bluuebunny/crossref_metadata_2025 huggingface dataset:
Higher NOTCH1 Mutation Load Reveals Favorable Prognosis in Pediatric T-Cell Acute Lymphoblastic Leukemia
Authors: Zhang Senlin , Ji Qi , Zhang Zhiqi , Chen Ping , Chu Xinran , Meng Na , Zhang Xiao , Gao Wei , Liu Minyuan , Liu Yu , Hu Shaoyan
Published: December 2024

Background: Acute lymphoblastic leukemia (ALL) is the most common pediatric malignancy, approximately 10-15% of which are derived from T cell precursors and/or immature T-cells. Previously, gene mutations were identified to be associated with the risk stratification, treatment response, and prognosis of pediatric T-ALL patients. NOTCH1 was the most common gene mutation in T-ALL patients. Previous studies only fucosed on the influence of NOTCH1 mutation on the prognosis of pediatric T-ALL, few studies explored the role of variant allele frequency (VAF) in NOTCH1 mutation.

Methods: We retrospectively reviewed children diagonsed as T-ALL in our center from April 2012 to November 2022. All included patients performed RNA sequencing (RNA-seq) using samples collected at diagnosis. Overall survival (OS) was calculated and compared by Kaplan-Meier analysis and log-rank tests. The primary objective of this study was to compare the influence of VAF in NOTCH1 mutation on the prognosis of pediatric T-ALL.

Results: A total of 123 children were enrolled. Among these patients, 98 were male and 25 were female, with a ratio of 3.9:1. The median age of all patients at diagnosis were 8.0 years (range 1.2-16.8 years). The median white blood cell (WBC) at diagnosis were 106.33 (range 1.05-750.20). The median hemoglobin and platelet count at diagnosis were 98.50 (range 37.00-159.00) and 63.00 (range 5.00-412.00), respectively. Regarding to the immunophenotype, there were 7 early thymic precursor (ETP) and 116 non-ETP. Sixty-one of 123 (49.5%) patients have NOTCH1 mutation, which did not influence the 5-year OS (77.1% ± 5.67% vs 74.2% ± 6.01%, P=0.81). Based on the maximally selected log-rank statistic, mean VAF was found to be the cutoff point for differentiating patient prognosis. Patients with a higher mutation load (VAF≥20%, n=37) had superior 5-year OS when compared to patients carrying a lower mutation load (VAF＜20%, n=24)(88.9% ± 5.23% vs 61.7% ± 10.1%, P=0.027).Conclusion: Our study indicated that NOTCH1 mutation did not influence the prognosis of children with T-ALL. While higher NOTCH1 mutation load may have a favorable prognosis, which may contribute to the risk stratification of pediatric T-ALL. Larger-scale and prospective randomized studies are warranted to further evaluate this conclusion.
Development and Validation of a Whole Genome Sequencing-Based Test for Cytogenetic Characterization of Acute Myeloid Leukemia
Authors: Piening Brian D , Wagner Josiah T , Welle John T , Brundu Francesco Gavino , Sayyari Erfan , Cosgrove Benjamin A , Lee Yeonghun , Dowdell Alexa K , Moung-Wen Christine , Truong Sean , Han James , Sathyan Pratheesh , Bifulco Carlo B.
Published: December 2024

Molecular assessment is a mainstay in the diagnosis and management of acute myeloid leukemia and currently includes a variety of approaches spanning analysis of small genomic variants via next generation sequencing (NGS) as well as large genomic rearrangements and copy number gains/losses via fluorescent in situ hybridization (FISH) and/or cytogenetics. With current advances in next generation sequencing throughput and decreasing costs, it is possible to characterize all of these variant types in a single assay using whole genome sequencing (WGS). Here we report the development and validation of a novel whole genome sequencing assay for AML characterization. Briefly, we curated a cohort of over 100 patient blood or bone marrow samples that were previously characterized by clinical cytogenetics, FISH and/or small panel NGS testing for sequencing via WGS. NGS libraries were prepared using a PCR-free and tagmentation-based protocol. Sequencing was performed on a Novaseq 6000 sequencer to an average per base coverage of over 100x, and variation was characterized using DRAGEN-SV, DRAGEN-CNV and small variant callers. WGS-based assessment showed strong concordance with prior assays. Key examples include accurate calling of common large deletions such as losses of chromosome arms 5q and 7q, as well as accurate detection of common inversions such as inv(16). Unlike karyotyping, WGS has significantly higher resolution than the cytogenetic band level, and as such we could observe specific breakpoints for interstitial deletions as well as detected additional structural variants that are likely too small for observation by cytogenetics. While additional validation work is ongoing our initial results as well as results from other groups show strong promise for the use of WGS for comprehensive genomic characterization in AML.
Artificial Intelligence Versus Expert Physician Assessments of Real-World Hematology Cases: Implications for Clinical Practice
Authors: Main Olivia , Struck Matthew , Vaughn John L , Hsu Jingmei , Abu Zaid Mohammad , Saint Fleur-Lominy Shella , Braunstein Marc J
Published: December 2024

