bluuebunny/crossref_metadata_2025 huggingface dataset:
Threshold Ferritin Values to Predict Control of Liver Iron Burden in Thalassemia
Authors: Lal Ashutosh , Weyhmiller Marcela G , Vichinsky Elliott
Published: October 2019

Transfusion-dependent (TD) and non-transfusion dependent (NTD) forms of thalassemia are associated with progressive iron overload reflected by increase in serum ferritin and liver iron concentration (LIC). Despite the adoption of non-invasive methods, measurement of LIC is available to only a minority of patients or can only be performed annually. Maintenance of low systemic iron usually depends on frequent determination of ferritin, a less reliable marker whose level can vary among individuals with similar LIC. We evaluated the relationship between LIC and ferritin in TD and NTD (including un-transfused (NT) or intermittently transfused (TI)) individuals to determine the validity of average annual ferritin to identify inadequate control of liver iron (defined as LIC >7 mg/g dry-liver-weight).

After excluding individuals with active hepatitis C virus infection, the LIC (measured by Ferritometer) and serum ferritin values were available from 115 TD (729 observations), 36 TI (139 observations) and 14 NT (28 observations) individual patients.

The median (range) ferritin and LIC were 1,684 (91-14,155) ng/mL and 10.2 (0.14- 59.4) mg/g for TD, 469 (50-4,536) ng/mL and 8.8 (2.4-33.1) mg/g for TI, and 407 (30-1,061) ng/mL and 5.7 (1.3-22.8) mg/g for NT groups, respectively. The slope of the regression line between ferritin and LIC was significantly different between the 3 groups (p=0.019), being lowest in TD, intermediate in TI, and highest in NT. The predicted LIC for ferritin level of 1000 ng/mL was 8.1 mg/g for TD, 12.1 mg/g for TI, and 13.5 mg/g for NT groups. Receiver operating characteristics (ROC) analysis showed that in NTD group (NT+TI), a ferritin threshold of >200, >300 and >500 ng/mL failed to correctly identify 7%, 21% and 38% of individuals with LIC >7 mg/g, respectively. In contrast, in the TM group, these ferritin values were associated with false negative rate of 0%, 0% and 2%, respectively. In a subgroup analysis restricted to TM patients with ferritin <1,000 ng/mL, LIC varied from 0.14 mg/g to 21.1 mg/g. ROC analysis in this subgroup showed no ability of ferritin to discriminate between individuals with LIC <3 mg/g or ≥3 mg/g (AUC 0.54, P=n.s.).

In conclusion, transfusions significantly alter the relationship between serum ferritin and LIC in thalassemia. In TM individuals, ferritin levels do not identify those with very low LIC. NTD patients with seemingly safe serum ferritin levels may have clinically significant hemosiderosis and be at risk for organ injury. These relationships should be factored into making decisions about screening or treatment of iron overload in untransfused or intermittently transfused individuals with thalassemia.

Disclosures

No relevant conflicts of interest to declare.
Nrf2 Activation and Fetal Hemoglobin Induction in Sickle Cell Disease
Authors: Krishnamoorthy Sriram , Gupta Dipti , Hobbs William E. , Loh Christine , Light David R. , Peters Robert , Sturtevant Sarah , Pace Betty , Nakamura Yukio , Lucas Brian , Vieira Benjamin F.
Published: October 2019

Sickle Cell Disease (SCD) is caused by a point mutation in the beta- chain of hemoglobin, triggering a complex pathophysiology resulting in recurrent, painful vaso-occlusive events (VOCs) and chronic hemolytic anemia. Induction of fetal hemoglobin (HbF), is a well-established approach towards the treatment and potentially cure for SCD. This is exemplified by the condition known as Hereditary Persistence of Fetal Hemoglobin (HPFH), which when present in SCD patients results in asymptomatic disease. Reactivation of fetal hemoglobin can be achieved by different methodologies both genetic manipulation and pharmacological agents. The mechanism of action of hydroxyurea, the only FDA approved drug for the treatment of SCD, is by activating HbF. We have investigated the role of Nrf2 in activating fetal hemoglobin and it potential to ameliorate the symptoms of SCD. Nrf2 is a basic leucine zipper transcription factor that is bound to a cytosolic protein Keap1, a Kelch domain containing protein, which targets the factor to the proteasome. Previous studies have shown that chemical activation of Nrf2 leads to induction of HbF. Here we show that siRNA based knockdown of Keap1 led to ~70 % reduction in Keap1 mRNA levels in Human Umbilical cord Derived Eryrthroid Progenitor cells (HUDEP), and concomitantly mediated a 2-fold induction of g-globin mRNA levels. Peripheral blood derived mononuclear cells differentiated into erythroid progenitors treated with bardoxolone-Me, a potent Nrf2 activator, resulted in a significant 4-fold induction in γ-globin mRNA, 2.5 fold induction in F-cells and up to 2.5-fold up-regulation in both Aγ and Gγ globin protein. Bardoxolone-Me treated erythroid progenitors also demonstrated a significant reduction in hypoxia-induced shape changes of sickle cells - about 42 % decrease at 100 nM and 55 % decrease at 250 nM. Bardoxolone-Me was also evaluated in a Townes SCD mouse model carrying an inducible γ-globin gene. A single oral dose of bardoxolone-Me at 30mg/kg, showed 9-fold induction in γ-globin mRNA levels at 6 h compared to untreated mice. Based on these findings, Nrf2 activation, can potentially be utilized for HbF induction in the treatment of SCD.

