Diagnosis and management of acquired aplastic anemia in childhood. Guidelines from the Marrow Failure Study Group of the Pediatric Haemato-Oncology Italian Association (AIEOP).

Acquired aplastic anemia (AA) is a rare heterogeneous disorder characterized by pancytopenia and hypoplastic bone marrow. The incidence is 2-3 per million population per year in the Western world, but 3 times higher in East Asia. Survival in severe aplastic anemia (SAA) has improved significantly due to advances in hematopoietic stem cell transplantation (HSCT), immunosuppressive therapy, biologic agents, and supportive care. In SAA, HSCT from a matched sibling donor (MSD) is the first-line treatment. If a MSD is not available, options include immunosuppressive therapy (IST), matched unrelated donor, or haploidentical HSCT. The purpose of this guideline is to provide health care professionals with clear guidance on the diagnosis and management of pediatric patients with AA. A preliminary evidence-based document prepared by a group of pediatric hematologists of the Bone Marrow Failure Study Group of the Italian Association of Pediatric Hemato-Oncology (AIEOP) was discussed, modified and approved during a series of consensus conferences that started online during COVID 19 and continued in the following years, according to procedures previously validated by the AIEOP Board of Directors.

[Update on prevention of infections in patients without spleen or with diminished splenic function]. / Update sulla prevenzione delle infezioni nei pazienti splenectomizzati o con iposplenismo funzionale.

Patients without spleen or with diminished splenic function are at high risk (10-50 times higher than in normal population) of developing life-threatening infections (OPSI). Mortality from OPSI is estimated at 50 to 80% of cases. More frequent causative agents are encapsulated bacteria: Streptococcus Pneumoniae, Haemophilus influenzae type b and Neisseria Meningitidis. The risk of OPSI can be reduced by immunizing patients against these pathogens and by prescribing antibiotic prophylaxis. Continuous antibiotic prophylactic for 2-5 years after splenectomy (longer periods might expose the patients to the risk of antibiotic resistance) with penicillin or amoxicillin/clavulanate acid is mandatory. Asplenic individuals should take empirical antibiotic therapy - so called "self-treatment" - and immediate medical consultation in presence of febrile illness. All patients and their parents should be carefully educated about the risk of infections in order to obtain a good long-term compliance with these recommendations.

Neonatal thrombosis.

Thrombosis is a special problem of the neonatal period, particularly in premature sick neonate, where it occurs with greater frequency than at other times of childhood. The aim of this article is to review the recommendations for the diagnosis and treatment of neonatal thrombosIs.

Benign transient blueberry muffin baby.

In this case-report a case of severe fetal anemia of unknown origin is presented. Diagnosis of fetal anemia was made at 24 weeks of gestational age, when fetal ascites was identified. Doppler sonography of medium cerebral artery showed a high systolic speed velocity (ACM-PSV), of 65 cm/s (>1.55 MoM). This value predicts a severe fetal anemia. Funicolocentesis confirmed hyporegenerative anemia, low reticulocytosis and low erythroblastosis. A fetal transfusion was performed. At birth anemia was still present and the baby presented blueberry muffin and liver erythropoietic foci. The blueberry muffin morphology presents as non-blanching, blue-red macules or firm, dome-shaped papules (2-8 mm in diameter). The eruption is often generalized but favors the trunk, head, and neck. Infectious (Toxoplasmosis, Cytomegalovirus, Rubella, Herpes, Parvo, Coxackievirus, Ebstein Barr, Syphilis), hematologic (sferocytosis, alloimmunization, foeto-maternal transfusion), metabolic, neoplastic (congenital leukemia, neuroblastome, congenital rhabdomyosarcome) and systemic (histiocytosis, lupus) pathologies indicated until now as possible disease causes were excluded. In the first day of life the neonate received a RBC transfusion for anemia (Hb=5.1 g/dL; Hct 15,7% at birth), followed within 48-72 hours by rapid disappearance of the rash, that wasn't then histologically examined. During two weeks of hospitalization reticulocytes raised spontaneously from 0.8% to 3.17%. Until two years of age the auxologic and clinical course was regular and the child is now in good health conditions. Due to the absence of systematic disease and the complete regression, no exact diagnosis and prognosis could be established in this case.

Management and investigation of neonatal thromboembolic events: genetic and acquired risk factors.

