Single-cell genomics details the maturation block in BCP-ALL and identifies therapeutic vulnerabilities in DUX4-r cases.

B cell progenitor acute lymphoblastic leukemia (BCP-ALL) is the most common childhood malignancy, driven by multiple genetic alterations that cause maturation arrest and accumulation of abnormal progenitor B cells. Current treatment protocols with chemotherapy have led to favorable outcomes but are associated with significant toxicity and risk of side effects, highlighting the necessity for highly effective, less toxic, targeted drugs, even in subtypes with a favorable outcome. Here, we used multimodal single-cell sequencing to delineate the transcriptional, epigenetic, and immunophenotypic characteristics of 23 childhood BCP-ALLs, belonging to the BCR::ABL1-positive, ETV6::RUNX1-positive, high hyperdiploid, and recently discovered DUX4-rearranged (DUX4-r) subtypes. Projection of the ALL cells along the normal hematopoietic differentiation axis revealed a diversity in the maturation pattern between the different BCP-ALL subtypes. Whereas the BCR::ABL1-, ETV6::RUNX1-positive, and high hyperdiploidy cells mainly showed similarities to normal pro-B cells, the DUX4-r ALL cells also displayed transcriptional signatures resembling mature B cells. Focusing on the DUX4-r subtype, we found that the blast population displayed multilineage priming toward non-hematopoietic cells, myeloid, and T cell lineages, but also an activation of PI3K/AKT signaling that sensitized the cells to PI3K inhibition in vivo. Given the multilineage priming of the DUX4-r blasts with aberrant expression of the myeloid marker CD371 (CLL-1), we generated chimeric antigen receptor T cells, which effectively eliminated DUX4-r ALL cells in vivo. These results provide a detailed characterization of BCP-ALL at the single-cell level and reveal therapeutic vulnerabilities in the DUX4-r subtype with implications for the understanding of ALL biology and new therapeutic strategies.

Evaluation of a Computer-Aided Clinical Decision Support System for Point-of-Care Use in Low-Resource Primary Care Settings: Acceptability Evaluation Study.

BACKGROUND: A clinical decision support system (CDSS) based on the logic and philosophy of clinical pathways is critical for managing the quality of health care and for standardizing care processes. Using such a system at a point-of-care setting is becoming more frequent these days. However, in a low-resource setting (LRS), such systems are frequently overlooked. OBJECTIVE: The purpose of the study was to evaluate the user acceptance of a CDSS in LRSs. METHODS: The CDSS evaluation was carried out at the Jimma Health Center and the Jimma Higher Two Health Center, Jimma, Ethiopia. The evaluation was based on 22 parameters organized into 6 categories: ease of use, system quality, information quality, decision changes, process changes, and user acceptance. A Mann-Whitney U test was used to investigate whether the difference between the 2 health centers was significant (2-tailed, 95% CI; α=.05). Pearson correlation and partial least squares structural equation modeling (PLS-SEM) was used to identify the relationship and factors influencing the overall acceptance of the CDSS in an LRS. RESULTS: On the basis of 116 antenatal care, pregnant patient care, and postnatal care cases, 73 CDSS evaluation responses were recorded. We found that the 2 health centers did not differ significantly on 16 evaluation parameters. We did, however, detect a statistically significant difference in 6 parameters (P<.05). PLS-SEM results showed that the coefficient of determination, R2, of perceived user acceptance was 0.703. More precisely, the perceived ease of use (ß=.015, P=.91) and information quality (ß=.149, P=.25) had no positive effect on CDSS acceptance but, rather, on the system quality and perceived benefits of the CDSS, with P<.05 and ß=.321 and ß=.486, respectively. Furthermore, the perceived ease of use was influenced by information quality and system quality, with an R2 value of 0.479, indicating that the influence of information quality on the ease of use is significant but the influence of system quality on the ease of use is not, with ß=.678 (P<.05) and ß=.021(P=.89), respectively. Moreover, the influence of decision changes (ß=.374, P<.05) and process changes (ß=.749, P<.05) both was significant on perceived benefits (R2=0.983). CONCLUSIONS: This study concludes that users are more likely to accept and use a CDSS at the point of care when it is easy to grasp the perceived benefits and system quality in terms of health care professionals' needs. We believe that the CDSS acceptance model developed in this study reveals specific factors and variables that constitute a step toward the effective adoption and deployment of a CDSS in LRSs.

