bluuebunny/crossref_metadata_2025 huggingface dataset:
Non-Myeloablative Allogeneic Hematopoietic Stem Cell Transplantation (SCT) with Pre-Transplant Targeted Immune Depletion Results in Rapid Full Donor Engraftment in Pediatric Patients with Malignancy.
Authors: Fry Terry J. , Cardesa-Salzman Teresa , Hakim Frances , Love Cynthia , Layton Paula , Gress Ronald , Fowler Daniel , Bishop Michael R. , Mackall Crystal L. , Wayne Alan S.
Published: April 2020

Background: Although myeloablative SCT is curative for a number of pediatric malignancies, it is associated with significant acute toxicity and late effects. Non-myeloablative SCT can result in successful engraftment of adults with diminished toxicity, but there is limited experience in pediatric pts where increased thymic function might confer a greater risk of graft rejection or mixed chimerism. Prolonged periods of mixed chimerism might in turn impair the graft-vs-tumor response and increase the risk of relapse in highly proliferative pediatric cancers.

Methods: Twenty-one pediatric pts (age 7–21, median 14 years) with high-risk malignancies (Hodgkins, ALL, AML, CML, rhabdomyosarcoma, Ewings sarcoma) were enrolled. One to three cycles (C#) of fludarabine-based induction chemotherapy were administered for disease control and host immune depletion (targeted CD4 count reduction). Pre-transplant conditioning consisted of cyclophosphamide (1,200 mg/m2/day) and fludarabine (30 mg/m2/day) x 4 days plus melphalan (100 mg/m2 x 1 dose in sarcoma pts). Unmodified, G-CSF mobilized peripheral blood stem cells collected from 5–6/6 HLA-matched first degree relatives were infused (median CD34 dose 11.4 x 106/kg, range 4.44–19.12; median CD3 dose 414 x 106/kg, range 228–815). Cyclosporine was used as GVHD prophylaxis.

Results: CD4 counts decreased from 332 +/− 65 at entry to 176 +/− 30 (mean +/− SEM/μL) after induction (Fig 1). Treatment was well tolerated and there was no transplant-related mortality. Median time to ANC > 500 cells/μL was post-transplant day (D+) 9 (range 7–11). Complete donor lymphoid chimerism (> 95% by VNTR-PCR on CD3 sorted peripheral blood) was achieved in all pts (18/22 by D+14 and 21/22 by D+28) (Fig 2). Acute GVHD developed in 21/22 patients, but was low grade (18/21 grades 1–2, 3/21 grade 3) and responsive to immunosuppression.

Conclusions: Rapid, complete donor engraftment and chimerism can be achieved in pediatric pts with cancer using targeted pre-transplant immune depletion and a non-myeloablative preparative regimen. This approach may reduce regimen-related toxicity, and thus has the potential to improve the long-term outlook for childhood cancer survivors.

Fig 1: CD4 Depletion Fig 1:. CD4 Depletion Fig 2: Donor Chimerism (CD2) Fig 2:. Donor Chimerism (CD2)
Coronary Artery Damage Induces Endothelial Progenitor Cell Recruitment and High Levels of Circulating EPCs Correlate with Coronary Artery Collaterals Formation.
Authors: Lev Eli I. , Kleiman Neal S. , Birnbaum Yocahi , Harris David , Korbling Martin , Estrov Zeev
Published: April 2020

Endothelial progenitor cells (EPCs) are bone marrow-derived undifferentiated cells that are rapidly mobilized in response to tissue ischemia and incorporated into sites of neovascularization. EPCs co-express surface CD34, CD133 and vascular endothelial growth factor receptor-2 (VEGFR-2) antigens and develop an endothelial phenotype in culture. In animal models of tissue ischemia EPCs were shown to participate in angiogenesis and vasculogenesis. We sought to determine whether circulating EPCs level correlate with collateral formation following a non-ST segment elevation myocardial infarction (NSTEMI). In addition, we sought to evaluate the effect of percutaneous coronary intervention (PCI) on the levels of circulating EPCs. Twenty patients who underwent PCI within a week of NSTEMI were divided into two groups: patients without collaterals [coll(−), n=10] and patients with Rentrop grade 3–4 collaterals [coll(+), n=10]. Two blood samples were drawn from all patients: before PCI and 24±2 hours after PCI. Using flow cytometry the percentage of cells co-expressing VEGFR-2 and CD133 was determined. In addition, EPC colonies were grown from peripheral blood mononuclear cells, characterized, and counted after 7 days of culture. The clinical characteristics of the two groups were similar. The coll(+) group had a higher degree of culprit vessel stenosis and lower initial TIMI flow grade. The relative number of EPCs (co-expressing VEGFR-2 and CD133) before PCI was significantly higher in the coll(+) group than in the coll(−) group (1.49±0.9% vs. 0.77±0.4%, P=0.045). There were no significant inter-group differences in the number of EPC colony-forming cells. The number of EPC colonies increased significantly in the coll(−) group following PCI (from 9.5±4.8 to 14.0±5.9 per 106 cultured cells, P=0.01). This study supports an association between circulating EPC levels and collateral formation in patients with a NSTEMI. Furthermore, these findings suggest that vascular injury during PCI triggers mobilization of EPCs to the peripheral blood, especially in patients without coronary collaterals. Our data suggest that patients with high levels of circulating EPCs are more likely to form coronary artery collaterals and that vascular injury induces EPC recruitment.
A Method for Rapid Purification of Murine Siderocytes.
Authors: Martin Florent M. , Bydlon Gabriela , Welsh Megan L. , Friedman Jeffrey S.
Published: April 2020