Introduction: Artificial intelligence (AI) is increasingly being incorporated into the healthcare space as a tool to support clinical decision making and enhance patient care. Professional societies including ASH, as well as private companies such as Primum, Inc, offer free consultations with appropriate experts who provide personalized responses to clinician-submitted hematology cases. However, the potential of AI tools to supplement or supplant expert consultations remains uncertain. We report results of a study comparing AI versus expert physician responses to 107 real-world hematology cases.

Methods: Among 107 cases, inquiries included lymphomas (30), myeloma (24), leukemias (11), myeloid disorders (10), as well as classical hematology cases (32), assessed among 20 unique experts. Responses to these de-identified cases submitted by practicing clinicians to the Primum platform (www.primum.co/) between June 2022-July 2023 were compared to GPT-4 responses (openai.com/chatgpt/). The instructional prompt to GPT-4 was, “You are an expert oncologist conversing with another oncologist as a peer. You prefer to rely on guidelines and data published in reputable medical journals when responding.” Five expert faculty at our institution adjudicated the blinded comparative responses, including their preference, quality and practical value scores, and prediction of which response was AI generated. Comparison of scores was by t-test to generate P-values between expert and AI groups, and Pearson correlation was used for comparisons between adjudication scores.

Results: Expert responses were preferred by >50% of adjudicators in 75% of cases (deviation ±25%). Randomized AI responses were correctly identified 90% of the time. Mean expert vs AI scores (Likert scale 0-4) for quality (2.0 vs 2.1, P=0.9) and practical value (2.1 vs 2.1, P=0.9) were equivalent. Interestingly, AI responses were preferred in 46% (n=15) of classical hematology and 31% (n=9) of lymphoma cases, largely due to being more concise. However there was no concordance between high practical value scores and disease subtype for either group.

Conclusions: Expert physician responses were preferred for most of the cases, suggesting an implicit value of personalized responses compared to AI. Results showed no significant differences in quality or practical utility between AI generated responses and those from experts, reflected a similarity in the information extracted from standardized guidelines. Our findings may be limited by the broad coverage of hematologic conditions for which experts and guidelines vary. Overall, these data suggest that while AI can supplement knowledge of management paradigms by providing basic management strategies, at present it cannot replace expert clinical consultation in clinical practice.
Unfractionated Heparin Resourced from Bovine, Ovine, and Porcine Origin Is Bioequivalent
Authors: Thakkar Nikunj , Meganathan Kannan , Gupta Yash , Kapur Gia , Walenga Jeanine M. , Hoppensteadt Debra , Jeske Walter , Aggarwal Pradeep , Fareed Jawed
Published: December 2024

