Repercusión clínica de la alfa-talasemia en nuestro medio. Impacto del screeningneonatal / Clinical consequences of alpha-thalassemia in the basque country, Spain. Impact of neonatal screening

INTRODUCCIÓN: La alfa-talasemia es la hemoglobinopatía más frecuente de expresión clínica variable en función del número de alelos mutados (1-2 alelos mutados: asintomático/anemia leve, 3-4 alelos mutados: enfermedad grave). Desde mayo de 2011 se ha añadido el estudio de hemoglobinopatías al screening neonatal en la Comunidad Autónoma del País Vasco (CAPV). OBJETIVOS: Valorar el impacto de la alfa-talasemia en nuestro medio y la utilidad del screening neonatal en su detección. MÉTODO: Revisión de pacientes con estudio genético positivo para alfa-talasemia durante 2 años (2012-2013) y estudio de la edad al diagnóstico, etnia, resultados analíticos y tratamiento. RESULTADOS: Se realizó un estudio genético de alfa-talasemia a 107 pacientes, de los cuales 61 presentaron alguna mutación. El 62% tenía un alelo mutado y el 38%, 2 alelos. La edad media al diagnóstico fue de 31 años, con un 28% menores de 18 años. La mayoría eran de procedencia europea con un porcentaje no desdeñable de africanos (26%) y árabes (13%) Todos los pacientes estudiados estaban asintomáticos con anemia leve en el 28%. Dos pacientes fueron diagnosticados por screening neonatal. La mayoría de pacientes no requirió tratamiento o precisó ferroterapia. CONCLUSIONES: La presencia de una o 2 mutaciones en los genes alfa carece de repercusión clínica, y el único interés de su estudio es que permite el consejo genético. En nuestro entorno no hemos encontrado pacientes con 3-4 mutaciones ni con sintomatología grave. A diferencia de lo que ocurre con otras enfermedades, nuestros resultados no apoyan que el screening neonatal de alfa-talasemia tenga un impacto significativo en nuestro entorno

INTRODUCTION: Alpha-thalassemia is the most common hemoglobinopathy with a variable clinical manifestation depending on the number of allele mutations (asymptomatic/mild anemia if 1-2 allele mutations, severe disease if 3-4 allele mutations). A study was conducted from May 2011 on hemoglobinopathies found in the neonatal screening in the autonomous community of the Basque Country (CAPV). OBJECTIVES: To analyze the impact of alpha-thalassemia in this area and the effectiveness of its neonatal screening. METHODS: A review was made of patients with a positive gene study for alpha-thalassemia over a 2-year period (2012-2013) and an analysis was made of the age at diagnosis, ethnic group, analytical result, and treatment. RESULTS: The genetic study was performed on 107 patients, of which 61 had some mutation, with 62% having one allele mutations and 38% with two alleles. The mean age at diagnosis was 31 years, with 28% being younger than eighteen years old. Most of the patients were European with a significant number of Africans (26%) and Arabs (13%). All patients were asymptomatic, and 28% had mild anemia. Two patients were diagnosed by neonatal screening. Most of them did not need any treatment or only required iron therapy. CONCLUSIONS: The detection of one or two alpha gene mutations has no clinical impact, but allows genetic counseling. No patient was found with 3-4 mutations or severe symptoms in our region. Contrarily to the diagnosis of other diseases, our results does not support that routine neonatal screening for alpha-thalassemia has any clinical impact in our community

[Clinical consequences of alpha-thalassemia in the Basque Country, Spain. Impact of neonatal screening]. / Repercusión clínica de la alfa-talasemia en nuestro medio. Impacto del screening neonatal.