Iron overload is a key contributor to the pathogenesis of multiple human disorders including the sideroblastic anemias. The specific iron compounds present in tissues or cells that are the targets of excess iron deposition remain poorly understood. Our objective is to further identify the composition of such iron aggregates. As there is evidence that some forms are magnetically active, we have developed a simple and specific method to purify iron-overloaded red blood cells using magnetic affinity columns. RBC derived from mice transplanted with SOD2-deficient hematopoietic stem cells served as a source of iron-laden cells (Friedman et al., Blood 2004; J. Exp. Med. 2001). Purification was based upon the observation that iron deposits in SOD2-deficient cells are magnetically susceptible and allow for retention of iron-laden cells in a strong magnetic field. Peripheral blood from SOD2-deficient chimeric mice was passed through magnetic separation columns; iron-overloaded cells were eluted and subsequently characterized by flow cytometry, western blot and microscopy. We were able to purify 3% of the total red cells as iron-laden siderocytes. More than 93% of the magnetically purified SOD2-deficient cells were identified as reticulocytes; they had numerous siderotic granules, produced enhanced reactive oxygen species levels, and showed increased protein oxidative damage, mitochondrial enrichment and mitochondrial membrane potential. Our method can be used to purify iron-laden cells as well as iron-associated subcellular fractions prepared from iron-loaded tissues, allowing elucidation of the structure, location and protein composition of such iron deposits. We believe that this data will help develop our understanding of the pathogenesis of sideroblastic anemia and other disorders characterized by iron overload.
Iron Deficiency and Vitamin B12/Folate Levels. A Case-Control Study.
Authors: Remacha Angel F. , Sardà Pilar , Royo Teresa , Fernández Nieves , Rojas Ester , Canals Carmen , Altés Albert
Published: April 2020

A number of cases with iron deficiency anemia (IDA) are associated with low vitamin B12 (LB12). However, LB12 is not synonymous with B12 deficiency. An increase in homocysteine (Hcy) or methylmalonic acid can differentiate cases with a real deficiency from those with apparently innocuous LB12. Our aim was to study LB12 and low red cell folate (LRCF) prevalence in IDA cases and to determine the existence of B12/folate deficiency. A prospective case-control study was carried out in patients with anemia consecutively admitted to our Hospital. The case group included 506 IDA patients (Hb <115g/l, MCV <98fl, serum ferritin <20microg/l or soluble transferrin receptor >5mg/l). The control group was made up of 117 patients with anemia of chronic disorders (ACD) (Hb <115g/l, MCV 80-98fl, iron <10micromol/l, total iron binding capacity <40micromol/l, serum ferritin >100microg/l and soluble transferrin receptor <4mg/l). Serum B12 and RCF were evaluated in all cases and controls. Serum homocysteine was determined in those with B12 and/or RCF below percentile 10 (B12 <200pmol/l, RCF <590nmol/l). HyperHcy was considered when Hcy exceeded >17micromol/l. Several variables were included in a multiple regression analysis to build a predictive model for IDA with LB12 and hyperHcy. LB12 was observed in 17.8% of IDA cases (87 cases), including 8.2% with B12<150pmol/l (percentile 2.5). Interestingly, 60% of patients with B12 <150pmol/l had hyperHcy and 48% of those with B12 between 150 and 200pmol/l. Low RCF was found in 6.3% (13 cases). All cases with RCF <500nmol/l (percentile 2.5) showed hyperHcy and 50% of cases with RCF between 500 and 590nmol/l. LB12 was observed in 7 patients in the control group (5.4%) and LRCF in 10%. LB12 was more frequent in IDA than in ACD (p<0.0001). The best predictive variable for IDA and LB12 with hyperHcy was age and the cut-off was 60 years (sensitivity: 91%). In summary, in our study 18% of cases with IDA showed LB12, and a high percentage had a real vitamin deficiency. Age was the main predictive factor. Thus, serum B12 should be determined in IDA patients over 60 years
Magnetic Ressonance Image T2* for the Evaluation of Iron Overload in Patients with Hereditary Hemochromatosis. A New Guide for the Indication of Therapeutic Phlebotomies.
Authors: Hamerschlak Nelson , Rosemberg Laercio , Parma Alexandre , Moreira Frederico R. , Fernanda Assir F. , Jose Kutner M. , Andreza Ribeiro A. , Marcelo Funari B.
Published: April 2020

Hereditary hemochromatosis is highly prevalent in those with northern European ancestry (1 in 8 individuals are heterozygous and 1 in 100 – 200 are homozygous). It is characterized by laboratory tests as ferritin > 150 ng/mL, transferrine saturation > 40% and HFE mutations (C282Y and H63D). Presently the indications for treatment (therapeutic phlebotomies, TP) are based solely on the ferritin levels. It is possible that patients with moderate or even high levels of ferritin do not have iron overload. Performing liver biopsies would be an option for the actual evaluation, though invasive and risky. A non-invasive method to evaluate this deposition would be helpful in order to determine which patients actually demand TP.

To evaluate if the use of Magnetic Ressonance Image (MRI) is a method for measuring tissue iron and could be a new guide for the indication of therapeutic phlebotomies, nineteen patients (mean age 43,47 y.o, +/− 9,85, gender = 16 male, 3 female) with hereditary hemochromatosis were scanned with T2- star (T2*) (GE equipment, Milwaukee, USA). The median of ferritin level was 594 (21–9300) The MRI method was previously validated to chemical estimation of iron in thalassemic major patients undergoing liver biopsies. The evaluated organs were liver and heart.

All patients were in normal range of myocardial T2*. The images of four patients (25%), showed liver iron deposition. Eleven patients who presented serum ferritin levels below 600 ng/ml showed no liver iron deposition. Just one among five patients (20%), who presented ferritin levels between 601 and 1000 ng/ml showed hepatic iron overload. The three patients with ferritin levels higher than 1000 ng/ml had liver iron deposition quantified using liver T2* MRI techique.