Newborns comprise the largest group of children developing thromoboembolic events (TE(S)), due to the peculiarities of their developmental hemostatic system. Moreover, in the sick newborn, especially preterm, numerous acquired perinatal and iatrogenic conditions might result in a disturbance between coagulation and fibrinolysis, leading to thrombus formation. Nevertheless, the contribution of acquired prothrombotic disorders in the pathogenesis of thromboembolic disease in newborns remains poorly defined. Few data are currently available regarding the influence of maternal or fetal genes on thrombotic risk in the fetus and neonate. Ongoing National and International registries are partially answering these questions. The purpose of this review is to evaluate the current knowledge about the role of inherited, acquired perinatal and maternal prothrombotic risk factors in neonatal cerebral nervous system (CNS) thrombotic events and non-CNS thrombotic events.

Interrelationships between "Candidatus Phytoplasma asteris" and its leafhopper vectors (Homoptera: Cicadellidae).

The titer of chrysanthemum yellows phytoplasma (CYP, "Candidatus Phytoplasma asteris") in the three vector species Euscelis incisus Kirschbaum, Euscelidius variegatus Kirschbaum, and Macrosteles quadripunctulatus Kirschbaum (Homoptera: Cicadellidae) was measured after controlled acquisition from infected Chrysanthemum carinatum (Schousboe) (daisy) plants. Phytoplasma DNA was quantified in relation to insect DNA (genome units [GU] of phytoplasma DNA per ng of insect DNA) by using a quantitative real-time polymerase chain reaction (PCR) procedure. The increase in phytoplasma titer recorded in hoppers after they were transferred to plants that were nonhosts for CYP provides definitive evidence for phytoplasma multiplication in leafhoppers. CYP multiplication over time in M. quadripunctulatus was much faster than in E. incisus and E. variegatus. CYP titer was also highest in M. quadripunctulatus, and this was reflected in the latent period in the insect. The mean latent period of CYP in M. quadripunctulatus was 18 d versus 30 d in E. variegatus. M. quadripunctulatus was the most efficient vector, giving 100% transmission for single insects compared with 75-82% for E. incisus or E. variegatus, respectively. By sequential transmission, we analyzed the time course of transmission: E. variegatus were persistently infective for life or until shortly before death. Occasionally, leafhoppers failed to maintain continuity of infectivity even after completion of the latent period. PCR analysis of transmitter and nontransmitter E. variegatus adults showed that some nontransmitters were CYP positive, whereas others were CYP negative. These findings suggest that both midgut and salivary gland barriers play a role in transmission efficiency.

Continuous antibiotic infusion for salvage therapy of partially implanted central venous catheter tunnel infections due to staphylococci.

Tunnel infection is an uncommon but serious complication observed in patients with partially implanted central venous catheters. International guidelines suggest that should include antibiotics and catheter removal. A success rate of only 5-20% was reported without catheter removal. We treated 13 episodes of tunnel Gram-positive bacterial infection occurring in pediatric patients with cancer or serious blood disorders with 24-hr intra-catheter antibiotic continuous infusion. This approach led to a 69% success rate. Continuous infusion might be an attractive option to treat tunnel Gram-positive bacterial infections when catheter removal might not be feasible or advisable.

Central venous catheter-related complications in children with oncological/hematological diseases: an observational study of 418 devices.

BACKGROUND: The use of indwelling central venous catheters (CVCs) has become commonplace in the management of children undergoing anticancer treatment. Several types of CVC are available, while information on complications observed in children is scarce. We describe the experience of two tertiary care centers in Italy that prospectively followed up three types of CVC used at both institutions over a 30-month period. PATIENTS AND METHODS: Between January 2000 and May 2002, double-lumen (DL) or single-lumen (SL) Hickman-Broviac (HB) catheters, and single-lumen pressure-activated safety valve (PASV) catheters were used and prospectively evaluated. Four types of possible complication were defined a priori: mechanical, thrombotic, malfunctioning and infectious. RESULTS: Four hundred and eighteen CVCs (180 SL-HB, 162 DL-HB and 76 PASV) were inserted in 368 children, for a total of 107 012 catheter days at risk of complication. At least one complication occurred while using 169 of the devices (40%): 46% of the DL-HB, 46% of the PASV and 33% of the SL-HB (P=0.02) catheters. Subjects with hematological malignancies or non-malignant diseases had significantly more complications than those with solid tumors (P <0.0001). Overall, 234 complications were documented: 93 infectious [complication rate per 1000 catheter days at risk (CR)=0.87], 84 malfunctioning (CR=0.78), 48 mechanical (CR=0.45) and nine thrombotic (CR=0.08). SL-HB had statistically fewer infectious complications, while PASV had more mechanical complications. In a multivariate regression model, the most significant risk factors for having a CVC complication were hematological disease [relative risk (RR)=3.0; 95% confidence interval (CI) 1.8-4.8] and age <6 years at CVC insertion (RR=2.5; 95% CI 1.5-4.1). As for the type of CVC, compared with SL-HB, the DL-HB catheter had a statistically significant two-fold increased risk of any complication (RR=2.1; 95% CI 1.2-3.6), while the PASV catheter had a borderline RR of 1.8 (95% CI 1.0-3.6). Analysis by tumor type showed a higher risk of any kind of complication in patients with solid malignancies who had received a DL-HB catheter as compared with an SL-HB catheter (RR=7.2; 95% CI 2.8-18.7). CONCLUSIONS: CVCs may cause complications in up to 40% of patients, with type of CVC, underlying disease and patient age being the three main factors that affect the incidence of CVC-related complications. SL-HB catheters have the best performance.

