bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluating the Safety of Erythropoiesis-Stimulating Agents (ESAs) in Patients with Breast Cancer, Lung Cancer, and Hematologic Malignancies: A Meta-Analysis of Randomized, Controlled Trials.
Authors: Glaspy J. , Henry D. , Vansteenkiste J. , Ludwig H. , Lillie T. , Tomita D. , Crawford J.
Published: October 2019

Background: Recent clinical trial data have generated safety concerns regarding ESA use, particularly as to whether the results observed in certain patients with breast cancer, lung cancer, and hematologic malignancies are generalizable to all patients with those tumor types. It is critical that the results of these studies are appropriately integrated into the total body of evidence in order to enable balanced conclusions to be drawn. We conducted a systematic literature review to assess the safety and efficacy of ESA therapy in patients with breast cancer, lung cancer, and hematologic malignancies.

Methods: The search was aligned with that conducted by the Cochrane Collaborative group (Bohlius 2006) and was therefore limited to randomized, controlled clinical trials in cancer patients that compared the use of ESAs with either observation (RBC transfusion as required) or placebo and that collected survival data (either long-term or during the study period). Results from trials were meta-analyzed using Comprehensive Meta-Analysis v 2.2 software. Heterogeneity between studies was evaluated using a chi-square test (Q). Random and fixed-effects models were used to estimate an overall odds ratio and 95% confidence interval; the inconsistency statistic, I2, is also provided.

Results: For breast cancer, seven studies were identified. Meta-analysis of data from these studies indicated an overall neutral risk of death for patients receiving ESAs, despite the large contribution (weighted at about 40% of the overall result) of the BEST study results (Leyland-Jones, 2005) (Table). Five ESA-controlled lung cancer studies were identified in CIA, one in radiotherapy, and one in anemia of cancer (AOC). In each of the studies in CIA, the ESA groups had neutral survival risks relative to the control group. Meta-analysis of the CIA, radiotherapy, and AOC lung cancer data combined indicated an overall neutral risk of death for patients receiving ESAs (Table). For hematologic malignancies, eight studies were identified (one of which had no deaths). Meta-analysis indicated an overall neutral risk of death for patients receiving ESAs (Table).

Conclusions: The results of some studies have suggested a detrimental effect on survival associated with ESA use in certain patients with breast, lung, and hematological malignancies. However, results do not appear to be generalizable to similarly designed, randomized controlled trials conducted in the same tumor types. Additionally, when these studies are integrated into the total body of evidence, ESAs have a neutral effect on survival in these patients.
Differential Localization and Conditioned Release of Pro- and Anti-Angiogenic Cytokines from Resting and Stimulated Platelets.
Authors: Brill Alex , Zelikowitz Tali , Shlomai Gad , Kalchenco Vladislav , Shai Ela , Shinder Vera , Varon David
Published: October 2019

Mechanisms regulating a selective release of pro- or anti-angiogenic cytokines from platelets have not been yet established. In this work, we studied the potential regulative role of shear and collagen in the release of VEGF and endostatin from human platelets. We present data suggesting that subjection of platelets to adhesive proteins under shear, results in selective secretion of VEGF but not endostatin. Furthermore, we demonstrate compartmentalized distribution of these cytokines inside platelets. Platelets subjected to flow (shear rate of 200–2000 s−1) for 4 min on surface-immobilized collagen, selectively released VEGF (from undetectable level to more than 80 pg/ml), whereas the endostatin level remained unchanged (about 65 ng/ml). The release of VEGF was independent of the presence of RBCs or plasma as was demonstrated in experiments with WBC-depleted whole blood, PRP, or washed platelets. A similar yet moderate effect was observed on fibrinogen-coated surface, whereas application of shear force only or incubation of platelets on immobilized collagen or fibrinogen under static conditions did not induce the cytokine release. Soluble collagen promoted release of VEGF that could be inhibited by aspirin in a dose-dependent fashion ranging below effective anti-aggregation doses, which is in accordance with the observed anti-angiogenic effect of NSAIDs. VEGF release was Ca2+-dependent and could be prevented by EDTA or PGE1. In contrast to its inhibitory effect on VEGF release, EDTA markedly increased secretion of endostatin suggesting that calcium depletion confers an anti-angiogenic profile to platelets. The difference in the release regulation of these two cytokines led us to examine their localization in platelet granules. Confocal microscopy evaluation of permeabilized fluorescently double-stained (for VEGF and endostatin) platelets showed a distinct staining of each cytokine with almost no co-localization. For better resolution we prepared sections of resting gluteraldehyde-fixed platelets for electron microscopy. Immunogold labeling of the two cytokines revealed localization of VEGF in α granules and of endostatin in sub granular structures. This differential localization of VEGF and Endostatin is consistent with thier conditioned and constitutive release patterns respectively. In conclusion, we propose a novel phenomenon of selective cytokine release from cytokine-dedicated platelet granules according to environmental signals, which further elucidates the control over the pro and anti angiogenic roles of platelets.
Sliding-Rebinding Mechanism Governs Glycoprotein Ib/von Willebrand Factor Catch Bonds.
Authors: Lou Jizhong , Zhu Cheng
Published: October 2019