Disclosures

Krishnamoorthy: Biogen: Employment, Equity Ownership, Other: share holder. Gupta:Biogen: Employment, Equity Ownership, Other: share holder. Hobbs:Biogen: Employment, Equity Ownership, Other: shareholder. Loh:Biogen: Employment, Equity Ownership, Other: share holder. Light:Biogen: Employment, Equity Ownership, Other: share holder. Peters:Biogen: Employment, Equity Ownership, Other: share holder. Sturtevant:Arietis: Employment. Pace:Augusta University: Employment; Biogen: Research Funding. Nakamura:Riken Institute: Employment. Lucas:Biogen: Employment, Equity Ownership, Other: share holder. Vieira:Biogen: Employment, Equity Ownership, Other: share holder.
Hydroxyurea Is Associated with Early Onset Malaria Episode in Treated Sickle Cell Disease Patients
Authors: Guindo Aldiouma , Sarro Yeya dit Sadio , Toure Boubacari Ali , Fane Baba , Coulibaly Mody , Diallo Oumahane Ouane , Dorie Alain , Diallo Dapa Aly
Published: October 2019

Hydroxyurea (HU) is the only drug which has demonstrated efficacy in terms of reduced incidence of VOC and ACS, reduced need for hospitalization and reduced number of blood transfusion in sickle cell disease. African countries are among those with highest rate of both malaria and sickle cell disease. Despite of that the heterozygous form (HbAS) is known to protect against malaria, there is no documented studies on the clinical effect of HU on malaria. 36 patients aged 4 to 60 years old and treated by HU at the sickle cell disease research and control center of Bamako for at least 2 years. The treated group was compared to a matched untreated sickle cell patients group. During the follow-up, malaria incidence and onset to clinical episode of malaria were compared between treated SCD patients and untreated group. Results of the comparison show that there is no increased incidence of malaria in the treated group after 2 years follow-up (P=0.9). However, a reduction on the time to first malaria episode within the sickle cell population treated with HU was observed (P=0002).Based on this observed reduced time to first malaria episode in HU treated SCD patients, the use of HU in malaria endemic areas needs to be revaluated. It is howether clear that a more comprehensive approach would hopefully reduce the morbidity due to HU use for SCD affected children.

Disclosures

No relevant conflicts of interest to declare.
Thromboelastography and the Functional Confirmation of Heparin-Induced Thrombocytopenia in Donor Whole Blood
Authors: Ero Mike , Yamini Bynagari , Lewis Bradley , Powers Kathleen , Cota Jacob , Switala Lauren
Published: October 2019

Thromboelastography (TEG) presents a novel testing environment to detect functional antibodies associated with heparin-induced thrombocytopenia (HIT). TEG is considered a qualitative and qualitative method for assess global hemostasis in a test environment that includes shear stresses. In this study we explore the sensitivity of TEG to detect a HIT-associated reaction when whole blood or platelet rich plasma (PRP) is mixed with heat inactivated positive HIT sera in the presence of low dose (0.2U/mL) or high dose (100U/mL) sodium heparin. TEG is designed to record the kinetic changes in whole blood or plasma-based samples during clot initiation, propagation and fibrinolysis. Here we show that HIT positive sera can cause a reaction in both whole blood and PRP when exposed to reactive normal donor whole blood or PRP. Curiously, whole blood was shown to be more sensitive to the presence of HIT positive sera than PRP. The ration of heat-inactivated sera to donor whole blood or PRP was 1 to 2 parts. HIT positive sera was obtained from a patient that was clinical diagnosed with HIT type II and had a clinically significant positive ELISA with an optical density of 1.735 ± 0.032. HIT positive sera with ELISA optical densities above 1.000 or associated with an enhanced likelihood of developing thrombosis. Additionally, the HIT positive sera was functionally positive with 13 qualified, reactive HIT normal platelet donors with a washed-platelet heparin-induced platelet activation (wp-HIPA) average result of 66 ± 11%. The wp-HIPA is an established reference method or GOLD STANDARD assay for the diagnosis of HIT. The positive TEG detection of this functional HIT antibody may reveal another, more rapid test approach for the hospital and reference laboratory diagnosis of HIT. Additional studies are warranted to further characterize the comparative sensitivities of TEG and wp-HIPA and other reference methods for the diagnosis of HIT.

Disclosures

No relevant conflicts of interest to declare.
Beyond Prothrombin Time and Activated Partial Thromboplastin Time: Clot Formation Rate and Clot Structure Index As Novel Parameters for Coagulation Test Running Head: Novel Parameters of Coagulation Test
Authors: Song Jaewoo , Jihoon Yoon , Minyong Lee , Tae Hyun Yoon
Published: October 2019

BACKGROUND: Coagulation analyzers based on turbidimetry provide clot waveform data. Clotting times are defined only a point on this curve and have limitations to represent the whole characteristics of curve. We investigated to represent the whole curve shape by additional parameters and explored its clinical utility.

METHODS: We applied the Gompertz growth model to the waveform and the two-dimensional curve shape can be expressed with novel parameters. The model was evaluated in terms of fit, applicability, and reproducibility. To understand how the properties of parameters affected by various conditions, we controlled fibrinogen concentration, clot structure, and factor activity. For clinical application of these parameters, a reference interval was established, and the distribution was studied in different populations (normal, lupus anticoagulant-positive, and hemophilia). Finally, they were examined for use as indicators of disease severity in hemophilia and direct oral anticoagulant monitoring.