Diagnostic yield and clinical impact of germline sequencing in children with CNS and extracranial solid tumors-a nationwide, prospective Swedish study.

Background: Childhood cancer predisposition (ChiCaP) syndromes are increasingly recognized as contributing factors to childhood cancer development. Yet, due to variable availability of germline testing, many children with ChiCaP might go undetected today. We report results from the nationwide and prospective ChiCaP study that investigated diagnostic yield and clinical impact of integrating germline whole-genome sequencing (gWGS) with tumor sequencing and systematic phenotyping in children with solid tumors. Methods: gWGS was performed in 309 children at diagnosis of CNS (n = 123, 40%) or extracranial (n = 186, 60%) solid tumors and analyzed for disease-causing variants in 189 known cancer predisposing genes. Tumor sequencing data were available for 74% (227/309) of patients. In addition, a standardized clinical assessment for underlying predisposition was performed in 95% (293/309) of patients. Findings: The prevalence of ChiCaP diagnoses was 11% (35/309), of which 69% (24/35) were unknown at inclusion (diagnostic yield 8%, 24/298). A second-hit and/or relevant mutational signature was observed in 19/21 (90%) tumors with informative data. ChiCaP diagnoses were more prevalent among patients with retinoblastomas (50%, 6/12) and high-grade astrocytomas (37%, 6/16), and in those with non-cancer related features (23%, 20/88), and ≥2 positive ChiCaP criteria (28%, 22/79). ChiCaP diagnoses were autosomal dominant in 80% (28/35) of patients, yet confirmed de novo in 64% (18/28). The 35 ChiCaP findings resulted in tailored surveillance (86%, 30/35) and treatment recommendations (31%, 11/35). Interpretation: Overall, our results demonstrate that systematic phenotyping, combined with genomics-based diagnostics of ChiCaP in children with solid tumors is feasible in large-scale clinical practice and critically guides personalized care in a sizable proportion of patients. Funding: The study was supported by the Swedish Childhood Cancer Fund and the Ministry of Health and Social Affairs.

Network Hyperexcitability in Early-Stage Alzheimer's Disease: Evaluation of Functional Connectivity Biomarkers in a Computational Disease Model.

Background: There is increasing evidence from animal and clinical studies that network hyperexcitability (NH) may be an important pathophysiological process and potential target for treatment in early Alzheimer's disease (AD). Measures of functional connectivity (FC) have been proposed as promising biomarkers for NH, but it is unknown which measure has the highest sensitivity for early-stage changes in the excitation/inhibition balance. Objective: We aim to test the performance of different FC measures in detecting NH at the earliest stage using a computational approach. Methods: We use a whole brain computational model of activity dependent degeneration to simulate progressive AD pathology and NH. We investigate if and at what stage four measures of FC (amplitude envelope correlation corrected [AECc], phase lag index [PLI], joint permutation entropy [JPE] and a new measure: phase lag time [PLT]) can detect early-stage AD pathophysiology. Results: The activity dependent degeneration model replicates spectral changes in line with clinical data and demonstrates increasing NH. Compared to relative theta power as a gold standard the AECc and PLI are shown to be less sensitive in detecting early-stage NH and AD-related neurophysiological abnormalities, while the JPE and the PLT show more sensitivity with excellent test characteristics. Conclusions: Novel FC measures, which are better in detecting rapid fluctuations in neural activity and connectivity, may be superior to well-known measures such as the AECc and PLI in detecting early phase neurophysiological abnormalities and in particular NH in AD. These markers could improve early diagnosis and treatment target identification.

Hub overload and failure as a final common pathway in neurological brain network disorders.

Understanding the concept of network hubs and their role in brain disease is now rapidly becoming important for clinical neurology. Hub nodes in brain networks are areas highly connected to the rest of the brain, which handle a large part of all the network traffic. They also show high levels of neural activity and metabolism, which makes them vulnerable to many different types of pathology. The present review examines recent evidence for the prevalence and nature of hub involvement in a variety of neurological disorders, emphasizing common themes across different types of pathology. In focal epilepsy, pathological hubs may play a role in spreading of seizure activity, and removal of such hub nodes is associated with improved outcome. In stroke, damage to hubs is associated with impaired cognitive recovery. Breakdown of optimal brain network organization in multiple sclerosis is accompanied by cognitive dysfunction. In Alzheimer's disease, hyperactive hub nodes are directly associated with amyloid-beta and tau pathology. Early and reliable detection of hub pathology and disturbed connectivity in Alzheimer's disease with imaging and neurophysiological techniques opens up opportunities to detect patients with a network hyperexcitability profile, who could benefit from treatment with anti-epileptic drugs.