The relationship between radiation fields and regional lymph nodes in carcinoma of the breast.

PURPOSE: To examine the relationships between tangential, anterior, and posterior radiation fields and regional lymph nodes, including Levels I-III axillary and supraclavicular lymph nodes. METHODS AND MATERIALS: Fifty-five patients underwent computed tomography (CT) scanning in the supine treatment position, and radiation fields were developed to treat appropriate breast and lymphatic regions. After conventional fields had been selected, Levels I-III axillary and supraclavicular lymph nodes were identified on multiple CT slices performed at 3-5-mm intervals and their depths to the anterior skin surface and the anterior-posterior separations at multiple levels were measured. RESULTS: The mean depths of the Levels I-III axillary nodes were 4.6, 5.1, and 3.6 cm, respectively. The mean depth of the supraclavicular nodes was 3.9 cm. The mean anterior-posterior separations at these levels were 15.4, 15.2, 15.2, and 14.6 cm. The mean depths of the nodes, therefore, were well anterior to the midline. In the two-field treatment group, Level I axillary nodes appeared in the tangential portals in 9/9 patients, either alone or with other lymph node groups. In the three-field group, Level I axillary nodes were in 16/16 tangential fields either alone or with level II nodes (8 patients). In 8 patients, Level III and the supraclavicular nodes were included in the anterior field and in the other 8, Levels II, III, and the supraclavicular nodes were in the anterior field. There was considerable variation in the nodal groups present in the posterior axillary boost field. No nodal groups were observed in 6 patients. CONCLUSION: There is considerable variation both in the depth of supraclavicular and axillary lymph nodes and the fields in which these nodal groups appear. To be certain that nodal groups which one plans to treat are actually treated, as well as to minimize nodal treatment when such treatment is not planned, it is recommended that before the placement of radiation fields, the nodal groups be outlined on a CT scan much as one would outline a tumor volume in other disease sites.

Analysis of the turin umbilical cord blood bank registry.

BACKGROUND: The polymorphic nature of the HLA system reduces a patient's probability of finding an HLA-compatible unrelated bone marrow (BM) donor, even though more than 6 million individuals are enrolled in international registries. Recently, umbilical cord blood (UCB) has been successfully employed as a source of HPCs. The use of such cells reduces the risk of GVHD and allows transplants with one or two HLA mismatches. UCB represents an expensive resource: therefore, it is necessary to carefully manage the UCB unit inventory. STUDY DESIGN AND METHODS: The current study analyzed the genetic heterogeneity of HLA-A, -B, and -DR gene frequencies between pools of UCB and unrelated-donor BM in the Piedmont (an administrative region of Italy). An Italian hematology patient's probability of finding complete or partial matches as a function of donor pool size was determined by considering subsamples randomly selected from the local unrelated BM donors. RESULTS: The HLA gene frequencies in UCB and unrelated-donor BM pools were not significantly different. The search simulation, based on actual HLA phenotypes, showed that the percentage of Italian patients matched with an HPC unit increases remarkably if 1 or 2 mismatches are accepted, reaching a proportion of 90 percent with an inventory of only about 500 units, while the increment is not so remarkable if the number of UCB units is greater. CONCLUSION: To optimize economic resources and to be internationally competitive, UCB banks should aim to increase the genetic heterogeneity of their units rather than increasing the UCB inventory, acquire efficient quality control systems, and acquire and preserve UCB units with a greater number of nucleated cells.

Antilymphocyte globulin, cyclosporine, prednisolone, and granulocyte colony-stimulating factor for severe aplastic anemia: an update of the GITMO/EBMT study on 100 patients. European Group for Blood and Marrow Transplantation (EBMT) Working Party on Severe Aplastic Anemia and the Gruppo Italiano Trapianti di Midolio Osseo (GITMO).

