Nutritional interventions in children with acute lymphoblastic leukemia undergoing antineoplastic treatment: a systematic review.

BACKGROUND: A compromised nutritional status jeopardizes a positive prognosis in acute lymphoblastic leukemia (ALL) patients. In low- and middle-income countries, ~ 50% of children with ALL are malnourished at diagnosis time, and undergoing antineoplastic treatment increases the risk of depleting their nutrient stores. Nutrition interventions are implemented in patients with cancer related malnutrition. We aimed to evaluate the effect of nutrition interventions in children diagnosed with ALL under treatment. METHODS: Using a predefined protocol, we searched for published or unpublished randomized controlled trials in: Cochrane CENTRAL, MEDLINE, EMBASE, LILACS, and SciELO, and conducted complementary searches. Studies where at least 50% of participants had an ALL diagnosis in children ≤ 18 years, active antineoplastic treatment, and a nutrition intervention were included. Study selection and data extraction were conducted independently by three reviewers, and assessment of the risk of bias by two reviewers. Results were synthesized in both tabular format and narratively. RESULTS: Twenty-five studies (out of 4097 records) satisfied the inclusion requirements. There was a high risk of bias in eighteen studies. Interventions analyzed were classified by compound/food (n = 14), micronutrient (n = 8), and nutritional support (n = 3). Within each group the interventions and components (dose and time) tested were heterogeneous. In relation to our primary outcomes, none of the studies reported fat-free mass as an outcome. Inflammatory and metabolic markers related to nutritional status and anthropometric measurements were reported in many studies but varied greatly across the studies. For our secondary outcomes, fat mass or total body water were not reported as an outcome in any of the studies. However, some different adverse events were reported in some studies. CONCLUSIONS: This review highlights the need to conduct high-quality randomized controlled trials for nutrition interventions in children with ALL, based on their limited number and heterogeneous outcomes. REGISTRATION OF THE REVIEW PROTOCOL: Guzmán-León AE, Lopez-Teros V, Avila-Prado J, Bracamontes-Picos L, Haby MM, Stein K. Protocol for a Systematic Review: Nutritional interventions in children with acute lymphoblastic leukemia undergoing an tineoplastic treatment. International prospective register of systematic reviews. 2021; PROSPERO CRD:42,021,266,761 ( https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=266761 ).

Engineering of potent CAR NK cells using non-viral Sleeping Beauty transposition from minimalistic DNA vectors.

Natural killer (NK) cells have high intrinsic cytotoxic capacity, and clinical trials have demonstrated their safety and efficacy for adoptive cancer therapy. Expression of chimeric antigen receptors (CARs) enhances NK cell target specificity, with these cells applicable as off-the-shelf products generated from allogeneic donors. Here, we present for the first time an innovative approach for CAR NK cell engineering employing a non-viral Sleeping Beauty (SB) transposon/transposase-based system and minimized DNA vectors termed minicircles. SB-modified peripheral blood-derived primary NK cells displayed high and stable CAR expression and more frequent vector integration into genomic safe harbors than lentiviral vectors. Importantly, SB-generated CAR NK cells demonstrated enhanced cytotoxicity compared with non-transfected NK cells. A strong antileukemic potential was confirmed using established acute lymphocytic leukemia cells and patient-derived primary acute B cell leukemia and lymphoma samples as targets in vitro and in vivo in a xenograft leukemia mouse model. Our data suggest that the SB-transposon system is an efficient, safe, and cost-effective approach to non-viral engineering of highly functional CAR NK cells, which may be suitable for cancer immunotherapy of leukemia as well as many other malignancies.

Primary CD33-targeting CAR-NK cells for the treatment of acute myeloid leukemia.