MRI T2* showed that some patients who would have an indication for TP based on laboratory tests, might avoid these procedures based on image results of internal organs. These patients can have an image follow up in order to decide when would be the appropriate time to start TP. This method can also be used to evaluate the efficacy of TP in patients who have already received this treatment. A larger group of patients would have to be evaluated in order to validate these results.
Anti-Angiogenic In Vivo Effect of Lenalidomide (CC-5013) in Myelodysplastic Syndrome with del(5q) Chromosome Abnormality and Its Relation to the Course of Disease.
Authors: Buesche Guntram , Dieck Stephanie , Giagounidis Aristoteles , Bock Oliver , Wilkens Ludwig , Schlegelberger Brigitte , Knight Robert , Bennett John , Aul Carlo , Kreipe Hans H.
Published: April 2020

Lenalidomide, a novel immunomodulatory drug (IMiD), is a multifunctional inhibitor of angiogenesis. Vascular endothelial growth factor (VEGF) and its receptor (KDR) are major regulators of angiogenesis, which plays a key role in the growth and progression of solid tumors and hematologic neoplasms, and increased plasma levels of KDR were correlated with a lower remission rate in patients with myelodysplastic syndromes (MDS).

From a total of 35 patients suffering from MDS with del(5q) and being treated within a multicenter trial on the efficacy of CC-5013, biopsies and aspirates from bone marrow taken before and 6 + 12 months after start of lenalidomide therapy were evaluated for the percentage of cells with del(5q), blast count, vascularization, and gene expression of VEGF and its receptor using cytologic, histopathologic, cytogenetic and molecular genetic methods. 20 patients with healthy marrow served as a control for normal marrow.

Before start of treatment, vascularity of bone marrow, measured as the total length of vessels within the marrow volume, was markedly increased in MDS exceeding that from normal marrow by a factor of 3.24 +/− 2.57 (P < 0.00005). Increase of vascularity correlated with increase of VEGF gene expression, which exceeded that from normal marrow by a factor of 2.68 +/− 2.21 (P = 0.0003), whereas KDR gene expression was not significantly changed. During therapy with lenalidomide, vascularity markedly decreased to normal values in 60 % of patients (21 /35; P < 0.00005). Normalization of vascularization correlated with a major cytogenetic response of disease (< 35 % metaphases with del(5q); P = 0.0005) which occurred in 21 patients, 12 of them with a complete cytogenetic remission. Anti-angiogenic inefficacy of lenalidomide correlated with progression of disease (>= 5 % blasts in blood or bone marrow; 14 patients; P = 0.0005). In contrast to vascularity, VEGF and KDR gene expression were not reduced during lenalidomide treatment. They increased in 8 (VEGF) and 12 (KDR) patients (P = 0.0005) independent of the cytogenetic response. Moreover, correlation between vascularity and VEGF gene expression disappeared, and an inverse correlation between KDR gene expression and vascularity occurred (P < 0.00005).

We conclude that in MDS with del(5q), lenalidomide uncouples angiogenesis from the effect of VEGF resulting in a significant reduction of marrow vascularity followed by an increase in gene expression of VEGF and KDR. Inhibition of angiogenesis correlates with a significant reduction of the MDS clone in bone marrow whereas increase of vascularization indicates progression of disease.
Routine Blood Draw during Chemotherapy Does Not Cause Significant Iron Deficiency.
Authors: Fesnak Andrew , Mastoris Jason , Ley Susan , Henry David
Published: April 2020

Chemotherapy-related anemia in cancer patients can be significant. Frequent blood draws prior to and during chemotherapy treatment may result in a loss of iron (Fe) that could exacerbate or cause anemia. Therefore, phlebotomy for diagnostic testing has the potential to lead to significant Fe loss. We conducted a retrospective case study on 40 randomly selected patients currently undergoing chemotherapy. A CBC and routine chemistry resulted in blood losses of 9 ml and 13 ml respectively. If an infusaport was used, an additional 10 ml was drawn and discarded. Blood loss was recorded for each visit during a chemotherapy course of some 4–6 cycles. Approximately 1 ml of compacted red blood cells is equivalent to 1 mg of Fe. Therefore, by multiplying the hematocrit (HCT) by the blood loss (ml), the amount of iron loss (mg) was determined for each patient visit. Fe losses for the patients in this study were compiled and averaged by gender (M/F), by method of access (port/IV), per cycle of chemotherapy and overall. The average overall loss of Fe during a course of chemotherapy was 45.7 mg. Female patients lost an average of 39.9 mg Fe, while male patients lost an average of 53.7 mg Fe, probably because of higher average HCTs in men. As expected, patients with infusaports lost more Fe (76.9 mg Fe/course) than patients with peripheral intravenous access (30.7 mg Fe/course). Correcting for variability in the number of cycles per course of chemotherapy revealed an average loss of 10.3 mg Fe per cycle of chemotherapy. The impact of Fe loss on a patient’s overall hematological condition is dependent on many factors. If a patient is initially Fe deficient, an additional loss of Fe will have a greater effect than if the patient has sufficient iron stores. For example, an Fe loss of 50 mg in an Fe replete patient (approx. 3000 mg Fe) versus an Fe deficient patient (approx. 1500 mg Fe) would only account for a 1.67% or 3.33% loss respectively. This loss is not likely to result in Fe restricted erythropoiesis. Therefore, the Fe loss due to diagnostic phlebotomy in chemotherapy patients is unlikely to cause significant Fe deficiency.
Modulation of Iron Homeostasis during Erythroid Differentiation Is Mediated by Complementary Transcriptional and Post-Transcriptional Mechanisms.
Authors: Samara Maria , Chiotoglou Ioanna , Likousi Sophia , Kollia Panagoula
Published: April 2020