RESULTS: The model was near-perfectly fitted to the waveform, mostly applicable, and reproducible. Two parameters of the model, κ and α, determined the shape of waveform; κ was linked to the fibrinogen content and clot structure, and α reflected clotting activity and influenced on κ inversely. The clot formation rate (CFR) and clot structure index (CSI), defined using κ and α, provided additive clinical information for hemostatic function evaluation, disease severity estimation, and anticoagulant monitoring beyond the clotting times.

CONCLUSIONS: The clotting curve model enabled to utilize the overall shape of clot waveform. CFR and CSI which derived from the model can be used as additional informative parameters of coagulation test.

Disclosures

No relevant conflicts of interest to declare.
Adherence Rates Between Once and Twice Daily Direct Oral Anticoagulants - Results of a Single University Pharmacy Cohort Study
Authors: Shatzel Joseph , Daughety Molly , Tao Derrick , Kim Edward , Olson Sven , Olyaei Ali , Deloughery Thomas G.
Published: October 2019

INTRODUCTION

Direct oral anticoagulants (DOACs) have been shown to have equal or superior efficacy and safety when compared to Vitamin K antagonists, and have become first line therapy for many disease processes. While both the once daily drug rivaroxaban and the twice daily drug apixaban have been shown to be highly effective anticoagulants, it is unknown if differences in their dosing frequency affects patient compliance and, consequently, the likelihood of anticoagulant failure. In this study, we retrospectively evaluated the medication adherence rates of all individuals prescribed therapeutic rivaroxaban or apixaban over a one year period in our pharmacy.

METHODS

In this retrospective cohort study, we obtained a list of all patients prescribed treatment dose rivaroxaban or apixaban from July 2015 to July 2016 (including the initial loading and maintenance dose) at our university-affiliated pharmacy. We excluded patients who received less than three separate refills or patients on prophylactic or decreased doses. Medication possession ratio for each individual was calculated based on refill dates and means were compared using an unpaired t-test.

RESULTS

During the study period, there were 756 therapeutically-dosed rivaroxaban or apixaban prescriptions. After excluding individuals who received fewer than three separate refills at our pharmacy (49.3%), 105 rivaroxaban refills and 278 apixaban refills were included (mean prescription size of 32.2 tabs for rivaroxaban and 65.7 tabs for apixaban). In the rivaroxaban group, the mean medication possession ratio across the cohort was 0.9321 (SD=0.1057). In the apixaban group, the mean medication possession ratio across the cohort was 0.9051 (SD=0.1467). The mean difference of the possession ratios was 0.0269 (95% confidence interval -0.0433 to 0.0971, p = 0.4472), thus there was no statistically significant difference in possession ratios between the study drugs.

CONCLUSIONS

Analyzing our internal pharmacy data, we found that among individuals who filled at least three times, medication adherence was high and not dissimilar between the two groups. Thus, the likelihood of compliance does not appear to be dependent on dosing frequency. However, it should be noted that nearly half of patients filled fewer than three times at our pharmacy and were thus excluded. It is unclear whether these patients completed their prescribed course, discontinued the drug all together or elected to refill at an alternative location, but it is likely that this may have caused an overestimation of drug adherence. While larger studies are needed to further assess adherence between the two drugs, these findings are reassuring that medication compliance between rivaroxaban and apixaban are similar in those who continue the drug.

Disclosures

No relevant conflicts of interest to declare.
Band 3 Phosphorylation Induces Irreversible Alteration of Stored Red Blood Cells
Authors: Azouzi Slim , Colin Aronovicz Yves , Pereira Catia , Romana Marc , Peyrard Thierry , Amireault Pascal , Le Van Kim Caroline
Published: October 2019

Introduction: Storage of red blood cells (RBCs) for transfusion purposes is accompanied by a number of morphological and biochemical changes (storage lesions) that reduce post-transfusion survival/efficacy and increase risk for adverse reactions in the recipients. The clearance of altered and older RBCs from circulation is triggered by the clustering of Band 3, an aggregate state that is recognized by a low-affinity naturally occurring IgG antibody (Nab). Considering the key role of Band 3 in the maintenance of RBC structure and survival, elucidation of functional and structural modifications of Band 3 during storage should lead to new approaches aiming to improve RBC storage and post-transfusion viability.

Results: Immunoblot analysis of RBC membrane proteins using an anti-phosphotyrosine antibody showed a progressive increase in the phosphorylation status of Band 3 during RBC storage (Figure 1).

In addition, using the quenching fluorescence of eosin-5-maleimide (EMA), we showed an increase of the mobile fraction of Band 3. These findings are consistent with previous demonstration that tyrosine phosphorylation of Band 3 reduces its affinity for ankyrin, leading to the release of the immobile fraction of Band 3 from the skeleton complex, and enhancement of the lateral mobility of Band 3 into the lipid bilayer. Immunoblot experiments using an antibody that specifically recognizes the clustered form of Band 3 revealed an increase of Band 3 cluster formation from the 28th day of storage. We also showed that the release of microparticles (MPs) that occurs during RBC aging increases from the 28th day of storage (Figure 2).

Finally, stopped-flow-based functional studies showed a decrease of the anion exchanger activity of Band 3 from the 28th day of storage.

Conclusion: Altogether, our results suggest that the 28th of storage represents a key moment for the molecular processes leading to irreversible lesions of RBCs and allow us to propose a new Band 3 phosphorylation/clustering-based mechanism of RBC aging.

Figure 1 Figure 1. Figure 2 Figure 2.