Acute myeloid leukemia (AML) is a malignant disorder derived from neoplastic myeloid progenitor cells characterized by abnormal proliferation and differentiation. Although novel therapeutics have recently been introduced, AML remains a therapeutic challenge with insufficient cure rates. In the last years, immune-directed therapies such as chimeric antigen receptor (CAR)-T cells were introduced, which showed outstanding clinical activity against B-cell malignancies including acute lymphoblastic leukemia (ALL). However, the application of CAR-T cells appears to be challenging due to the enormous molecular heterogeneity of the disease and potential long-term suppression of hematopoiesis. Here we report on the generation of CD33-targeted CAR-modified natural killer (NK) cells by transduction of blood-derived primary NK cells using baboon envelope pseudotyped lentiviral vectors (BaEV-LVs). Transduced cells displayed stable CAR-expression, unimpeded proliferation, and increased cytotoxic activity against CD33-positive OCI-AML2 and primary AML cells in vitro. Furthermore, CD33-CAR-NK cells strongly reduced leukemic burden and prevented bone marrow engraftment of leukemic cells in OCI-AML2 xenograft mouse models without observable side effects.

Perspective: Creating the Evidence Base for Nutritional Support in Childhood Cancer in Low- and Middle-Income Countries: Priorities for Body Composition Research.

There is a striking disparity in survival rates for children in low- and middle-income countries (LMICs) compared with high-income countries (HICs). Many of the contributing factors are preventable, including the comorbidity of malnutrition. There are emerging data that malnutrition, as reflected in body composition changes, impacts survival of cancer. However, not enough priority is given to nutrition management of children with cancer, particularly in LMICs. The primary purpose of this article is to review the current knowledge on childhood cancer and body composition in LMICs and identify priorities for future research into the interlinking associations between cancer, body composition, and clinical outcomes for childhood cancer patients. Evidence will ensure feasible and effective nutrition management is prioritized in childhood cancer centers in LMICs and contribute to improving outcomes for children with cancer.

Nutritional support strategies in pediatric cancer patients in Mexico / Estrategias de soporte nutricio en pacientes pediátricos con cáncer en México

Background: Meeting the nutritional needs of pediatric patients on oncology services in low budget public hospitals of Mexico is a continuous challenge, due to its financial resources. Objective: To evaluate the effectiveness of a nutritional strategy for children and adolescents with cancer in a public hospital of Mexico, based on a complacency diet. Methods: Across-sectional study included 58 children and adolescents (1-18 years old). An assessment of nutritional status was applied and a dietary diary was elaborated for 24 hours with the double weight method. Results: 43 patients (74.4%) had an adequate nutritional status. The average energy intake was 72.8% and average protein intake 168.3% of the requirements. The hospital meals accounted for 67.5% of the energy intake, 28.5% resulted from snacks and 3.9% from oral nutritional supplements or polymeric smoothies. Conclusion: The nutritional strategy based on offering a menu at the request supported by smoothies or oral nutritional supplements and the permission to introduce snacks to the hospital offers convenience and flexibility for meal times and favors the energy intake in hospitalized pediatric oncology patients.

Introducción: debido a la escasez de recursos económicos, los hospitales públicos de México tienen un reto continuo para satisfacer las necesidades nutricionales de niños en los servicios de oncología pediátrica. Objetivo: evaluar la eficacia de una estrategia nutricional en niños y adolescentes con cáncer, de un hospital público de México, basada en una dieta a complacencia. Métodos: se llevó a cabo un estudio transversal en el que se incluyeron 58 niños y adolescentes (1-18 años de edad). Se realizó una evaluación antropométrica del estado nutricio y se elaboró un diario dietético durante 24 horas con el método de doble pesada. Resultados: 43 pacientes (74.4%) tenían un estado nutricio adecuado. El consumo promedio de energía fue 72.8% y de proteínas 168.3% del requerimiento. Del total de las calorías consumidas 67.5% provenían del menú hospitalario, 28.5% de refrigerios y 3.9% de suplementos alimenticios o licuados artesanales. Conclusión: la estrategia nutricional basada en una dieta a complacencia apoyada por licuados y suplementos alimenticios más un permiso para la introducción de refrigerios al hospital, favoreció la ingestión calórica, ofreció comodidad y flexibilidad durante las horas de comida a los pacientes oncológicos pediátricos hospitalizados.