INTRODUCTION: Alpha-thalassemia is the most common hemoglobinopathy with a variable clinical manifestation depending on the number of allele mutations (asymptomatic/mild anemia if 1-2 allele mutations, severe disease if 3-4 allele mutations). A study was conducted from May 2011 on hemoglobinopathies found in the neonatal screening in the autonomous community of the Basque Country (CAPV). OBJECTIVES: To analyze the impact of alpha-thalassemia in this area and the effectiveness of its neonatal screening. METHODS: A review was made of patients with a positive gene study for alpha-thalassemia over a 2-year period (2012-2013) and an analysis was made of the age at diagnosis, ethnic group, analytical result, and treatment. RESULTS: The genetic study was performed on 107 patients, of which 61 had some mutation, with 62% having one allele mutations and 38% with two alleles. The mean age at diagnosis was 31 years, with 28% being younger than eighteen years old. Most of the patients were European with a significant number of Africans (26%) and Arabs (13%). All patients were asymptomatic, and 28% had mild anemia. Two patients were diagnosed by neonatal screening. Most of them did not need any treatment or only required iron therapy. CONCLUSIONS: The detection of one or two alpha gene mutations has no clinical impact, but allows genetic counseling. No patient was found with 3-4 mutations or severe symptoms in our region. Contrarily to the diagnosis of other diseases, our results does not support that routine neonatal screening for alpha-thalassemia has any clinical impact in our community.

Male flight phenology of the European grapevine moth Lobesia botrana (Lepidoptera: Tortricidae) in different wine-growing regions in Spain.

Lobesia botrana is the most significant pest of grape berries in Spain. Further knowledge of its phenology would enable wine growers to decide on an optimal treatment schedule. The aim of this study is, therefore, to predict the flight peaks of L. botrana in seven wine-growing regions of Spain. The main goal is to provide a prediction model based on meteorological data records. A logistic function model, based on temperature and humidity records, together with an exhaustive statistical analysis, were used to compare the wine-growing regions in which the male flight phenology of L. botrana displays similar patterns and to sort them into groups. By doing so, a joint study of the dynamics of the moth is possible in the regions within each group. A comparison of the prediction errors before and after applying the Touzeau model confirmed that the fit of the latter model is not sufficiently accurate for the regions under study. Moth flight predictions with the logistic function model are good, but accuracy may still be improved by evaluating other non-biotic and biotic factors.

A prospective biological study in relation to a family with Li-Fraumeni syndrome

INTRODUCTION: The Li-Fraumeni syndrome (LFS) is an autosomal dominant hereditary disorder associated with different tumor types in childhood and young adults. Approximately 70% of LFS cases contain germline mutations in the TP53 gene. We report a case of a family suspected of LFS. MATERIALS AND METHODS: The proband and four members of the family affected were diagnosed with cancer at an early age and they all died except the proband. Exons 5-9 from TP53 gene were analysed by direct amplification and sequencing in 7 family members. RESULTS: The analysis revealed a germline nonsense mutation in exon 8 at codon 306 of the codified region of the TP53 gene, causing a change of CGA to TGA (Arg→Stop) in the proband, her mother, her cousin and her maternal uncle. Proband's maternal grandmother and aunt do not have the mutation. CONCLUSIONS: The members of this family that were studied meet the criteria of classic LFS and the described mutation increases their susceptibility to develop cancer. The proband's maternal grandfather died of lung cancer in 1993, and we believe that he was the carrier of the mutation in this family (AU)

Efficacy and safety of liposomal cytarabine in children with primary CNS tumours with leptomeningeal involvement.

PURPOSE: To assess the efficacy and safety of liposomal cytarabine in the treatment of de novo and relapsed leptomeningeal involvement in children with primary CNS tumours. METHODS: Data from clinical charts were entered into a database for consecutive unselected patients (n=20) from nine Spanish centres. Diagnosis of leptomeningeal involvement was confirmed by cytology, MRI and/or CT scan. The dose of liposomal cytarabine used varied from 20 to 50 mg, by age. RESULTS: There were 8 females and 12 males, mean age 7.3 years (range 8 months to 18 years). The tumours were: 10 medulloblastomas, 4 ependymomas, 3 primitive neuroectodermal tumours and 3 other tumours. Fourteen had undergone previous chemotherapy and 12 radiotherapy. Nine received concurrent chemotherapy and 2 concurrent radiotherapy. Median follow-up was 244.5 days (range 12- 869). Patients received a median of 5 doses (range 1-9) of liposomal cytarabine. A neurological response (complete or partial) was seen in 11/19 (58%) and a cytological response in 7/10 (64%). Median time to neurological progression exceeded 180 days (range 12-869). Adverse effects were reported in 11/20 patients, but none was grade IV. DISCUSSION: Liposomal cytarabine was well tolerated and efficacious in this patient group, but prospective randomised trials are needed.

