bluuebunny/crossref_metadata_2025 huggingface dataset:
Characterization Of The Immature Platelet Fraction (IPF) Parameters In Children With Immune Thrombocytopenia
Authors: Ghemlas Ibrahim A. , Klaassen Robert J. , Barrowman Nick , Leung Elaine W.
Published: October 2019

Background

Immune thrombocytopenia (ITP) is characterized by impaired megakaryocte production and maturation, as well as premature platelet destruction. The effect of this disease on platelet production is not clear. The Immature Platelet Fraction (IPF) is a novel parameter available on the Sysmex XE-Series Hematology analyzers. It can be expressed as both IPF percent (IPF %) and absolute IPF count (AIPF#). It has been shown that IPF% is higher in Immune Thrombocytopenia (ITP) than in the normal population, and is an indicator of bone marrow platelet production or thrombopoiesis.

Objectives

To characterizes the IPF parameters in pediatric patients with ITP at diagnosis and during different phases of the disease (newly diagnosed, persistent, and chronic).

Method

This is a retrospective, single institution study performed at a tertiary care pediatric hospital. We reviewed the medical charts and electronic databases of all patients with ITP who had measured IPF parameters between June 2011 and June 2013. The standard definitions and terminology of the International Working Group were used.

Patient age, phase of ITP at the time of the blood test (newly diagnosed, persistent, and chronic), initial platelet count, IPF%, AIPF#, and type of therapy given (including observation alone) were recorded. We then compared the platelet count, IPF%, and AIPF# between the ITP phases at the time of initial CBC and looked at the relationship between the platelet count and IPF%.

Comparisons between groups were performed using Kruskal-Wallis tests or Mann-Whitney tests, as appropriate. Association between measured blood parameters was measured using the Spearman correlation coefficient.

Results

Conclusion

IPF parameters may be useful in understanding the mechanism of ITP through the evolution of the disease. From the time of diagnosis of ITP through progression to chronic ITP, there is a steady decrease in IPF% and increase in AIPF# .The high IPF% in the newly diagnosed setting suggests that megakaryocytes are still active, whereas the lower IPF% in chronic ITP indicates inhibition of megakaryopoiesis or a different underlying pathophysiology. This may have important clinical implications when considering TPO receptor agonist therapy.

Disclosures:

No relevant conflicts of interest to declare.
Alternative and Terminal Complement Pathway Biomarkers At Presentation More Precisely Define The Clinical Diagnosis Of aHUS
Authors: Cataland Spero R , Holers V. Michael , Yang Shangbin , Wu Haifeng M
Published: October 2019

Introduction

Recent studies demonstrating the effectiveness of eculizumab in the treatment of atypical hemolytic uremic syndrome (aHUS) have increased the need for more rapid and objective diagnostic tests to help confirm the diagnosis of aHUS over other thrombotic microangiopathies (TMA).

Methods

We performed a retrospective study of all patients enrolled in the Ohio State University TTP/aHUS Registry since 2003. From this cohort of patients diagnosed with an acute TMA (platelets<100 x 109/ with schistocytes present, and without an alternative explanation), patients with a pretreatment serum creatinine >2.25 mg/dL and measureable ADAMTS13 activity (>10%) were analyzed. The clinical and demographic data for these 19 patients are shown in Table 1. Banked plasma samples from these study subjects were used to measure complement activation factors Bb (alternative pathway (AP)), C4d (classical pathway), C3a, (generalized complement activation), C5a, and C5b-9 complex (terminal complement pathway (TCP)). These complement biomarker data were analyzed in the context of a documented mutation in complement regulatory proteins and response to therapy with PEX and/or eculizumab. Response was defined as a normal platelet count and improved serum creatinine (at 6 months) independent of PEX therapy or with continued eculizumab therapy.

Results

The median complement biomarker data at presentation are shown in Table 2. Complement activation products are generally sensitive biomarkers for aHUS patients. Notably, elevation of the AP (Bb) and the TCP (C5b-9) biomarkers were more prominent and were seen in 16/19 and 19/19 patients respectively. This is in contrast to previously published data from acquired TTP patients from our group that demonstrated less pronounced activation of the AP and TCP at presentation (accepted for publication, JTH). Similar levels of alternative, classical and terminal complement activation were seen among patients regardless of mutation status or response to PEX. In a preliminary analysis using a one sample T-test model, (Bb) activation was shown to be significantly lower in the non-responder to eculizumab compared to the 8 responding patients. TCP activation was also lower in the non-responder but did not show statistical significance.

Conclusions

Complement biomarkers of the alternative and terminal complement pathway may more precisely define the diagnosis of aHUS. These hypothesis generating data suggest that pre-treatment complement biomarkers provide valuable information in the diagnosis of aHUS and could be useful in the prediction of response to eculizumab

Disclosures:

No relevant conflicts of interest to declare.
Mechanism Of Anti-Myeloma Effects Due To Silencing Of Deptor
Authors: Yang Yonghui , Lichtenstein Alan
Published: October 2019

