The Youth Fitness International Test (YFIT) battery for monitoring and surveillance among children and adolescents: A modified Delphi consensus project with 169 experts from 50 countries and territories

Background: Physical fitness in childhood and adolescence is associated with a variety of health outcomes and is a powerful marker of current and future health. However, inconsistencies in tests and protocols limit international monitoring and surveillance. The objective of the study was to seek international consensus on a proposed, evidence-informed, Youth Fitness International Test (YFIT) battery and protocols for health monitoring and surveillance in children and adolescents aged 6–18 years. Methods: We conducted an international modified Delphi study to evaluate the level of agreement with a proposed, evidence-based, YFIT of core health-related fitness tests and protocols to be used worldwide in 6- to 18-year-olds. This proposal was based on previous European and North American projects that systematically reviewed the existing evidence to identify the most valid, reliable, health-related, safe, and feasible fitness tests to be used in children and adolescents aged 6–18 years. We designed a single-panel modified Delphi study and invited 216 experts from all around the world to answer this Delphi survey, of whom one-third are from low-to-middle income countries and one-third are women. Four experts were involved in the piloting of the survey and did not participate in the main Delphi study to avoid bias. We pre-defined an agreement of ≥80% among the expert participants to achieve consensus. Results: We obtained a high response rate (78%) with a total of 169 fitness experts from 50 countries and territories, including 63 women and 61 experts from low- or middle-income countries/territories. Consensus (>85% agreement) was achieved for all proposed tests and protocols, supporting the YFIT battery, which includes weight and height (to compute body mass index as a proxy of body size/composition), the 20-m shuttle run (cardiorespiratory fitness), handgrip strength, and standing long jump (muscular fitness). Conclusion: This study contributes to standardizing fitness tests and protocols used for research, monitoring, and surveillance across the world, which will allow for future data pooling and the development of international and regional sex- and age-specific reference values, health-related cut-points, and a global picture of fitness among children and adolescents

Retrospective Comparison between MEC and FLAG-Ida Regimens for Refractory or Relapsed Acute Myeloid Leukemia in Adults

Introduction: There is no consensus regarding the best salvage regimen for refractory or relapsed acute myeloid leukemia (r/rAML), with classic regimens traditionally based on high-dose cytarabine in a changeable combination with anthracyclines, purine analogs, and etoposide. Outcomes of r/rAML patients in developing countries are underreported, even though the same regimens are widely used. Methods: This is a retrospective single-center study, conducted in an academic center in Brazil. Local research ethics committee approved this analysis. All patients above 16 years of age who received MEC (mitoxantrone, etoposide and cytarabine) or FLAG-IDA (fludarabine, cytarabine, filgrastim and idarubicin) as originally reported (Amadori, S. et al. and Steinmetz, H. T. et al.) for r/rAML between December/2009 and January/2019 were included. Only patients with refractory or relapsed disease following standard upfront therapy ("7+3" regimen) were included in this analysis, being divided among refractory (less than partial response after one cycle of "7+3"), early relapsed (relapse within one year from first complete response [CR]) and late relapsed (relapse after one year of CR). Only the first salvage was considered for this study. Results: Sixty patients were included in the final analysis, with a median age of 45 years (range, 17 - 69). There were no cases of therapy-related AML. Four AML cases (7%) were secondary to myeloproliferative neoplasm (MPN) or myelodysplastic syndrome (MDS). All FLT3-ITD positive cases had an associated NPM1 mutation. Two patients had chronic human immunodeficiency virus infection and received antiretroviral therapy. Baseline characteristics of the whole cohort are summarized in Table 1. Three patients had undergone SCT in first CR and were post-SCT relapses. Twenty-eight patients received MEC and 32 received FLAG-IDA. By comparing the baseline characteristics of both groups, no difference statistically significant was found except for the indication for salvage treatment, in which there were more refractory cases in FLAG-IDA group (56 vs. 28%, p=0.029) (Table 2). Overall, 17/60 achieved CR and 12/60 CRi, with a total CR rate (CR+CRi) of 48.3% (95% confidence interval [CI], 35.4 - 61.5). Sixteen patients (27%) early died before a response assessment. By univariate analysis, only age affected the CR rate (p=0.045). No difference in CR rate was found between the two protocols (MEC 53.5 vs. FLAG-IDA 43.7%, p=0.447). Looking into this data, it can be seen that there were more refractory patients in FLAG-IDA arm (37.5 vs. 4%, p=0.02) but more patients early-died in MEC arm (35.7 vs. 18.7%, p=0.137), even though the latter was not statistically significant. After correcting the initial differences between the two groups regarding indication for salvage through a propensity score calculation, a post-matching cohort with 44 subjects was found. In this cohort, no difference in refractoriness rate could be detected (p=0.077). In the whole cohort, 17 patients proceeded to allogeneic SCT - 15 in CR/CRi and 2 with active disease, with no difference in SCT execution rate between the two groups (p=0.470). 4/17 transplanted patients were alive. Median follow-up was 48 months. Median survival for total cohort was 4 months (95% CI, 2.7 - 9.2), with a 3-year OS of 9.7% (95% CI, 4 - 23.7) and a 3-year EFS of 7.5% (95% CI, 2.5 - 22.4). In the univariate analysis for OS, age (p=0.04), FLT3 status (p&amp;lt;0.001) and SCT procedure (p=0.002) were statistically significant. Chosen regimen did not influence OS or EFS as well as the genetic risk, colonization or time of relapse (Figure 1). In a multivariable model for EFS including age, FLT3 status and SCT procedure, only the last two indicators remained significant: FLT3-ITD mutation (Hazard ratio [HR] = 4.6 [95% CI 1.9 - 11.4], p&amp;lt;0.001) and SCT procedure (HR = 0.43 [95% CI 0.22 - 0.82], p=0.01). Conclusion: In this analysis, there was no difference concerning the chosen regimen for r/rAML, even though a possible higher refractoriness rate could be seen in FLAG-IDA arm. High early toxicity was found, emphasizing the role of supportive care and judicious selection of patients to intensive salvage therapy in our setting. FLT3-ITD mutation and SCT remained as significant factors for survival in a multivariable analysis, which is in line with previous studies. Disclosures No relevant conflicts of interest to declare. </jats:sec

