized questions, the following results were obtained: the combination of cytarabine at high doses with methotrexate at high doses during interval therapy did not improve prognosis. The addition of 6-mercaptopurine iv during maintenance increased the risk of late relapse. E. coli asparaginase was more toxic and has a higher efficacy than Erwinia asparaginase. Leukocyte counts >100 x 10(9)/l, specific genetic abnormalities, a poor initial response to steroids or a high level of minimal residual disease at early time points were consistently associated with an adverse prognosis in the 58881 trial.

Outcome of unrelated bone marrow donor searches in 174 children resulting in 45 patients transplanted in the HLA-matched and -mismatched situation.

The aim of the study was to evaluate the outcome of unrelated bone marrow donor (UBMD) searches initiated for 174 children between 1986 and 1997. Seven patients were registered twice so that a total of 181 UBMD searches took place. At the time of registration, patients suffered from hematological malignancies (n = 121), non-malignant hemopathies (n = 26) and inborn errors (n = 34). Forty-five of the patients (26%) were given transplants from unrelated donors of whom 26 (58%) were HLA-mismatched transplants. Our strategy accepted HLA mismatches at the time of donor selection, using Thymoglobuline as part of the conditioning regimen. Of the 45 patients given unrelated donor transplants, overall survival was 60% at 3 years and concerned 27 patients of whom 14 were from HLA-mismatched donors. Disease-free survival for hematological malignancies was 65% in HLA-matched transplants and 50% in HLA-mismatched transplants. For some patients (16%) urgency led us to use alternative options: non-identical related donor (n = 14), autograft (n = 10), related cord blood transplant (n = 4). For others, UBMD searches were stopped because of favorable evolution (n = 29), death (n = 24), disease progression (n = 22) or other reasons (n = 21). By the end of the follow-up period, 88 patients had died (50%), 75 (43%) are currently alive with or without being transplanted of whom eight are still having active searches and 11 are no longer contactable. In conclusion, in severe disease in children, an immediate transplant from a partially matched donor might be preferable to a prolonged search for a full match. Consequently, this strategy increases the number of patients for whom a suitable donor can be found. We have chosen this option in order not to delay BMT; in so doing we have obtained encouraging results which include high overall survival, low incidence of acute GVHD grade III-IV and low percentage of relapse even in mismatched pairs.

Antileukemic and long-term effects of two regimens with or without TBI in allogeneic bone marrow transplantation for childhood acute lymphoblastic leukemia.

Between September 1986 and June 1997, 24 children with high-risk ALL in CR1 were allografted after TAM (fractionated TBI, high-dose Ara-C, and melphalan; n = 10) or BAM protocol (busulfan, high-dose Ara-C, and melphalan; n = 14). The EFS for transplants from sibling donors was 33% with TAM and 62% with BAM (P = 0.148). The probability of acute GvHD was 70% with TAM and 15% with BAM (P = 0.003). Four of 17 evaluable patients relapsed: one after TAM and three after BAM. In all, 46 other children transplanted in CR beyond CR1 were studied for sequelae. Long-term side effects were more frequent in TAM vs BAM. In children with ALL, busulfan may be a good alternative to TBI to improve the quality of life.

Myelodysplastic syndromes in childhood: is the FAB classification relevant? Report of 81 children from a French multicentre study. French Group of Cellular Hematology.

We reviewed the peripheral blood and bone marrow smears of 81 children with myelodysplastic syndrome (MDS). The morphological FAB classification was applicable in 59 children (72.8%): RAEB and RAEBt were the most frequent, 32 cases (39.5%). CMML was observed in 15 cases (18.5%) and in 25% of them, serological evidence for a recent EBV infection was demonstrated. In 22 cases (27.2%), the FAB classification was not convenient. In some of these children, dysmyelopoiesis was associated with constitutional disorders. Among these various inherited conditions, Down syndrome in which myelodysplasia is the expression of an abnormal clonal hematopoiesis, and mitochondrial cytopathies in which MDS is the hematological expression of a polyclonal multi-organ disease. The FAB classification does not appear to be satisfactory for all the disorders included in the group of childhood MDS and should be modified for specific use in children.

Nuclear texture during the cell cycle in acute lymphoid leukemia.

Description of morphological and textural changes during cell cycle were studied in 31 diploid Acute Lymphoid Leukemia ALL cases. Feulgen stained nuclei were measured by image analysis. Cells with 2C, 3C and 4C content of DNA were considered as being in G1, S and G2 phase of cell cycle respectively. The main observed transformations associated with cell cycle were continuous increases in nuclear size and in quantities of black/white chromatin clumps and points. An overall correct classification of 92.5% was achieved by multivariate data analysis. However, significant differences between A L L cases were noticed.

[Transient erythroblastopenia in early childhood]. / L'érythroblastopénie transitoire de la petite enfance.

BACKGROUND: Transient erythroblastopenia is rare in young children although its frequency is increasing. POPULATION AND RESULTS: Six infants (four boys, two girls), aged 29-41 months (mean: 33) were admitted for polar and asthenia. Only one displayed infectious episode two months earlier. Hemoglobin ranged from 40 to 67 g/l and reticulocyte number from 1 to 10 G/l. Mean corpuscular volume was normal as was Coombs' test. There was a profound erythroblastopenia in the bone marrow in five of the six patients. Parvovirus B19 infection was excluded in all. The white cell and platelet counts were normal. All patients were given an unique blood transfusion. Reticulocytosis spontaneously appeared within a few weeks in three patients. Another patient had normal number of erythroid precursors in the bone marrow 1 month after admission. CONCLUSION: Diagnosis of transient erythroblastopenia can only be made after exclusion of known causes such as drugs, virus, immune deficiency, leukemia and of Blackfan-Diamond disease. Its persistence must lead to search for another cause.