Disclosures

No relevant conflicts of interest to declare.
Loss of Src-like Adaptor Protein 2 Expression Increases the Transforming Potential of Oncogenic FLT3-ITD
Authors: Moharram Sausan A. , Kazi Julhash U. , Rönnstrand Lars
Published: October 2019

The receptor tyrosine kinase FLT3 is found to be a mutated oncogene in hematological malignancies including acute myeloid leukemia (AML). FLT3 inhibitors in combination with chemotherapy display promising results in a clinical setting, but patients relapse after short-term treatment due to the development of resistant disease. Therefore, targeting signaling proteins downstream of FLT3 can be an alternative approach for the treatment of patients carrying mutant FLT3. Activated FLT3 is constitutively phosphorylated on several tyrosine residues. These tyrosine residues facilitate association of SH2 domain-containing signaling proteins. By using a panel of SH2 domain-containing proteins we identified SLAP2 as a potent interaction partner of FLT3. The interaction in between FLT3 and SLAP2 occurs when FLT3 is activated and an intact SH2 domain of SLAP2 is required for the interaction. SLAP2 associates with FLT3 mainly through its SRC binding sites and expression of SLAP2 inhibited oncogenic FLT3-ITD-mediated cell proliferation and colony formation in vitro, and tumor formation in vivo. By analysis of patient expression data, we found that loss of SLAP2 expression correlates with poor prognosis of AML patients carrying FLT3-ITD. SLAP2 inhibits FLT3-mediated downstream signaling such as activation of AKT, ERK, p38 and STAT5. Inhibition is partially mediated through ubiquitination-mediated degradation of FLT3. Taken together our current study demonstrates that SLAP2 is an important regulator of FLT3-mediated oncogenic signaling and thus modulation of the SLAP2 expression levels can be an alternative approach for the treatment of FLT3-ITD positive malignancies.

Disclosures

No relevant conflicts of interest to declare.
Circulating CD2 Negative T Cells in Pediatric Acute Leukemia
Authors: Li Weijie , Shao Lei , Ahmed Atif , Myers Doug , August Keith J
Published: October 2019

Introduction: Leukemia cells are able to escape from immunosurveillance using immune tolerance mechanisms as the majority of leukemia antigens are either shared or aberrantly expressed self-proteins. T cells reactive to these antigens are purged during thymic selection. CD2, a pan-T-cell antigen, is expressed early during T cell developments in thymus and is found on all subsets of mature T cells. Recent studies show that there are low levels of extrathymic CD2 negative (CD2-) T cells, which show immature T cell features and can be induced to differentiate into mature helper and cytotoxic T cells in vitro. Since circulating CD2- T cells could represent pre-selection immature T cells, they may play an important role in tumor immunity.

Methods: 81 pediatric B-cell acute lymphoblastic leukemia (B-ALL) patients, 22 pediatric acute myeloid leukemia (AML) patients and 22 normal controls were included in this study. B-ALL group included 45 NCI-standard risk (SR) patients and 36 NCI-high risk patients. All the leukemia patients were diagnosed at Children's Mercy Hospital in the past ten years with a diagnostic peripheral blood (PB) specimen. The PB specimens were studied by four-color multiparameter flow cytometry with antibodies for T cell markers (CD2, CD3, CD4, CD5, CD7 and CD8) and CD45, and analyzed by BD FACSDiva 8.0.1. CD2- and CD3+ T cells were recorded as % of total T cells. Student's t-test was used to compare results.

Results: The percentages of CD2- T cells in AML (mean ± STD: 1.31% ± 1.41%) and B-ALL (0.84% ± 0.67%) were significantly higher than that seen in control group (0.51% ± 0.52%, p<0.05). No significant difference was found between AML and B-ALL. There was no significant difference between HR B-ALL (0.96% ± 0.81%) and SR B-ALL (0.74% ± 0.52%). Interestingly, CD2- T cells in 4/5 B-ALLs with 11q23 (KMT2A) rearrangement were undetectable. All 3 therapy-related AML patients studied had KMT2A gene rearrangement, and had no detectable CD2- T cells with poor clinical outcome (overall survival less than 1 year). The 3 AMLs associated with Down syndrome, a prognostically favorable AML group, showed relative high levels (≥ 1.49%) of CD2- T cells.

Conclusions: Circulating CD2- T cells are increased in peripheral blood in pediatric AML and B-ALL patients. KMT2A gene rearrangement, an unfavorable cytogenetic abnormality, is associated with a decrease in CD2- T cells. The relationship of KMT2A gene rearrangement and decrease in circulating CD2- T-cells as well as the relationship of CD2- T cells to clinical outcome should be evaluated in future studies. The role of CD2- T cells in tumor specific immunomodulation should be explored, and may impact future studies of cell-based cancer immunotherapeutics.

Disclosures

No relevant conflicts of interest to declare.
Prognostic Impact of Absolute Lymphocyte Count/Absolute Monocyte Count Ratio and Prognostic Score in Patients with Nasal Type, Extranodal Natural Killer/T Cell Lymphoma
Authors: Li Na , Zhang Li , Song Hao-lan , Zhang Jing , Weng Hua-wei , Zou Li-qun
Published: October 2019