The interaction of platelet receptor Glycoprotein Ib (GPIb) and the plasma protein von Willebrand factor (VWF) initiates platelet adhesion and agglutination at the site of vascular injury. The binding sites of GPIb and vWF have been mapped to be the N-terminal domain of GPIb α subunit (GPIbαN) and the A1 domain of VWF respectively. The co-crystal structure of wild-type GPIbαN and VWF-A1 complex is solved and two separated binding interfaces have been identified. One is between the β-switch region of GPIbαN and the central β sheet of A1, another is between the β-finger region of GPIbαN and the loops on the bottom of A1. It has been demonstrated that flow enhances GPIb-VWF binding. Moreover, recent single-molecule experiments with atomic force microscopy (AFM) have shown that GPIb forms catch bonds with VWF. Using GPIbαN/VWF-A1 crystal structure, we studied the dissociation of GPIbαN from VWF-A1 with steered molecular dynamics (SMD) simulations. Our results show that the sliding-rebinding mechanism we proposed previously for selectin/ligand catch bonds also operates for the GPIb/VWF system. When force is applied to GPIbαN/VWF-A1 complex, the interactions between GPIbαN β switch and A1 central β sheet dissociate first, this may lead to the sliding of GPIbαN β finger on the A1 bottom surface to allow new interactions formation. The sliding and forming new interactions will in turn enhance the rebinding of GPIbαN β switch and A1 central β sheet and prolong bond lifetime. The N- and C- terminal flanking sequence of A1 serves as a flexible hinge to regulate catch bonds. As shown in the crystal structure, the A1 N-terminal residue D506 interacts with R543 and R687. The presence of these interactions favors the fast-dissociation pathway, while their dissociation signifies the transition to the sliding pathway. Our results have provided an explanation for the AFM experimental data showing that catch bonds were eliminated by two A1 gain-of-function mutants R543Q and R687E, because these single residue replacements eliminate their interaction with D506, making the transition to occur at much lower forces and prolonging bond lifetime at low forces. R543Q mutant naturally occurs in some patients with type 2B von Willebrand disease (VWD) and R687E mutant also exhibits type 2B VWD phenotype. Our results may provide an explanation for type 2B VWD based on the mechanically regulated nonequilibrium structure-function relationship of GPIb/VWF interaction.
Iron Deficiency and the Role of Nutrition among Female Military Recruits.
Authors: Israeli Eran , Merkel Drorit , Constantini Naama , Yanovich Ran , Evans Rachel K. , Shahar Danit , Moran Daniel S.
Published: October 2019

The impact of iron deficiency is considerable when enhanced physical fitness is required. Female military recruits represent a unique population faced with intense physical and cognitive demands.

Purpose: To examine the prevalence of iron deficiency and the impact of dietary habits among female recruits in the Israel Defense Forces (IDF).

Methods: 348 recruits completed the study (188 female combatants, 58 male combatants, 92 non-combat females). Dietary intake was assessed using a Food Frequency Questionnaire (FFQ). Blood samples were collected for CBC, iron indices and vitamin B12. The common definitions for anemia and iron store deficiency were used as follows: Hemoglobin (Hgb) < 12gr/dl for females and <14gr/dl for males; Serum ferritin < 12 mg/dl.

Results: The prevalence of iron deficiency and iron deficiency anemia was 29.8% and 12.8%, respectively, among female combatants. Similar data were found among non-combat females (27.2% and 17.4% respectively) as compared to 5.2% and 0%, among males. No significant difference in iron or total calorie intake was detected between subjects with iron deficiency (with or without anemia) when compared to subjects with normal iron status in the same study group. Plant sources constituted 85% of dietary iron source for females, in comparison to 73% for males.

Conclusions: A high prevalence of iron deficiency was found among female recruits. Coupled with the iron loss during menstruation, inadequate iron intake may have a permissive role for iron deficiency in female recruits, and is an important issue facing females in the military.
Population-Based Prevalence of Anemia, Iron, Folic Acid and Vitamin B12 Deficiency among Young Adults in Israel.
Authors: Merkel Drorit , Balicer Ran , Davidovitch Nadav , Grotto Itamar , Zarka Salman , Huerta Michael
Published: October 2019

Background: The prevalence of anemia and iron deficiency among adolescents and young adults in Israel has not yet been assessed. Studies performed among specific populations in Israel demonstrated highly variable rates of anemia of 6–58%, with iron deficiency rates of 13–38%. We have set out to investigate the prevalence of anemia, iron, folic acid and vitamin B12 deficiency among young males and females that are requited to the army in Israel (IDF).

Methods: A random sample of 366 new recruits to the IDF (270 males and 96 females) participated in the study and undergone blood testing for Hemoglobin, Iron, Transferrin, Ferritin, Vitamin B12, Folic acid on recruitment day.

Results: Anemia among females (Hb<12 gr/dl), was 15.1% compared with 11.4% among males (Hb<14 gr/dl). Transferrin saturation values indicating iron deficiency (15%>) were also more prevalent among females compared with males (28.1% and 9.7%, respectively), as were low ferritin rates (37.2% and 14.3%, respectively). Vitamin B-12 deficiency (<180 pg/ml) was found in 6.6–9.6% of the subjects, and folic acid deficiency was detected in 6.4–11.7% of the subjects. Low-level paternal education and immigration were two factors found to be negatively associated with anemia. Smoking was associated with low ferritin levels in males. Anemia and iron levels were not affected significantly by the type of service designed, as combat soldiers or for clerical work.

Conclusions: Anemia and iron deficiency occur frequently among young adults requited to the IDF. They were more prevalent among females; but in males the prevalence is higher than expected. Low content of iron in the diet, infection like H Pylori and engaging in strenuous exercise preparing to service, may contribute to depleted iron stores. Low-level paternal education and immigration was surprisingly protecting factor, may be as a result of different eating habits. Anemia and iron deficiency, are known to reduce physical work capacity and mental performance, therefore it is important to perform more research to identify possible etiologies for intervention like education for proper nutrition, and adjustment of the diet in the military to tackle this prevalent problem.
Utilization of Darbepoetin alfa in Relation to Cancer Patients’ Hemoglobin Levels.
Authors: Hess Gregory , Hill Jerrold , Hulnick Scott , Nordyke Robert
Published: October 2019

Background: Prevailing guidelines through 2006 recommended initiating erythropoiesis stimulating agents (ESAs) for chemotherapy-induced anemia (CIA) at hemoglobin (Hb) levels <11 g/dL, maintaining near 12 g/dL, and withholding at >13 g/dL.