Introduction: Unfractionated heparin (UFH) in the United States is sourced from porcine mucosa and is mainly supplied from China. This sole dependence on one source can potentially lead to a serious health crisis for this essential medicine if there is a shortage of UFH due to any supply chain disruption. A realistic solution would be to develop bovine and ovine mucosa as alternate sources to porcine mucosa to produce UFH. In this study, the pharmacologic profile of single-sourced bovine, ovine, and porcine heparins were evaluated to demonstrate and validate their bio-equivalence. The immunological effect of these heparins in terms of heparin-induced thrombocytopenia (HIT) was also assessed. Materials: Multiple batches of UFH active pharmaceutical ingredient (API) from KinMaster (Brazil), Ronnsi (China), and Medefil (USA) were included in this study. USP compliant anti-Xa and anti-IIa assays (Aniara Diagnostics, USA) were used. HIT antibody was a pool of sera from clinically diagnosed HIT patients. Methods: Molecular weight profile of each heparin type was determined by HPLC. The anticoagulant effects of gravimetric amounts (µg/mL) of each heparin were evaluated by the anti-Xa, anti-IIa, and aPTT (HemosIL, Werfen) assays, then assessed for neutralization by protamine sulfate (PS) in each assay. The HIT profile was evaluated by the platelet aggregation assay. Results: The heparins, irrespective of their source, demonstrated comparable molecular weight profiles (15,020 Daltons bovine, 14,100 Daltons ovine, 14,500 Daltons porcine). While the anti-Xa and anti-IIa showed similar potency for ovine (191 anti-Xa, 188 U/mL anti-IIa) and porcine UFH (205 U/mL anti-Xa, 195 U/mL anti-IIa), the bovine UFH consistently showed lower potency for both activities (108 U/mL anti-Xa, 110 U/mL anti-IIa). Complete neutralization by PS was observed with all UFHs at all concentrations. The HIT profile, irrespective of heparin origin, exhibited a similar, expected, parabolic curve profile at equivalent heparin concentrations with no enhanced effect observed for either bovine or ovine UFH compared to porcine UFH. Conclusion: These studies support the hypothesis that heparin from bovine and ovine origin exhibit comparable in vitro anticoagulant, neutralization, and immunologic profiles, with an equivalent molecular weight profile, and can be considered for use as an alternative source to porcine heparin. This study suggests that heparin derived from bovine and ovine sources produced under current manufacturing practices are effective and safe alternatives to porcine heparin.
Sumoylation As a Novel Target for T-Cell Neoplasms
Authors: Milshteyn Larry , Lownik Joseph , Villamejor Anton , Merchant Akil
Published: December 2024

Despite breakthroughs in our understanding of peripheral T-cell lymphoma (PTCL) through studies such as genetic profiling, this disease has proven to be difficult to manage compared to it B-cell counterparts. There have been few advances in treatment regimens since the initial trials with CHOP-based chemotherapy (Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone) for many decades. In recent years, there have been more targeted therapies such as Brentuximab-Vedotin, however this is not applicable to most PTCL. Given the persistent poor outcomes in this patient population, novel therapeutic options are needed.

Similar to B-cell lymphomas, a subset of PTCL lymphomas exhibit alterations in cMYC expression. Recent studies have demonstrated a unique susceptibility of cMYC-driven B-cell lymphomas to the inhibition of SUMOylation. SUMOylation is a process of post translational modification (PTM), similar as ubiquitination. However, SUMOylation results in alteration of protein function, rather than explicit changes such as targeting for destruction. Using a recently descript PTCL model, LM-23, which overexpresses cMYC, we found that inhibition of SAE-1/2 with SB-4826, which are necessary for SUMOylation, led to decreased tumor growth in a subcutaneous tumor model, as well as cell death in in vitro models.

Here, we demonstrate a susceptibility of T-cell neoplasms (PTCL and T-lymphoblastic leukemia) to the inhibition of SUMOylation by targeting SAE-1/2 with SB-4826. Using multiple neoplastic T-cell lines, we demonstrate a low micromolar ICI50 for SB-4826 for neoplastic T-cell lines including LM-23 and Jurkat, similar to B-cell lymphoma cells lines. This ICI50 value is significantly lower than non-neoplastic T-cells, suggesting decreased effects on non-neoplastic counterparts of the functional immune system. Additionally, LM-23 tumor bearing mice treated with SB-4826 showed significant reductions in tumor volume compared to CHOP treated mice.

Additional studies on murine and human PTCL and T-ALL cell lines will be presented. While further preclinical studies are necessary, these studies identify SUMOylation as a novel therapeutic target in PTCL and T-ALL, especially cMYC- driven T-cell neoplasms.
Role of Alpha Granule Secretion in Platelet Glucose Metabolism
Authors: Prakhya Shravani , Whiteheart Sidney W. , Joshi Smita , Vekaria Hemendra , Sullivan Patrick
Published: December 2024

Platelets play a critical role in hemostasis and thrombosis through their activation, shape change, secretion, and aggregation. These highly metabolically active cells shift from a low-energy resting state to a high-energy activated state. Platelet secretion is a key step in hemostasis, involving the release of cargo from alpha, dense, and lysosomal granules, which merge with the plasma membrane to modify the local environment to help form a clot achieving hemostasis.