DEPTOR is a recently described 48 kDa protein that binds to mTOR and inhibits this kinase within TORC1 and TORC2 complexes. Over-expression of DEPTOR specifically occurs in the multiple myeloma genetic sub-class that contains IgH translocations. Most interestingly, DEPTOR knock-down in over-expressing MM cell lines induces growth arrest and apoptosis, indicating DEPTOR could serve as a therapeutic target in selected patients. To investigate the mechanism of MM cytoreduction induced by DEPTOR silencing we generated a doxycycline-inducible DEPTOR shRNA. Induced DEPTOR knockdown in 8226 and OPM-2 cell lines resulted in phosphorylation of p70S6K and 4E-BP1 (due to release of TORC1 inhibition) as well as apoptosis, cell cycle arrest and senescence. RAPTOR knockdown in these MM cells prevented TORC1 stimulation and the anti-MM effects resulting from DEPTOR silencing. Thus, the acute activation of TORC1 mediated the apoptosis and growth arrest. Although DEPTOR silencing and mTORC1 activation resulted in depressed AKT activity, probably due to the TORC1-PI3K/AKT negative feedback loop, this was not relevant to anti-MM effects as over-expression of wild type or a phosphomimetic version of AKT did not prevent the adverse effects. Similarly, induction of ER stress was also not relevant to the anti-MM effects as markers for UPR activation did not occur during DEPTOR silencing. Although western blot did not show alteration of p53 expression, p21 and p27 were induced subsequent to DEPTOR knockdown. Associated RAPTOR knockdown prevented the upregulation of p21 but did not affect p27 levels. In addition, over-expression of AKT did not prevent the upregulation of p21. To test whether p21 was integral to DEPTOR knockdown effects, we silenced p21. P21-silenced MM cells were protected against apoptosis, cell cycle arrest and senescence induced by DEPTOR knockdown. Furthermore, DEPTOR knockdown in a murine xenograft model, achieved by ingestion of doxycyline, resulted in tumor regression, TORC1 activation, apoptosis and p21 induction. These data indicate a novel pathway to explain the lethal effect of DEPTOR knockdown in MM cells. The pathway is initiated by acute activation of mTORC1, with subsequent p21 induction. The data also suggest that DEPTOR over-expression in some MM clones is pro-tumoral due to its ability to suppress expression of CDK inhibitors like p21 and p27.

Disclosures:

No relevant conflicts of interest to declare.
Inherent CD40L Expression Complements CD8+ T Cell Dependent Anti-Tumor Immunity
Authors: Thiel Andreas , Frentsch Marco , Stark Regina , Japp Alberto Sada , Listopad Joanna , Matzmohr Nadine , Meier Sarah , Busch Dirk , Schulz Axel , Blankenstein Thomas
Published: October 2019

Introduction & Objective

Adoptive T cell therapy with tumor-specific CD8+ T cells is a promising treatment option for a variety of malignant diseases. However, it is unclear which subset of CD8+ T cells characterized by distinct functions is most suitable for achieving effective and durable anti tumor responses. So far CD8+ T cells have been considered to act predominantly as cytotoxic effector cells in cellular anti-tumor immunity. In this respect cytolytic molecules such as perforin and granzymes and apoptosis-inducing receptors of the tumor necrosis family such as FasL, TNFα and TRAIL have been regarded as major CD8+ T cell effector mechanisms.

Methods & Results

We here demonstrate in an experimental tumor model that CD40L, the key molecule for “immunological help”, is expressed by up to 50% of tumor-specific CD8+ T cells in B6 mice challenged with SV40 T antigen+ cancer cells. To study the influence of CD40L on anti-tumor CD8+ T cell immunity in vivo we challenged Rag1-/- mice with cancer cells and transferred wt or CD40L-/- CD8+ T cells. Transfer of wt CD8+ T cells prevented the establishment of a solid tumor, whereas injection of CD40L-/- CD8+ T cells alone or in addition with wt CD4+ T cells resulted in a non-controlled tumor development similar to non-treated tumors. The requirement of CD40L on CD8+ T cells for tumor rejection was further confirmed by injecting cancer cells in mice that lack CD40L expression only on mature CD8+ T cells. CD40Lflox x E8Icre mice were more susceptible to tumor formation than wt mice. Furthermore we demonstrated that CD8+ T-cell derived CD40L had to interact with CD40 on cancer cells, an eminent signal to induce apoptosis in various cancer cell types.

Conclusion

Our results reveal a crucial functional relevance of CD40L expressed by CD8+ T cells in anti-tumor immunity. Various cancer cell types express CD40 and its engagement induces pro-apoptotic or growth-inhibitory signals in a variety of cancer cells. Therefore CD40 agonists are recognized as promising agents for therapeutic interventions. We here introduce CD40L+ CD8+ memory T cells as a new major physiological source of CD40L, essential for rejection of tumors. Our data reveal that the presence or absence of CD40L+ CD8+ T cells represents a crucial element in control of CD40 expressing cancers disclosing novel treatment approaches in adoptive T-cell therapies novel treatment approaches.

Disclosures:

No relevant conflicts of interest to declare.
Allogeneic Cytokine-Induced Killer Cells Eliminate Host Dendritic Cells Due To The Enhanced Killing Activity By IFN-Gamma, Leading To Less Graft-Versus-Host Disease
Authors: Mase Shintaro , Fujiki Toshihiro , Kuroda Rie , Araki Raita , Maeba Hideaki , Koizumi Shoichi , Yachie Akihiro , Nishimura Ryosei
Published: October 2019