Objective and Purpose: To determine darbepoetin alfa (DA) administration patterns in cancer patients and selected factors related to such use.

Methods: A retrospective ESA administration-level analysis of Varian Medical Systems electronic medical records (EMRs), which includes 122,985 cancer patients across 13 states and 82 physical sites of care. The study period was 1/1/2005 – 11/30/2006. All DA administrations were recorded with the most recent Hb (day of or up to 7 days prior to administration). The proportion of DA administrations at Hb ≥ 12 and Hb ≥ 13 g/dL were the primary outcome measures. Utilization by Hb level was analyzed for all administrations, stratifying by year, gender, and anemia type. The types of anemia assessed were CIA, anemia of cancer (AOC), and myelodysplastic syndrome (MDS).

Results: During the 23 month period, there were 33,923 DA administrations associated with Hb results in 5,252 patients. The proportion of all DA administrations given at Hb≥12 was 7.7%, for Hb≥13 g/dL it was 1.1%; proportions for CIA, AOC, and MDS were 8.1 /1.2% (N = 25,638 administrations), 7.5 /1.0% (N = 7,054), and 2.3 /0.2% (N = 1,231) for Hb ≥12 and ≥13 g/dL respectively. The difference across all three indications was statistically significant (P < 0.005) for both Hb thresholds. Overall, the proportion of all DA administrations at Hb ≥12 g/dL and ≥13 g/dL declined from 8.6% to 7.1% (p<.0001) and from 1.3% to 1.0% (p<.06) respectively in 2005 vs. 2006.

Conclusions: In this population, DA administration at Hb ≥ 12 and Hb ≥ 13 occurred in approximately 7.7% and 1.1% of administrations, respectively. The results suggest that for the majority of administrations the prevailing guidelines at the time were adhered to by clinicians. Further research is required to understand dose titrations at Hb from 12 – 13 g/dL.
Inflammatory Cytokines: TNFα, IL-1β, IL-6 and IL-8 in Pulmonary Hypertension of Sickle Cell Disease.
Authors: Vicari Perla , Noguti Maria Aparecida E. , Morelli Vania M. , Cançado Rodolfo D. , Figueiredo Maria Stella
Published: October 2019

Background: Although pulmonary hypertension (PHT) is a common complication in patients with sickle cell disease (SCD), the rate of development of PHT and the factors that affect disease progression are unknown.

Objectives: To evaluate the plasma levels of cytokines in SCD comparing with healthy subjects and to find out if there is a relationship among cytokines and PHT.

Patients and methods: Dosage of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNFα), interleukin-8 (IL-8) and interleukin-1 beta (IL-1β) had been evaluated in 107 steady-state sickle cell patients, from the UNIFESP/EPM and College of Medical Sciences of the Santa Casa de Misericórdia, and in 108 blood donors. The presence of PHT was evaluated in sickle cell patients by transthoracic Doppler echocardiogram and the results were associated with age, hemoglobin and fetal hemoglobin, lactic dehydrogenase and cytokines levels.

Results: The presence of PHT was significantly related with age, low hemoglobin and high lactic dehydrogenase levels. There were no difference of plasma levels of IL-6, IL-1β and TNFα between patients and controls. The IL-8 levels were predominantly higher in patients than in controls (p=0.0001). Among patients with SCD, IL-8 levels were significantly higher in those with PHT (p=0.02). In addition, increased levels of IL-8 (>95th percentile of the control group) were detected in 33.3% in patients with PHT in comparison with 10.8% in those without (OR: 4.1; 95%CI 1.3–12.7).

Conclusion: These results indicate that age, hemoglobin, lactic dehydrogenase levels, and elevated levels of IL-8 could be risk factors of PHT in SCD. However a larger study with SCD patients with PHT is required to clarify this question. (Funded by Fapesp 04/04498–4).
Procoagulant Activity in Sickle Cell Anemia.
Authors: Vicari Perla , Lourenço Dayse M. , Morelli Vania M. , Noguti Maria Aparecida E. , Figueiredo Maria Stella
Published: October 2019

Sickle cell anemia (SCA) is associated with a hypercoagulable state that may contribute to the vaso-occlusive episodes observed in the disorder. Although numerous studies have been conducted to elucidate the mechanisms responsible for the prothrombotic state, the role of thrombogenisis in SCA complications remains controversial. We measured D-Dimer, thrombin-antithrombin complexes (TAT), prothrombin fragment 1+2 (F1+2), plasminogen activator inhibitor 1 (PAI-1), von Willebrand factor (vWF) and factor VIII (FVIII), in 42 homozygous sickle cell patients (HbSS), 26 women and 16 men, aged 14 to 48 years (mean age 26.8 years), 9 with hydroxyurea (HU) therapy, and correlated these data with clinical manifestations. Among the 42 studied patients, we found elevated plasma level (above the normal range) of these markers in 36 patients for D-Dimer (mean = 1481, range 280 – 5145 ng/mL), in 29 patients for TAT (mean = 7.35, range 2.2 – 45.0 microg/L) and FVIII (mean = 173, range 22.6 – 310.6%); in 25 patients for F1+2 (mean = 1.12, range 0.3 – 2.65 mM/L), in 21 patients for vWF (mean = 175, range 58 – 280%), and in 7 subjects for PAI-1 (mean = 41, range 11.5 – 103 ng/mL). There was no significantly correlation between hemostatic markers and the presence of leg ulcers or retinopathy in SCA patients. Factor VIII levels were significantly elevated in the 19 subjects with pulmonary hypertension, in the 5 with stroke and in the 33 patients who had not been treated with HU (p<0.05). TAT levels were also significantly elevated in the patients without HU (p<0.05). These findings confirmed the presence of a hypercoagulable state in patients with sickle-cell anemia, which could be driven by disease severity. (Supported by Fapesp 02/13801–7)
Hemoglobin San Martin: A New Unstable Variant Associated with Hemoglobin S in an Argentinean Boy.
Authors: Feliu-Torres Aurora , Eandi-Eberle S. , Calvo K. , Bragós I. , Ojeda M. , Voss M. , Pratti A. , Milani A. , Targovnik H. , Sciuccati G. , Bonduel M. , Diaz L. , Staciuk R. , Noguera N.
Published: October 2019