Efficacy and safety of liposomal cytarabine in children with primary CNS tumours with leptomeningeal involvement

PURPOSE: To assess the efficacy and safety of liposomal cytarabine in the treatment of de novo and relapsed leptomeningeal involvement in children with primary CNS tumours. METHODS: Data from clinical charts were entered into a database for consecutive unselected patients (n=20) from nine Spanish centres. Diagnosis of leptomeningeal involvement was confirmed by cytology, MRI and/or CT scan. The dose of liposomal cytarabine used varied from 20 to 50 mg, by age. RESULTS: There were 8 females and 12 males, mean age 7.3 years (range 8 months to 18 years). The tumours were: 10 medulloblastomas, 4 ependymomas, 3 primitive neuroectodermal tumours and 3 other tumours. Fourteen had undergone previous chemotherapy and 12 radiotherapy. Nine received concurrent chemotherapy and 2 concurrent radiotherapy. Median follow-up was 244.5 days (range 12- 869). Patients received a median of 5 doses (range 1-9) of liposomal cytarabine. A neurological response (complete or partial) was seen in 11/19 (58%) and a cytological response in 7/10 (64%). Median time to neurological progression exceeded 180 days (range 12-869). Adverse effects were reported in 11/20 patients, but none was grade IV. DISCUSSION: Liposomal cytarabine was well tolerated and efficacious in this patient group, but prospective randomised trials are needed (AU)

Methotrexate consolidation treatment according to pharmacogenetics of MTHFR ameliorates event-free survival in childhood acute lymphoblastic leukaemia.

Recent advances in treatment for childhood acute lymphoblastic leukaemia (ALL) have significantly increased outcome. High-dose methotrexate (MTX) is the most commonly used regimen during the consolidation period, but the optimal dose remains to be defined. We investigated the usefulness of the MTHFR genotype to increase the MTX dosage in the consolidation phase in 141 childhood ALL patients enrolled in the ALL/SHOP-2005 protocol. We also investigated the pharmacogenetic role of polymorphisms in genes involved in MTX metabolism on therapy-related toxicity and survival. Patients with a favourable MTHFR genotype (normal enzymatic activity) treated with MTX doses of 5 g m⁻² had a significantly lower risk of suffering an event than patients with an unfavourable MTHFR genotype (reduced enzymatic activity) that were treated with the classical MTX dose of 3 g m⁻² (P=0.012). Our results indicate that analysis of the MTHFR genotype is a useful tool to optimise MTX therapy in childhood patients with ALL.

Evidence in medulloblastomas.

Medulloblastoma is the most common infratentorial malignant tumour under 15 years of age. In recent protocols, the patients are stratified for treatment in standard risk or high risk, according to the clinical variables as age, localized or disseminated disease, degree of surgical resection and more recently expected biological behaviour based on retrospective and prospective studies of former samples analyzed. The objectives for future treatments are reduce morbidity without jeopardizing survival.

Evidence in medulloblastomas

Medulloblastoma is the most common infratentorial malignant tumour under 15 years of age. In recent protocols, the patients are stratified for treatment in standard risk or high risk, according to the clinical variables as age, localized or disseminated disease, degree of surgical resection and more recently expected biological behaviour based on retrospective and prospective studies of former samples analyzed. The objectives for future treatments are reduce morbidity without jeopardizing survival (AU)

No disponible

Nonhost versus host resistance to the grapevine downy mildew, Plasmopara viticola, studied at the tissue level.