The impact of (simulated) resolution on breast cancer diagnosis based on high-resolution 3D micro-CT microcalcification images.

BACKGROUND: Breast microcalcifications (MCs) are considered to be a robust marker of breast cancer. A machine learning model can provide breast cancer diagnosis based on properties of individual MCs - if their characteristics are captured at high resolution and in 3D. PURPOSE: The main purpose of the study was to explore the impact of image resolution (8 µm, 16 µm, 32 µm, 64 µm) when diagnosing breast cancer using radiomics features extracted from individual high resolution 3D micro-CT MC images. METHODS: Breast MCs extracted from 86 female patients were analyzed at four different spatial resolutions: 8 µm (original resolution) and 16 µm, 32 µm, 64 µm (simulated image resolutions). Radiomic features were extracted at each image resolution in an attempt, to find a compact feature signature allowing to distinguish benign and malignant MCs. Machine learning algorithms were used for classifying individual MCs and samples (i.e., patients). For sample diagnosis, a custom-based thresholding approach was used to combine individual MC results into sample results. We conducted classification experiments when using (a) the same MCs visible in 8 µm, 16 µm, 32 µm, and 64 µm resolution; (b) the same MCs visible in 8 µm, 16 µm, and 32 µm resolution; (c) the same MCs visible in 8 µm and 16 µm resolution; (d) all MCs visible in 8 µm, 16 µm, 32 µm, and 64 µm resolution. Accuracy, sensitivity, specificity, AUC, and F1 score were computed for each experiment. RESULTS: The individual MC results yielded an accuracy of 77.27%, AUC of 83.83%, F1 score of 77.25%, sensitivity of 80.86%, and specificity of 72.2% at 8 µm resolution. For the individual MC classifications we report for the F1 scores: a 2.29% drop when using 16 µm instead of 8 µm, a 4.01% drop when using 32 µm instead of 8 µm, a 10.69% drop when using 64 µm instead of 8 µm. The sample results yielded an accuracy and F1 score of 81.4%, sensitivity of 80.43%, and specificity value of 82.5% at 8 µm. For the sample classifications we report for F1 score values: a 6.3% drop when using 16 µm instead of 8 µm, a 4.91% drop when using 32 µm instead of 8 µm, and a 6.3% drop when using 64 µm instead of 8 µm. CONCLUSIONS: The highest classification results are obtained at the highest resolution (8 µm). If breast MCs characteristics could be visualized/captured in 3D at a higher resolution compared to what is used nowadays in digital mammograms (approximately 70 µm), breast cancer diagnosis will be improved.

Poor Subjective Sleep Quality Predicts Symptoms in Irritable Bowel Syndrome Using the Experience Sampling Method.

INTRODUCTION: Sleep quality may affect symptom experience in irritable bowel syndrome (IBS). Our aim was to investigate the relationship between sleep quality and gastrointestinal (GI) symptoms using actigraphy and the experience sampling method. METHODS: Patients with IBS were recruited from a tertiary Neurogastroenterology clinic and the community. GI symptoms and mood were recorded on a smartphone application, 10 times per day, over 7 consecutive days. Subjective sleep quality was recorded every morning to reflect the night before. Objective measures of sleep quality were estimated from wrist-worn actigraphy. Cross-lagged structural equation models were built to assess the directionality of sleep-symptom relationships over time. RESULTS: Eighty patients with IBS completed the study (mean age: 37 years [range 20-68], 89% female, 78% community). Approximately 66% had a Pittsburgh Sleep Quality Index score ≥ 8, indicating a clinically significant sleep disturbance. Approximately 82% (95% CI: 72-90) screened positive for a sleep disorder, most commonly insomnia. In cross-lagged analysis, poor subjective sleep quality predicted next-day abdominal pain (0.036 < P < 0.040) and lower GI symptoms (0.030 < P < 0.032), but not vice versa. No significant relationship with GI symptoms was found for any objective sleep measure using actigraphy. DISCUSSION: Poor subjective sleep quality was associated with higher next-day lower GI symptom levels, but not vice versa. Objective sleep measures did not predict next-day abdominal symptoms, potentially supporting the conclusion that it is the perception of sleep quality that is most influential. This study may be used to guide future research into the effect of sleep interventions on GI symptoms.