A new unstable hemoglobin (Hb) detected in a 10 year-old boy from San Martin, Buenos Aires, Argentina, is hereby described. The patient (pt) was born at term, after a normal pregnancy, by cesarean section. He had a history of multiple episodes of pallor, jaundice and dark urine related to infections, since 6 months of age. The physical examination only revealed pallor and icterus, with no hepatosplenomegaly. The pt and his mother showed the presence of an anomalous band on both alkaline and acid pH electrophoresis. Isopropanol and sickling tests were positive. In order to identify the abnormal Hb variant the β globin gene was analysed. Three exons were amplified and automatically sequenced with direct and reverse probes.

Table 1. Hematological data Patient Mother Hb g/dl/PCV % 10.9/36 10.5/34 MCV fl/MCH pg 79.4/24.1 80.7/24.6 RDW % 15.7 18.2 Reticulocyte count % 5.2 8.0 Electrophoresis (pH 9) A/X/A2 A/X/A2 Electrophoresis (pH 5) X/A-A2 X/A-A2 Sickling/Isopropanol tests Positive/Positive Positive/Positive Inclusion bodies Positive Positive

Two mutations were identified in the same β globin gene. One in Exon 1, corresponding to Hb S [Ex1 β6 Glu→Val (GAG→GTG)]; and the second one in Exon 2 [Ex2 β85 (F1) Phe→Leu (TTT→CTT)]. This second mutation is responsible for a new unstable Hb that has not been described so far, in association with Hb S. The substitution occurs in an external position between two hydrophobic residues of different size.
The BLyS/BAFF Receptor-Ligand System in HCV Induced B-Cell Clonal Disorders.
Authors: Landau Dan Avi , Rosenzwajg Michelle , Saadoun David , Klatzmann David , Cacoub Patrice
Published: October 2019

The study aim was to examine the B-Lymphocytes Stimulator (BLyS) receptor-ligand system in HCV induced B lymphocyte clonal disorders. 94 patients with chronic HCV [including 35 HCV+ mixed cryoglobulinemia (MC)-vasculitis and 9 HCV+ B-non Hodgkin’s lymphoma (B-NHL) patients] and 15 healthy volunteers were included. A 2-fold serum BLyS increase was associated with HCV-induced MC-vasculitis, and a three-fold increase with HCV-induced B-NHL, compared with HCV+ patients without vasculitis or healthy controls (p<0.05). Lower mBLyS expression in HCV-induced MC vasculitis was observed. CD19+ BLyS binding and BR3 staining showed a step wise decrease with highest values in healthy controls and HCV+ without MC, and lowest in B-NHL (p<0.05, p<0.0001, respectively) with a further decrease in Vh1-69+ (heavy chain rearrangement often found in clonal disorders associated with HCV) clonal B-cells. BLyS anti-apoptotic effects were maintained despite this decrease in BR3 staining. Complete clinical remission after anti-viral treatment was associated with a decrease in serum BLyS, and an increase in BR3 staining. Rituximab treatment was associated with a five-fold increase in serum BLyS (p<0.001), mirroring the depletion of CD19+ cells. BR3 staining in repopulating B-cells was significantly decreased (p<0.005). In conclusion, the BLyS ligand-receptor activity is increased in HCV induced B-cell clonal disorders, indicating a possible role for treatment targeting the BLyS receptor-ligand system.

Figure Figure Figure Figure
Clinical and Virological Responses to Anti-Viral Treatment Correlates with Regulatory T-Cells Evolution in Patients with HCV-Induced Cryoglobulinemia Vasculitis.
Authors: Landau Dan Avi , Rosenzwajg Michelle , Saadoun David , Trebeden-Negre Helene , Cacoub Patrice , Klatzmann David
Published: October 2019

Background- Mixed cryoglobulinemia (MC) vasculitis is an autoimmune disorder associated with chronic hepatitis C virus (HCV) infection. We previously reported that MC vasculitis is associated with a quantitative defect of peripheral blood regulatory T cells (Tregs). We aimed to prospectively evaluate the evolution of this defect during the course of anti-viral treatment.

Methods- Treg frequencies and numbers were analyzed in 131 HCV chronically infected patients (including 66 with MC vasculitis) and 20 healthy volunteers. Measurements were taken before, during and after treatment with Pegylated Interferon and Ribavirin.

Findings- At baseline, patients with MC vasculitis had significantly lower frequency and number of Tregs than patients without MC vasculitis. Complete remission of MC vasculitis following anti-viral treatment was associated with a significant increase in Treg levels compared to baseline levels. In contrast, Treg levels in non- or partial-responders, which did not differ from those of complete responders at baseline, remained unchanged over the course of the study, and where significantly lower that those of complete responders.

Interpretation- The strong positive correlation between clinical responses and Treg levels provides additional support for the central role of Treg cells in the pathogenesis of HCV-induced MC-vasculitis. Furthermore, it emphasizes the dual role of Treg cells in chronic HCV infection: while they may hinder viral elimination, Treg cells also have a beneficial role in limiting autoimmune tissue injury.