Patient-Generated Subjective Global Assessment of nutritional status in pediatric patients with recent cancer diagnosis.

BACKGROUND: The subjective global assessment (SGA) is a simple, sensitive tool used to identify nutritional risk. It is widely used in the adult population, but there is little evidence on its effectiveness in children with cancer. OBJECTIVE: This cross-sectional study was undertaken to demonstrate significant correlation between a simplified version of the Patient-Generated SGA (PG-SGA) and anthropometric assessment to identify nutritional status in children recently diagnosed with cancer. METHODS: The nutritional status of 70 pediatric cancer patients was assessed with the PG-SGA and anthropometric measurements. The relation between the assessments was tested with ANOVA, independent samples t-test, Kappa statistic, and non-parametric Spearman and Kendall correlation coefficient. The PG-SGA divided the patients into four groups: well nourished, mildly, moderately and severely malnourished. RESULTS: The prevalence of malnutrition according to the PG-SGA was 21.4%. The correlations (r ≥ 0.300, p < 0.001) and the concordance (k ≥ 0.327, p < 0.001) between the PG-SGA and anthropometric indicators were moderate and significant. CONCLUSIONS: The results indicate that the PG-SGA is a valid tool for assessing nutritional status in hospitalized children recently diagnosed with cancer. It is important to emphasize that the subjective assessment does not detect growth retardation, overweight or obesity.

Patient-Generated Subjective Global Assessment of nutritional status in pediatric patients with recent cancer diagnosis / Estado nutricio en pacientes pediátricos con reciente diagnóstico de cáncer mediante la Evaluación Global Subjetiva Generada por el Paciente

Background: The subjective global assessment (SGA) is a simple, sensitive tool used to identify nutritional risk. It is widely used in the adult population, but there is little evidence on its effectiveness in children with cancer. Objective: This cross-sectional study was undertaken to demonstrate significant correlation between a simplified version of the Patient-Generated SGA (PG-SGA) and anthropometric assessment to identify nutritional status in children recently diagnosed with cancer. Methods: The nutritional status of 70 pediatric cancer patients was assessed with the PG-SGA and anthropometric measurements. The relation between the assessments was tested with ANOVA, independent samples t-test, Kappa statistic, and non-parametric Spearman and Kendall correlation coefficient. The PG-SGA divided the patients into four groups: well nourished, mildly, moderately and severely malnourished. Results: The prevalence of malnutrition according to the PG-SGA was 21.4%. The correlations (r ≥ 0.300, p < 0.001) and the concordance (k ≥ 0.327, p < 0.001) between the PG-SGA and anthropometric indicators were moderate and significant. Conclusions: The results indicate that the PG-SGA is a valid tool for assessing nutritional status in hospitalized children recently diagnosed with cancer. It is important to emphasize that the subjective assessment does not detect growth retardation, overweight or obesity (AU)