Alpha granules, the most numerous and diverse, are crucial for platelet functions such as hemostasis, inflammation, immunity, wound healing, and angiogenesis. They contain numerous bioactive proteins, including integrins, immunoglobulin family receptors, and GLUT3, a glucose transporter.

In resting conditions, GLUT3 is found in alpha granules but translocates to the plasma membrane upon platelet activation, facilitating glucose uptake necessary for platelet function. GLUT3 deletion impairs platelet activation and function, highlighting the importance of glucose metabolism.

This study, using the V2Δ3Δ8-/- mouse model with deficient SNARE proteins, reveals that GLUT3 translocation is critical for platelet secretion and clot formation. We show clot contraction defect in V2Δ3Δ8-/- platelets that can be rescued by the addition of pyruvate (downstream intermediate metabolite whose destiny is determined by the availability of oxygen within the environment) indicating the metabolic aspect of platelet secretion. Further research is needed to understand GLUT3 levels in these mice. Our findings underscore the link between platelet secretion and metabolism, showing that GLUT3 translocation from granules to the surface is crucial for platelet function and metabolism.
Inflammasome Cytokine Secretion in Heparin-Induced Thrombocytopenia Is Supported By Platelet-Derived Mediators and Complement
Authors: Michael James V , Khandelwal Sanjay , Tawk Antonios , Lazar Sophia , Arepally Gow , McKenzie Steven E
Published: December 2024

Background: Heparin-induced thrombocytopenia (HIT) is an adverse drug reaction that is caused by IgG immune complexes that activate platelets and monocytes through Fc Receptor for IgG IIA (FcγRIIA). These immune complexes also fix complement. Stimulated monocytes produce proinflammatory cytokines including inflammasome dependent IL-1β release, which has not been investigated in HIT.

Aims: Platelets have been shown to support monocyte inflammasome cytokine release during inflammation, primarily in microbial infection. This study sought to investigate the role of inflammasome cytokine production in HIT pathology.

Methods: We investigated the role of the NLRP3 inflammasome following immune complex (IC) challenge in healthy donor whole blood or immortalized monocyte-like cells. The contribution of inflammasome assembly and cytokine release on HIT pathology was assessed utilizing NLRP3 inhibitor MCC950 in the triple allele ‘HIT’ mouse model. Plasma IL-1β cytokine production was measured using ELISA, and complete blood counts were taken to assess thrombocytopenia. Furthermore, the contribution of complement was assessed using IC challenge of isolated primary blood mononuclear cells suspended in plasma or heat-inactivated plasma.

Results: Following human whole blood challenged or isolated mononuclear cell/platelet suspensions with two distinct immune complexes (heat aggregated IgG or heparin/PF4 complexes) we observed a significant increase in inflammasome cytokine production at 22 hours. Mononuclear/platelet cell fractions challenged with heparin/PF4 complexes had a significant increase in inflammasome cytokine secretion that was reduced with pretreatment with an FcγRIIA blocking antibody, or removal of complement with heat-inactivated plasma. We observed that administration of heparin and monoclonal αPF4/heparin antibody KKO to HIT mice resulted in thrombocytopenia and significantly increased circulating IL-1β, whereas mice treated with NLRP3 inflammasome inhibitor MCC950 protected mice from a platelet drop and cytokine production in our humanized mouse model of HIT in vivo.

Conclusions: These data demonstrate for the first time that HIT IC mediates the production and secretion of inflammasome cytokines, which is influenced by the presence of platelets in a FcγRIIA dependent manner as well as by complement. Furthermore, the NLRP3 inflammasome is shown in HIT model mice to be a critical component of HIT pathophysiology. These results provide a scientific rationale for exploring mechanisms that drive platelet/monocyte/complement communication and targeting the inflammasome as a possible therapeutic strategy in HIT.
Long Term Follow up of a Child with a Rare Hemoglobinopathy: Hemoglobin Little Venice
Authors: Abdulhai Safa , Narang Shalu , Herrick Jennifer L.
Published: December 2024