Cytokine-induced killer (CIK) cells are ex vivo–expanded T lymphocytes expressing both natural killer (NK)– and T-cell markers. We have reported that adoptive transfer of allogeneic CIK cells in a murine model caused minimal graft-versus-host disease (GVHD) with retention of antitumor activity mediated by NKG2D, which is an activating receptor expressed on NK cells. It was reported previously that IFN-gamma was a critical cytokine for preventing GVHD because CIK cells generated from IFN-gamma knock out mice caused lethal GVHD. One possible mechanism of protective effect against GVHD was that a large amount of IFN-gamma secreted by CIK cells could promote Fas-mediated apoptosis of recipient antigen activated donor T cells. However the mechanism of suppression of GVHD with CIK cells is not fully understood. Host residual dendritic cells (DCs) are most important cells in initiating GVHD reaction. Therefore, we hypothesize that CIK cells eliminate host DCs as same as kill tumor cells, and then reduce GVHD severity. To test this, 51Cr release assay was performed using BM derived DCs as target cells. We showed that allogeneic CIK cells had cytolytic activity against DCs, in marked contrast killing activity of IFN-gamma deficient CIK cells was much less compared to that of WT CIK cells (p< 0.05). Expression level of surface markers including NKG2D and CD8/CD4 ratio was not different between WT and IFN-gamma KO CIK cells. To further explore the mechanism why IFN-gamma deficient CIK cells reduced killing activity against DCs, IFN-gamma neutralizing antibody was added into killing mixture with WT CIK cells. However killing activity of WT CIK cells against DCs with IFN-gamma antibody did not changed compared to that of WT CIK alone. These results suggested that IFN-gamma itself did not affect killing activity directly, but IFN-gamma was essential cytokine to enhance killing activity during the culture of CIK cells. Next concern was whether CIK cells eliminated host DCs in vivo or not, we compared the residual number of host-type splenic DCs between the mice receiving bone marrow (BM) cells plus WT CIK cells and IFN-gamma deficient CIK cells. As shown in the figure below, the number of host DCs in the spleen in the mice receiving WT CIK cells was significantly lower compared to those of the mice receiving IFN-gamma KO CIK cells (p<0.05). In conclusion, allogeneic CIK cells eliminated host DCs due to the enhanced killing activity by IFN-gamma, leading to much less GVHD.

Disclosures:

No relevant conflicts of interest to declare.
Daily G-CSF (filgrastim) and a Single Dose Of Pegylated G-CSF (pegfilgrastim) After Chemotherapy Result In Different Kinetics Of Circulating Hematopoetic Progenitors: Implication For Potential Stem Cell Harvesting
Authors: Schaub Felix , Federmann Birgit , Kanz Lothar , Möhle Robert
Published: October 2019

Several studies have shown that a single dose of pegylated G-CSF (pegfilgrastim, Neulasta®) administered after chemotherapy allows sufficient collection of hematopoietic progenitor cells (HPC) for autologous transplantation. Pegfilgrastim has not been approved for HPC mobilization, but the decision for stem cell harvesting may be made after pegG-CSF has already been given. In this case, particular kinetics of circulating HPC after pegG-CSF must be taken into account to guide stem cell harvesting. In an intra-individual analysis, we compared mobilization of HPC in 12 lymphoma patients undergoing two identical cycles of salvage chemotherapy (etoposide, ifosfamide, cisplatin, ± epirubicin, ± rituximab) within a clinical trial (ClinicalTrials.gov: NCT00306111). G-CSF (filgrastim, Neupogen® 5 ug/kg/d) was given daily after the 1st cycle starting at day 3, while a single dose of pegfilgrastim (Neulasta®, 6 mg) was administered after the 2nd cycle. Circulating HPC were analyzed by flow cytometry and colony assays. We found that neutrophil recovery was remarkably pronounced after pegG-CSF resulting in a significant higher white blood count at day 12 compared with filgrastim (WBC: 6.8 ± 1.9 G/l vs. 3.2 ± 0.8 G/l, mean ± SEM), but a similar WBC at day 14 and day 16. However, kinetics of circulating HPC were markedly different: A trend to higher numbers of CD34+ progenitors was observed after pegfilgrastim at day 12 compared to filgrastim, followed by a sharp drop at day 14: 25 ± 12 /μl (pegfilgrastim) vs. 69 ± 22 /μl (filgrastim). Particularly the number of more primitive CD34+CD38- progenitors was significantly reduced at day 14: 3.7 ± 3.0 /μl (pegfilgrastim) vs. 11.7 ± 6.3 /μl (filgrastim). Similar results were found for the more primitive CD34+CD133+ und CD34+CD90+ populations. The colony formation (cloning efficiency) of the HPC was not different. Also, coexpression of homing-related receptors (CXCR4, CD62L/L-selectin) was similar in both groups. We conclude that after chemotherapy and pegG-CSF, sufficient numbers of HPC are circulating which allows for HPC collection during the early recovery phase. However, the HPC count is rapidly dropping once the WBC has recovered, in line with the known elimination of pegGCSF by binding to neutrophils. Thus, when a stem cell harvest is scheduled after neutrophil recovery in these patients, daily addition of non-pegylated G-CSF should be considered.

Disclosures:

Kanz: Amgen GmbH: Research Funding. Möhle:Amgen GmbH: Research Funding. Off Label Use: Pegfilgrastim is not approved for stem cell mobilization.
Allogeneic Hematopoietic Stem Cell Transplantation Of Patients With Wiskott-Aldrich Syndrome With Total Body Irradiation (TBI), Thiotepa and Fludarabine Or Cyclophosphamide Followed By T-Cell Depleted Grafts From Alternative Donors
Authors: Prockop Susan E. , Boulad Farid , Kernan Nancy A. , Khalif Ramzi , Kobos Rachel , Scaradavou Andromachi , O'Reilly Richard J.
Published: October 2019