One hundred consecutive patients with severe aplastic anemia (SAA) received horse antilymphocyte globulin (ALG), cyclosporin A (CyA), 6-methylprednisolone (6Mpred), and granulocyte colony-stimulating factor (G-CSF) as first-line therapy. The median age was 16 years (range, 1-72 years) and median neutrophil count was 0.2 x 10(9)/L (range, 0-0.5 x 10(9)/L). Trilineage hematologic recovery (at a median interval of 96 days from treatment) was seen in 77 patients (48 complete, 29 partial) after 1 (n = 50) or more courses of ALG (n = 27). Of the 23 nonresponders, 11 patients died at a median interval of 83 days (range, 16-1132 days), 6 were considered treatment failures and underwent transplantation, and 6 were pancytopenic. Cytogenetic abnormalities were seen in 11% of patients, clonal hematologic disease in 8%, and relapse of marrow aplasia in 9%. The actuarial survival at 5 years was 87% (median follow-up 1424 days): 76% versus 98% for patients with neutrophil counts less than versus greater than 0.2 x 10(9)/L (P =.001) and 88% versus 87% for patients aged less than versus more than 16 years (P =.8). The actuarial probability of discontinuing CyA was 38%. Patients who did not achieve a white blood cell (WBC) count of 5 x 10(9)/L during G-CSF treatment have a low probability of responding (37%) and a high mortality rate (42%). This update confirms a high probability for SAA patients of becoming transfusion independent and of surviving after treatment with ALG, CyA, 6Mpred, and G-CSF, with a significant effect of neutrophil counts on outcome. Problems still remain, such as absent or incomplete responses, clonal evolution, relapse of the original disease, and cyclosporine dependence. Early transplantation, also from alternative donors, may be warranted in patients with poor WBC response to G-CSF. (Blood. 2000;95:1931-1934)

[Neonatal arteriovenous thrombosis: report of a case]. / Trombosi artero-venosa ad insorgenza prenatale: presentazione di un caso.

UNLABELLED: Limb vascular thrombosis is a severe, rare entity, often needing invasive surgery and sometimes leading to loss of function. An infant with in utero arteiro-venous thrombosis is reported. CASE REPORT: The baby, a female infant, was born at 34 weeks from a mother affected by gestational diabetes. She was referred to Neonatal Care Unit because of mild respiratory distress syndrome. She had no malformations. Spontaneous acute ischemia of right upper limb was noticed soon after admission: the limb appeared pale, cold, atonic and areflexic; no signs were noticed on it. Axillary artery and vein thromboses were soon confirmed by ultrasonography and arteriography. Intravenous administration of recombinant tissue plasminogen activator was carried on for 36 hours and followed by heparin and antithrombin III administration. Partial revascularization was obtained after a few hours: at the beginning of the treatment the limb became cyanotic, then edematous and finally the normal colour appeared everywhere but in the hand, was it became visible after a few days, when edema was reabsorbed. No recurrence of thrombosis occurred with heparin prophylaxis. Pain was treated with analgesic therapy, and motor impairment required physiotherapy. The doppler ultrasonographies which were performed subsequently confirmed a complete revascularization of axillary artery and vein. Coagulation and metabolic parameters (clotting tests, protein C, protein S, prothrombin, aminoacids) were studied but disorders predisposing to thrombosis were not found both in the patient and in her parents. CONCLUSION: Early identification of limb vascular thrombosis through external symptoms is very important, as it can avoid invasive surgical procedures.

Rabbit antithymocyte globulin (r-ATG) plus cyclosporine and granulocyte colony stimulating factor is an effective treatment for aplastic anaemia patients unresponsive to a first course of intensive immunosuppressive therapy. Gruppo Italiano Trapianto di Midollo Osseo (GITMO)

About 30% of patients with severe aplastic anaemia (SAA) unresponsive to one course of immunosuppressive (IS) therapy with antithymocyte or antilymphocyte globulin can achieve complete or partial remission after a second IS treatment. Among various second-line treatments, rabbit ATG (r-ATG) could represent a safe and effective alternative to horse ALG (h-ALG). In a multicentre study, 30 patients with SAA (17 males and 13 females, median age 21 years, range 2-67) not responding to a first course with h-ALG plus cyclosporin (CyA) and granulocyte colony stimulating factor (G-CSF), were given a second course using r-ATG (3.5 mg/kg/d for 5 d), CyA (5 mg/kg orally from day 1 to 180) and G-CSF (5 microg/kg subcutaneously from day 1 to 90). The median interval between first and second treatment was 151 d (range 58-361 d). No relevant side-effects were observed, but one patient died early during treatment because of sepsis. Overall response, defined as transfusion independence, was achieved in 23/30 (77%) patients after a median time of 95 d (range 14-377). Nine patients (30%) achieved complete remission (neutrophils >/=2.0 x 109/l, haemoglobin >/=11 g/dl and platelets >/=100 x 109/l). The overall survival rate was 93% with a median follow-up of 914 d (range 121-2278). So far, no patient has relapsed. Female gender was significantly associated with a poorer likelihood to respond (P = 0.0006). These data suggest that r-ATG is a safe and effective alternative to h-ALG for SAA patients unresponsive to first-line IS treatment.