We report the second known case in the world of a rare beta chain variant hemoglobinopathy Hemoglobin Little Venice [β42 Phe→Cys, HBB:c.128T>G] originally found in 2009 in a 7 month-old Asian Indian female with severe chronic hemolytic anemia during infancy who is now 15 years of age. Her newborn hemoglobinopathy screen showed FA. She presented with jaundice at 1 month of age with a bilirubin of 15 mg/dL initially attributed to breast milk and was managed with supportive care. Hemoglobin electrophoresis with confirmatory DNA sequencing was performed by Mayo Clinic laboratories at 7 months of age to establish the diagnosis. At that time hemoglobin was 5.6 g/dL and bilirubin was 6.9 mg/dL. Hemoglobin electrophoresis showed Hb A 71.6%, Hb A2 2.5%, Hb F 24.5% and Hb variant 1.4%. Stability studies were abnormal. The testing revealed a previously undescribed beta 42 mutation of TTT>TGT (Phe>Cys). Our patient has been receiving blood transfusions every four weeks leading to iron overload at 5 years of age treated with an iron chelator. Her growth and development have been normal, similar to peers. At age 9, she had cholecystectomy for gallstones. At the age of 11, she had SARS COVID-19 infection that was treated with supportive care and she recovered well. She was noted to have mild thrombocytopenia ranging from 70-110's and had splenectomy at 13 due to increased frequency of blood transfusion and chronic splenomegaly. At 14, she was treated for asymptomatic babesiosis with atovaquone and azithromycin.

At present, she continues to require regular transfusions every 4 weeks due to severe hemolytic anemia and has significant thrombocytosis along with leukocytosis and nucleated red blood cells. She has significant transfusion-associated hemosiderosis and receives double chelation with deferasirox and deferiprone with marked history of noncompliance. Last MRI of Liver T2* in 2023 showed an approximate hepatic iron concentration of greater than 20 mg/g that is significantly elevated and MRI of heart T2*decay time of greater than 20 ms, which indicates low risk of clinically significant myocardial iron deposition. Both parents and two sisters have no evidence of hemolytic anemia and there are no other family members with chronic anemia or history of splenectomies.

The importance of phenylalanine in position 42 was described by Bartram et al in 2012 for the position's role in maintaining the solubility and stability of the β-hemoglobin chain. When replaced with cysteine, it disrupts oxygen delivery to the cells. This rare hemoglobinopathy requires multiple transfusions to treat vaso-occlusive episodes. At present, little is known regarding treatment choices for this rare hemoglobinopathy therefore, we will continue chronic blood transfusions and encourage compliance with iron chelation. A similar variant affecting the same codon, Hb Hammersmith [β42 Phe→Ser, HBB:c.128T>C] has comparatively more data in the literature which may offer some general guidance.
Platelet to Lymphocyte Ratio (PLR) As a Marker for Aortic Stenosis Development in a Mouse Model: Relationship to Platelet TGFβ1
Authors: Subramani Kumar , Afzal Tayyab , Babii Denys , Word Trevor , Ahamed Jasimuddin
Published: December 2024

Objective: Aortic stenosis (AS) is an age-related degenerative valvular disease that can lead to heart failure and sudden death. There is no biomarker for early detection of AS. However, an elevated neutrophil-to-lymphocyte ratio (NLR), reflective of systemic inflammation, is associated with higher mortality in cardiovascular disease, including AS and, recently, the platelet-to-lymphocyte ratio (PLR) was proposed as an additional inflammatory biomarker linked to AS. We have shown that platelet-derived TGF-β1 contributes to AS progression in LDLR-/-ApoB100/100 (LA100) mice, a model that simulates human AS valve pathology. We now evaluate PLR, along with NLR and plasma TGF-β1 levels, as possible correlates of AS progression in this model.

Methods: PLR, NLR, and plasma TGF-β1 were measured in control C57Bl/6 mice and LA100 mice before AS development (2-3 months of age), at the point of moderate AS (10 months of age), and upon development of severe AS (22 months of age). LA100 mice with depletion of TGF-β1 in platelets (LA100-PF4CreTgfb1flox/flox) and LA100 mice treated with low dose galunisertib, an inhibitor of the TGFβ-I receptor kinase, were similarly assessed at 22 months of age.