Wiskott-Aldrich syndrome (WAS) is a rare X-linked congenital immunodeficiency syndrome characterized by micro-thrombocytopenia, eczema, autoimmune syndromes and malignancies that are often fatal. Early hematopoietic stem cell transplant (HSCT) experience for patients with WAS from alternative donors was associated with poor outcome including a high rate of graft rejection. Since 1998 we have transplanted 13 patients with WAS with grafts from alternative donors. Specifically, 9 of these patients received T cell depleted transplants and are the focus of this abstract. Grafts were from matched unrelated donors (N=5) mismatched unrelated donors (N=2) mismatched related donors (N=2). Patient age at transplant ranged from 1.1-21.5 years (median 3.3). Cytoreduction included Hyperfractionated TBI with Thiotepa and Cyclophosphamide or Fludarabine (N=7) Busulfan with Melphalan and Fludarabine (N=1) Cyclophosphamide with Thiotepa and Fludarabine (N=1). Prior to 2002 no children under 24 months received TBI. Subsequently CNS shielding was used with TBI for patients under the age of 3. All patients received ATG for graft rejection prophylaxis. Six patients had previously undergone splenectomy. Stem cell grafts were Lectin/E rosette separated T cell depleted bone marrow (N=4) or Isolex/E rosette separated T-cell depleted PBSC (N=5). Eight patients engrafted with median neutrophil engraftment on day 12 (11 -16). One patient who received cytoreduction with Cyclophosphamide, Thiotepa and Fludarabine suffered primary graft failure, had autologous recovery and went on to receive a second transplant and is alive and well. All patients developed Grade I – II mucositis. One patient suffered an early toxic death after developing acute encephalopathy during cytoreduction with Busulfan (8mg/kg) Melphalan (140mg/m2) and Fludarabine (125mg/m2) and one other patient with a prior history of lymphoma had progression of lymphoma and early death post HSCT. One developed acute GvHD (Grade III GI). Three patients developed autoimmune disorders associated with mixed chimerism. All three patients had complete resolution of their autoimmune disease and two of these three patients reverted to full donor chimerism. With a post HSCT follow-up period of a median of 7.5 years (3-15 years) seven of these nine patients are alive and disease-free. In summary, T-cell depleted grafts appear to extend transplant as a treatment option for patients with WAS who are without matched related donors. Recent successful experience with T cell depletion following chemotherapy only regimens for other patient populations will provide a way to explore non-TBI based cytoreduction and T cell depletion as an approach for future patients.

Disclosures:

No relevant conflicts of interest to declare.
Donor Genotypes For Interleukin-17A Gene Single Nucleotide Polymorphisms (SNPs) Allow Anticipation Of Complications After HLA-Identical Allogeneic Stem Cell Transplantation (allo-SCT)
Authors: Buces Elena , Martínez-Laperche Carolina , González-Rivera Milagros , Bosch-Vizcaya A , Martin-Antonio Beatriz , Guillem Vicent , Nieto Jb , González M. , La Camara Rafael De , Brunet Salut , Jimenez-Velasco Antonio , Espigado Ildefonso , Vallejo Carlos , Sampol Antonia , Serrano David , Kwon Mi , Gayoso Jorge , Balsalobre Pascual , Urbano-Izpizua Alvaro , Solano Carlos , Gallardo David , Díez Martín José Luis , Buno Ismael
Published: October 2019

Introduction

Graft versus host disease (GvHD) is the main cause of morbimortality after allogeneic stem cell transplantation (allo-SCT). Several single-nucleotide polymorphisms (SNPs) in in the promoter region of cytokine genes have shown to alter their expression and are therefore associated with donor-recipient alloreactivity and, ultimately, with SCT outcome. Interleukin 17 (IL-17) is secreted by CD4+ T-cells and has been implicated in the pathogenesis of various autoimmune diseases but its importance in SCT is not well-known.

Objective

To analyse the influence of IL-17A SNP genotypes on the risk and severity of GvHD and other complications after HLA-identical allo-SCT.

Patients and Methods

Genomic DNA obtained from peripheral blood samples belonging to 546 patients and their HLA-identical sibling donors (Table 1) included in the DNA Bank of the Spanish Group for Hematopoietic Stem Cell Transplantation (GETH). Genotyping of the polymorphisms of interest, rs8193036 (-737C>T), rs2275913 (-197G>A), rs3819024 (-444A>G), rs4711998 (-877A>G), were performed by multiplex primer extension followed by mass spectrometry (MALDI-TOF; Sequenom MassArray).

Results

Genotype frequencies are shown in Table 2 and the association between IL-17A genotypes and complications after allo-SCT are shown in Table 3. Patients transplanted from donors harboring genotype CC for the SNP rs8193036 show increased risk of grade III-IV acute GvHD (7/26 vs 47/397, p=0.035) and of grade II-IV acute GvHD (13/26 vs 133/409, p=0.048). Patients transplanted from donors harboring allele A in the SNP rs4711998 show increased risk of extensive chronic GvHD (53/161 vs 43/177, p=0.045). Relapse rate was not related with IL-17A SNP genotypes. Finally a higher risk of toxicity-related mortality (TRM) was observed in patients transplanted from donors harboring allele A for SNP rs2275913 (78/293 vs 46/227, p=0.048), donors harboring allele G for SNP rs3819024 (78/279 vs 46/242, p=0.011) and donors harboring allele A for SNP rs4711998 (68/250 vs 55/229, p=0.044).

Conclusions

IL-17A SNP genotyping might be useful to anticipate complications after sibling HLA-identical allo-SCT and, therefore, to improve the clinical management of transplanted patients. This results further support the idea of a genetic predisposition to certain complications after allo-SCT.

Paper presented on behalf of the GvHD/Immunotherapy committee of the Spanish Group for Hematopoietic Transplantation (GETH).

Disclosures:

No relevant conflicts of interest to declare.
Alpha 1 Antitrypsin, C Reactive Protein, and Hemolysis Markers: Association With Cytokines Profile In Sickle Cell Disease Patients In Steady-State and Crisis-State
Authors: Carvalho Magda , Boas Wendell Vilas , Veloso Cerqueira Bruno Antônio , Reis Joao Oliveira , Araujo Theo , Rocha Larissa , Luz Nivea , Lopes Valma , Borges Valeria , Goncalves Marilda Souza
Published: October 2019

Introduction

Sickle cell disease (SCD) has a heterogeneous clinical picture, characterized by hemolysis, chronic inflammation and vaso-occlusive events and painful crisis.