Correlations, in MC-vasculitis patients, between CD4+CD25 high levels and response to anti-viral treatment using clinical (A+B) or laboratory (C+D) measures. CR-complete response, NR/PR-no or partial response. Correlations, in MC-vasculitis patients, between CD4+CD25 high levels and response to anti-viral treatment using clinical (A+B) or laboratory (C+D) measures. CR-complete response, NR/PR-no or partial response.
Risk of Cataracts among Idiopathic Thrombocytopenic Purpura (ITP) Patients in the UK General Practice Research Database (GPRD).
Authors: Feudjo-Tepie Maurille A. , Hall Susan A. , Logie John W. , Robinson Noah J. , Bennett Dimitri
Published: October 2019

ITP is a disease caused by inadequate platelet production as well as increased platelet destruction. Oral systemic steroids are recommended as first-line treatment. Prolonged use of oral steroids in other disease populations has been associated with an approximately two-fold increase in the risk of developing a cataract. This study aimed to quantify the underlying risk of cataracts among ITP patients compared with non-ITP patients. Using the GPRD, a retrospective matched cohort study was conducted in which each ITP patient newly diagnosed between 1992 and 2005 and age 18 years or older was matched to 5 non-ITP patients on gender, age, practice and duration of follow-up. ITP patients and cataract events were identified using specific Read/Oxmis disease codes and validated by a clinical epidemiologist. The exposure of interest was oral steroid use and the primary outcome was cataracts (recorded as cataracts or cataract surgery). Patients with a history of cataracts were not excluded from the study. Potential covariates of interest were diabetes, schizophrenia, glaucoma, splenectomy and hypertension. The risk of cataracts was quantified using incidence rates and 95% confidence intervals (CI) and, the difference between groups was estimated using a rate ratio and 95% CI. All analyses were further stratified by age and gender. Adjusted rate ratios were estimated using the Cox proportional hazard model. Seven hundred sixty ITP patients were identified, 745 (98%) of whom had 5 matched controls. The entire sample had a mean age of 56.4 years and 60.1% were female. Among ITP patients, users of oral steroids had a cataract incidence rate of 14.0 per 1000 person-years (PY) (95% CI: 8.7 – 21.4) and non steroid users 6.1 per 1000 PY (95% CI: 2.7 – 11.4). In the non-ITP population, these figures were 16.9 per 1000 PY (95% CI: 11.9 – 23.3) and 9.2 per 1000 PY (95% CI: 7.6 – 11.0), respectively. The incidence of cataracts was observed to increase with age. Adjusting for steroid use and other factors, the risk of cataracts was similar in the ITP and non-ITP populations (adjusted rate ratio 0.8, 95% CI: 0.5 – 1.2) whereas, oral steroid use was associated with an increased risk of cataracts in both ITP and non ITP populations (adjusted rate ratio 1.6, 95% CI: 1.2 – 2.2). There was no evidence of increased risk with either inhaled steroids, or intranasal steroids. As expected, our study shows that the use of oral steroids is associated with an increased risk of cataracts in both ITP and non-ITP populations. However, we found no evidence of a difference in the risk of cataracts between an ITP and a matched non-ITP population.
Microfluidic Tools To Probe the Spatial Dynamics of Coagulation.
Authors: Kastrup Christian J. , Runyon Matthew K. , Shen Feng , Ismagilov Rustem F.
Published: October 2019

To investigate the biophysical mechanisms that regulate the spatial dynamics of blood coagulation, we have developed a set of microfluidic tools that allow analysis and perturbation of blood coagulation on the micrometer scale with precise control of fluid flow, geometry, and surface chemistry. Physiological coagulation occurs in a localized manner; specifically, coagulation is believed to occur exclusively at regions of substantial vascular damage and does not spread throughout the entire vascular system. In vitro analysis and characterization of these spatial dynamics requires the ability to reproduce and perturb this system, an ability that is not provided by the mixed reactor systems commonly used for in vitro studies of blood coagulation. We developed microfluidic devices with micrometer-scale channels and methods to coat these channels with various phospholipids, including components of the blood coagulation network such as thrombomodulin and tissue factor, to reproduce in vitro the geometry and surface chemistry of blood vessels in vitro. In a microfluidic device with channels coated with phospholipids and thrombomodulin, we demonstrated that clots propagate in a wave-like fashion with a constant velocity in the absence of flow. We also showed that propagation of coagulation from an occluded channel to a channel with flowing blood plasma can be regulated by the geometry of the junction and the shear rate in the channel with flowing plasma. We also developed microfluidic tools to probe the spatial dynamics of initiation of clotting by patterning surfaces with tissue factor reconstituted into phospholipids bilayers. When human plasma or whole blood was exposed to these surfaces in a microfluidic device, clotting occurred only on patches of tissue factor larger than a threshold size. This threshold patch size is controlled by the rate of activation of clotting factors at the patch and the rate of transport of activated factors off the patch. These results suggest a mechanism for how tissue factor can circulate in blood without causing clotting, and how small regions of vascular damage can exist without causing clotting. These results also suggest new biophysical mechanisms that may control interactions between the coagulation cascade and bacterial surfaces.
Biochemical Comparison of VWF/FVIII Concentrates - Are There Differences in Product Characteristics and Purity?.
Authors: Schwartz B.A. , Pock K. , Stadler M. , Gruber G. , Kannicht C. , Romisch J. , Svae T.-E.
Published: October 2019

Introduction: Product characteristics and purity are important in assessing the safety and efficacy of VWF/FVIII products. Purity has been defined as the specific activity of the active ingredients in relation to the total protein in the products. This is important because it indicates the content of co-purified plasma proteins in the product. An extensive biochemical comparison of several VWF/FVIII concentrates licensed for the treatment of Haemophilia A and/or von Willebrand disease (VWD), including the novel new generation VWF/FVIII concentrate (Wilate), was performed to compare their properties.