Introducción: la evaluación global subjetiva (EGS) es una herramienta sensible y simple que se utiliza para identificar el riesgo nutricional. Es ampliamente utilizada en la población adulta, pero hay poca evidencia sobre su efectividad en niños con cáncer. Objetivo: este estudio transversal fue realizado para demostrar una correlación significativa entre una versión simplificada de la EGS generada por el paciente (EGS-GP) y la evaluación antropométrica para identificar el estado nutricio en niños con reciente diagnóstico de cáncer. Métodos: el estado nutricio de 70 pacientes pediátricos con cáncer fue evaluado con la EGS-GP y las mediciones antropométricas. La relación entre las evaluaciones fue examinada con ANOVA, t de Student para muestras independientes, concordancia de Kappa, coeficientes de correlación no-paramétricas de Spearman y Kendall. La EGS-GP dividió a los pacientes en cuatro grupos: bien nutrido, levemente, moderadamente y gravemente desnutrido. Resultados: la prevalencia de desnutrición de acuerdo a la EGS-GP fue 21.4%. Las correlaciones (r ≥ 0,300, p < 0,001) y la concordancia (k ≥ 0,327, p < 0,001) entre la EGS-GP y los indicadores antropométricos fueron moderadas y significativas. Conclusiones: los resultados indican que la EGS-GP es una herramienta válida para la evaluación del estado nutricio en niños hospitalizados con reciente diagnóstico de cáncer. Es importante enfatizar que la evaluación subjetiva no detecta retraso en el crecimiento, sobrepeso u obesidad (AU)

Training of Visual-Spatial Working Memory in Preschool Children.

Working memory, the ability to store and manipulate information is of great importance for scholastic achievement in children. In this study, we report four studies in which preschoolers were trained on a visual-spatial working memory span task, namely the Corsi Block Task. Across all four studies, we found significant training effects for the intervention groups compared to active control groups. Confirming recent research, no transfer effects to other working memory tasks were found. Most importantly, our training effects were mainly brought about by children performing below the median in the pretest and those showing median performance, thereby closing the gap to children performing above the median (compensation effect). We consider this finding of great interest to ensure comparable starting conditions when entering school with a relatively short intervention.

In-vivo phase contrast magnetic resonance angiography of the cerebrovascular system: a comparative study with duplex sonography.

PURPOSE: Assessment of the cerebral blood flow (CBF) is crucial in the evaluation of patients with steno-occlusive diseases of the arteries supplying the brain for prediction of stroke risk. Quantitative phase contrast magnetic resonance angiography (PC-MRA) can be utilised for noninvasive quantification of CBF. The aim of this study was to validate in-vivo PC-MRA data by comparing them with colour-coded duplex (CCD) sonography in patients with cerebrovascular disease. METHODS AND MATERIALS: We examined 24 consecutive patients (mean age 63 years) with stenosis of arteries supplying the brain using PC-MRA and CCD. Velocities were measured in a total of 209 stenotic and healthy arterial segments (110 extra- and 99 intracranial). RESULTS: Moderate to good correlation of velocity measurements between both techniques was observed in all six extracranial and five out of seven intracranial segments (p <0.05). Velocities measured with CCD sonography were generally higher than those obtained by PC-MRA. Reversal of flow direction was detected consistently with both methods. CONCLUSION: PC-MRA represents a robust, standardised magnetic resonance imaging technique for blood flow measurements within a reasonable acquisition time, potentially evolving as valuable work-up tool for more precise patient stratification for revascularisation therapy. PC-MRA overcomes relevant weaknesses of CCD in being not operator-dependent and not relying on a bone window to assess the intracranial arteries.

Improving our understanding of the use of traditional complementary/alternative medicine in children with cancer.

BACKGROUND: Children with cancer in high-income and low-income countries often use traditional complementary/alternative medicine (TCAM). With efforts by the World Health Organization and international twinning programs improving access to conventional care for patients with childhood cancer, understanding the global use of TCAM is important because reliance on TCAM may affect time to presentation, adherence, and abandonment of care. In the current study, the authors describe the process and validation of an international survey documenting the use of TCAM among children with cancer. METHODS: The survey was designed to collect information on TCAM use and associated factors through both open-ended and close-ended questions. During the period between June 2012 and December 2013, the survey was administered to 300 children and adolescents (or their parents) who were undergoing treatment for cancer at a collaborating institution located in Mexico, Uruguay, and Nicaragua. RESULTS: For the majority of constructs, the survey demonstrated strong test-retest reliability as evidenced by an intraclass correlation of at least ≥0.79 in each of the participating countries. The survey demonstrated good internal consistency and reliability across countries (α range from. 77 to. 85 for the belief scale; and an α range from. 60 to. 86 for the cause scale) and convergent validity between TCAM beliefs and behavior constructs (adjusted correlation range, 0.35-0.60). CONCLUSIONS: The results of the current study demonstrate the successful development of a cross-cultural survey that produced results that were reliable and valid. These findings will aid investigators in providing guidelines concerning TCAM, support the development of education and research priorities, and identify variables associated with TCAM that are region-specific.