Nasal type, extranodal natural killer (NK)/T-cell lymphoma (ENKTL) is a heterogeneous disorder with poor prognosis, requiring risk stratification in this population. We designed to investigate the prognostic significance of absolute lymphocyte count (ALC), absolute monocyte count (AMC), ALC/AMC ratio and ALC/AMC prognostic score (low risk, normal ALC and AMC; intermediate risk, low ALC or high AMC; high risk, low ALC and high AMC) and to determine whether ALC/AMC ratio or prognostic score is a better predictor of prognosis in ENKTL. A total of 264 patients with newly diagnosed ENKTL were retrospectively analyzed in present study. Receiver Operating Curve analysis showed that optimal cut-off values of ALC, AMC and ALC/AMC ratio were 1.0×109/L, 0.5×109/L and 2.85, respectively. In multivariate analysis all tested factors including ALC, AMC, ALC/AMC ratio and prognostic score were independent risk factors. After a median follow-up of 30 months (range 1-87), an estimated 3-year overall survival (OS) in the 264 patients was 75.4%. Patients with ALC/AMC ratio≥2.85 had a better OS and progression-free survival (PFS) than those with ALC/AMC ratio<2.85 at diagnosis (3-year OS rate: 83.4% versus 61.9%, P < 0.001; 3-year PFS rate: 76.5% versus 53.0%, P< 0.001). Significant difference has been noticed in the patients according to ALC/AMC prognostic score in 3-year OS (low risk vs. intermediate risk, 88.3% vs. 66.5%, p = 0.001; low risk vs. high risk, 88.3% vs. 0%, p < 0.001; intermediate risk vs. high risk, 66.5% vs. 0%, p = 0.001) and in 3-year PFS(low risk vs. intermediate risk, 80.7% vs. 58.3%, p = 0.002; low risk vs. high risk, 80.7% vs. 0%, p < 0.001; intermediate risk vs. high risk, 58.3% vs. 0%, p = 0.003) . The International Prognostic Index (IPI) and Korean Prognostic Index (KPI) were used for predicting these patients' prognosis, the result showed that the discrimination was not power. When applying ALC/AMC ratio and prognostic score to the IPI and KPI model, the latter showed a better discrimination as compared to the former.

Disclosures

No relevant conflicts of interest to declare.
Development of a Novel Prognostic Scoring System of Time to First Treatment for Chinese Patients with Chronic Lymphocytic Leukemia
Authors: Li Heng , Xiong Wenjie , Li Zengjun , Li Shuhua , Lv Rui , Zou Dehui , Qiu Lugui
Published: October 2019

Background: The established clinical staging systems (Rai/Binet) of chromic lymphoma leukemia (CLL) had limitedly discriminated among prognostic groups, especially for the patients in early stages and without treatment indications. In the past two decades, several prognostic factors have been identified to predict the outcome of patients with CLL, but only a few studies investigated the prognostic improvement of the combination of more markers together. In order to predict the time to first treatment (TTFT) in patients of early stages, we evaluated the prognostic role of conventional bio-markers as well as cytogenetic abnormalities and combined them together in a new prognostic scoring system, the CLL prognostic index.

Patients and Methods: Taking advantage of a population of 402 untreated Chinese patients with CLL at early and advanced stage of disease, we identified the strongest prognostic markers of TTFT and, subsequently, in a cohort of 173 patients who had complete data for all 3 variables, we integrated the data of traditional staging system, cytogenetic aberrations and mutational status of immunoglobulin heavy chain variable region (IGHV) in CLL-PI. The median follow-up time was 45 months (ms). Multivariable statistics were applied with software SPSS 17.0, and the end point was TTFT.

Results: Based on multivariate Cox regression analysis, three independent factors for TTFT were identified: advanced clinical stage (Rai risk group), 17p deletion and unmutated IGHV. Applying weighted grading of these independent factors, a CLL-PI was constructed based on regression parameters, which could categorize four different risk groups [low risk (score 0), intermediate low (score 1), intermediate high (score 2) and high risk (score 3-6)] with significantly different TTFT (median TTFT of NR, 65.0 ms, 36.0 ms and 19.0 ms, respectively, p<0.001).

Conclusions: This study developed a weighted, integrated CLL-PI prognostic system of CLL patients which combines the critical genetic prognostic markers (IGHVmutation status, 17p deletion) with traditional clinical stage (Rai staging system). This novel modified PI system could be used to discriminate among groups and may help predict the TTFT and prognosis of patients with CLL.

Disclosures

No relevant conflicts of interest to declare.
Secondary Adrenal Insufficiency Is Associated with Poor Survival Outcomes in Multiple Myeloma
Authors: Ahn Seo-Yeon , Jung Sung-Hoon , Kim Hee Kyung , Kang Ho-Cheol , Yang Deok-Hwan , Lee Seung-Shin , Ahn Jae-Sook , Kim Yeo-Kyeoung , Kim Hyeoung-Joon , Lee Je-Jung
Published: October 2019

Background: Glucocorticoids has been a backbone of various treatment regimens for multiple myeloma (MM). The repeated and chronic use of high doses of glucocorticoids is associated with development of secondary adrenal insufficiency (AI), and AI could be a major problem in critically-ill patients. However, there has been no specialized data about incidence and clinical significance of secondary AI in hospitalized patients with MM.

Purpose: The objective of this retrospective study is to evaluate incidence, predictive factors, and clinical significance of secondary AI in hospitalized patients with MM.

Methods: We retrospectively evaluated medical records of MM patients who were hospitalized in Chonnam National University Hwasun Hospital, South Korea from December 2014 to December 2015. The definite AI was diagnosed when the peak cortisol concentration was less than < 500 nmol/L (18 mcg/dL) after ACTH administration.

Results: Between December 2014 and December 2015, 77 patients were hospitalized, and 58 underwent rapid ACTH stimulation test. The most frequent cause of hospitalization was infection (70.7%), followed by weakness (24.1%), and the others (5.3%). The definite AI was confirmed in 19 patients (32.7%). To evaluate the predictive factors of AI, all variables including clinical characteristics, laboratory results, cumulative steroid dose, and treatment duration at hospitalization were analyzed, but there were no significant predictors for AI. In addition, the patients with AI had a significantly poor survival outcomes compared to those without AI (the median overall survival of 42.3 months vs. 82.7 months; P = 0.037) (Figure 1).