Methods: Different batches of a number of commercially available VWF and VWF/FVIII products were analysed using state-of-the-art VWF and FVIII assays including VWF multimer analysis with examination of the multimeric triplet structure. The total protein as well as any accompanying plasma proteins, which may co-harvested in the final concentrate, were also quantified.

Results: All concentrates generally contained the specified VWF and FVIII amounts and activities. The VWF and FVIII specific activities and overall purity was highest for Wilate®, while all other concentrates contained considerable amounts of albumin used as a stabilizer as well as other residual plasma proteins that where found in varied concentration specific for the concentrate. The VWF:RCo/FVIII:C ratios varied greatly. The new generation product (Wilate®) was the only product tested that has high purity and showed a physiological 1:1 ratio. As compared to some of the other products, Wilate’s, native multimeric triplet structure was preserved.

Conclusion: There was a great variation in properties and purity of the concentrates tested. The new generation VWF/FVIII concentrate (Wilate®), showed a high purity and physiological VWF/FVIII ratio that should reduce the load of non-essential proteins given to the patient during treatment. Even though there are some differences in the content of the highest VWF multimers in this concentrate, the role of this in the in vivo physiological process of clot formation has not been established. The altered triplet structure seen in some of the older generation products may be the result of proteolysis in the manufacturing process. The clinical consequence of this has also not been established. The physiologic ratio of VWF and FVIII as well as their optimal PK profile, may ease the difficulties of dosing and monitoring in these patients.
Higher Incidence of Venous Thromboembolism Is Associated with Initial Cycles of Chemotherapy in Lymphoma Patients: Creatinine and Hemoglobin as Key Risk Factors.
Authors: Zhou Xiao , Huen Auris , Teegala Shyam , Ji Yuan , Fayad Luis , Hagemeister F.B. , Vadhan-Raj Saroj
Published: October 2019

Background: While Lymphoma patients are at increased risk of venous thromboembolism (VTE), the timing of VTE occurrence in reference to chemotherapy (CT) and risk factors are not well defined.

Methods: Medical records of all newly referred lymphoma patients (1046) to MD Anderson Cancer Center (MDACC) in 2003 were retrospectively reviewed over a follow-up period of two years for demographics, tumor histology, laboratory values, CT regimens, incidence of VTE, risk factors and management of VTE.

Results: Four hundred and twenty-two (422) out of 1046 patients received at least one cycle of CT at MDACC (total CT cycles 2126). The median age of the patients was 57 years (range, 17 to 87). Fifty eight % of pts were male and 62% were newly diagnosed. Seventy-three patients (17.3%) out of 422 had 80 new episodes of VTE; 58 deep vein thromboses (DVT) only, 17 pulmonary embolisms (PE) only, and 5 were combined DVT and PE. Only less than 5% (20/422) of pts received thromboprophylaxis during treatment for lymphoma. Interestingly, 68% (54/80) of episodes occurred by cycle 3 of CT suggesting that VTE episodes occurred primarily in patients with highest disease burden or during initiation of CT. Since the incidence was highest during the initial cycles of CT, we analyzed risk factors for the first regimen of CT. By multivariate logistic regression analysis, gender (female vs. male, OR=3.6, 95%CI 1.707 to 7.61, p=0.0008), high hemoglobin (OR=1.29, 95%CI 1.059 to 1.561, p =0.011), high serum creatinine (OR=3.36, 95%CI 1.372 to 8.228, p=0.0080), doxorubicin (DOX) and/or methotrexate (MTX)-based CT regimen (OR=2.948, 95%CI 1.352 to 6.429, p=0.0066) were found to be important risk factors for new VTE. Specifically, the estimated risk for lymphoma patients with baseline hemoglobin 12 gm/dL receiving DOX and/or MTX based CT with renal insufficiency (creatinine 2.0mg/dL) is 50% in females and 21% in males.

Conclusions: Lymphoma patients are at higher risk for VTE in the initial cycles of CT (cycles 1–3). Patients with high hemoglobin, elevated creatinine, female gender, and those receiving DOX and/or MTX based CT regimens are at higher risk for VTE than others. These clinically relevant findings suggest that a thromboprophylaxis strategy is needed in the patients presenting with these risk factors, particularly, in the initial cycles of chemotherapy.
A Novel Marker for Blood Platelet Storage Lesion: Newly Synthesized Rap1 in Integrin Signaling.
Authors: Schubert Peter , Thon Jonathan N. , Walsh Geraldine M. , Serrano Katherine , Moore Edwin D. , Kast Juergen , Devine Dana V.
Published: October 2019