Aims

Investigate the levels of Alpha 1 antitrypsin (A1AT), C reactive protein (CRP), hemolysis markers and its association with cytokines profile in SCD patients in steady-state and crisis-state.

Methods

It was developed a cross sectional study in a total of 72 SCD patients in steady-state (SP) and 23 SCD patients in crisis (CP) age-and-sex-matched. Hematological analysis was performed by automatic cell counter, hemoglobin profile by HPLC, and biochemistry analyses of inflammation and infection markers and lipid, hepatic, and kidney metabolism markers were investigated by immunochemistry assays. Plasma levels of TNFα, IFNγ, IL-10, IL-1β, IL-6 and IL-8 were measured using Cytometric Bead Array - CBA (BD Biosciences Pharmingen, USA) according to the manufacturer’s protocol.

Results

Statistical analysis showed that SCD steady-state patients group had the highest IL-12 concentration (p<0.0001) and there were a decrease in TNFα, IL-10, IL-1β, and IL-6 levels (p< 0.0001) when compared to CP group (figure 1). However, significant differences in IL-8 levels were not finding in the comparison between SCD in steady-state and crisis patients groups. Biomarkers analyses of SCD steady-state patients showed significant negative correlation between IL-8 with A1AT (r= -0.25; p= 0.03) and CRP (r= -0.24; p= 0.04) and significant positive correlation with lactate dehydrogenase (LDH) (r= 0.25; p= 0.03). The IL-6 showed significant positive correlation with white blood cell count (WBC) (r= 0.52; p< 0.0001), ferritin (r= 0.30; p= 0.001) and CRP (r= 0.42; p= 0.0002). TNFα showed a significant positive correlation with leukocyte count (r= 0.28; p= 0.02) and A1AT (r= 0.29; p= 0.01) and IL-10 showed a significant positive correlation with platelets count (r= 0.30; p= 0.01) and A1AT (r= 0.29; p= 0.01).

Conclusions

Immunological aspects of SCD patients have been increasingly studied. The high levels of Th2 cytokines (IL-6 and IL-10) and proinflammatory cytokines (TNFα and IL-1β) in SCD patients in crisis-state, possibly is related to severe clinical manifestations, despite the fundamental role of these cytokines in the pathophysiology is not yet completely clear. The correlation between these cytokines and biomarkers associated with important clinical manifestations in SCD, such as WBC, platelet count, A1AT and CRP, highlights the important role of inflammatory mediators in SCD and its possible association with an expression or activation of adhesion molecules in neutrophils and vascular endothelium.

Disclosures:

No relevant conflicts of interest to declare.
Psychological Factors Associated With Episodic Oral Chelation Adherence In Thalassaemia
Authors: Jane Vosper , Psy D Clin , Evangeli Michael , Psy D Clin , Porter John , Shah Farrukh
Published: October 2019

Objectives

Beta-Thalassaemia-Major is a life-long genetic haemoglobin disorder where patients require intensive regimens, including frequent blood transfusions and daily chelation therapy. Despite the introduction of oral chelators, non-adherence continues to be prevalent. Understanding psychosocial correlates of chelation adherence is important when considering potential interventions to improve adherence as they may be potentially modifiable. Previous studies of the relationships between psychosocial factors and chelation adherence have neither been theory driven nor assessed theoretically important variables such as self-efficacy and outcome expectancies. In addition, there has been little investigation of situational determinants of adherence (cognitive, behavioural or affective). This study, informed by the Health Action Process Approach, investigated within-participant correlates of oral chelation adherence on a daily (episodic) basis.

Design

The study used a within-participant cross sectional design. Thirty seven adult participants with Beta-Thalassaemia Major were recruited from clinics at two hospitals, of which 31 were able to identify an adherent and non-adherent episode within the last two months. Sampling was systematic.

Main outcome measures

A structured interview was developed to assess cognitive, behavioural and affective situational variables related to recent adherent and non-adherent episodes. The main cognitive variables (situational self-efficacy and outcome expectancies) were derived from The Health Action Process Approach (HAPA). Behavioural situation variables included substance use, day of the week, activity, location, access to medication, reminder cues and social context. Affective situational variables were mood and bodily pain.

Results

Positive outcome expectancies and higher self-efficacy together significantly predicted adherent episodes (p<0.001), however, only self-efficacy independently predicted adherent episodes (β=-.0.26, SE=0.11, p=0.018). This relationship persisted when potentially confounding behavioural factors were controlled (difficulty in accessing medication, location and whether alone) (See Table 1).

Conclusion

Findings were consistent with the HAPA and suggested the importance of situational cognitive factors, particularly self-efficacy, to chelation adherence. These findings add to the evidence of the effect of self-efficacy on medication adherence across medical conditions and extend previous work in emphasising situational variation in self-efficacy. Adherence interventions should consider situational variables (cognitive and behavioural) that are potentially modifiable.

Disclosures:

No relevant conflicts of interest to declare.
Regional Myocardial Contractility In Thalassemia Major By Magnetic Resonance Tagging
Authors: Meloni Antonella , Tudisca Chiara , Grassedonio Emanuele , Izzi Giancarlo , Lendini Maddalena , Biguzzi Rino , Filati Graziella , Maggio Aurelio , Marinelli Martina , Midiri Massimo , Lombardi Massimo , Pepe Alessia
Published: October 2019

Introduction

Magnetic resonance (MR) tagging analyzed by dedicated tracking algorithms allows very precise measurements of myocardial motion and characterization of regional myocardial function. No extensive data are available in literature. Our aim was to quantitatively assess for the regional myocardial contractility in thalassemia major (TM) patients and to correlate it with heart iron overload and global biventricular function.