Combining Clinical Features with Genetic Factors Improves Survival Prediction for Adults with Acute Myeloid Leukemia: Validation of a New Score System in 3 Cohorts

Introduction: Risk stratification in acute myeloid leukemia (AML) is continually being refined as we learn more about the molecular pathophysiology of this heterogeneous disease. European LeukemiaNet (ELN) 2017 used widely to stratify the 'genetic' risk of AML, but there are considerable challenges in its application, particularly in centres where molecular genetic testing either not available, or not sufficiently timely for clinical decision making. Up to a third of the study subjects cannot be stratified using a full cytogenetic-molecular model in real-time, real-life setting. There are few attempts to combine clinical features and genetic factors aiming to find a scoring system to improve AML survival prediction. There is only one to our knowledge (Sorror ML et al. 2017). This study has generated an Adapted Genetic Risk (AGR) assessment, and used it in combination with clinical risk parameters to create a novel scoring system which has now been validated using two independent cohorts. Methods: A training cohort from São Paulo (FMUSP, n = 167) of intensively treated AML patients (18-65 years) was assessed using ELN2017 genetic criteria. A comparative validation with our AGR which permits missing cytogenetic or molecular data (Figure 1) split these patients into favorable-risk (FR), intermediate-risk (IR), and adverse-risk (AR). This cohort was also used for Cox Proportional-Hazard Model (CPHM) univariate and multivariate analysis to find clinical parameters that would inform a novel Survival AML Score (SAMLS). Variables which are included in SAMLS had to be either significant in both CPHM models or significant in univariate and crucial for multivariate fitness as measured for the Akaike Information Criterion (AIC). We then applied the AGR strategy and SAMLS to 2 independent test cohorts of intensively treated adult AML patients : Riberao Preto (FMRP, n=145) and Oxford (OUH, n=157). The study was approved by the institutional review boards of the 3 participating centers. Informed consent was obtained from all patients according to the Declaration of Helsinki. Results: Table 1 shows the clinical characteristics for all the 3 cohorts. The median follow-up (FUP) was 72.3, 44.4, and 70.5 months for FMUSP, FMRP, and OUH, respectively. The median Overall Survival (OS) was 12.4, 12.5, and 56.4 months and the 5-year OS were 29.6%, 29.7%, and 49.7% respectively. Both ELN2017 and AGR correlated with significant differences in OS (p-value &lt;0.001) and DFS (ELN p=0.002, AGR p=0.003) in the FMUSP cohort. The ROC c-statistic were 0.68 (ELN) and 0.66 (AGR). AGR was validated in FMRP and OUH cohorts, with statistically significant stratification of OS across the 3 risk groups in both cohorts (FMRP p=0.03, OUH p=0.003); and DFS in FMRP (p = 0.04), but not in OUH (p = 0.7)(Table 2 and Figure 2). Multivariate CPHM model for OS in FMUSP which yielded the smallest AIC were: Age, HR 1.52; Albumin, HR 0.50; WBC, HR 1.37; Haemoglobin, HR 1.48; Platelet count, HR 0.64; and AGR-IR, HR 2.23 and AGR-AR HR, 4.66 (Figure 3). Variables which met SAMLS inclusion criteria are in Table 3. SAMLS stratifies AML as low-risk (LR-AML) (SAMS &lt;=1.5) or high-risk (HR AML) (SAMLS &gt;=2) (Table 3 and Figure 4 C-D), where there is a significant difference in survival in the FMUSP training cohort (p &lt;0.001). The 5-year OS was 55% and 9% for LR and HR AML respectively. The ROC c-statistic for OS in FMUSP using SAMLS was 0.80 (21% bigger than using AGR only). SAMLS risk stratification was validated in both FMRP and OUH cohorts for OS (FMRP p-value 0.003, OUH p-value &lt; 0.001) and DFS (p-value 0.04 OUH only). Prediction accuracy was also increased since ROC c-statistic was 0.65 for OS in FMRP (a 10% increase), and 0.77 in OUH (a 22% increase) (Figure 4). Conclusion: ELN2017 genetic risk score for AML was validated in a cohort from a low-medium income country (LMIC). AGR is a proposed risk evaluation that can be used for AML patients for whom fully genetic testing is not feasible (required for ELN2017) and was as accurate as ELN2017. AGR predicts survival in 3 independent cohorts, from LMIC and developed nation settings. When other biological and clinical factors are added to AGR, we were able to show SAMLS is better to predict overall survival than AGR. Importantly, serum Albumin, a simple and routine test parameter, was an independent predictor of OS for AML in all 3 cohorts. Therefore the use of SAMLS can predict early and late mortality and can impact on treatment decisions. Disclosures Quek: Celgene: Research Funding, Speakers Bureau; Agios: Research Funding. Vyas:Astellas: Speakers Bureau; Pfizer: Speakers Bureau; Abbvie: Speakers Bureau; Daiichi Sankyo: Speakers Bureau; Novartis: Research Funding, Speakers Bureau; Forty Seven, Inc.: Research Funding; Celgene: Research Funding, Speakers Bureau. </jats:sec