Platelet transfusion is a standard live-saving medical procedure for patients with platelet-deficient diseases like leukemia. Platelets have a limited shelf-life of 5–7 days for transfusion purposes. This is in part due to a storage-related deterioration typified by altered morphology features and platelet metabolism as well as increased platelet activation. While the manifestations of the platelet storage lesion (PSL) are well known, the precise biochemical pathways involved in the initiation or exacerbation of this process have yet to be identified. Recently, we analyzed protein changes in the platelet proteome at day 1 and day 7 of storage by using a comprehensive proteomic approach. Out of 503 proteins, twelve were identified as significantly and consistently changing in relative concentration across all proteomic probes, including glycoprotein (GP) IIb/IIIa, Rap1 and talin, which showed an increase in their concentration paralleled with an increase in surface expression of GPIIb/IIIa. Synthesis of Rap1 in stored platelets could be demonstrated after incubation with the translational inhibitor rapamycin at a final concentration of 10 nM for twelve hours and subsequent activation with thrombin. Flow cytometry revealed that storage lead to a moderate level of platelet activation (10.5 ± 1.4% at day1 and 28.8 ± 1.3% at day 7 of storage) compared to ADP-treated controls (73.7 ± 1.2%) monitored by CD62P surface expression, in a rapamycin-independent manner. Microscopic analyses revealed similar re-localization patterns for GPIIIa, Rap1 and talin comparing changes during platelet storage and agonist induced activation. A significant correlation (p=0.007) between Rap1 activation and CD62P surface expression was seen. This observation is in strong agreement with a model for platelet GP IIb/IIIa activation [Han et al., Current Biology, 16, 1796–1806, 2007] also suggesting a calcium-dependent initiation of signal transduction. To analyze this hypothesis in more detail, treatment of platelets sampled at days 1, 4 and 7 of storage with 1 mM EDTA for 2 hours resulted in decreased Rap1 activation, in reduced surface expression of CD41 (GPIIb) and CD61 (GPIIIa) as well as in a lower level of platelet activation compared to untreated controls, respectively. This study unravels one aspect of the PSL, showing involvement of integrin signaling and identifying Rap1 as a novel marker for PSL. Therefore, this pathway offers potential targets for intervention which might lead to a reduction in platelet activation during storage, and may enable platelets to be stored for longer periods of time. From a transfusion point of view, however, extending the shelf-life of platelet units will ultimately need to be balanced with maintaining the quality of transfused platelets, their functionality, and efficacy in the patient.
Preparation of Platelet Membrane Microparticles with High Pressure Homogenization Method.
Authors: Li Cui-ping , OuYang Jian , Huang Cheng-yin , Shi Guang-yao , Pei Xiao-ping
Published: October 2019

Objective To investigate the preparation technique of infusible platelet membrane microparticles (IPMs), and evaluate hemostatic function and effect of IPMs on pathological thrombogenicity after transfused into model of rabbit thrombocytopenia.

Methods Whole bloods collected in the street were used to prepare platelet concentrates(PCs),white cells were removed by white cell filter, and red cells by centrifugation at 1000rpm in for 10min. After that, platelets were washed twice with 0.9% NaCl solution by repeated resuspension and centrifugation, and adjusted concentration to 2×109/ml with 0.9% NaCl. The washed platelets were disrupted by repeated freezing (at −80°) and thawing (at 25°) three times, and were heated at 60° for twenty hours to inactivate any viral contaminants. Finally, the heat 2 treated platelets were crushed by high pressure homogenizer to form IPMs. In this study, particle analyser was applied to mean diameter and the particle size distribution of IPMs, APCT to test the procoagulation activity of IPMs in vitro. Hemostatic function and effect of IPMs onpathological thrombogenicity were observed after IPMs were transfused into thrombocytopenia rabbitmodels.

Results mean diameter of IPMs was from 200 to 300 nm. The procoagulation activity of 50Lg/ml of IPMs was equal to 250×109/L of fresh platelets. Rabbit ear bleeding time and APCT significantly shortened from two hours to twelve hours after transfusion of 2mg IPMs per Kg into thrombocytopenia rabbit models, but other indexes such as PT, APTT, Fg, and TT changed less.

Conclusions IPMs possess good hemostatic function and less effect on pathological thrombogenicity. It is a kind of promising biologic hemostatic reagent.
High Frequency of HPA-1B in Leukemia Patients.
Authors: Novaretti Marcia C.Z. , Bonifacio Silvia L. , Ruiz Azulamara S. , Fontes Lia V.Q. , Dorlhiac-Llacer Pedro E. , Chamone Dalton A.F.
Published: October 2019

Background: The HPA-1 alloantigen is a biallelic co-dominant system on human platelets carried on glycoprotein IIIa. Alloimmunization against the HPA-1 has clinical relevance in multiple transfused patients, in neonates with alloimmune thrombocytopenia and in platelet refractoriness. Accurate HPA genotyping is important to facilitate the provision of HPA-matched blood components for these patients. The purpose of this study was to determine the HPA-1 gene frequencies in apheresis blood donors and in leukemia patients.

Methods: Genomic DNA was extracted from 149 peripheral blood samples of apheresis regular donors and from 84 leukemia patients with chronic myeloid leukemia (CML=56), acute myeloid leukemia (AML=13), chronic lymphoid leukemia (CLL=6) and acute lymphoid leukemia (ALL=9) using a commercial DNA extraction kit (QIAamp DNA, QIAGEN, Germany). Sequence specific PCR (SSP-PCR) was performed amplifying the HPA-1a/HPA-1b gene using a pair of primer for each allele under the following conditions: the PCR was carried out in a final volume of 20μL, containing 0.2μg of genomic DNA, 0.2mM of each dNTP, 5% of glycerol, 1.5 units of platinum Taq polymerase (Invitrogen, U.S.A) in the buffer supplied, 5.0mM MgCl2 and 10.0 pmoles of each primer. Fragments of 196 bp derived from HPA-1a/1a mutation were separated for 90 minutes at 102V using 0.5μg.mL-1 ethidium bromide-stained 2.0% agarose gels and visualized in a UV light apparatus (Eagle Eye II, EUA).

Results: Table 1 shows the results of HPA1a/b genotyping and gene frequencies in apheresis regular donors and in leukemia patients. HPA-1b/HPA-1b genotype frequency in patients with AML was higher when compared to apheresis blood donors.

Conclusion: In our study, high prevalence of HPA-1b in homozygous in AML patients was detected. This data can be useful to evaluate the alloimmunization against platelet specific antigens in acute myeloid leukemia patients.