[Effect of the nutritional recovery on the concentration of Interleukin-2 in severely malnourished children]. / Efecto de la recuperación nutricia sobre la concentración de Interleucina-2 en niñios con desnutrición grave.

The severely malnourished child has dysfunction of the immune response that may increase the risk of morbidity or mortality due to infectious diseases, therefore, the purpose of this study was to demonstrate the effect of intensive nutritional support on the cellular and serum concentration of IL-2 and CD4+, as well as CD8+ T cells in children with severe protein energy malnutrition. A clinical assay was carried out in a tertiary care hospital. 10 severely malnourished children < 48 months of age who received formula without lactose via enteral feeding for two weeks and ad libitum for an additional two weeks were included. Cellular and serum concentrations of IL-2 and the subpopulation of CD4+ and CD8+ were obtained. A control group (n = 13) was included. A paired student t test for initial-final determinations and the Mann-Whitney Test for comparison with control group were used, and null hypothesis was rejected with a p value < 0.05. There was a noteworthy increase in the comparison between the initial vs. final percentage of the cellular expression of IL-2 (p < 0.001) and in the serum concentration of IL-2 (p = 0.001). Therefore, four weeks of nutritional recovery significantly restored the production of IL-2, independently of the nutrients involved in the process, although, the rate of restoration seems to depend on the severity of the children primary PEM.

Efecto de la recuperación nutricia sobre la concentración de Interleucina-2 en niños con desnutrición grave

El niño con desnutrición grave tiene una disfunción de la respuesta inmune que puede aumentar de manera significativa la morbilidad y la mortalidad por infecciones. Por ello, el objetivo del presente estudio fue demostrar el efecto del apoyo nutricio intensivo en la concentración en suero y celular de IL-2 y sub-poblaciones de células CD4+, y CD8+ T en niños con desnutrición proteínico-energética grave. En un ensayo clínico se incluyeron 10 niños con desnutrición primaria grave, menores de 48 meses de edad, quienes recibieron una fórmula sin lactosa por alimentación enteral continua por dos semanas y dos semanas más ad libitum. Se obtuvieron la concentración sérica y celular de IL-2 y las sub-poblaciones de linfocitos CD4+ y CD8+ en los casos y en un grupo control (n = 13). Con la prueba t de student pareada se compararon los valores inicial vs. final de los sujetos y se utilizó la prueba U-Mann-Whitney para la comparación con el grupo control. Se rechazó la hipótesis nula con una p < 0,05. Se observó un incremento notable inicial vs. final en el porcentaje de expresión celular de IL-2 (p < 0,001) y en la concentración sérica de esta citocina (p = 0,001). Por tanto, cuatro semanas de apoyo nutricio intensivo fueron suficientes para mostrar un incremento significativo en la producción de IL-2, independientemente de los nutrimentos involucrados, aunque aparentemente este incremento dependió de la gravedad de la DPE.