WHO-2016 Classification in ALL By Cytogenetics, FISH and Molecular Biology - Experience of Two Reference Centers in Brazil

Abstract Introduction Almost all neoplasms have their prognosis determined by cytogenetic and molecular factors, which determines a tailored approach for each case. According to the World Health Organization, every case of Acute Lymphoblastic Leukemia (ALL) must be classified not only immunophenotypically but also from a genetic point of view. Over the last few years, it has been recognized the differences in incidence and genetic profile of ALL from Latin America (LA). In Brazil, a large country with a distinctive ethnical background when compared to the rest of LA, few reports on ALL have been published and there is a limited availability of genetic tests for classification, especially in public health service. Objective To describe cytogenetic (karyotype and fluorescence in situ hybridization, FISH), molecular markers and World Health Organization (WHO) -2016 classification of diagnostic samples sent to two reference centers in Brazil. Material and Methods This is a cross-sectional study involving patients diagnosed with ALL from January 2014 to May 2018. Diagnostic bone marrow specimens were analyzed by G band conventional karyotyping (Nomenclature according International System for Human Cytogenomic 2016) (n: 157), molecular markers [(genic fusions by RT-PCR - BCR-ABL1 (n: 96), TCF3-PBX1 (n: 77), ETV6-RUNX1 (n: 83), KMT2A-AFF (n:74)] and B-ALL multi-probe FISH (n:54) were employed according to manufacturer's recommendations and following international guidelines. It was attempted to classify all cases by WHO-2016, as well as by age. Samples with no metaphases, non-conclusive or without molecular tests were considered non-classifiable Results Samples from 157 ALL patients at diagnosis were analyzed. Median age was 8 years old (1 month - 88 years) [6 (3.8%) cases had less than 12 months; 99 (63%) between 1 to 15 years; 22 (14%) between 16 and 39 years and 30 (19.1%) older than 40 years]. The majority were B cell lineage ALL (93%). Thirty cases were excluded due to missing immunophenotyping, karyotype and/or molecular studies. Alterations were detected in 94 (74%) of 127 cases [88 (76%)/116 in B-ALL and 6 (54%)/11 in T-ALL. It was possible to classify by WHO 2016 B-ALL subtypes 116 cases, all of them stratified by age groups (Graphic 1). Conclusion Our results are consistent with the literature, showing that KMT2A rearrangement predominates in infant ALL, while a pediatric age range from 1 to 15 years old, with a predominance of good prognostic subtypes: hyperdiploidy and ETV6-RUNX1. In adults, there is predominance of the BCR-ABL1 subtype, which seems to be more frequent than non-Latin cohorts. B-ALL NOS was detected in 27.8% of the cases, predominating in the age group of 16 to 39 years, which may correspond to Ph-like ALL, a recently described subtype linked to a worse prognosis and seemingly more common in latinos. Figure. Figure. Disclosures No relevant conflicts of interest to declare. </jats:sec

A multicenter comparative acute myeloid leukemia study: can we explain the differences in the outcomes in resource-constrained settings?

Outcomes in acute myeloid leukemia (AML) are dependent on patient- and disease-characteristics, treatment, and socioeconomic factors. AML outcomes between resource-constrained and developed countries have not been compared directly. We analyzed two cohorts: from São Paulo state, Brazil (USP, n = 312) and Oxford, United Kingdom (OUH, n = 158). USP cohort had inferior 5-year overall survival compared with OUH (29% vs. 49%, adjusted-p=.027). USP patients have higher early-mortality (23% vs. 6%