[Aseptic femur head osteonecrosis during treatment of acute lymphoblastic leukemia in the child]. / Ostéonécrose aseptique de la tête fémorale au cours du traitement des leucémies aiguës lymphoblastiques de l'enfant.

UNLABELLED: Avascular femoral head necrosis (AFN) is an uncommon complication of acute lymphoblastic leukemia (ALL) occurring in association with serious functional late effects. One of the many risk factors is high-dose corticosteroid therapy. CASE REPORT: Three children belonging to a series of 266 patients developed AFN. The diagnosis was not made immediately when X-rays were normal. In spite of the fact that treatment was begun as soon as possible, the three children had a difference in the length of their legs, with reduction of their walking perimeter and, in one case, an arthroplasty was necessary. CONCLUSION: If some patients treated for ALL limp or suffer when walking or when practising sports, the diagnosis of AFN is to be evoked. The diagnosis is not only based on simple X-rays but also on magnetic resonance imaging, which is more sensitive and reveals lesions earlier. The treatment consists of immobilization of the hip, whether or not associated with surgical procedures.

[Granulocytic sarcoma (chloroma): rare extramedullary tumors associated with acute non-lymphoblastic leukemia]. / Sarcomes granulocytaires (chloromes): tumeurs extramédullaires rares associées aux leucémies aiguës non lymphoblastiques.

The authors report 5 new cases of pediatric granulocytic sarcomas. These rare extramedullary tumors are composed of immature granulocytic cells, usually associated with an acute non lymphoblastic leukemia, but may appear several months before. Their characteristics are exposed (epidemiology, clinical features, cytology and cytogenetics), and therapeutic rules are discussed, especially for the granulocytic sarcomas without evidence of bone marrow involvement. The prognosis is known to be poor.

[Langerhans cell histiocytosis associated with myasthenia in an infant]. / Histiocytose langerhansienne associée à une myasthénie chez un nourrisson.

The pathogenesis of Langerhans cell histiocytosis (LCH) is unclear, but there is increasing evidence that an immunological dysfunction is present. We describe an infant who presented a LCH associated with myasthenia gravis. The thymus is known to play an important role in the pathophysiology of myasthenia gravis and is often involved in LCH. Infancy and signs of organ dysfunction are predictive of poor prognosis: immunotherapy is to be investigated (thymic hormone, cyclosporin, alpha interferon), as well as allogeneic bone marrow transplantation.

Renal enlargement as presentation of isolated renal relapse in childhood leukemia.

Extramedullary relapses in children with acute lymphoblastic leukemia occur most frequently in the central nervous system and in the testis. In this report, the authors describe a 16-year-old girl with an isolated renal relapse of acute lymphoblastic leukemia after a disease-free interval of 2 years and 8 months. This clinically inconspicuous renal relapse was suggested by a routine follow-up renal sonography. No evidence of disease was found in bone marrow or peripheral blood. Renal biopsy was required to establish the diagnosis. Treatment consisted of intensive chemotherapy and autologous bone marrow transplantation. The patient has been in second complete continuous remission for 7 years. The authors recommend the use of an intensive multidrug salvage regimen.

Burkitt's lymphoma. Distinction of subgroups by morphometric analysis of the characteristics of 55 cell lines.

In an attempt to clarify the controversy about the distinction between Burkitt's and non-Burkitt's small noncleaved lymphomas, 55 cell lines derived from 48 Burkitt's lymphoma patients were characterized by morphometry on plastic-embedded sections. The results of the measurements permitted the identification of five main cytologic types, with regard to nuclear size, nuclear area dispersion and irregularity of nuclear profiles. The presence of the Epstein-Barr virus (EBV) and the geographic origin of the tumors seemed to play essential roles in the determination of nuclear size, with a significantly larger size seen in EBV-positive cell lines, and especially in the African lines among these. Immunoglobulin profile and monoclonal antibody expression also correlated with the nuclear size. Two conclusions may be drawn from this analysis. An in vivo transformation of the cells of Burkitt's lymphoma can be postulated to explain the wide morphologic spectrum of lymphomas presenting a rearrangement of chromosome 8. The fact that typical and atypical Burkitt's lymphomas cannot be differentiated by study of their derived cell lines raises the question as to the validity of the distinction between the two subtypes of small noncleaved lymphomas.

Adult acute lymphoblastic leukaemia: is cell proliferation related to other clinical and biological features?

Flow cytometry with propidium iodide and fluorescein isothiocyanate was used to study 46 cases of adult acute lymphoid leukaemia (ALL) before any form of chemotherapy. Cell proliferation was related to the other clinical and biological characteristics and its prognostic significance was evaluated. The following cell-cycle variables were determined: S, G2 + M, and the Low Protein Content fraction of G1 (LPC fraction). The L3 group, corresponding to B-ALL, had significantly higher proliferation than L1 and L2 (P less than 0.01). The proliferation rate was not significantly higher for T-ALL than for the other phenotypes. Complete remission was successfully induced significantly more often in cases with the LPC fraction under 50% (P less than 0.05). Failure was mainly related to resistance to chemotherapy. Of the four patients who died during aplasia, three had an LPC fraction below 25%. Duration of complete remission and survival were significantly shorter for L3 which is the most proliferative ALL (P less than 0.01). Survival was also found to be longer (P less than 0.05) when G2 + M was between 3.8% and 5.1%. This finding and the negative correlation between S and G2 + M (P less than 0.01) are discussed.