Iron is essential for cell proliferation, heme synthesis and a variety of cellular metabolic processes. Transferrin receptors (TfR)-1 and -2, ferritin and DMT1/Nramp2 are critically implicated in iron homeostasis. In this study, we evaluated TfR1/TfR2 (both alpha and beta isoforms), ferritin H-/-L-subunit and DMT1/Nramp2 mRNA expression as well as TfR1 protein expression in a model system of human erythropoiesis in an attempt to understand mechanisms critically involved in iron metabolism during normal erythroid maturation. CD34+ erythroid precursors collected from peripheral blood samples of normal individuals were cultured in free serum StemSpan medium in the presence of stem-cell factor (SCF, 100ng/ml) and erythropoietin (4u/ml). Real-time quantitative RT-PCR analysis showed that TfR1 mRNA levels increased significantly during cell proliferation and erythroid maturation (4–7-fold over days 4–12); in contrast, TfR2-alpha mRNA transcripts were low at the proerythroblast stage, then showed a slight increase (1.2–1.3-fold over days 4–12) and eventually remained stable up to terminal differentiation. TfR2-beta mRNA levels were generally low and did not fluctuate significantly throughout erythroid differentiation. TfR1 and TfR2-alpha mRNA stability was analyzed in cultures exposed to actinomycin-D (actD: 5μg/ml) for 24 and 48hrs on day 8 of culture (proerythroblast stage). The levels of both TfR1 and TfR2-alpha mRNA transcripts increased by 2.0–3.0-fold in actD-treated-CD34+ cells. Western blotting experiments were performed with an anti-TfR1-specific antibody on lysates derived from CD34+ cells throughout erythroid differentiation (days 3–14 of culture); in all experiments, actin served as control. Quantitative gel-banding densitometry was performed using Epson GT-8000 Laser Scanner. A significant increase of TfR1 protein was observed during erythroid maturation (from day 3 up to day 9), whereas a gradual decrease was observed after day 12 of culture. Assessment of H- and L-ferritin mRNA content at different stages of erythroid maturation demonstrated slightly higher levels of H-ferritin, albeit without significant changes throughout erythroid maturation. Similar results were obtained for DMT-1/Nramp-2 mRNA. These findings suggest that:

TfR1 upregulation starting from early erythroid stages and ongoing throughout erythroid maturation is mediated via transcriptional and post-transcriptional mechanisms, especially at more advanced differentiation stages; TfR2-alpha expression is uniformly low throughout erythroid differentiation and regulated by both transcriptional and post-transcriptional mechanisms.

These observations suggest that increased iron demands of developing erythroid cells might be met by increased TfR-1 expression, in a context of high TfR-1 mRNA transcripts with increased stabiliy at more advanced maturation stages.
No Significant Molecular Response in Polycythemia Vera Patients Treated with Imatinib or Interferon alpha.
Authors: Jones Amy V. , Higley Katherine , Curtis Claire , Kreil Sebastian , Zoi Katerina , Hochhaus Andreas , Reiter Andreas , Oscier David , Merber Alec , Silver Richard T. , Cross Nicholas C.P.
Published: April 2020

Imatinib mesylate and interferon alpha (rIFNa) have both been reported to induce remission in patients with polycythemia vera (PV), but until recently it has not been possible generally to gauge the depth of these responses due to the absence of a specific cytogenetic or molecular marker of the disease. Here we have used ARMS and pyrosequencing assays to detect and quantify the V617F JAK2 mutation in granulocytes or mononuclear cells from 111 PV patients, of whom 14 were undergoing treatment with imatinib (300–800 mg/day; median follow up 17 months; range 5–31), seven were undergoing treatment with rIFNa (dose range from 2MU three times/week to 3MU/day; median follow up 60 months; range 13–132), and 90 were untreated or treated only by phlebotomy, hydroxyurea or anagrelide (control group). Clinical responses in the 14 imatinib treated cases were none (NR; n=3), partial (PR; n=9) or complete (CR; n=2); responses in the seven rIFNa treated cases were PR (n=1) or CR (n=6). The V617F mutation was detected in all cases undergoing treatment with imatinib or rIFNa and in 82 (91%) of the control PV cases. The median percentage of mutated JAK2 alleles (%V617F) did not differ significantly between the imatinib treated cases (median 59%, range 8–91), the rIFNa treated cases (median 27%, range 19–87) or the V617F positive cases from the control group (median 53%, range 5–100). In the imatinib group, the median %V617F for cases with NR, PR and CR were 72% (44–89; n=3), 60% (30–91; n=9) and 15% (8 and 21; n=2), respectively. In the rIFNa treated group the single case with a PR had 87% V617F compared to a median of 26% (19–39) for the six cases in CR. Pretreatment samples were available for 9 of the imatinib treated cases. Of these, all seven of the NR or PR cases showed a marginal increase (median 1.2 fold, range 1.0–1.5) in the percentage of V617F alleles on treatment. In contrast, the two CR patients showed a 2–3 fold reduction in %V617F on treatment. We conclude that although PV patients may benefit from treatment with imatinib or rIFNa, molecular analysis indicates that responses are modest.
Activated JAK2 Signaling in Primary Human Hematopoietic Cells Drives Erythropoietin-Independent Erythropoiesis and Myelofibrosis.
Authors: Kennedy James A. , Barabe Frederic , Barber Dwayne L. , Dick John E.
Published: April 2020

