We suggest that, as a global phenomenon, life consists of two inseparable components. On the one hand, life is associated with the process of existence of autonomous living bodies with certain individual characteristics, while on the other hand, life is a planetary system, consisting of the whole almost infinite number of such bodies on Earth. It is a heterogeneous but monolithic system of interdependent and interacting organisms with diverse characteristics.

The existence of individual life, that is, the existence of each individual cell or multicellular organism, is physically and genetically limited in time. The main reason for the deterioration and destruction of organisms is their inevitable degradation based on the second law of thermodynamics, which is only temporarily overcome by them thanks to genetic programs for maintaining integrity.

Topic: 12. Bone marrow failure syndromes incl. PNH - Clinical Background:HAX1-related congenital neutropenia (HAX1-CN; Kostmann syndrome), is an orphan autosomal recessive inborn disease caused by pathogenic mutations in the HAX1 gene. HAX1-CN contributes to 12.3% of genetically classified cases of CNs, being the third largest group after ELANE and SBDS associated neutropenias in the Severe Chronic Neutropenia International Registry (SCNIR) in Europe. Affected patients suffer from bone marrow failure, as assessed by a maturation arrest of the myelopoiesis, revealing persistent severe neutropenia in the peripheral blood (ANC less than 500/μl) from birth. The disorder is strongly associated with severe bacterial infections in untreated patients. Increase in ANC under G-CSF therapy has reduced infections significantly. Prolonged life expectancy has revealed a high risk for developing myelodysplastic syndrome or acute myeloid leukemia (MDS/AML). The SCNIR monitors the clinical course, treatment, and outcome of patients with severe chronic neutropenia subtypes since 1994, including the world’s largest collection of long-term data on HAX1-CN. Aims: The aim of this clinical observation study is to document the natural course of disease, response to treatment and long-term outcome of HAX1-CN patients. Methods: All HAX1-CN patients enrolled in the SCNIR in Europe were included in this report. Informed consents were obtained according to the Declaration of Helsinki. Standardized clinical parameters at diagnosis and during annual follow-up, as well as family history were collected by the registry. Results: Here we describe the course of HAX1-CN disease, response to treatment and long-term outcome in 72 patients with different types of HAX1 mutations enrolled in the SCNIR in Europe, which is the World’s largest cohort of pediatric and adult HAX1-CN patients reported. The patients cohort characteristics: 39 male, 33 female; 56 minor (below 18 years) and 16 adults (median age 10.4 years, range 1 to 40.8 years). All 72 patients received long-term treatment with hematopoietic growth factor G-CSF and responded well to individual G-CSF doses, (median dose 3.59 µg/kg/d). All studied patients benefit from G-CSF therapy, which results in significant reduction of infections and overall improvement of quality of life. MDS/AML has developed in 11% of the studied cohort in all ages. Acquired somatic mutations in CSF3R and other leukemia-associated genes play a role in leukemogenesis and may be detected prior to MDS/AML. Non-hematological manifestations frequently include CNS (seizures), musculoskeletal system (short statue), and reproductive system (various hypogonadism forms). Summary/Conclusion: Patients with all known types of HAX1 mutations present with severe congenital neutropenia, but respond well to long-term G-CSF treatment. Continuous G-CSF therapy significantly improves the quality of life and allows pediatric patients to reach adulthood. Secondary ovarian insufficiency is frequently observed in young HAX1-CN female patients early after puberty and should be closely monitored during the course of disease. Patients with MDS/AML require stem cell transplantation. Regular monitoring of somatic leukemia associated mutations is recommended. The SCNIR provides a long-term follow up and monitoring of severe neutropenic patients, including the collection of the CN patient´s samples in a centralized biobank, which enables bringing forward the understanding of the mechanisms and consequences of this orphan disease, as well as development of efficient diagnostic and treatment standards. Keywords: Neutropenia, Myelodysplastic syndrome, Bone marrow failure, Acute myeloid leukemia

Based on the facts stated in the book, we can reasonably conclude that living bodies are the habitat of genomes, where they are localized and reproduce. Through the bodies they inhabit, genomes are in contact with the external environment, receiving matter, energy, and information. This ensures their homeostasis and replication. That is, living bodies are not the main objects of life, but only its temporary holders and carriers. They are not the content, but only a form; not the cause, but only an effect.