Table 1 Leukemia type Number of samples tested HPA-1 Genotype Frequency (%) Gene Frequency a/a a/b b/b HPA-1a HPA-1b CML 56 85.71 12.50 1.78 0.920 0.080 AML 13 76.92 15.38 7.69 0.846 0.154 CLL 06 50.00 50.00 0 0.750 0.250 ALL 09 88.88 11.11 0 0.944 0.055 Apheresis donors 149 73.82 22.82 3.36 0.852 0.147
Severe Refractory Autoimmune Hemolytic Anemia with Both Warm and Cold Autoantibodies: Complete Response with Rituximab.
Authors: Gupta Shilpi , Varma Seema , Szerszen Anita , Nakhl Fadi , Gottesman Aaron , Forte Frank J. , Dhar Meekoo
Published: October 2019

Mixed warm and cold autoimmune hemolytic anemia (AIHA) runs a chronic course with severe, intermittent exacerbations. Therapeutic options for treatment of hemolysis associated with mixed AIHA are limited. There have been only two reported cases of effective use of rituximab in the treatment of mixed AIHA. We report a case of severe mixed AIHA that did not respond to steroids and responded to one cycle of rituximab. A 62-year-old male presented with dyspnea, jaundice and splenomegaly. Blood work revealed severe anemia (hemoglobin 4.9 g/dl) with biochemical evidence of hemolysis. Exposure to cold led to worsening of hemolysis and hemoglobinuria. Direct antiglobulin test was positive for IgG and complement (C3d); and cold agglutinins were detected. Bone marrow revealed erythroid hyperplasia. Positron emission tomography scan showed no sites of pathologic uptake. There was no other evidence of a lymphoid or myeloid disorder. Initial therapy consisted of avoidance of cold, intravenous methylprednisolone and a trial of plasmapheresis; however, there was no clinically significant response and the patient continued to be transfusion dependent. He was then started on intravenous rituximab 375 mg/m2/week. After two treatments, hemoglobin stabilized and transfusion requirement diminished.

Figure Figure

Rituximab, continued for a total of four weeks, led to complete resolution of hemolytic anemia and associated symptoms. At his last visit, about 8 months after initial rituximab treatment patient continues to be in complete remission. This is the first reported case of mixed type AIHA not responding to steroid therapy with complete response to only one cycle of rituximab. Previous two reports of rituximab use in mixed AIHA have described initial brief response to steroids and the use of rituximab at the time of relapse. In both the cases, response to one cycle of rituximab was short-lived requiring a second cycle of rituximab. Our case demonstrates that severe hemolysis associated with mixed AIHA can be unresponsive to steroid therapy and a single cycle of rituximab may lead to prompt and durable complete remission. Rituximab is an effective treatment for mixed AIHA, especially when immediate response is desired, and merits further evaluation in this setting.
Effect of Dioxin (TCDD) on Gene Transcription of Human CD34+ Hematopoietic Cells.
Authors: Fracchiolla Nicola S. , Servida Federica , Bertazzi Pier A. , Corradini Paolo , Colombi Antonio , Todoerti Katia , Agnelli Luca , Neri Antonino , Deliliers Giorgio Lambertenghi
Published: October 2019

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) binds to aryl hydrocarbon receptor (AhR), a member of the erb-A family, allowing, after DNA binding, gene expression regulation. TCDD has a large number of biological effects, as skin and cardiovascular disease, diabetes and cancer. An increase in myeloid leukemia, Hodgkin’s and non-Hodgkin’s lymphomas, was observed after 15 years in the population exposed to TCDD after the 1976 accident in Seveso, Italy. In the present study, we analyzed the in vitro effect of TCDD exposure on human CD34+ progenitor cells from G-CSF stimulated leukapheresis of 4 normal donors. Gene expression modulation induced by TCDD was analysed on highly purified (>96%) CD34+ cells, after exposure to 10 nM of TCDD for 12 hrs. Gene expression profiles have been generated by high-density oligonucleotide arrays (Affymetrix GeneChip U133A) and subsequently analyzed with a supervised approach (DNA-Chip Analyzer, dChip 2006). The differential expression of 257 transcripts (150 up regulated and 106 down-regulated) distinguished the 4 TCDD treated from the 4 untreated control samples. Interestingly, a number of the differentially expressed genes were involved in skin and cardiovascular diseases, diabetes, and different cancers, all of which have been associated with TCDD exposure. Among skin diseases, defects in laminin beta 3, ALOX12B and keratin 2a, all downregulated in TCDD exposed CD34+ cells, are associated with development of epidermolysis bullosa, erythroderma ichthyosiform, and Siemens ichthyosis bullosa, respectively. As far as diabetes and cardiovascular disease pathogenesis are concerned, defects of SLC2A4 gene, dowregulated by TCDD, is associated with the development of non insulin dependent diabetes, while epoxide hydrolase 2 and EGR2 are associated with cardiovascular disease. Among cancer related genes, ARHGAP26 and ABL2 are associated with juvenile myelomonocytic leukemia and acute myeloid leukemia with eosinophilia, respectively. Nevertheless, the expression of numerous other genes potentially involved in hemopoiesis/leukemogenesis, was modulated by TCDD exposure. Among these examples are c-kit ligand, LIF receptor, pre B lymphocyte gene 1, piwi-like 2, FLT3 ligand, chemokine ligands 14 and 15, and cdk2, that were all up regulated, while MLL4, wnt inhibitory factor 1, chemokine ligand 7, and lymphoid blast crisis oncogene, were down regulated. In conclusion, the gene expression pattern induced by TCDD exposure on the CD34+ normal progenitor cells is consistent with the spectrum of TCDD induced toxicities/diseases. In particular, it provides the basis for a possible role of TCDD in the neoplastic transformation of hemopoietic stem cells and support the epidemiologic data of increased hematologic cancer risk in the population exposed accidentally to the substance.