An activating mutation in the JAK2 tyrosine kinase has recently been identified in patients with polycythemia vera (PV), essential thrombocythemia (ET) and idiopathic myelofibrosis (IMF). However, at this time, evidence of a causative role for activated JAK2 signaling in the pathogenesis of these myeloproliferative disorders is limited. Given that these are clonal stem cell diseases, the impact of deregulated JAK-STAT signaling must be considered in the context of primitive human hematopoietic cells. To this end, a lentiviral vector encoding the TEL-JAK2 (5–19) fusion was employed to infect lineage-depleted human cord blood, resulting in constitutive activation of STAT5 as well as the ERK and PI-3 kinase signaling pathways. Interestingly, when grown in culture under conditions that normally support the exclusive production of cells from the granulopoietic and monocytic lineages, cells expressing TEL-JAK2 underwent a burst of erythropoietin (EPO)-independent erythropoiesis; an outcome that could even occur in serum-free media in the absence of supportive cytokines. Furthermore, TEL-JAK2 cells exhibited erythroid colony-forming capacity in the absence of exogeneous EPO, a hallmark of PV. In order to gain insight into the in vivo effects of activated JAK2 signaling, transduced cord blood cells were injected intrafemorally into sublethally irradiated NOD/SCID mice. When animals were sacrificed 3 weeks post-transplant, the percentage of human engraftment was comparable between TEL-JAK2 and control animals; however, total cellularity was significantly reduced in the injected femur of TEL-JAK2 mice. At 9 weeks post-transplant, this reduction in cellularity was noted not only in the injected femur, but also in distant marrow cavities. Histological examination of the bone marrow from TEL-JAK2-transplanted mice showed a decrease in cellularity, the presence of an atypical megakaryocyte population, and patent sinusoids. Most notably, reticulin staining revealed the existence of a fibrous network in the bone marrow of TEL-JAK2 mice, indicative of myelofibrotic change. Taken together, these in vitro and in vivo studies provide functional evidence that in human hematopoietic cells, activated JAK2 signaling can initiate disease processes bearing similarity to both PV and IMF. Furthermore, they provide the first example of an experimental xenotransplant model of IMF which can be utilized to provide insight into both the pathogenesis of this disease and potential therapeutic targets.
Cancer as the Initial Presentation in Patients with Fanconi’s Anemia.
Authors: Alter Blanche P.
Published: April 2020

Background: Patients with Fanconi’s Anemia (FA) have very high risks of developing leukemia and solid tumors. Cancer is thought to follow the diagnosis of FA in most patients, but we know about several patients in whom a cancer diagnosis led to the diagnosis of FA.

Hypotheses: FA patients who present with cancer comprise a substantial proportion of the FA patients who have cancer. Undiagnosed FA may contribute significantly to apparently sporadic cancer patients who are atypically young and lack usual risk factors.

Experimental Design: A systematic review of the medical literature.

Methods: Medline search terms were “Fanconi Anemia” and “Cancer,” “Leukemia” or “Myelodysplastic Syndrome (MDS).” Malignancies after stem cell transplant were excluded.

Results: 90 patients were reported with a solid tumor, 117 with leukemia, and 61 with MDS (11 of whom developed leukemia). These events preceded the diagnosis of FA in ~25% of patients. The median ages at diagnosis of FA were 9, 23, and 12 years respectively. 40% of the tumors were squamous cell carcinomas of the head, neck, or esophagus (HNSCC), and 10% each were brain, Wilms, and gynecologic tumors. The relative frequency of the tumor types was similar whether the first diagnosis was cancer or FA. 90% of the leukemias were acute myeloid leukemia (AML). Among FA patients with tumors as adults (>18 years old), the age at cancer diagnosis was similar whether cancer occurred first or FA was diagnosed first (median ages 31 and 27), but the age at FA was significantly older when cancer came first (32 vs 11 yrs). Among FA patients with tumors <18 years old, those with cancer first had cancer younger than those with FA first (median ages 2 vs 6 years), while the age at diagnosis of FA was similar (2 vs 1 years). In both the <18 and >18 year old patients with leukemia or MDS, these complications occurred at similar ages whether they preceded or followed the diagnosis of FA.

Conclusions: This literature review is limited by over-reporting of patients who presented with cancer and were then identified as FA, and under-reporting of patients who presented with cancer in whom FA was never diagnosed. The magnitude of these biases cannot be determined from the literature, or from cohorts of patients known to have FA. We propose that a systematic evaluation for FA should be done in young, risk-factor negative HNSCC patients, to determine the contribution of FA to this subset of cancer in the general population. Heightened awareness of features of FA may also be helpful in the diagnosis of FA in patients with brain, Wilms, and gynecologic tumors.
A Pilot Study of Rabbit Antithymocyte Globulin - TECELAC Combined with Cyclosporine and Prednisolone as Immunosuppressive Therapy for Severe Aplastic Anemia.
Authors: Chandy Mammen , George Biju , Viswabandya Auro , Bajel Ashish , Mathews Vikram , Srivastava Alok
Published: April 2020

Immunosuppressive therapy is the treatment of choice in patients with severe aplastic anemia (SAA) not eligible for an allogeneic bone marrow transplant. We treated 10 patients with a combination of Tecelac (Biotest, Germany) (1.5 mg/kg/day for 4 days), Cyclosporine (5 mg/kg/day for 6 months) and Prednisolone (2mg/kg/day for 3 weeks and taper over 1 week). Tecelac is a rabbit anti-T cell immunoglobulin produced by Biotest Germany from rabbits immunized with human peripheral blood lymphocytes. Antibiotic and blood product support was given as required. Ten patients (8 males; 2 females) with a median age of 26 years (range: 18–40) were treated. The median time from diagnosis to treatment was 2 months (range: 1 – 4). The median absolute lymphocyte count (ALC) pre ATG was 1537/cumm (range: 1224 – 1748) while the median ALC post ATG was 40/cumm (range: 20 – 200). None of the patients developed serum sickness. Two patients expired due to bacterial infection (Staphylococcal sepsis and Escherichia Coli sepsis) on day +14 and day +40 post ATG. Response was seen in 5(62.5%) out of 8 evaluable patients. Two patients achieved complete normalization of blood counts. Two patients have become transfusion independent for 6 – 12 months of which one had a relapse after 12 months. One patient showed improvement in the absolute neutrophil count (ANC) and platelet count with a decrease in transfusion frequency. Three patients (37.5%) showed no improvement in blood counts and continue to remain transfusion dependant. At a median follow up of 22 months (16 – 30), the overall survival is 80% with a disease free survival of 37%. Rabbit ATG induces remission in a small number of patients with severe aplastic anemia and the results are comparable with some reports using equine ATG/ALG. Larger studies need to be done to evaluate the efficacy of rabbit ATG in severe aplastic anemia.
Management of Hereditary Spherocytosis in a Public Health Care Provider in a Developing Country.
Authors: Feldman Leonardo , Drelichman Guillermo , Basack Nora , Rodriguez Ernesto , Freigeiro Daniel , Aversa Luis
Published: April 2020