It is obvious that living bodies are very vulnerable. They consist of naked, delicate, pliable cells that do not have significant levels of protection against environmental factors. In particular, low and high temperatures, lack of food and water, pressure drops, radiation, mechanical impacts, and the action of toxins can all be harmful and even lethal to them. Yet life on Earth emerged under just such geophysical conditions.

This book addresses age-old questions about the nature of life by analyzing, synthesizing and rethinking the known facts that characterize life.

As noted earlier, the genome is the main manipulator of matter and energy (Chap. 7 ) and information (Sects. 13.6 and 13.7 ). In its conventional meaning, a genome is a collection of genetic material and information contained in the complete set of DNA in an organism's chromosomes.

Information is a fundamental category, but difficult to define. Generally, information is defined as a collection of data that can be generated, transmitted, accumulated, perceived, and used. Information itself is immaterial, but it is a property of matter, such as, e.g., discreteness and motion.

Life is represented by individual living bodies (cells and multicellular organisms), which are the possessors of individual life, as well as by the planetary system, consisting of trillions of representatives of different biological species.

Only unicellular and multicellular organisms, which were briefly described in the previous chapters, are the genuine representatives of living bodies. All of them possess universal principles of organization that distinguish them from the total mass of physical bodies.

Time is one of the basic characteristics of the material world, which determines the dynamism, direction, and interconnection of processes in space. This is a form of being of matter, which characterizes the duration of existence, and the sequence and direction of changes in the states of developing material systems. This is the vector of motion of matter, the duration of motion of matter, and a measure of changes in the motion of matter. In fact, it is not even a physical, but rather a philosophical category, introduced by humans for the convenience of orientating ourselves in space. It is a measure of changes, directed exclusively from the past into the future.

It is obvious that living bodies are made of substances. But this is only one aspect of their existence. It has now been established that information plays an equally important role in their lives.

Living bodies consume all the substances necessary for life from the external environment. All cells and organisms need nutrients for: (1) constant renewal of their molecular composition and (2) energy.

After successful reproduction, living bodies have to exist in an active state for a certain, usually quite long period of time. This is necessary to be reasonably sure that reproduction will be successful. However, according to the laws of thermodynamics, all highly organized biological systems inevitably collapse over time.

Multicellular organisms are characterized by the presence of a specific pattern and sequence of developmental processes from their genesis in the form of a single cell to the adult multicellular organism. In essence, this is a process of self-construction, another critically important property of living bodies, along with self-reproduction and self-reparation.

Summary HAX1 ‐related congenital neutropenia ( HAX1 ‐CN) is a rare autosomal recessive disorder caused by pathogenic variants in the HAX1 gene. HAX1 ‐CN patients suffer from bone marrow failure as assessed by a maturation arrest of the myelopoiesis revealing persistent severe neutropenia from birth. The disorder is strongly associated with severe bacterial infections and a high risk of developing myelodysplastic syndrome or acute myeloid leukaemia. This study aimed to describe the long‐term course of the disease, the treatment, outcome and quality of life in patients with homozygous HAX1 mutations reported to the European branch of the Severe Chronic Neutropenia International Registry. We have analysed a total of 72 patients with different types of homozygous ( n = 68), compound heterozygous ( n = 3), and digenic ( n = 1) HAX1 mutations. The cohort includes 56 paediatric (<18 years) and 16 adult patients. All patients were initially treated with G‐CSF with a sufficient increase in absolute neutrophil counts. Twelve patients required haematopoietic stem cell transplantation for leukaemia ( n = 8) and non‐leukaemic indications ( n = 4). While previous genotype–phenotype reports documented a striking correlation between two main transcript variants and clinical neurological phenotypes, our current analysis reveals novel mutation subtypes and clinical overlaps between all genotypes including severe secondary manifestations, e.g., high incidence of secondary ovarian insufficiency.

Living bodies are physical bodies with biological features and properties. These are autonomous, highly organized biological systems, which are the units and carriers of individual life.