Conclusions: This study showed that the secondary AI is not a rare condition among hospitalized patients with MM, and there was no specific predictable symptoms or signs. In addition, development of AI in the treatment period is associated with a poor prognosis. This study suggests that evaluation of AI is routinely needed in hospitalized patients with MM.

Disclosures

No relevant conflicts of interest to declare.
Simple Prognostic Score for Evaluation of Elderly Multiple Myeloma Patients
Authors: Radocha Jakub , Zak Pavel , Machalkova Katerina , Beranova Katerina , Hanousek Jiri , Maisnar Vladimír
Published: October 2019

Introduction: Treatment of elderly multiple myeloma patients remains a clinical challenge. The frailty and comorbidities represent major obstacles in successful treatment. We therefore conducted a single center analysis of elderly myeloma patients in order to identify possible prognostic factors which affect their prognosis. We focused on simple clinical parameters that can be used as a clinical tool in daily practice.

Methods: All patients treated at our department for myeloma from years 2007-2014 who were older than 65 years were included in the analysis. Demographic, baseline disease and treatment characteristics were collected. Adverse clinical characteristics were selected based on univariate analysis. These include renal insufficiency at the time of diagnosis (creatinine >2.0 mg/dL), male sex a performance status ECOG>2 on diagnosis. The simple model assigning one point for each of these factors was given to each specific patient. Overall survival was calculated based on subgroups with 0-3 points as a sole endpoint in elderly patients.

Results: We identified 184 patients (83 males and 101 females, median age 73 years) with multiple myeloma. 76 patients (41.3%) were older than 75 years, 47 (25.5%) patients had renal insufficiency, 59 (32.1%) patients were ECOG>2. Only 20 patients (10.9%) were offered autologous transplantation. 165 patients (89.7%) were treated with novel agents frontline (bortezomib, thalidomide or lenalidomide). The median overall survival was 58.2, 44.4, 31.6 and 3.9 months in groups assigned 0, 1, 2 and 3 points respectively. The differences were statistically significant (p=0.0001, log-rank test).

Conclusion: This simple model might easily identify patients at high risk of early mortality based on three simple clinical characteristics available in all patients at the time of disease onset. Model like this needs a validation using a larger cohort of patients.

Supported by PRVOUK P37.

Figure 1 Figure 1.

Disclosures

No relevant conflicts of interest to declare.
Inferior Vena Cava Filter - Appropriate Use and Retrieval
Authors: Shah Rena , Turk Anita , Rahim Bilal , Arafat Waddah , Nazeef Moniba , Mattison Ryan J.
Published: October 2019

Inferior vena cava (IVC) filters, first introduced in 1998, have been utilized to reduce risk of pulmonary embolism (PE) in the setting of an inability to anticoagulate patients. The use of IVC filters has increased and continues to rise, especially with the introduction of retrievable IVC filters. Since their initial introduction, guidelines have been developed on the appropriate use of IVC filters. According to the American College of Chest Physicians (ACCP), the use of an IVC filter is limited to patients with an absolute contraindication to therapeutic anticoagulation or failure or complication of anticoagulation in the setting an acute proximal venous thrombus. Relative indications for IVC filter placement include high clot burden in setting of low cardiopulmonary reserve, high risk patients, or severe trauma without documented thrombosis. In 2010, the FDA announced a safety communication recommending removal of retrievable IVC filters due to reports of several adverse clinical outcomes associated with retained filters including thrombus formation, recurrent PE, filter migration, erosion or perforation through the IVC wall, and filter fracture with fragment embolization. In 2014, the FDA recommended removal of the IVC filter within 2 months after filter placement if the patient's risk of thrombosis had passed.

In this retrospective analysis of IVC filter management, we reviewed indications for placement according to current guidelines as set by the ACCP, initiation of appropriate anticoagulation, complication rates, and retrieval rates. In addition, we compared the data prior to the FDA recommendations in late 2014 and data after the recommendations to determine if there was a change in practice.

After reviewing 179 patients, 89 patients in 2014 and 90 patients in 2015, who underwent IVC filter placement, only 81% (N=145) of patients had appropriate indications for IVC filter placement and 30% (N=54) of patients had inappropriate anticoagulation after IVC filter placement, given as prophylactic dosing of low molecular weight heparin. A comparison of retrieval rates prior to and after the FDA warning, showed a 19% (60% in 2014 vs 79% in 2015) improvement in IVC filter removals. There was an 11% complication rate, mainly related to IVC filter related acute DVT or IVC occlusion.

A root cause analysis specifically for inappropriate IVC filter placement and appropriate anticoagulation and determined that familiarity of the guidelines and non-evidence based recommendations from consultants were major factors. Based on the analysis, we next plan to utilize the electronic health record system to help clinicians understand indications and when to initiate appropriate anticoagulation, with the opportunity for hematology consultants to be involved in situations that do not clearly fit within published guidelines.