Hereditary Spherocytosis (HS) is the most common cause of non-immune hemolytic anemia in Argentine people of European ancestry, it is characterized by chronic hemolysis, which is reduced or abrogated by splenectomy.. Because of the risk of postsplenectomy sepsis, especially among children under 5 years old, partial splenectomy has been advocated as an alternative. This procedure seems to ensure prolonged reduction but not complete elimination of hemolysis and it is possible some regrowth of the splenic remnant and a secondary total splenectomy must be performed in some patients (pts). This problem is worse especially when pts. live in rural areas and a close observation is necessary. We analyzed retrospectively the evolution of 83 pediatric pts with HS with low resources, other health priorities and in some cases an underling nutritional deficit. Diagnostics was made in a public hospital between October 1971 and December 2002 and the last control was in December 2004. The pts. Median age at diagnostic was 4.7 years (14 days to 14 years). Severe forms were observed in 18%, mild in 20% and moderate in 62%. Twenty four pts were phenotypically sporadic. Biochemical analysis (SDS-PAGE) were performed in 30 pts and/or family members, combined spectrin- ankirin deficiency were observed in most of them. Sixty-nine hemolytic crisis was observed in 30 pts (37.5%). and 17.5% developed an aplastic crisis. Fifty-two pts. (65%) received 249 Red Blood Cell Transfusions (Trs), 36% between 1 and 2, 22.5% 3 to10, and 6% between 10 to 34 Trs. Gallstones were observed in 4 PTs (5%). Total splenectomy was performed in 46 of 83 pts (55%), median age: 7 years (4–15) 42 pts had conventional and 4 have undergone laparoscopyc procedure. Ninety six per cent of pts were splenectomized after age of 5. The median time from diagnostic to splenectomy was 1 year (0.2–8.9). All pts were immunized against Pneumococcus, Haemophilus, and Meningococus and received prophylactic antibiotics. With a median follow up of 18.5 years (3–30 y) after splenectomy all pts showed a significant clinical improvement and no further transfusion requirement. In all cases the hemoglobin increased (median pre and post splenectomy 8.6/13gr/dl) and reticulocyte counts decreased (8 / 1.4%). We do not observe procedure relate mortality, sepsis, thrombosis, and aplastic or hemolytic crisis post-splenectomy. On the basis of our experience we favor the total splenectomy performed by a training team in countries with low resources and in pts with deficient hygienic and housing conditions that inhabit in places with long distances from centers to ensure wider access to training health care providers.
Subsets and Function Changes of Th Cells in the Bone Marrow of Patients with Immune Related Pancytopenia.
Authors: He Guangsheng , Wang Xiuli , Wu De Pei , Sun Aining , Jin Zhengming
Published: April 2020

Objectives

To explore the subsets and function of T helper (Th) in bone marrow of the patients with immune related pancytopenia(IRP).

Methods

The CD4+ cells producing IFN-γ or IL-4 in cytoplasm were defined as Th1 or Th2 cells respectively. All these cells in bone marrow were measured from 16 normal controls, 25 untreated IRP patients; The mRNA expressions of IL-4, IL-10, IFN-γ and IL-2 genes in unstimulated bone marrow mononuclear cells(BMMNC)from 25 untreated IRP patients, 10 normal controls were measured by reverse transcription polymerase chain reaction (RT-PCR).

Results

The percentage of Th1 cells, Th2 cells and ratio of Th1/Th2 in bone marrow of normal controls was: 0.42%, 0.24%, 1.57 respectively, and the percentage of Th1 cells in untreated patients with IRP was 0.58%, which was not markedly different from the that of normal controls(t=0.903, P>0.05). But the percentage of Th2 cells of the patients with IRP was significantly higher than that of normal controls(t=4.673, P<0.01), and the balance of Th1/Th2 shifted to Th2 more significantly by comparing to that of normal controls (t=4.880, P<0.01). The mRNA expressions of IL-4 and IL-10 in the Th2 cells of the untreated IRP patients were significantly higher than those of the normal controls, however difference of the expressions of IFN-γ and IL-2 in the Th1 cells were not significantly.

Conclusions

The percentage of Th2 cells increased in the patients with IRP, and the balance of Th1/Th2 shifted to Th2. And the expression of Th2 type cytokines was more frequent in IRP. The imbalance of subtypes of Th lymphocytes and hyperfunction of Th2 lymphocytes might play important roles in the pathogenic mechanism of IRP, which lead to more B lymphocytes and producing autoantibodies consistenly.
The Association between Serum Copper and Anemia in the Adult NHANES II Population.
Authors: Molnar Istvan , Il’yasova Dora , Ivanova Anastasia , Knovich Mary A.
Published: April 2020

Anemia is prevalent in older adults. Although the majority of cases are due to nutritional deficiencies, chronic inflammation, or renal disease, anemia remains unexplained in about one third of cases (Guralnik et al., Blood, 2004, p2263). Copper deficiency has been reported as a rare cause of anemia and neutropenia. We hypothesized that copper deficiency could account for some cases of unexplained anemia in adults. To test this hypothesis, we examined the relationship between serum copper and unexplained anemia in 11,240 adults (15 years and older) who participated in the Second National Health and Nutrition Examination Survey (NHANES II). Anemia was defined as hemoglobin level below 13.5 g/dL in males and below 11.5 g/dL in females. In this study population, 638 or 5.7% of adults were anemic. Of these, anemia was unexplained by vitamin B12, folate, or iron deficiencies, chronic inflammation, or renal disease in 421 or 3.7% of the total subjects studied. Thus, unexplained anemia constituted approximately 65% of all anemia cases in this sample of US adults.