Following inoculation of host and nonhost plants with Plasmopara viticola, the grapevine downy mildew, a histological survey was undertaken to identify the stage where its development is contained in nonhosts and in resistant host plants. Three herbaceous nonhost species, Beta vulgaris, Lactuca sativa, and Capsicum annuum, and three grapevine species displaying different level of resistance (Vitis vinifera [susceptible], Vitis riparia [partially resistant] and Muscadinia rotundifolia [totally resistant]) where inoculated by P. viticola using a controlled leaf disk inoculation bioassay. During the early steps of infection, defined as encystment of zoospores on stomata, penetration of the germ tube, and production of the vesicle with the primary hypha, there was no evidence of a clear-cut preference to grapevine tissues that could attest to host specificity. The main difference between host grapevine species and nonhosts was observed during the haustorium formation stage. In nonhost tissues, the infection was stopped by cell wall-associated defense responses before any mature haustorium could appear. Defense responses in resistant grapevines were triggered when haustoria were fully visible and corresponded to hypersensitive responses. These observations illustrate that, for P. viticola, haustorium formation is not only a key stage for the establishment of biotrophy but also for the host specificity and the recognition by grapevine resistance factors.

Intervención psicológica en sujetos durante la reanimación de su parada cardiorrespiratoria / Psychological intervention with patients subject to cardiopulmonary resucitation

En esta investigación se estudian los aspectos psicológicos y fisiológicos relacionados con la muerte y con la parada cardiorrespiratoria. Se aporta un protocolo psicológico de estimulación verbal para aplicarlo al sujeto, durante la reanimación de su parada cardiorrespiratoria y los datos preliminares sobre la eficacia de dicha intervención, con una muestra de 30 pacientes, que presentaban una parada cardiorrespiratoria extrahospitalaria. Los resultados obtenidos aconsejan continuar con la investigación aumentando la muestra de sujetos. (AU)

Outcome of high-risk neuroblastoma using a dose intensity approach: improvement in initial but not in long-term results.

BACKGROUND: Stage 4 and MYCN amplified (MNA) neuroblastoma in children have a poor prognosis. Our aim was to increase initial and long-term response in this population. PROCEDURE: High-risk children were studied according to the International Neuroblastoma Staging System, then treated with high-dose cyclophosphamide and high-dose carboplatin, followed by surgery and autologous stem cell transplant or maintenance chemotherapy. RESULTS: From June 1992 to December 1998, 83 children were admitted in the study (72 stage 4> 1 year, 5 stage 4 MNA infants, and 6 MNA stage 3 children); tumor tissue was obtained from 73, MYCN was performed in 65, being amplified in 21 (32%). Induction chemotherapy was administered in the expected time in 35% of patients. Its toxicity was mainly hematologic followed by infections, and there were 3 chemotherapy-related deaths. Delayed surgery was performed on 60 patients with complete or >90% resection in 80% of cases. Chemotherapy plus surgery produced some response in 90% of patients, 53% were in CR/VGPR; 49 children received autologous SCT, and 16 received maintenance chemotherapy for 9 months. Follow-up ranges are 1-87 months, mean 30 months. S and EFS at 4 years are 0.33 (SD 0.02). CONCLUSIONS: High-dose cyclophosphamide and high-dose carboplatin are effective in the initial treatment of neuroblastoma; combined with surgery they produce some response in most patients. Nevertheless, the CR/VGPR rate reaches only 53%. Survival time has also been prolonged but most patients relapse with metastases.