Methods

Seventy-four TM patients (46 F; 31.8 ± 8.5 yrs) enrolled in the MIOT (Myocardial Iron Overload in Thalassemia) network underwent MR (1.5T). Three short-axis (basal, medial and apical) tagged MR images were analyzed off-line using harmonic phase (HARP) methods (Diagnosoft software) and the circumferential shortening (Ecc) was evaluated for all the 16 myocardial segments. Four main circumferential regions (anterior, septal, inferior, and lateral) were defined. The same axes were acquired by a T2* GRE multiecho technique to assess myocardial iron overload (MIO). Biventricular function parameters were quantitatively evaluated by cine images.

Results

Segmental ECC values ranged from -9.66 ± 4.17 % (basal anteroseptal segment) to 13.36 ± 4.57 % (mid-anterior segment). No significant circumferential variability was detected.

Compared with previous studied healthy subjects, TM patients showed strain values significantly lower in all the circumferential regions at each level (mean difference from 4 % to 13 %; P<0.001 for all the comparisons).

Segmental Ecc values were not significantly correlated with the correspondent T2* values and no correlation was detected considering the global values, averaged over all segmental values. Three groups identified on the basis of cardiac iron distribution: no MIO, heterogenous MIO and homogeneous MIO. The global ECC was comparable among the three groups (-11.56 ± 1.60 % vs -11.70 ± 2.43 % vs -11.14 ± 1.95 %; P=0.602).

Global ECC values were not significantly correlated with age and were comparable between the sexes.

Circumferential shortening was not associated to left ventricular (LV) volumes and ejection fraction (with a P>0.5 in all the comparisons).

Conclusions

TM patients showed a significantly lower cardiac contractility compared with healthy subjects, but this altered contractility was not related to cardiac iron, volumes and function.

Disclosures:

No relevant conflicts of interest to declare.
Monocytosis Correlated With Acute Alcoholic Hepatitis: A Case Report and Literature Review
Authors: Shi Qi , Thomas Lisa
Published: October 2019

Introduction

Alcohol is a most frequent cause of liver disease in western countries. Alcoholic hepatitis is observed in approximately 20% of heavy drinkers. Acute alcoholic hepatitis (AH) is associated with mortality as high as 50%.Up to 40% of patient with severe alcoholic hepatitis die within 6 months after the onset of the clinical syndrome. Identifying individuals with a high mortality risk is crucial in the management of acute alcoholic hepatitis. We observed a patients with acute alcoholic hepatitis tend to have an increased level of monocytes.

Case presentation

47-year-old male with a significant history of alcohol abuse for 30 years presented with confusion, generalized shaking, and tremors for 4 days was admitted to the hospital. The patient was hospitalized 6 months ago for acute alcoholic hepatitis. Physical examination: Bp 140/80mmHg, Ultrasound of Abdomen showed hepatomegaly with enlarged liver measuring 19.1 cm in the midclavicular line and hepatic steatosis and gallbladder sludge without evidence of wall thickening or pericystic fluid. CT of abdomen Suspected fatty infiltration of the liver. Patient had ammonia level of 56 -58. His MELD score was between 52 in which the alcoholic hepatitis was diagnosed. The patient was treated with Ativan, Chlordiazepoxide, Thiamine, folic acid, Mulativitamin, and lactulose. After patient was treated for 7 days, Symptoms had been well controlled, and all of tests went to back normal range. Table1 shows clinical data of current and previous admission.

Discussion

Alcoholics develop acute hepatitis as an inflammatory reaction to the cells affected by fatty change. Diagnosis of alcoholic hepatitis based on clinical symptoms and laboratory finding alone including elevated AST/ALT (but may < 300 IU/mL), AST>ALT of 2, Total serum bilirubin > 5mg/deciliter, elevated INR, thrombocytopenia, and hypoalbuminimia, (cirrhosis). Leukocytosis with neutophilic predominance has been reported to correlates with degree of injury. As a feature of alcoholic liver disease, monocytosis was first reported on 1983, however, the mechanism mediates this clinical feature has been unclear. Recently data has been shown that activated monocytes have been postulated to play an important role in the pathogenesis of alcoholic liver disease (ALD), in which can produce Interleukin-1 (IL-1) induces interleukin-6 (IL-6) production during acute alcoholic liver injury phase reactant. The number of monocytes, one of the most important components of the inflammatory process in ALD maybe as an independent marker that can be utilized to determine the disease severity and predict outcome of the patients.

Conclusion

Our result suggests that monocytosis is associated with acute alcoholic hepatitis (Table 1). Further research may provide us with a better understanding of the clinical scenario and help elucidate the best prevention and treatment options of alcohol–related liver disease.

Disclosures:

No relevant conflicts of interest to declare.
The Relevance Of CD4 Cell Counts and Abnormal Bone Marrow Findings Among HIV-Infected Patients
Authors: Rattanathammethee Thanawat , Norasetthada Lalita , Tantiworawit Adisak , Rattarittamrong Ekarat , Chai-adisaksopha Chatree , Hantrakool Sasinee , Nawarawong Weerasak
Published: October 2019

Background

Hematologic and bone marrow abnormalities in patients with the HIV infection are common. The incidence of cytopenias correlates directly with the degree of immunosuppression. The causes of these abnormalities include impaired hematopoiesis, immune-mediated cytopenia, nutritional deficiencies, and drug effects.

Objectives

The aim was to study the correlation of CD4 cell counts and bone marrow abnormalities in HIV-infected patients, including the clinical factors predicting bone marrow infection.

Methods

We retrospectively reviewed the records of HIV-infected adult patients who had undergone a bone marrow examination in Chiang Mai University Hospital between 2006 and 2010. The clinical characteristics, laboratory results and bone marrow findings were recorded.