Overuse of EEG and ECG in children with breath-holding spells and its implication for the management of the spells.

AIM: Breath-holding spells (BHS) are common in children, but evidence-based clinical guidelines are lacking. We investigated a large population-based cohort of BHS patients, to propose a refined description of typical BHS and guidelines for its management. METHODS: In a cross-sectional retrospective study, patients diagnosed with BHS in Southern Sweden 2004-2018 were recruited. Disease characteristics and diagnostic data were collected from patient medical records. RESULTS: In total, 519 patients, mean age at diagnosis 19.8 ± 13.8 months with equal gender distribution, were included. In 48.3%, BHS had already been diagnosed after one spell. During spells, 78.0% of patients were unresponsive. For 71.5%, atonic, tonic, tonic-clonic or myoclonic seizures were reported, and 78.0% of patients had a spell lasting less than 1 min. Electroencephalography was conducted in 30.4% and Electrocardiography in 45.1%. Six children (3.8%) had a pathological electroencephalogram, four of which had concomitant epilepsy and only 0.9% of children had electrocardiogram findings suggesting pathology, none showing long QT syndrome. CONCLUSION: Children with BHS were frequently subjected to unnecessary diagnostic interventions. We characterise a typical presentation of BHS and propose a management-algorithm, which is expected to reduce unnecessary usage of electroencephalography and electrocardiography.

Treatment outcomes of childhood PICALM::MLLT10 acute leukaemias.

The prognostic impact of PICALM::MLLT10 status in childhood leukaemia is not well described. Ten International Berlin Frankfurt Münster-affiliated study groups and the Children's Oncology Group collaborated in this multicentre retrospective study. The presence of the PICALM::MLLT10 fusion gene was confirmed by fluorescence in situ hybridization and/or RNA sequencing at participating sites. Ninety-eight children met the study criteria. T-cell acute lymphoblastic leukaemia (T-ALL) and acute myeloid leukaemia (AML) predominated 55 (56%) and 39 (40%) patients, respectively. Most patients received a chemotherapy regimen per their disease phenotype: 58% received an ALL regimen, 40% an AML regimen and 1% a hybrid regimen. Outcomes for children with PICALM::MLLT10 ALL were reasonable: 5-year event-free survival (EFS) 67% and 5-year overall survival (OS) 76%, but children with PICALM::MLLT10 AML had poor outcomes: 5-year EFS 22% and 5-year OS 26%. Haematopoietic stem cell transplant (HSCT) did not result in a significant improvement in outcomes for PICALM::MLLT10 AML: 5-year EFS 20% for those who received HSCT versus 23% for those who did not (p = 0.6) and 5-year OS 37% versus 36% (p = 0.7). In summary, this study confirms that PICALM::MLLT10 AML is associated with a dismal prognosis and patients cannot be salvaged with HSCT; exploration of novel therapeutic options is warranted.

An International Survey of Allogeneic Hematopoietic Cell Transplantation for X-Linked Agammaglobulinemia.

PURPOSE: X-linked agammaglobulinemia (XLA) is an inborn error of immunity caused by variants in Bruton's tyrosine kinase (BTK). XLA patients require lifelong immunoglobulin replacement therapy (IgRT). Only few XLA patients are indicated for allogeneic hematopoietic cell transplantation (HCT) because of severe complications. Accordingly, the published transplantation experience in XLA is minimal. We aimed to collect clinical data of XLA patients who received HCT in an international framework and to establish appropriate transplantation criteria and methods for XLA patients. METHODS: XLA patients were recruited through a questionnaire and a literature review. The data are on patient characteristics and transplantation methods and outcomes. RESULTS: In this study, twenty-two XLA patients who underwent HCT were recruited. The indication for HCT was recurrent or life-threatening infection in sixteen patients, malignancy in three, and other factors in three. A myeloablative conditioning, reduced toxicity myeloablative conditioning (RT-MAC), and reduced intensity conditioning (RIC) were selected in four, ten, and eight patients, respectively. Engraftment was achieved in 21 patients (95%). In all patients, 2-year overall survival (OS) and event-free survival (EFS) were 86% and 77%, respectively. In patients who received RT-MAC or RIC using treosulfan, busulfan, or melphalan, 2-year OS and EFS were 82% and 71%, respectively. Finally, twenty-one patients (95%) obtained complete or stable high-level mixed chimerism (50-95%), and the 1-year discontinuation rate of IgRT was 89%. CONCLUSION: Based on the concept in which IgRT is the standard treatment for XLA, HCT may be an effective and safe alternative treatment option for XLA patients, and IgRT can be discontinued following transplantation. It is ideal to perform HCT in XLA patients for whom transplantation is indicated before they develop organ damage.