Results: PLR was significantly higher in mice with severe and moderate AS vs. control LA100 mice (192 ± 49, p<0.01, 249 ± 63 vs. 503 ±139, p=0.009, respectively). NLR was also increased in LA100 vs. control mice (n=12; p<0.01). Total TGF-β1 plasma levels were significantly higher in aged LA100 mice (n=21; 22 months) than in age-matched control C57Bl/6 mice (22 months; p<0.0001). Plasma TGF-β1 levels correlated with both PLR (R=0.26; p=0.020) and NLR (R=0.6, p=<0.001) in LA100 mice, but not in C57Bl/6 mice. Increased PLR and NLR negatively correlated with decreased fractional valve opening, a measure of AS progression, in LA100 mice (p<0.05 for both). To assess the role of platelet-derived TGF-β1 in influencing PLR, we utilized LA100 mice deficient in platelet TGF-β1 (LA100-PF4CreTgfb1flox/flox). They were partially protected from developing AS at 22 months, despite having higher PLR than control LA100 mice at 22 months of age (735 ± 245 vs. 503 ± 139). Moreover, treatment of LA100 mice with low dose galunisertib, was associated with a higher PLR (192 ± 49 vs. 671 ± 290; p<0.05), but a reduced NLR (p=0.03), compared to vehicle-treated control mice.

Conclusions: 1. Increased PLR, NLR, and plasma TGF-β1 levels are surrogate markers of AS progression in a robust mouse model that simulates human AS pathology. 2. Demonstration of higher PLR in mice with altered TGF-β1, via either platelet-specific TGF-β1 depletion or treatment with galunisertib, along with finding a lower NLR in the latter, warrants further study into the mechanism by which PLR may serve as a prognostic marker for AS progression apart from inflammation.
Type B Lactic Acidosis, an Unusual but Important Marker for Diagnosis of Hematologic Malignancy
Authors: Teibel Zachary Raphael , Arora Sahej , Silver Stephen , Anderson Nevin , Sbenghe Maria
Published: December 2024

ABSTRACT

Introduction:

Lactic Acid is a byproduct of the normal physiologic processes present in the human body. However, elevated lactic acid in the body, or lactic acidosis, can be a key finding in diseased states as well. Malignancies, especially hematological, are a rare but important cause of lactic acidosis without systemic hypoperfusion, with resolution being directly related to the treatment of the culprit malignancy.

Case:

A 50-year-old male presented to the ED and was diagnosed with acute pancreatitis based on symptoms, lipase levels, and imaging findings. He was found to have leukocytosis and anion gap metabolic acidosis with elevated lactic acid and beta-hydroxybutyrate. He was treated with IV fluids with resolution of all metabolic parameters except lactic acidosis and new pancytopenia. A bone marrow biopsy was performed outpatient due to persistent pancytopenia and lactic acidosis and found to be consistent with B-Cell Acute Lymphoblastic Leukemia. Initiation of chemotherapy normalized lactic acid levels within 5 days.

Discussion:

Lactic Acidosis is a common marker of systemic hypoperfusion, but it can rarely occur in the absence of it, especially in malignancies. One mechanism for this is the “Warburg phenomenon” and another could be Riboflavin/Thiamine deficiency. Patients may have potentially long-standing lactic acidosis, and it may be the initial presentation of malignancy, like in our patient. Treatment of underlying cancer resolves this Type B lactic acidosis.

Conclusion:

Lactic Acidosis in an otherwise vitally stable patient with deranged cell counts should raise concern for Type B Lactic acidosis due to possible hematologic malignancy.
A Rare Case of Ectopic Splenic Transplantation in a 16 Year Old with Hereditary Spherocytosis
Authors: Mehta Prutha , Zhao Xiaofeng , Presenza Thomas , Ahmed Rafat
Published: December 2024

Background: Hereditary Spherocytosis is a well known cause of hemolytic anemia. Splenectomy is indicated in patients who are on chronic transfusions to decrease the ongoing hemolysis. Transplantation of ectopic splenic tissue after splenectomy, although rare, is possible. There has been 1 such documented case report in the adult population, but none in the pediatric population. Clinical symptoms are uncommon, however, can include vague abdominal pain, nausea, vomiting, and organomegaly. Given its proximity to surrounding structures and organs, extra splenic tissue is often mistaken as gallstones, pancreatic masses, lymphomas, neuroendocrine tumors, and even hepatocellular carcinoma. It is understood that in the presence of trauma, ectopic splenic tissue is transplanted into the surrounding parenchyma, thereby allowing its regeneration. However, the etiology of ectopic splenic tissue regeneration in the absence of trauma, such as in this case, has never been reported.