Results

There were 185 HIV-infected patients with a median age of 41 years (range 24-75). At the time of bone marrow examination, 84.3% of patients had fever and/or cytopenia in which 48% of them had bicytopenia/pancytopenia. Abnormal bone marrow findings were found in 77 (41.6%) patients, including dysplastic changes (22.1%), bone marrow infection (12.4%) and lymphoma involving bone marrow (2.7%). The bone marrow infection were independently associated with CD4 counts of less than 50/microlitre [OR 5.5 (95%CI: 1.21-25.46), p-value = 0.02], hepatosplenomegaly [OR 4.16 (95%CI: 1.40-12.34), p-value = 0.010] and fever > 38.5°C [OR 3.90 (95%CI: 1.06-14.28), p-value = 0.040]. Among patients with disseminated fungal infection, blood and bone marrow cultures were positive in 67.6% and 67.6%, respectively while only 37.8% of patients, fungi can be demonstrated microscopically in Wright-stained bone marrow smears. For patients with disseminated mycobacterial infection, blood and bone marrow cultures were positive in 44.4% and 77.8%, respectively while only one-third of patients, acid-fast bacilli can be detected microscopically in bone marrow smears.

Conclusions

Indices of suspected bone marrow infection among patients with HIV infection were lower CD4 cell counts of less than 50/microlitre, hepatosplenomegaly and high-grade fever. Blood and bone marrow cultures were more sensitive than microscopic examination of bone marrow in detection of disseminated fungal or mycobacterial infection. For feverish HIV patients, the specific antimicrobial therapy can be initiated promptly after microscopic detection of microorganism in the bone marrow smear.

Disclosures:

No relevant conflicts of interest to declare.
Quantitative Defects Of Cellular Immune Responses In Patients With Newly-Diagnosed Diffuse Large B-Cell Lymphoma
Authors: Rujirojindakul Pairaya
Published: October 2019

Altered immune status in non-Hodgkin lymphoma is characterized by undesired autoimmune phenomena and frequent occurrence of infections. The immune defects may be responsible for the initiation, maintenance and progression of malignant clone. We therefore evaluated immune effector cells between 35 patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL) and 34 age- and sex- matched healthy controls using three-color flow cytometry. For patients with DLBCL, there were 19 males and 16 females with a mean age of 59.9 ± 15.6 years. There were 6, 17 and 13 patients with ECOG > 2, stage III-IV and high intermediate to high International Prognostic Index, respectively. We found significant decreases in CD3+CD4+, CD4/CD8 ratio, CD4 central memory (CD4+CD45RO++CD27+) and B cells (Figure 1). From conditional logistic regression, only CD4/CD8 ratio showed significant association with being cases with the odds ratio of 0.29 (95% CI 0.12, 0.68).

Disclosures:

No relevant conflicts of interest to declare.
Fungus Bloodstream Infection In Patients With Haematological Malignanciest
Authors: Feng Ru , Jing Hui , Wei Yongqiang , Huang Fen , Zhang Yu , Li Xiaofang , Wei Qi , Dai Min
Published: October 2019

Objective

To investigate clinical characteristics, fungal species, predisposing and prognostic factors of hematological patients with fungemia. Method: The clinical data of clinical features, distribution of fungus, risk factors of 47 hematological patients with fungemia in our department were retrospectively analyzed. Results: All patients suffered from fever and received broad-spectrum antibiotic treatment. Agranulocytosis occurred in 42(89.4%) patients. Thirty-two (68.1%) patients were nosocomial infections. Forty-three (91.5%) patients were complicated by infections of other sites, the most common site of infections was from respiratory(78.6%). 29 (61.7%) patients with more than 15 hospitalized days before fungemia. Candida tropicalis (57.1%)was the most frequently fungal isolate. Among Of the 47 patients, 12 (25.5%) patients were dead. By multivariate logistic regression analysis, the duration of agranulocytosis, presence of shock, and the initiation of antifungal therapy are the independent prognostic factors for mortality. Conclusion: To pay attention to antifungal prophylaxis for hematological patients with the predisposing factors of fungemia. To treat fungemia promptly and appropriately, shorten duration of agranulocytosis and prevent shock to improve the prognosis.

Disclosures:

No relevant conflicts of interest to declare.
Quantification Of Malondialdehyde Adducts In Platelet Activation As An Indicator Of Proinflammatory and Prothombotic State
Authors: Zagol-Ikapite Irene , Sosa Iberia Romina , Judd Audra M , Boutaud Olivier , Oates John A
Published: October 2019

Background

The formation of malondialdehyde (MDA) has been previously described as a product of the thromboxane synthase. However, the reported approaches for its quantification have not been reliable, stymieing its use in research. As a reactive di-carbonyl, MDA reacts with primary amines, notably lysines on proteins, to form covalent adducts of several types. Three of the products of the reaction of MDA with lysine are an N-propenal adduct, a dihydropyridine ring adduct (N-lysyl-4-methyl-2, 6-dihydropyridine-3, 5-dicarbaldehyde), and a lysyl-MDA crosslink. Measurement of platelet protein modifications, such as MDA adducts, could provide a specific marker of in vivo activation of platelets, since these modifications accumulate over the lifespan of the platelet.