Combined GLUT1 and OXPHOS inhibition eliminates acute myeloid leukemia cells by restraining their metabolic plasticity.

Acute myeloid leukemia (AML) is initiated and propagated by leukemia stem cells (LSCs), a self-renewing population of leukemia cells responsible for therapy resistance. Hence, there is an urgent need to identify new therapeutic opportunities targeting LSCs. Here, we performed an in vivo CRISPR knockout screen to identify potential therapeutic targets by interrogating cell surface dependencies of LSCs. The facilitated glucose transporter type 1 (GLUT1) emerged as a critical in vivo metabolic dependency for LSCs in a murine MLL::AF9-driven model of AML. GLUT1 disruption by genetic ablation or pharmacological inhibition led to suppression of leukemia progression and improved survival of mice that received transplantation with LSCs. Metabolic profiling revealed that Glut1 inhibition suppressed glycolysis, decreased levels of tricarboxylic acid cycle intermediates and increased the levels of amino acids. This metabolic reprogramming was accompanied by an increase in autophagic activity and apoptosis. Moreover, Glut1 disruption caused transcriptional, morphological, and immunophenotypic changes, consistent with differentiation of AML cells. Notably, dual inhibition of GLUT1 and oxidative phosphorylation (OXPHOS) exhibited synergistic antileukemic effects in the majority of tested primary AML patient samples through restraining of their metabolic plasticity. In particular, RUNX1-mutated primary leukemia cells displayed striking sensitivity to the combination treatment compared with normal CD34+ bone marrow and cord blood cells. Collectively, our study reveals a GLUT1 dependency of murine LSCs in the bone marrow microenvironment and demonstrates that dual inhibition of GLUT1 and OXPHOS is a promising therapeutic approach for AML.

Diagnostic Yield From a Nationwide Implementation of Precision Medicine for all Children With Cancer.

PURPOSE: Several studies have indicated that broad genomic characterization of childhood cancer provides diagnostically and/or therapeutically relevant information in selected high-risk cases. However, the extent to which such characterization offers clinically actionable data in a prospective broadly inclusive setting remains largely unexplored. METHODS: We implemented prospective whole-genome sequencing (WGS) of tumor and germline, complemented by whole-transcriptome sequencing (RNA-Seq) for all children diagnosed with a primary or relapsed solid malignancy in Sweden. Multidisciplinary molecular tumor boards were set up to integrate genomic data in the clinical decision process along with a medicolegal framework enabling secondary use of sequencing data for research purposes. RESULTS: During the study's first 14 months, 118 solid tumors from 117 patients were subjected to WGS, with complementary RNA-Seq for fusion gene detection in 52 tumors. There was no significant geographic bias in patient enrollment, and the included tumor types reflected the annual national incidence of pediatric solid tumor types. Of the 112 tumors with somatic mutations, 106 (95%) exhibited alterations with a clear clinical correlation. In 46 of 118 tumors (39%), sequencing only corroborated histopathological diagnoses, while in 59 cases (50%), it contributed to additional subclassification or detection of prognostic markers. Potential treatment targets were found in 31 patients (26%), most commonly ALK mutations/fusions (n = 4), RAS/RAF/MEK/ERK pathway mutations (n = 14), FGFR1 mutations/fusions (n = 5), IDH1 mutations (n = 2), and NTRK2 gene fusions (n = 2). In one patient, the tumor diagnosis was revised based on sequencing. Clinically relevant germline variants were detected in 8 of 94 patients (8.5%). CONCLUSION: Up-front, large-scale genomic characterization of pediatric solid malignancies provides diagnostically valuable data in the majority of patients also in a largely unselected cohort.

Temporal dynamics of TNF-mediated changes in hematopoietic stem cell function and recovery.