Microcefalia, opacidad corneal bilateral y holoprosencefalia lobarcongénitas con desarrollo posterior de un rabdomio sarcoma en un paciente expuesto a radiación prenatal / Microcephaly, bilateral corneal opacity and congenital lobar holoprosencephaly with subsequent development of a rhabdomyosarcoma in a patient exposed to prenatal radiation

Introducción. La mayoría de las malformaciones congénitas de causa identificada se corresponden con causas genéticas, multifactoriales o secundarias a algún teratógeno. Muchas malformaciones congénitas tienen un origen desconocido, pero la asociación de diferentes malformaciones permite al menos definir el momento prenatal en que la noxa afectó el desarrollo embrionario o fetal. Caso clínico. Presentamos el caso de un recién nacido de una gestación de 40 semanas, con exposición prenatal a radiaciones ionizantes, hallazgos ecográficos prenatales de microcefalia y cariotipo normal. El neonato presenta opacidades corneales, microcefalia y malformación encefálica compleja. Las opacidades corneales, unidas al glaucoma congénito constituyen un síndrome de Peters que condiciona ceguera. El pacientes fue tratado con trabeculectomía y trasplante corneal bilateral. La microcefalia y la holoprosencefalia lobar con agenesia de cuerpo calloso determinaron un escaso desarrollo psicomotor, hipertonía y una epilepsia con registro electroencefalográfico de hemihipsarritmia, tratada sin éxito con valproato y vigabatrina. A los 21 meses el paciente desarrolla un rabdomiosarcoma embrionario de base de lengua, y fallece en el contexto de una infección sistémica tras la quimioterapia. Conclusiones. La asociación de malformaciones descrita no ha sido referida anteriormente en las bases de datos internacionales. Aunque la posible relación causal entre radioexposición prenatal y el cuadro clínico no puede demostrarse, la posibilidad teratogénica y carcinogénica de dicha exposición llevan a insistir en evitar que las mujeres gestantes o que desconocen su estado gestacional estén presentes en las salas de radiodiagnóstico (AU)

Spectrum of germline RB1 gene mutations in Spanish retinoblastoma patients: Phenotypic and molecular epidemiological implications.

Mutation analysis of retinoblastoma is considered important for genetic counseling purposes, as well as for understanding the molecular mechanisms leading to tumors with different degrees of penetrance or expressivity. In the course of an analysis of 43 hereditary retinoblastoma Spanish patients and kindred, using direct PCR sequencing, we have observed 29 mutations; most of them (62%) have not been reported previously. Of the mutations, 69% correspond to nonsense mutations (mainly CpG transitions) and frameshifts, with the expected outcome of a truncated Rb protein that lacks the functional pocket domains and tail. The remainder corresponds to splicing mutations, most of them (62%) targeted to invariant nucleotides, with the predicted consequence of out of frame exon skipping. Two of the splicing mutations in our study were found associated to families with a low-penetrance phenotype. Additionally, most of the mutations affecting splice junctions corresponded to retinoblastoma cases of either sporadic or hereditary nature with delayed onset (32 months on average). In contrast, most of the nonsense and frameshift mutations are associated with an early age at diagnosis (8.7 months on average). These differences are discussed in the context of the relationships between genotype and low expressivity phenotype. The differences in the spectrum of RB1 mutations found in this and other European surveys are also discussed in the context of alternate DNA methylation and mismatch repair phenotypes.

Results of the cooperative protocol (N-III-95) for metastatic relapses and refractory neuroblastoma.

BACKGROUND: Prognosis of relapsed and refractory neuroblastoma is uniformly fatal; new therapeutic approaches are needed. PROCEDURE: Relapsed and refractory neuroblastoma patients were treated with continuous infusion chemotherapy combined with MIBG. RESULTS: Over 4 years, 35 heavily pretreated patients were registered, 29 with bone or/and bone marrow metastases. Grade 3 or 4 hematologic toxicity was frequent, without toxic deaths. Sixteen patients responded. The probability of 5-year overall survival was 0.19. CONCLUSIONS: This approach is feasible and toxicity manageable; it rescued some patients and prolonged their survival. It merits assay in newly diagnosed high-risk neuroblastoma patients.

Exogenously incorporated ketocarotenoids in large unilamellar vesicles. Protective activity against peroxidation.