Median serum copper level was significantly higher in all anemia cases (126 μg/dL, p <0.0001), in explained anemia (133 μg/dL, p<0.0001), and in unexplained anemia (122 μg/dL, p<0.02) as compared to non-anemic adults (119 μg/dL, ref). Spline regression showed a U-shaped relationship between serum copper levels and unexplained anemia. The prevalence of unexplained anemia increased significantly at both lower and higher copper levels as compared to the median (119 μg/dL): odds ratios for unexplained anemia were 1.2 (95% CI: 1.1–1.3) in the association with a decrease of serum copper from median to 10th percentile (92 μg/dL) and 1.8 (95% CI: 1.6–2.2) in the association with an increase of serum copper to 90th percentile (161 μg/dL).

This study likely underestimates the prevalence of anemia of chronic illness, as only a single marker of inflammation (serum iron) was available to capture these subjects. Furthermore, copper levels are known to be elevated in inflammation. Thus, unrecognized cases of anemia of chronic illness might explain the observed association between high serum copper levels and unexplained anemia. On the other hand, subjects with low serum copper levels and unexplained anemia might have nutritional deficiency.

In conclusion, this analysis of the NHANES II data confirms (1) that unexplained anemia is common among the US adults, and (2) that both lower and higher than median serum copper levels are positively associated with unexplained anemia. These findings support the need for further study of copper status in adults with unexplained anemia.
Randomized, Open-Label Study of Epoetin alfa 40,000 U Once Weekly Versus 80,000 U Every Two Weeks in Anemic Patients with Cancer Receiving Chemotherapy.
Authors: Henry David H. , Xie John , Woodman Richard C.
Published: April 2020

Epoetin alfa administered three times weekly or once weekly (QW) has been proven and widely accepted in the management of chemotherapy (CT)-induced anemia. Extended dosing intervals less frequent than QW would provide added convenience for patients. An ongoing randomized open-label study was designed to compare the efficacy and safety of a regimen of 80,000 U of epoetin alfa every two weeks (Q2W) to the commonly used regimen of 40,000 U QW. Two hundred and eighty patients with nonmeyloid malignancy, baseline (BL) hemoglobin (Hb) ≤ 11 g/dL, and scheduled to receive CT for a minimum of 12 weeks will be enrolled. Doses will be adjusted to maintain Hb values of approximately 12 g/dL. Endpoints include the comparison of change in mean Hb values at the end of the study (EOS) between the two treatment groups and Hb over time. The first 71 randomized patients (mean age 64 years, 72% women, 31% breast cancer) with at least one post-BL Hb or transfusion were analyzed. Preliminary results (see table) demonstrate similar Hb increases for each group. In the QW group, 50% (10/20) of patients and in the Q2W group 76% (16/21) of patients had ≥ 1 g/dL Hb increase during the first 4 weeks. Five (14%) QW and 7 (20%) Q2W patients had a serious adverse event; no clinically relevant thrombovascular events were reported; 1 patient (QW) died on study. These results suggest that initiating epoetin alfa treatment for CT-induced anemia with 80,000 U every two weeks provides similar efficacy and safety as treatment with 40,000 U weekly.

Mean Hb Over Time Epoetin alfa 40,000 U QW Epoetin alfa 80,000 U Q2W Weeks on Study Mean ± SD (N) Mean ± SD (N) BL 9.9 ± 0.9 (36) 9.8 ± 0.9 (35) 4 11.0 ± 1.2 (20) 11.2 ± 1.2 (21) 6 10.9 ± 1.4 (13) 11.0 ± 1.5 (18) 8 10.7 ± 1.3 (7) 11.7 ± 1.6 (11) 12 (EOS) 11.6 ± 1.1 (3) 11.1 ± 1.1 (5)
A Randomized Controlled Trial of Patient Controlled Analgesia Versus Continuous Infusion of Morphine during Vaso-Occlusive Crisis in Sickle Cell Disease.
Authors: van Beers Eduard J. , Nieuwkerk Pythia T. , van Tuijn Charlotte F.J. , Friederich Philip W. , Vranken Jan H. , Biemond Bart J.
Published: April 2020

Pain during vaso-occlusive crisis (VOC) in sickle cell disease (SCD) is commonly treated with continuous intravenous infusion (CI) of morphine. During CI the treating physician titrates the dose of morphine until adequate relief of pain has been established. Patient controlled analgesia (PCA) allows the patient to self-administer doses of morphine for the relief of pain and has shown to be equianalgesic in post surgical patients with lower morphine consumption than with CI of morphine. Morphine has many dose-related side-effects and high plasma levels of morphine are associated with serious complications. Therefore, we conducted the first randomized controlled trial to compare the administration of morphine with PCA versus CI in sickle cell patients with VOC. 26 consecutive episodes of VOC in 21 patients with SCD were included. Patients were randomized between PCA and CI of morphine within 24 hours after hospital admission. Endpoints of the study were: the mean and cumulative morphine dose, pain intensity and quality of life (QoL). Pain intensity was measured daily using a ten-point-scale verbal pain score. Reduction of pain intensity was measured by subtracting a pain score on a ten point visual analogue scale (VAS) before randomization from the same measurement two days after randomization. QoL was measured using the Medical Outcomes Study 36-item Short Form Healthy Survey (SF36).