Methods and Results

To investigate thromboxane synthase-dependent formation of MDA adducts on platelet proteins, we developed an LC/MS/MS method for analysis of one of the MDA adducts, the lysyl-MDA crosslink, employing a [13C12] labeled internal standard. We demonstrated that levels of lysyl-MDA crosslink in human platelets are increased following its activation with arachidonic acid. This increase is inhibited by aspirin, the thromboxane synthase inhibitor, ozagrel and by γ-ketoaldehyde specific scavengers: 3-Methoxysalicylamine (3-MOSA) and Salicylamine (SA). To determine whether lysyl-MDA crosslinks reflect in vivo platelet activation, we analyzed samples from patients with medical conditions known to be associated with increased platelet activation. We employed traditional methods of measuring platelet activation: flow cytometry of p-selectin and reticulated platelets, and serum thromboxane, to measure platelet activation in patients with metabolic syndrome and sickle cell disease. These assays were compared with the levels of lysyl-MDA-crosslinks. In both populations, the levels of MDA-lysine-crosslink are increased by 2.5 fold compared to healthy volunteers and provide greater discrimination between groups than p-selectin expression and reticulated platelets. The inhibition of the lysyl-MDA crosslink adduct in patients taking NSAIDs further confirms the specificity for thromboxane synthase-dependent MDA modifications on platelet proteins.

Discussion

The results of this study provide compelling evidence that MDA-protein adducts in platelets may be a useful marker of in vivo platelet activation in humans and potentially helpful in predicting thrombotic risk and the benefit of antiplatelet therapy in patients with medical conditions associated with platelet hyperactivity.

Disclosures:

No relevant conflicts of interest to declare.
Platelet Delta Storage Pool Deficiency In Children : A Case Series
Authors: Abraham Shirley M. , Boayue Koh , Ahmed Ibrahim
Published: October 2019

Introduction

Delta storage pool deficiency (δ-SPD) is a rare group of platelet disorders characterized by a reduction in the number or content of dense granules. δ-SPD causes a mild to moderate bleeding diathesis characterized mainly by mucocutaneous bleeding. A suspected case of δ-SPD can be diagnosed by the patient’s presentation, a family history and suggestive clinical bleeding or preliminary laboratory results such as a typical platelet aggregation pattern, characterized by normal aggregation with ristocetin and lack of second wave of aggregation with ADP or epinephrine. However not all patients have a typical presentation. This is a review of 6 pediatric patients with δ-SPD at our institution.

Results

We have 3 male and 3 female children with a confirmed diagnosis of δ-SPD. Their current age ranges from 19 months-17 years. Four of the 6 patients are Hispanic and 2 Caucasian. A positive family history of excessive bleeding was obtained in 4 patients. The youngest patient was 2 weeks at diagnosis. Epistaxis was the most common presenting symptom. The youngest patients in the group presented with subdural hematomas before the age of 2. The 17 year old presented with significant menorrhagia and anemia, requiring red cells and platelet transfusions in addition to antifibrinolytic agents and oral contraceptives.

The preliminary work up in all patients included a CBC, PT, PTT and platelet function analysis (PFA).PFA was reported as abnormal in only 1 patient and was not accurate in another patient due to platelet clumping. Platelet aggregation studies and Von Willebrand’s panel were done and reported as normal in 5 patients. Platelet count ranged from 248,000- 552,000/mm3. Electron microscopy ranged from 1.69-3.59 dense granule/platelet (normal 4-6 dense granule/platelet).

All of the patients were primarily managed by preventive measures and antifibrinolytic agents. Platelet transfusions have been reserved for life threatening bleeds or surgical procedures.

Conclusions

The presentation of this rare bleeding disorder is not limited to mucocutaneous bleeding. Presenting symptoms in the very young could be limited to an intracranial hemorrhage. Electron microscopy to diagnose this condition should be pursued despite normal platelet function and aggregation studies, especially in patients with a high index of suspicion based on their clinical presentation or family history.

Disclosures:

No relevant conflicts of interest to declare.
Anti-Rh(D) Utilization Prior To and Following The FDA Mandate For Hemoglobinuria Screening 03/11/10
Authors: Varma Mala , Melinscak Hrvoje , Shapira Ilan , Sara Gabriel , Grossbard Michael L.
Published: October 2019

Background

Anti-Rh(D) has appeal for use in immune thrombocytopenia (ITP) due its rapid onset of action (24 hours) and short infusion time (10 minutes).  There is reluctance by some physicians to use anti-Rh(D), however, following FDA reports in 2000 of 15 cases of acute hemoglobinemia and/or hemoglobinuria (Gaines Blood 2000) and in 2005 of 6 cases of disseminated intravascular coagulation in association with acute hemoglobinemia and/or hemoglobinuria (Gaines Blood 2005). On 03/11/10, the FDA issued a black box warning stating that patients with ITP treated with WinRho (anti-Rh(D)) should be monitored in a healthcare setting for 8 hours following infusion for symptoms of intravascular hemolysis and for hemoglobinuria. Our institution adopted this 8-hour monitoring practice.

Specific Aims

To determine if the FDA black box warning has impacted on anti-Rh(D) utilization at St. Luke's-Roosevelt Hospital Center, New York, NY.

Methods

Institutional Review Board approval was obtained. The charts of consecutive patients with ITP treated with anti-Rh(D) who were followed in a hematology-oncology practice between 01/01/06 and 06/30/13 were reviewed. The ICD-9 code 287.31 for ITP was used to identify inpatients treated with anti-Rh(D) between 01/01/06 and 06/30/13. The number of outpatient and inpatient anti-Rh(D) infusions per annum was computed.

Results

The annual number of outpatient and inpatient anti-Rh(D) infusions is shown in Table 1. Infusions occurred predominantly in the outpatient setting. Eight-hour monitoring has been adhered to. While there has been some fluctuation in anti-Rh(D) utilization, there has not been a significant decline.

Conclusion

Despite the FDA requirement for patients to spend increased time at health care centers following anti-Rh(D) infusions, anti-Rh(D) utilization at our institution has not declined.

Disclosures:

No relevant conflicts of interest to declare.