The ability of astaxanthin and canthaxanthin as chain-breaking antioxidants was studied in Cu(2+)-initiated peroxidation of phosphatidylcholine large unilamellar vesicles (LUVs). Both carotenoids increased the lag period that precedes the maximum rate of lipid peroxidation, though astaxanthin showed stronger activity. For these experiments, different amounts of xanthophylls were exogenously added to previously made LUVs, non-incorporated pigment being afterwards removed. Differential scanning calorimetry assays with L-beta,gamma-dimyristoyl-alpha-phosphatidylcholine LUVs demonstrated that xanthophylls incorporated as described interact with the lipid matrix becoming interspersed among the phospholipid molecules.

Prospective evaluation of the International Neuroblastoma Staging System (INSS) and the International Neuroblastoma Response Criteria (INRC) in a multicentre setting.

The aim of this study was to classify prospectively a series of neuroblastoma tumours according to the International Neuroblastoma Staging System (INSS) and the International Neuroblastoma Response Criteria (INRC) and to evaluate the difficulties and pitfalls involved in a multicentre setting. Each hospital provided their data for central review. The surgical procedures and their complications were reported. Kaplan-Meier estimates of survival and event-free survival were calculated according to stage and response to therapy. From June 1992 to December 1996, 194 patients were included in the study, with a mean age of 2 years. Initial studies were performed according to INSS recommendations without major problems. INSS stage was correctly applied to all patients except for 9 (95%). Post-operative complications were observed in 15 patients (8.3%). Response to therapy (INRC) was studied in 63 stage 4 patients, 11 of whom were not classified correctly (17%). Differences in survival according to stage (INSS) and group of response to therapy (INRC) were statistically significant (P < 0.001). In conclusion the INSS was easy to use and separated different prognostic groups. Surgical complications and mortality did not increase in this series because of using the INSS. The feasibility of INRC was evaluated in a small series of stage 4 patients and the designation of response was problematic in a relatively high proportion of cases. The prognostic value of the different responses was highly significant, but less informative than had been hoped for.

Reversible cardiomyopathy secondary to alpha-interferon in an infant.

Interferon-alpha (IFN-alpha) is a biological response modifier with antiviral and tumoral effect that is used in the treatment of chronic myelogenous leukemias. Adverse effects are well documented and cardiovascular disturbances mostly include hypotension and tachycardia and rarely cardiomyopathy. We report on an infant with chronic myelomonocytic leukemia (CML) diagnosed at 3 months of age who was treated with increasing IFN-alpha dosage (2.5-5.5 million U/m2/day) given subcutaneously for 7.5 months. At that age, he presented anorexia, general malaise, and nocturnal sweating for about a week, followed by respiratory distress and tachycardia. Diagnosis of congestive heart failure was suspected and documented by cardiomegaly and echographic changes of left ventricular dilated cardiomyopathy, with a 40% left ventricular ejection fraction (EF) and 20% fractional shortening (FS). He was treated with digoxin, furosemide, and angiotensin converting inhibitors, and IFN-alpha was discontinued. Progressive improvement of cardiac function was observed within 7 months of the events with normalization of the echocardiographic findings (EF 60%, FS 31%). We should emphasize the possibility of severe and reversible cardiac toxicity of IFN-alpha in infancy.

[Vaccination of chickenpox in children with acute lymphoblastic leukaemia]. / Vacunación de varicela en niños con leucemia linfoblástica aguda.

Varicella vaccine has shown its efficacy to prevent the disease and complications in healthy and immunodeficient children. In this article the authors evaluate the immunologic status of acute lymphoblastic leukaemia at diagnosis and at follow up and the development of chickenpox and/or herpes zoster. Children with negative serology and continuous complete remission of acute lymphoblastic leukaemia for one year were vaccinated. Of 71 children diagnosed of acute lymphoblastic leukaemia from 1983 to 1996, 25 received the vaccine and seroconversion was obtained in 76% after one dose and 92% after the second dose. Vaccine tolerance was adequate. The incidence of herpes zoster infection was decreased in vaccinated children during chemotherapy compared to the wild-virus infected ones. Nowadays that vaccine for healthy children is recommended, we consider a priority to protect from chickenpox the children affected by leukaemia that are in continuous complete remission of the disease.