Disclosures

No relevant conflicts of interest to declare.
JAK2V617F Promotes Atherosclerosis
Authors: Wang Wei , Wang Ying , Woods Brittany , Abramowicz Sandra , Welch Carrie , Levine Ross L. , Tall Alan , Wang Nan
Published: October 2019

Myeloproliferative disorder (MPD) patients are at high risk of atherothrombotic events including myocardial infarction and stroke. The somatic mutation (JAK2V617F) is commonly found in MPD patients and is associated with increased vascular risk. Moreover, the prevalence of JAK2V617F mutation is also significantly increased in non-MPD coronary artery disease (CAD) and peripheral artery disease (PAD) patients compared to the general population. Our goal was to investigate potential mechanisms of accelerated atherothrombosis using a JAK2V617F mouse model.

Subletahlly irradiated Ldlr-/- mice were transplanted with bone marrow cells from wild type (WT) or Mx1-Cre/Jak2V617F (Jak2VF) mice and fed a high fat high cholesterol Western type diet (WTD). After 7 weeks of WTD Jak2VFmice had sustained neutrophilia, monocytosis and erythrocytosis; despite lower plasma cholesterol levels they showed ~1.6 fold larger atherosclerotic lesions in the aortic root (p=0.003) and accelerated carotid artery thrombosis (FeCl3 injury). After 12 weeks of WTD feeding, lesion area was only increased 1.3-fold compared to controls but showed features of plaque instability (increased necrotic core area). Early lesions (7 weeks) displayed significantly increased neutrophils (p=0.05, n=7) but not Mac 3+ macrophages. The increased neutrophil infiltration in Jak2VF mice correlated with atherosclerotic lesion size (p=0.001, r=0.78), suggesting a critical role of neutrophils in early atherogenesis. Advanced lesions (12 weeks) also showed significantly increased neutrophil (p=0.001) and macrophage (p=0.05) infiltration. No difference in CD3+ T cells or CD41+ platelet infiltration was observed at either time-point. In addition, five out of nine Jak2VF mice had prominent iron deposition (Prussian blue) and RBC marker Ter-119 staining in advanced atherosclerotic lesions (p<0.05). RBC marker Ter-119 co-localized with Mac-3(+) macrophages surrounding necrotic cores, indicating erythrophagocytosis and plaque instability.

In summary, the Jak2V617F mutation promotes early atherosclerotic lesion development and plaque instability in advanced lesions. Neutrophil infiltration appears to be an important contributor to both early lesion development and necrotic core formation. These studies also suggest a novel role for RBC infiltration, iron deposition and erythrophagocytosis in advanced lesional necrotic core formation in JAK2V617F mice.

Disclosures

Levine: Novartis: Consultancy; Qiagen: Membership on an entity's Board of Directors or advisory committees. Tall:Amgen: Consultancy; CSL Behring: Consultancy.
Large Scale Discoveries of Genes and Polymorphisms Associated with Variation in Hematologic Traits
Authors: Soranzo Nicole
Published: October 2019

Hematopoiesis generates mature blood cells from hematopoietic stem cells (HSC) in distinct lineages to release of trillions of mature cells each day into the peripheral blood stream to perform essential functions such as oxygen transport, hemostasis and host defense. The formation and turnover of blood cells are tightly controlled and so the properties of blood cells, including their volume and count, have large heritabilities and are easily influenced by genetic variation. Here we describe the most statistically powerful genome wide association study (GWAS) of blood cell indices to date. We tested associations of 29.5 million polymorphic DNA sequence variants derived using the the Affymetrix axiom array with interpolation of 20 million variants using the UK 10000 genome data with 36 different hematological indices of red cells, white cells and platelets, some of which, such as the reticulocyte count, have been explored for the first time. We discovered significant associations at thousands of associated genetic variants, including hundreds of associations for low frequency genetic variants, thus identifying associations with larger effects on indices than those reported for common variants by previous discovery studies. We have described detailed follow-up studies of the novel associations. Using cell type-specific epigenome and gene expression data generated by the BLUEPRINT project and results from chromatin conformation capture in major blood cell types, we can identify the likely causal variants and their functional impact at a large number of the novel loci. Finally, we have evaluated the contribution of genetic variants to common and complex diseases. In conclusion, we have interrogated phenotypes across the whole hematopoietic tree and increased the number of traits associated with blood cell phenotypes by an order of magnitude. Overall, our results demonstrate widespread and powerful genetic influences on the formation and regulation of the major human blood cell types, identifying many novel genes involved and show the value of genome-wide functional annotation from relevant primary cell populations for interpreting genetic association results.

Disclosures

No relevant conflicts of interest to declare.
Shwachman-Diamond Syndrome and the Quality Control of Ribosome Assembly
Authors: Warren Alan J.
Published: October 2019

The synthesis of new ribosomes is a fundamental conserved process in all cells. Ribosomes are pre-assembled in the nucleus and subsequently exported to the cytoplasm where they acquire functionality through a series of final maturation steps that include formation of the catalytic center, recruitment of the last remaining ribosomal proteins and the removal of inhibitory assembly factors. Surprisingly, a number of key factors (SBDS, DNAJC21, RPL10 (uL16)) involved in late cytoplasmic maturation of the large (60S) ribosomal subunit are mutated in both inherited and sporadic forms of leukemia. In particular, biallelic mutations in the SBDS gene cause Shwachman-Diamond syndrome (SDS), a recessive bone marrow failure disorder with significant predisposition to acute myeloid leukemia. By using the latest advances in single-particle cryo-electron microscopy to elucidate the function of the SBDS protein, we have uncovered an elegant mechanism that couples final maturation of the 60S subunit to a quality control assessment of the structural integrity of the active sites of the ribosome. Further molecular dissection of this pathway may inform novel therapeutic strategies for SDS and leukemia more generally.

References:

1. Weis F, Giudice E, Churcher M,et al. Mechanism of eIF6 release from the nascent 60S ribosomal subunit. Nat Struct Mol Biol, (2015) Nov;22(11):914-9.