Patients with PCA demonstrated to have significant lower morphine consumption as compared to patients randomized to CI. The mean and total cumulative morphine dose was 0.5 mg/h and 33 mg in the PCA-group versus 2.3 mg/h and 275 mg in the CI-group, respectively (p=0.02 and p<0.001). The pain intensity was not different between the groups. The mean daily ten-point-scale verbal pain score was 5.1 in the PCA group versus 5.3 in the CI-group (p=0.20). Reduction in pain intensity (VAS) two days after randomization was −2.4 in the PCA-group versus −3.8 in the CI-group (p=1.00). Also no difference in QoL was found.

We conclude that the use of PCA in sickle cell patients with VOC results in adequate pain relief at a significant lower morphine dose as compared to morphine administration by continuous infusion.

Figure. Mean morphine dose per patient Figure. Mean morphine dose per patient
Cancer Incidence in Sickle Cell Disease. Howard University, 1996–2004.
Authors: Dawkins Fitzroy , Ufearo Hilary , Pantin Jeremy , Kwagyan John , Nwokolo Catherine , Onyekwere Onyinye C. , Gordeuk Victor R. , Castro Oswaldo
Published: April 2020

There are no prospectively collected data on cancer incidence and mortality in patients with sickle cell disease. This information would be a useful baseline for cancer surveillance, particularly in sickle patients exposed to potentially carcinogenic interventions such as hydroxurea administration and stem cell transplantation. A review of cancer cases among 696 adult sickle cell patients (mean age 28.8 y) at Howard University for the years 1986–1995 (2,684 patient-years, pt. yrs.) estimated the cancer incidence and mortality at 1.74 and 1.04 per 1000 pt. yrs, respectively (Am J Hematol1997;55:188). These figures were comparable to those reported for adult African American patients of similar age in the SEER database.

Because sickle cell patients are now surviving longer, we examined again the cancer incidence and mortality at our institution for the years 1996 – 2004. In determining the patient-years of observation we assumed that if a patient was seen at least once during a given calendar year, the patient had been observed for that whole year. A total of 677 adult sickle cell patients (mean age 35.1 ± 12.5 y) were followed from 1996 through 2004 (2,317 pt.yrs.). There were 54.5 % females and 45.5 % males; the Hb genotype distribution was SS=70.5%, SC=19.2%, S-Thal=9.7%, and other=1%. The table shows the characteristics of 7 sickle cell patients who developed cancer during the study period. Their ages ranged between 38 and 64 years. All but one (Pt. 7) were female and all but one (Pt. 2) had Hb SS. Patients 1 and 3 had been treated with hydroxyurea.

Based on these cases, the estimated cancer incidence was 3.02 per 1000 patient years, still below the upper 95% confidence limit in the 1986–1995 estimate (4.3 per 1000 patient years). Two additional cancer patients were seen at our institution, one with prostate cancer and the other with metastatic breast cancer. They were not included in the incidence estimate since they were specifically referred to our institution because of the cancer diagnosis. The current incidence of cancer in adult sickle cell patients at our institution is not increasing appreciably even though they are getting older and some are taking hydroxyurea.

Patient Age (y) Sex Hb type Cancer type 1 43 F SS Cervical carcinoma in situ 2 38 F SC Hodkin’s disease 3 64 F SS Uterine carcino-sarcoma 4 43 F SS Metastatic adeno-ca., primary unknown 5 57 F SS Renal adenocarcinoma 6 48 F SS Breast cancer 7 38 M SS Anaplastic B-cell lymphoma (HIV)
Painful Episodes in Children with Sickle Cell Disease and Asthma Are Temporally Associated with Respiratory Symptoms.
Authors: Glassberg Jeffrey A. , Spivey John F. , Strunk Robert , Boslaugh Sarah , DeBaun Michael R.
Published: April 2020

Background: Previously our research group demonstrated that a diagnosis of asthma is associated with an increased rate of painful episodes in children with sickle cell disease (SCD); however, little is known about the temporal relationship between an asthma exacerbation and a painful episode in a child with SCD. We tested the hypothesis that respiratory symptoms either precede or occur concomitantly with painful episodes more frequently in children with SCD and asthma when compared to children without asthma.

Methods: As part of standard care, a cohort study was conducted. The primary hematologist referred all children with SCD for evaluation by a pulmonologist. The definition of asthma was based on the National Heart Lung and Blood Institute’s guidelines. The primary outcome recorded was respiratory symptoms occurring up to 96 hours prior to a painful episode. Respiratory symptoms were defined as any of the following:

cough wheeze tachypnea retractions, or grunting.

Pain was defined as the complaint of body pain (excluding the head) requiring the administration of opioids in the hospital, clinic, or emergency department.. Cases and controls were children with and without asthma, respectively. Medical records from all hematology clinic, emergency department, and inpatient visits over a 25-month period were reviewed for painful episodes and the presence of respiratory symptoms.

Results: A total of 74 children were evaluated by a hematologist and referred to pulmonologist for an asthma between 6/15/2004 and 1/31/2005. Of the eligible patients, 36 were diagnosed with asthma (mean age 9.8 years; median 9.6 years; range 2.4–19.4) and 38 were determined not to have asthma (mean age, 9.8 years; median 9.7 years; range 2.4–19.5). For children with asthma versus those without asthma, the odds ratio of having a pain episode associated with antecedent or concurrent respiratory symptoms was 4.9 (95% confidence intervals, 2.2–10.7).

Conclusions: In children with both SCD and asthma, respiratory symptoms are a risk factor for subsequent painful episodes.