Severe congenital neutropenia (CN) and Shwachman-Diamond Syndrome (SBDS) are pre-leukemia bone marrow failure syndromes with a high cumulative incidence of developing MDS or AML. Clonal hematopoiesis (CH) due to nonsense mutations in the intracellular part of CSF3R or missense TP53 mutations has been reported previously in CN or SBDS patients, respectively. So far, studies of CH in CN were conducted by sequencing CSF3R only (Germeshausen et al., 2007, Klimiankou et al., 2019) or in ELANE-CN patients (Jun Xia et al., 2018). Precise characterization of the timeline and occurrence of somatic mutations found at the neutropenia, pre-leukemia or leukemia stage in CN is essential to make a timely and correct decision on the requirement of bone marrow transplantation prior to transformation to overt leukemia. We therefore aimed to assess the acquisition of somatic leukemia-associated mutations in a large number of genes in a worldwide largest and most representative cohort of CN patients. We performed error-corrected sequencing with fixed single-stranded unique molecular indexes (UMIs) on panel of 31 genes and "hotspot" regions in 340 genes reported to be mutated in de novo MDS/AML. We analyzed 146 CN patients representing most of genetic subtypes of CN, 21 SBDS patients, 29 CN patients who progressed to MDS or AML, and 18 healthy individuals. The median age of CN and SBDS patients was 13,73 and 10,5 years, respectively. For 53 CN patients, we collected sequential samples with a median observation time of 1,1 years. We found that the prevalence of CH with at least 1 somatic DNA lesions in CN group was 49,5 % which is much higher than in healthy individuals of the same age. The prevalence of CH with CSF3R mutations varied between 20 and 38 % in patients with genetic defects in ELANE (n = 75), HAX1 (n = 26), SRP54 (n = 8), JAGN1 (n = 6), and G6PC3 (n = 5). The percentage of CH positive cases without CSF3R mutations ranged between 12 % and 50 %. CN patients acquired somatic coding mutations most frequently in CSF3R (49 %) following by TP53 (4,1 %), ASXL1 (4,1 %), DNMT3A (2,1 %), TET2 (2,1 %), JAK2 (1,37 %), SETBP1 (1,37 %), ARID1B (1,37 %), GNAS (1,37 %), and ZRSR2 (1,37 %). Interestingly, in the SRP54-CN group, we found 1 patient with CSF3R mutation, 1 patient with TP53 mutations, and 1 patient with both mutations. Out of 3 CLPB-CN patients, 1 patient has CSF3R and 1 patient acquired TP53 mutations. High prevalence of CSF3R (67 %), RUNX1 (44 %), SETBP1 (22 %), ASXL1 (17 %), ZRSR2 (11 %), NPM1 (11 %) and PTPN11 (11 %) mutations was detected in CN patients with overt MDS/AML, arguing for a specific pathway which initiates and drives leukemic transformation in CN. Comparison of CN patients who later developed MDS/AML with MDS/AML-free CN cohort revealed enrichment of CSF3R (Fisher's exact test; OR 3,42; 95% CI, 1,27, - 9,36, p = 0,01), and ASXL1 (Fisher's exact test; OR 7,4; 95% CI, 0,93 - 59,16, p = 0,03) mutations. In contrast, RUNX1 and SETBP1 mutations were associated with overt MDS/AML in CN. These data argue that the acquisition of CSF3R and ASXL1 mutations are early events in CN leukemogenesis, whereas RUNX1 and SETBP1 mutations may have stronger leukemogenic potential and therefore are rarely found at the neutropenia stage. Moreover, mutation burden at the neutropenia stage in CN patients who later progressed to MDS/AML was significantly higher (p = 0.016, by Fisher's exact test), as compared to CN group who haven't developed leukemia so far. The number of mutations in samples prior AML/MDS was dependent on duration to overt AML/MDS with gradual accumulation of genetic lesions over time. CH was detected in 66,7 % of SBDS patients with a high prevalence of TP53 mutations (9 out of 14 patients with CH) followed by missense mutations in IDH1 (n = 1), FOXP1 (n = 1), and PTPN11 (n = 1). Our results are in line with previous publications about dominant role of TP53 mutation in SBDS patients. Prevalence of CH didn't differ between CN patients depending on G-CSF dose (median = 4,06 μg/kg/d) in two biggest CN cohorts harboring ELANE or HAX1 mutations. Taken together, CN per se contributes to high level of CH already in the young age, as compared to healthy population. Acquisition of multiple genetic lesions, especially RUNX1, SETBP1, ASXL1, TP53, PTPN11 in association with CSF3R mutation might be a strong indicator of the advanced pre-leukemia stage in CN patients at neutropenia stage and requires closer patient follow up.