While tumor necrosis factor (TNF) is a critical mediator of appropriate immune response and tissue repair, its misregulation is linked to cancer, autoimmunity, bone marrow failure, and aging. Understanding the context-dependent roles of TNF is essential for elucidating normal and pathogenic conditions and to guide clinical therapy advancements. Prior studies suggested that TNF restricts the self-renewal capacity of hematopoietic stem cells (HSCs), but its long-term effect on HSCs remains unclear. Here, we demonstrate that in vivo TNF administration results in a transient exit of HSCs from quiescence, which coincides with a compromised repopulation capacity. These functional changes are; however, fully reversible even following prolonged/chronic transient exposure to TNF. Notably, antagonizing TNF signaling in transplantation recipients enhances donor HSC reconstitution. Our findings provide molecular and functional insight into HSC regulation, with implications for both acute and chronic inflammatory conditions.

Evaluating a clinical decision support point of care instrument in low resource setting.

BACKGROUND: Clinical pathways are one of the main tools to manage the health care's quality and concerned with the standardization of care processes. They have been used to help frontline healthcare workers by presenting summarized evidence and generating clinical workflows involving a series of tasks performed by various people within and between work environments to deliver care. Integrating clinical pathways into Clinical Decision Support Systems (CDSSs) is a common practice today. However, in a low-resource setting (LRS), this kind of decision support systems is often not readily accessible or even not available. To fill this gap, we developed a computer aided CDSS that swiftly identifies which cases require a referral and which ones may be managed locally. The computer aided CDSS is designed primarily for use in primary care settings for maternal and childcare services, namely for pregnant patients, antenatal and postnatal care. The purpose of this paper is to assess the user acceptance of the computer aided CDSS at the point of care in LRSs. METHODS: For evaluation, we used a total of 22 parameters structured in to six major categories, namely "ease of use, system quality, information quality, decision changes, process changes, and user acceptance." Based on these parameters, the caregivers from Jimma Health Center's Maternal and Child Health Service Unit evaluated the acceptability of a computer aided CDSS. The respondents were asked to express their level of agreement using 22 parameters in a think-aloud approach. The evaluation was conducted in the caregiver's spare-time after the clinical decision. It was based on eighteen cases over the course of two days. The respondents were then asked to score their level of agreement with some statements on a five-point scale: strongly disagree, disagree, neutral, agree, and strongly agree. RESULTS: The CDSS received a favorable agreement score in all six categories by obtaining primarily strongly agree and agree responses. In contrast, a follow-up interview revealed a variety of reasons for disagreement based on the neutral, disagree, and strongly disagree responses. CONCLUSIONS: Though the study had a positive outcome, it was limited to the Jimma Health Center Maternal and Childcare Unit, and hence a wider scale evaluation and longitudinal measurements, including computer aided CDSS usage frequency, speed of operation and impact on intervention time are needed.

Inhaled Δ9-tetrahydrocannabinol does not enhance oxycodone-induced respiratory depression: randomised controlled trial in healthy volunteers.

BACKGROUND: In humans, the effect of cannabis on ventilatory control is poorly studied, and consequently, the effect of Δ9-tetrahydrocannabinol (THC) remains unknown, particularly when THC is combined with an opioid. We studied the effect of THC on breathing without and with oxycodone pretreatment. We hypothesised that THC causes respiratory depression, which is amplified when THC and oxycodone are combined. METHODS: In this randomised controlled crossover trial, healthy volunteers were administered inhaled Bedrocan® 100 mg (Bedrocan International B.V., Veendam, The Netherlands), a pharmaceutical-grade high-THC cannabis variant (21.8% THC; 0.1% cannabidiol), after placebo or oral oxycodone 20 mg pretreatment; THC was inhaled 1.5 and 4.5 h after placebo or oxycodone intake. The primary endpoint was isohypercapnic ventilation at an end-tidal Pco2 of 55 mm Hg or 7.3 kPa (VE55), measured at 1-h intervals for 7 h after placebo/oxycodone intake. RESULTS: In 18 volunteers (age 22 yr [3]; 9 [50%] female), oxycodone produced a 30% decrease in VE55, whereas placebo was without effect on VE55. The first cannabis inhalation resulted in VE55 changing from 20.3 (3.1) to 23.8 (2.4) L min-1 (P=0.06) after placebo, and from 11.8 (2.8) to 13.0 (3.9) L min-1 (P=0.83) after oxycodone. The second cannabis inhalation also had no effect on VE55, but slightly increased sedation. CONCLUSIONS: In humans, THC has no effect on ventilatory control after placebo or oxycodone pretreatment. CLINICAL TRIAL REGISTRATION: 2021-000083-29 (EU Clinical Trials Register.).

