Supplement Article

s for “The Crucible” session: How can Haematology change the world? Jessica Dunphy: Measurement of Serum Hepcidin: A Future Tool to Reduce the Global Burden of Iron Deficiency Anaemia? Anaemia represents a huge global burden of disease. In 2010, around third of the world’s population was affected by anaemia, with an estimated 50% of those cases attributable to iron deficiency. The majority of these cases of iron deficiency anaemia (IDA) occur in lowand middle-income countries. IDA primarily affects children and women, due to increased iron requirements secondary to growth, pregnancy or menstrual loss. Iron deficiency in children can affect both physical growth and cognitive performance, which will potentially have a lifelong impact. Thus, iron supplementation is recommended to ensure children reach their full potential. Indiscriminate use of iron supplementation, however, has been linked to increased mortality from malaria and other infections, notably diarrhoeal disease. Consequently, there is a need to find a reliable diagnostic test to discriminate between IDA and anaemia secondary to other causes. While there are a variety of tests currently available to diagnose anaemia (including serum haemoglobin and ferritin), there remain challenges with their use and/or interpretation, especially in the lowand middle-income setting. Serum hepcidin has been posited as a potential alternative to current tests. Hepcidin plays a key role in iron regulation; low expression increases plasma iron concentrations while high expression decreases plasma concentrations. Recent research in both developed and developing countries has demonstrated that serum hepcidin concentration may potentially be able to differentiate IDA from anaemia of inflammation. Further research is still required before hepcidin becomes widely used as a marker for IDA. A reliable hepcidin point-of-care test still needs to be developed and there must be clinical trials comparing hepcidin to the currently used test. , Hepcidin does, however, have the potential to represent the “holy grail” of iron deficiency diagnostics: the ability to identify children most likely to benefit from, and least likely to be harmed by, iron supplementation. Anaemia represents a huge global burden of disease. In 2010, from, and least likely to be harmed by, iron supplementation. Jennifer Darlow: Antimicrobial resistance: Biting the hand that feeds Haematology, more than many specialities, manages patients with compromised immune systems (e.g. neutropenic, bone marrow transplant patients). These patients regularly contract infections and consequently receive broad spectrum antibiotics. This includes carbapenems, particularly in the context of rising antimicrobial resistance and recent piperacillin-tazobactam shortages. In the last decade the emergence and spread of carbapenem resistance presents antimicrobial dependent medicine with an unprecedented crisis. Globally, carbapenem resistance is rising – in parts of India, resistance rates are above 50%. Even in the developed world, carbapenem resistance is a growing problem, costing millions and leading to patient mortality. This is compounded by the fact that the new antimicrobial pipeline is sparse. Widespread use of carbapenems contribute to this problem, by providing selection pressure that allows resistant organisms to flourish. Although haematology uses a relatively small quantity of antibiotics, its intensive use of carbapenems drives resistance disproportionately. Haematologists are therefore contributing to the aforementioned antimicrobial resistance situation. This is self-defeating in the medium-to-long term. If carbapenem resistance continues to be encouraged, immunosuppressive therapeutic interventions for haematological conditions, such as bone marrow transplant, will be unviable. Haematology is changing the world by driving a global crisis from which it will be difficult to return. There are strategies that we can adopt to help avoid this nightmare scenario: 1 With close collaboration with infection specialist colleagues, we can alter our prescribing habits to reduce antimicrobial resistance selection pressure whilst still treat patients appropriately. 2 Wider and more consistent use of diagnostics, along with development and adoption of new diagnostics, can allow targeting of patients who require antibiotics and reduce unnecessary prescriptions for those that don’t. 3 We can encourage investigation into the use of broad-spectrum antibiotic in haematological patients, to determine where it is necessary and where narrow therapy can be safely used instead. Megan Kell: Working towards universal healthcare: A role for haematology The United Nations’ Sustainable Development Goals (SDGs) set in 2015, include the attainment of universal health coverage, as well as a reduction in mortality from non-communicable diseases (NCDs) including cancer, and conditions relating to pregnancy and childbirth. These issues disproportionately affect Low and Middle Income Countries (LMICs) where 78% of deaths from NCDs and 99% of maternal deaths occur. Around 25% of these maternal deaths may be due to lack of blood transfusion4 and the provision of oncology treatment is often dependent on the availability of safe transfusion. There is huge inequality in blood availability worldwide. Donation rates in higher income countries are around 32 per 1000 population per year, compared to only 4 per 1000 population per year in lower income countries. Increasing investment and development of new technologies and drugs is significantly improving outcomes and survival in higher income countries. However, for these benefits to be realised, countries require functioning health systems with adequate access to reliable pathology and laboratory services. This is often lacking in lower resource settings.Haematology is an essential component of laboratory and pathology departments, enabling accurate diagnostics and safe transfusion. There is a need to advocate for the prioritisation of laboratory and transfusion services in health system planning and funding. Development of training programmes for biomedical scientists and post-graduate physicians will enable the improvement of laboratory and transfusion services to provide support for developing health systems. Haematology services can help reduce deaths from lack of 34 a 2019 The Authors. British Journal of Haematology a John Wiley & Sons Ltd British Journal of Haematology, 185, (Suppl. 1), 3–202 blood, improve the process of accurate diagnostics and support developing oncology programmes. Haematologists can help through advocacy and support for training in low resource settings. In order for the SDGs to be met, significant improvements in laboratory and transfusion services worldwide are essential. This is how haematology can help to change the world for the better. References: 1. Publications UN. Sustainable Development Goals Knowledge Platform [Available from: sustainabledevelopment.un. org accessed 21/11/2018. 2. Wilson ML, Fleming KA, Kuti MA, et al. Access to pathology and laboratory medicine services: a crucial gap. Lancet2018;391 (10133):1927-38. https://doi.org/10.1016/s0140-6736(18)30458-6 [published Online First: 2018/03/20] 3. WHO. Trends in maternal mortality: 1990 to 2015. Geneva, 2015. 4. Bates I, Chapotera GK, McKew S, et al. Maternal mortality in sub-Saharan Africa: the contribution of ineffective blood transfusion services. BJOG : an international journal of obstetrics and gynaecology 2008;115(11):1331-9. https://doi.org/10.1111/j.1471-0528.2008. 01866.x [published Online First: 2008/10/01] 5. WHO. Global status report on blood safety and availability 2016. Geneva, 2017. 6. Bates I, Maitland K. Are Laboratory Services Coming of Age in Sub-Saharan Africa? Clinical Infectious Diseases2006;42(3):383-84. https://doi.org/10.1086/499368 7. Horton S, Sullivan R, Flanigan J, et al. Delivering modern, high-quality, affordable pathology and laboratory medicine to lowincome and middle-income countries: a call to action. Lancet 2018; 391(10133):1953-64. https://doi.org/10.1016/s0140-6736(18)30460-4 [published Online First: 2018/03/20] Edmund Watson: A brave new world: Life after an allograft “How can Haematology change the world? Devastatingly. It can take the world you thought you knew and give it back to you completely