Effect of the nutritional recovery on the concentration of Interleukin-2 in severely malnourished children. The severely malnourished child has dysfunction of the immune response that may increase the risk of morbidity or mortality due to infectious diseases, therefore, the purpose of this study was to demonstrate the effect of intensive nutritional support on the cellular and serum concentration of IL-2 and CD4+, as well as CD8+ T cells in children with severe protein energy malnutrition. A clinical assay was carried out in a tertiary care hospital. 10 severely malnourished children < 48 months of age who received formula without lactose via enteral feeding for two weeks and ad libitum for an additional two weeks were included. Cellular and serum concentrations of IL- 2 and the subpopulation of CD4+ and CD8+ were obtained. A control group (n = 13) was included. A paired student t test for initial-final determinations and the Mann-Whitney Test for comparison with control group were used, and null hypothesis was rejected with a p value < 0,05. There was a noteworthy increase in the comparison between the initial vs. final percentage of the cellular expression of IL-2 (p < 0,001) and in the serum concentration of IL-2 (p = 0,001). Therefore, four weeks of nutritional recovery significantly restored the production of IL-2, independently of the nutrients involved in the process, although, the rate of restoration seems to depend on the severity of the children primary PEM.

Effect of nucleotide intake and nutritional recovery on insulin-like growth factor I and other hormonal biomarkers in severely malnourished children.

The objective of the present study is to demonstrate the effect of nucleotide intake and intensive nutritional support on the concentration of insulin-like growth factor I (IGF-I) and other hormonal biomarkers in severely malnourished children. Twenty-six severely malnourished children < 48 months of age received formula without lactose via enteral feeding for 2 weeks and ad libitum for an additional 2 weeks. Anthropometrical measurements were performed and serum concentrations of IGF-I, insulin-like growth factor binding protein-3 (IGFBP-3), leptin, soluble leptin receptor (sOB-R), as well as the estimated molar excess of sOB-R over leptin were obtained. Two groups were formed. One group received formula with nucleotides (NT+; n 13) and the other without nucleotides (NT-; n 13). A control group was included (n 13). Parametric and non-parametric tests as well as ANOVA models were used. Nutritional recovery, nucleotides intake, type of malnutrition, age and the interaction between gender and malnutrition influenced the concentration of IGF-I (P < 0.001). Nutritional recovery, nucleotides intake, gender and type of malnutrition had an effect on IGFBP-3 (P < 0.001). Nutritional recovery had a significant effect on serum leptin (P = 0.001). Age and nutritional recovery had an effect on sOB-R (P < 0.001); all variables included affected the molar excess of sOB-R over leptin (P < 0.001). In conclusion, nucleotide intake and nutritional recovery had a notable effect on IGF-I, IGFBP-3 and other hormonal biomarkers. This outcome could stimulate the catch-up growth of severely malnourished infants and toddlers during the nutritional recovery period.

Influence of nutritional recovery on the leptin axis in severely malnourished children.

CONTEXT: Leptin might be more important as a starvation hormone than as a satiety signal. The role of the soluble leptin receptor (sOB-R) and its regulation in children with protein energy malnutrition (PEM) is poorly understood. DESIGN: We elucidated the effect of intensive nutritional support on the leptin axis in 26 severely malnourished toddlers who received infant milk-based formula for 2 wk via continuous enteral tube feeding followed by 2 wk ad libitum feeding. Serum levels of leptin, sOB-R, IGF-I, and IGF-binding protein-3 as well as anthropometric measurements were determined at the beginning of the study and at 2-wk intervals. The control group consisted of 13 well-nourished children. RESULTS: The following were changes in the PEM toddlers after the nutritional support. Leptin increased significantly (P < 0.001), reaching 166% of levels observed in control group. sOB-R decreased significantly (P < 0.001), and a 142-fold molar excess of sOB-R over leptin was found. There were significant correlations between leptin and IGF-I after 2 wk and IGF-binding protein-3 during the whole study. sOB-R was not correlated with any anthropometric data, whereas IGF-I was a predictor of sOB-R variance in the PEM toddlers (19.9%, P = 0.022). CONCLUSION: It can be concluded that sOB-R has a modulatory effect on leptin in PEM children during nutritional recovery and participates in their adaptive survival mechanisms. Leptin and the molar excess of sOB-R over leptin are better biomarkers of nutritional status than IGF-I in PEM children during nutritional recovery.