Characteristics and outcome of primary resistant disease in paediatric acute myeloid leukaemia.

A significant proportion of events in paediatric acute myeloid leukaemia (AML) are caused by resistant disease (RD). We investigated clinical and biological characteristics in 66 patients with RD from 1013 children with AML registered and treated according to the NOPHO-AML 93, NOPHO-AML 2004, DB AML-01 and NOPHO-DBH AML 2012 protocols. Risk factors for RD were age10 years or older and a white-blood-cell count (WBC) of 100 × 109 /L or more at diagnosis. The five-year overall survival (OS) was 38% (95% confidence interval [CI]: 28%-52%). Of the 63 children that received salvage therapy with chemotherapy, 59% (N = 37) achieved complete remission (CR) with OS 57% (95% CI: 42%-75%) compared to 12% (95% CI: 4%-35%) for children that did not achieve CR. Giving more than two salvage chemotherapy courses did not increase CR rates. OS for all 43 patients receiving allogeneic haematopoietic stem cell transplantation (HSCT) was 49% (95% CI: 36%-66%). Those achieving CR and proceeding to HSCT had an OS of 56% (95% CI: 41%-77%, N = 30). This study showed that almost 40% of children with primary resistant AML can be cured with salvage therapy followed by HSCT. Children that did not achieve CR after two salvage courses with chemotherapy did not benefit from additional chemotherapy.

Cannabis-opioid interaction in the treatment of fibromyalgia pain: an open-label, proof of concept study with randomization between treatment groups: cannabis, oxycodone or cannabis/oxycodone combination-the SPIRAL study.

BACKGROUND: Opioids continue to be widely prescribed for chronic noncancer pain, despite the awareness that opioids provide only short-time pain relief, lead to dose accumulation, have numerous adverse effects, and are difficult to wean. As an alternative, we previously showed advantages of using pharmaceutical-grade cannabis in a population of chronic pain patients with fibromyalgia. It remains unknown whether combining an opioid with pharmaceutical-grade cannabis has advantages, such as fewer side effects from lesser opioid consumption in chronic pain. METHODS: Trial design: a single-center, randomized, three-arm, open-label, exploratory trial. Trial population: 60 patients with fibromyalgia according to the 2010 definition of the American College of Rheumatologists. INTERVENTION: Patients will be randomized to receive up to 4 daily 5 mg oral oxycodone sustained release (SR) tablet, up to 5 times 150 mg inhaled cannabis (Bediol®, containing 6.3% Δ9-tetrahydrocannabinol and 8% cannabidiol), or the combination of both treatments. Treatment is aimed at self-titration with the daily maximum doses given. Treatment will continue for 6 weeks, after which there is a 6-week follow-up period. Main trial endpoint: The number of side effects observed during the course of treatment using a composite adverse effect score that includes the following 10 symptoms: dizziness (when getting up), sleepiness, insomnia, headache, nausea, vomiting, constipation, drug high, hallucinations, and paranoia. Secondary and tertiary endpoints include pain relief and number of oxycodone doses and cannabis inhalations. DISCUSSION: The trial is designed to determine whether self-titration of oxycodone and cannabis will reduce side effects in chronic pain patients with fibromyalgia. TRIAL REGISTRATION {2A AND 2B}: EU trial register 2019-001861-33, URL https://www.clinicaltrialsregister.eu , on July 17, 2019; World Health Organization International Clinical Trials Research Platform NL7902, URL https://trialsearch.who.int , on July 26, 2019.

Assessment of formats and completeness of paper-based referral letters among urban hospitals in Rwanda: a retrospective baseline study.