Objective: We report a 16 year old female with a history of hereditary spherocytosis s/p splenectomy who presented with 2 years of intermittent, dull, non radiating RUQ abdominal and midsternal pain. RUQ ultrasound revealed multiple progressively increasing masses in the hepatic and biliary regions. Further characterization on MRI of the abdomen and pelvis revealed 4 large echogenic hepatic lesions and multiple small echogenic lesions in the gallbladder concerning for hepatocellular carcinoma. Core needle biopsy of the lesion was indicated.

Design/Methods: Chart review was performed through the electronic medical record to obtain information about the patient and case.

Results: Core needle biopsy of the hepatic lesion was consistent with spleen tissue; no hepatocytes present; no evidence of carcinoma. The findings are consistent with splenosis or overgrowth of ectopic spleen tissue. A scintigraphy with sensitive heat-denatured technetium-99m-labeled red blood cells is recommended to evaluate other hepatic masses.

Conclusion(s): Transplantation of ectopic splenic tissue in a patient who has undergone total splenectomy is an extremely rare finding in pediatric patients.
Real-World Experience of Efficacy and Toxicity Issues of Inotuzumab Ozogamicin in Adult Patients with Relapsed or Refractory Acute Lymphoblastic Leukemia
Authors: Yoon Jae-Ho , Kwag Daehun , Min Gi June , Park Sung-Soo , Park Silvia , Lee Sung-Eun , Cho Byung-Sik , Eom Ki-Seong , Kim Yoo-Jin , Kim Hee-Je , Min Chang-Ki , Cho Seok-Goo , Lee Seok
Published: December 2024

Background: In adult patients with relapsed or refractory (R/R) B-cell precursor acute lymphoblastic leukemia (BCP-ALL), CR rates are low and survival outcomes are very poor. For effective salvage therapy and allogeneic hematopoietic cell transplantation (allo-HCT) in remission, inotuzumab ozogamicin (INO) or blinatumomab (BLIN) have been introduced and revealed their efficacy in clinical trials. We analyzed the treatment outcomes of INO for R/R BCP-ALL patients.

Methods: One hundred patients with R/R BCP-ALL (Ph-positive 25, Ph-negative 75) were treated with a median 2 cycles (range: 1-5) of INO. We applied weekly INO with a dosage of 0.8mg/BSA for first week followed by 0.5mg/BSA for second and third week. For second cycle, we applied 0.5mg/BSA of weekly INO for 3 weeks in patients with complete remission (CR) after first cycle. For post-remission treatment, allo-HCT was planned for all patients.

Results: At the time of INO salvage treatment, 7 (7.0%) were primary refractory (4 BLIN-failure), 36 (36.0%) had relapsed during/after consolidation chemotherapy (23 BLIN-failure), and 57 (57.0%) had relapsed after first (n=47) or second (n=10) previous allo-HCT (23 BLIN-failure). At the time of relapse, bone marrow relapse (BMR) alone was observed in 61 (61.0%) and isolated extramedullary relapse (EMR) in 11 (11.0%), and both BMR+EMR in 28 (28.0%). At the end of first INO cycle, overall response was achieved in 60 (60.0%) patients (57.1% for primary refractory, 61.7% for early relapse < 12 months, and 57.6% for later relapse) and 7 of them underwent allo-HCT. We observed 12 (12.0%) early deaths, 28 non-responders, and 4 of them discontinued INO due to VOD/SOS and infectious complications. At the end of second INO cycle, best response was observed in 67 (67.0%) with MRD response of 63.1% and among them, 39 (58.2%) underwent allo-HCT. Among the rest 28 responders, 9 died in CR (2 VOD/SOS, 7 sepsis), 16 relapsed, and 3 are alive in CR after INO consolidation. Follow-up duration was median 24 months (range 8.5-53.5), and 2-year OS was 20.4%, and patients treated with allo-HCT showed 37.7% of 1-year OS.