Cell adhesion molecules in cord blood hematopoietic progenitors.

We investigated the expression of different cell adhesion molecules on cord blood (CB) and bone marrow (BM) CD34+/CD38+ and CD34+/CD38- cells. CD11a and CD62L were more expressed in CB than in BM CD34+/CD38- subset, suggesting a possible advantage in homing and engraftment. A short exposure to various cytokines increased CD62L expression only in the more differentiated CB and BM CD34+/CD38+ cells.

Cord blood transplantation (CBT) in hemoglobinopathies. Eurocord.

Patients with beta-thalassemia (Hbeta th) and sickle cell anemia (SCA) can be treated with bone marrow transplantation. Stem cells from cord blood have several theoretical advantages, however, the place of cord blood transplant for hemoglobinopathies has not yet been established. We report here the EUROCORD experience of 10 patients (Hbeta th = 7, SCA = 3) transplanted with related cord blood.

Use of recombinant granulocyte colony-stimulating factor in Fanconi's anemia.

BACKGROUND AND OBJECTIVE: Granulocyte colony-stimulating factor (G-CSF) has been shown to improve the neutropenic status of patients with bone marrow failure. The side effects in prolonged treatment still need to be determined. DESIGN AND METHODS: We have studied the efficacy and the long-term side effects of G-CSF in four patients with Fanconi's anemia and severe neutropenia. RESULTS: Three patients responded with an increase in their absolute neutrophil count; neither improvement in platelet count and hemoglobin concentration nor effect on transfusion requirements was seen. CFU-GM and BFU-E were undetectable before, during and after treatment. Responders showed an important reduction in number and severity of infections, with a marked improvement of clinical status. The fourth patient developed acute myeloid leukemia after 4 weeks of G-CSF treatment. During maintenance, one patient was treated with G-CSF for 18 months, until she received bone marrow transplantation, without presenting side effects. In the second responding patient G-CSF treatment was stopped because of appearance of immature cells in peripheral blood and myeloid blasts in bone marrow. The third responding patient presented immature peripheral myeloid cells during the third year of G-CSF treatment: disappearance of immature cells was observed after G-CSF reduction. In two cases FISH analysis revealed monosomy 7 after G-CSF treatment. INTERPRETATION AND CONCLUSIONS: G-CSF use results in an improvement of clinical status, but long term administration may cause adverse experiences and requires a close hematological monitoring.

Cell adhesion molecule expression in cord blood CD34+ cells.

Self-renewal, proliferation, differentiation, homing, and mobilization of hematopoietic progenitor cells (HPCs) are regulated by a complex mechanism that involves the bone marrow (BM) microenvironment. Cell adhesion molecules (CAMs) expressed on HPCs and on endothelial and stromal cells play a pivotal role in this process. In this study, we have used three-color cytofluorometric analysis to compare CAM expression in the subsets of cord blood (CB) and BM HPCs and examined the effect of a short exposure to various cytokines on L-selectin expression. The study was carried out on unseparated samples to avoid any possible bias from positive CD34 selection. CAMs were highly expressed in both CB and BM CD34+CD38+ cells. In this population, L-selectin, H-CAM, and LFA-1 were significantly more expressed in BM than in CB. With regard to the more immature progenitors, the subsets of CD34+/CD38-/L-selectin+ and CD34+/CD38-/LFA1+ cells were significantly larger in CB than in BM. Since the expression of such CAMs has been related to the repopulating capacity of HPCs, our results suggest a possible advantage in homing and engraftment of more undifferentiated CB as opposed to BM HPCs. A 4/24-h exposure to various cytokines significantly increased the percentage of CB CD34+/CD38+/L-selectin+ cells, while HPCs were differentiated since the percentage of CD34+/CD38-/L-selectin+ cells was reduced. These data show that a short exposure to cytokines increases L-selectin expression in the more differentiated CB HPCs. This could improve their homing in a transplant setting.