BACKGROUND: Patient referral is a process in which a healthcare provider decides to seek assistance due to the limitations of available skills, resources and services offered locally. Paper-based referrals predominantly used in low-income countries hardly follow any procedure. This causes a major gap in communication, coordination, and continuity of care between primary and specialized levels, leading to poor access, delay, duplication and unnecessary costs. The goal of this study is to assess the formats and completeness of existing paper-based referral letters in order to improve health information exchange, coordination, and continuity of care. METHODS: A retrospective exploratory research was conducted in eight public and three private healthcare facilities in the city of Kigali from May to October 2021. A purposive sampling method was used to select hospitals and referral letters from patients' files. A data capture sheet was designed according to the contents of the referral letters and the resulting responses were analyzed descriptively. RESULTS: In public hospitals, five types of updated referral letters were available, in total agreement with World Health Organization (WHO) standards of which two (neonatal transfer form and patient monitoring transfer form) were not used. There was also one old format that was used by most hospitals and another format designed and used by a district hospital (DH) separately. Three formats were designed and used by private hospitals (PH) individually. A total of 2,304 referral letters were perused and the results show that "external transfer" forms were completed at 58.8%; "antenatal, delivery, and postnatal external transfer" forms at 47.5%; "internal transfer" forms at 46.6%; "Referral/counter referral" forms at 46.0%; district hospital referrals (DH2) at 73.4%. Referrals by private hospitals (PH1, PH2 and PH3) were completed at 97.7%, 70.7%, and 0.0% respectively. The major completeness deficit was observed in counter referral information for all hospitals. CONCLUSION: We observed inconsistencies in the format of the available referral letters used by public hospitals, moreover some of them were incompatible with WHO standards. Additionally, there were deficits in the completeness of all types of paper-based referral letters in use. There is a need for standardization and to disseminate the national patient referral guideline in public hospitals with emphasis on referral feedback, referral registry, triage, archiving and a need for regular training in all organizations.

Supportive care in pediatric acute myeloid leukemia:Expert-based recommendations of the NOPHO-DB-SHIP consortium.

INTRODUCTION: Pediatric acute myeloid leukemia (AML) is the second most common type of pediatric leukemia. Patients with AML are at high risk for several complications such as infections, typhlitis, and acute and long-term cardiotoxicity. Despite this knowledge, there are no definite supportive care guidelines as to what the best approach is to manage or prevent these complications. AREA COVERED: The NOPHO-DB-SHIP (Nordic-Dutch-Belgian-Spain-Hong-Kong-Israel-Portugal) consortium, in preparation for a new trial in pediatric AML patients, had dedicated meetings for supportive care. In this review, the authors discuss the available data and outline recommendations for the management of children and adolescents with AML with an emphasis on hyperleukocytosis, tumor lysis syndrome, coagulation abnormalities and bleeding, infection, typhlitis, malnutrition, cardiotoxicity, and fertility preservation. EXPERT OPINION: Improved supportive care has significantly contributed to increased cure rates. Recommendations on supportive care are an essential part of treatment for this highly susceptible population and will further improve their outcome.

Duplex Sequencing Uncovers Recurrent Low-frequency Cancer-associated Mutations in Infant and Childhood KMT2A-rearranged Acute Leukemia.

Infant acute lymphoblastic leukemia (ALL) with KMT2A-gene rearrangements (KMT2A-r) have few mutations and a poor prognosis. To uncover mutations that are below the detection of standard next-generation sequencing (NGS), a combination of targeted duplex sequencing and NGS was applied on 20 infants and 7 children with KMT2A-r ALL, 5 longitudinal and 6 paired relapse samples. Of identified nonsynonymous mutations, 87 had been previously implicated in cancer and targeted genes recurrently altered in KMT2A-r leukemia and included mutations in KRAS, NRAS, FLT3, TP53, PIK3CA, PAX5, PIK3R1, and PTPN11, with infants having fewer such mutations. Of identified cancer-associated mutations, 62% were below the resolution of standard NGS. Only 33 of 87 mutations exceeded 2% of cellular prevalence and most-targeted PI3K/RAS genes (31/33) and typically KRAS/NRAS. Five patients only had low-frequency PI3K/RAS mutations without a higher-frequency signaling mutation. Further, drug-resistant clones with FLT3 D835H or NRAS G13D/G12S mutations that comprised only 0.06% to 0.34% of diagnostic cells, expanded at relapse. Finally, in longitudinal samples, the relapse clone persisted as a minor subclone from diagnosis and through treatment before expanding during the last month of disease. Together, we demonstrate that infant and childhood KMT2A-r ALL harbor low-frequency cancer-associated mutations, implying a vast subclonal genetic landscape.