2. Wong CC, Traynor D, Basse N, et al. Defective ribosome assembly in Shwachman-Diamond syndrome. Plenary Paper, Blood. 2011 Oct 20;118(16):4305-12.

3. Finch AJ, Hilcenko C, Basse N, et al. Uncoupling of GTP hydrolysis from eIF6 release on the ribosome causes Shwachman-Diamond syndrome. Genes Dev (2011) 25: 917-929.

4. Menne TM, Goyenechea B, Sánchez-Puig N, et al. The Shwachman-Bodian-Diamond syndrome protein mediates translational activation of ribosomes in yeast. Nature Genetics (2007) 39: 486-95.

Disclosures

No relevant conflicts of interest to declare.
THE BLOOD PLATELETS
Authors: LAWRENCE JOHN S. , VALENTINE WILLIAM N.
Published: October 2019

1. The rate of utilization of blood platelets in radiated, thrombopenic cats has been measured directly. Thrombopenic animals, incapable of significant platelet regeneration, were cross circulated via carotid to carotid anastomoses with normal animals. After return to independent circulation the rate of disappearance of cross circulated platelets was measured by periodic counts.

2. By this method it was possible to elevate the platelet count anywhere from 100,000 to around 400,000 per cubic millimeter. The highest count obtained followed cross circulation with a splenectomized animal. In most instances the platelet level attained was within the physiologic range of that found for normal cats by the same method.

3. The cross circulated platelets gradually disappeared from the circulation over a two to a slightly more than four day period. Under the conditions of this experiment the entire platelet mass would have to be replaced therefore every two to five days. The same figures probably apply within narrow limits to the normal cat.

4. The average rate of platelet utilization was approximately 2500 per cubic millimeter per hour. In seven of eight experiments the rate of disappearance varied from about 1600 per cubic millimeter per hour to about 2800 per cubic millimeter per hour. In the experiment using a splenectomized donor the rate of disappearance was about double the average for the rest of the group.

5. Attention is called to possible therapeutic implications of these findings in idiopathic thrombopenic purpura.
A SIMPLE APPARATUS AND PROCEDURE FOR PREPARING AND ELECTROPLATING RADIOACTIVE IRON
Authors: GREENBERG G. R. , HUMPHREYS S. R. , ASHENBRUCKER HELEN , LAURITSEN MARJORIE , WINTROBE M. M.
Published: October 2019

A simple, easily constructed apparatus for electroplating radioactive iron has been described by which certain disadvantages of other forms of apparatus have been eliminated. Sixteen samples can be plated each day without difficulty.

The technic employed for preparing the radioactive iron for electroplating has been given.
THE EFFECT OF DIET ON THE HEMOGLOBIN, ERYTHROCYTE, AND LEUKOCYTE CONTENT OF THE BLOOD OF THE RHESUS MONKEY (MACACA MULATTA)
Authors: JONES EDITH SEYMOUR , MCCALL KEITH B. , ELVEHJEM C. A. , CLARK P. F
Published: October 2019

1. Rhesus monkeys fed purified rations supplemented with adequate amounts of the B vitamins, ascorbic acid, and whole liver substance maintained the following average blood picture:

See PDF for Table

2. Natural diets or purified rations supplemented with liver extract do not support the above blood picture. The hemoglobin is lower and there is an increase in the range of the total leukocyte count and in the neutrophil-lymphocyte ratio to 2.0 ([unknown]). These figures are similar to the values in the literature and generally accepted as the normal.

3. Previous reports have shown the characteristic blood dyscrasias which develop when monkeys are fed certain B vitamin-deficient diets. These changes are summarized graphically in this paper.

4. The importance of determining the concentration of hemoglobin and the formed elements of the blood as a diagnostic test in nutritional studies has been shown.
THE ASSOCIATION OF THE GUILLAIN-BARRÉ SYNDROME WITH INFECTIOUS MONONUCLEOSIS
Authors: RICKER WALTER , BLUMBERG ALFRED , PETERS CLIFFORD H. , WIDERMAN ARNOLD
Published: October 2019

Infectious mononucleosis in which death was due to associated ascending paralysis, indistinguishable from that in Guillain-Barré syndrome, was encountered in 2. cases at the Army Institute of Pathology. Study of the data from these cases strongly suggests that infectious mononucleosis is one of the many diseases or agents which may precipitate or give rise to the Guillain-Barré syndrome.
OBSERVATIONS ON THE ANEMIA IN DUCKS INFECTED WITH P. LOPHURAE
Authors: RIGDON R. H. , ROSTORFER H. H.
Published: October 2019

This study of the anemia produced by P. lophurae in ducks emphasizes the significance of a decrease in the number of red cells in this disease, and furthermore, it suggests that the rapid diminution in the number of parasites following the peak of the parasitemia may be directly related to the character of this anemia since these parasites apparently do not prefer young erythroblasts to mature erythrocytes.

The observations made in this study show that erythrocytes in the ducks first appear as spherical bodies in stained smears and when mature they are elliptical in shape. Under abnormal conditions such as may occur with a severe parasitemia, erythroblasts appear in the peripheral blood in large numbers, sometimes almost completely replacing the adult type of red cell. Both microcytes and macrocytes appear in the blood stream. The amount of hemoglobin within some of these young erythrocytes is small as indicated by the hemoglobin determinations and the staining reaction. Small young erythroblasts with little hemoglobin appear in the peripheral blood when the maximum load is placed upon the hematopoietic tissues.