Conclusion: Our data suggested that INO can be a feasible choice for salvage for adults with R/R BCP-ALL which showed a good CR rate. However, we experienced unexpectedly high regimen-related mortality caused by hepatotoxicity and infectious complications or thrombocytopenia due to marrow suppression. Risk-adapted dose adjustment or patient selection for INO are important for better treatment outcomes.
Potential Benefits of Using the Combination of Ibet with Ibtk Chronic Lymphocytic Leukemia and Other Tumor Types
Authors: de Carvalho Jose Leilton C. , Fernandes Pedro , Marques Fernanda de Morais , Pfister Verena , Goncalves Matheus Vescovi , Tavares Ana Paula , Lins Bruna B. , Asprino Paula , Bettoni Fabiana , Masotti Cibele , Camargo Anamaria , Arrais-Rodrigues Celso , Amano Mariane
Published: December 2024

Chronic lymphocytic leukemia (CLL) is characterized by clonal leukemia of mature B lymphocytes, being the most frequent leukemia in adults. B-cell receptor (BCR) down-regulation of the signaling pathway is believed to play a crucial role in cell survival and survival in CLL. The use of a BTK inhibitor (iBTK), e.g. ibrutinib, has shown high efficacy and low toxicity, but with frequent relapse in high-risk patients. Next generation sequencing identified genes associated with epigenetic regulation in CLL suggesting new therapeutic targets. The family of proteins with bromo-domains and extraterminal domains (BET) is composed of BRD2, BRD3, BRD4 and BRDT, which regulates expression of genes associated with growth and cell cycle, metabolism and tumor development. BET inhibitors (iBET) have shown promising results in studies, especially in acute leukemias. However, few studies have evaluated the role of antineoplastic iBET in CLL. Our objective was to evaluate the effect of iBET with iBTK combined treatment in ex vivo cells from patients with CLL and in other cell lines carrying ibrutinib target kinases. This is an observational and experimental study, in which we performed ex vivo functional (cell proliferation and death) and molecular (qPCR) assays with cells from CLL patients and cell lines (MOL13 and H1975). Our results demonstrated that the combination of IBTK (ibrutinib) with IBET (JQ1) induces apoptotic death in primary CLL cells and modulated genes that were essential in CLL development, such as IKZF3, TCL1A, BCL2 and MYC. We also demonstrated that the combination can inhibit proliferation, increasing apoptotic death and decreasing the expression of the MYC oncogene in the MOLM13 (acute myeloid leukemia cell line), in addition we identified that the H1975 (lung cancer cell line) had a significant reduction in proliferation with the combination of iBET with iBTK. According to this scenario, we conclude that the combination of iBET with iBTK seems to be a possible therapeutic strategy both in CLL and in other types of cancer, however, further analyses are needed.
Detection of M-Protein in Transplant-Ineligible Multiple Myeloma Patients on Daratumumab Using Liquid Chromatography Quadruple Time of Flight Mass Spectrometry
Authors: Balta Kaan Yusuf , Nicholas Matthew , Strelau Matthew , Phua Chai Wye W.
Published: December 2024

Background

Given the recent transition to novel front-line combinations capable of achieving a deeper response, the incorporation of measurable residual disease (MRD) into the response criteria for multiple myeloma (MM) could allow for better prognostication and potentially introduces MRD-adaptive treatment approaches. Liquid chromatography high-resolution mass spectrometry (LC-HRMS) is a powerful analytical tool that combines physical separation with high-resolution mass spectrometric detection. Mass spectrometry (MS) has emerged as a new diagnostic platform for monitoring M-proteins in MM, offering enhanced sensitivity for detecting M-proteins from peripheral blood compared to conventional serum protein electrophoresis/immunofixation analysis. Its utility has been endorsed in the 2021 IMWG guidelines.

Methods

Peripheral blood samples from MM patients were collected and used for validation of the MS. Samples were prepared in a multistep analytical process involving sample preparation by affinity purification targeting the conserved regions of immunoglobulins G, A, M, kappa, and lambda to enrich immunoglobulins and wash away serum proteins. Samples were analyzed on an Agilent 6545XT AdvanceBio LC/Q-TOF. M-proteins were identified by intact light chain masses above the polyclonal background. Samples were analyzed and compared to immunofixation electrophoresis (IFE) and flow cytometry (FC) (preliminary 10-4, forthcoming 10-5). Results were grouped into 4 categories: IFE+/QTOF+, IFE+/QTOF-, IFE-/QTOF+, IFE-/QTOF-. Limit of detection (LOD) studies were conducted by spiking IgG-kappa biologics into serum for both LC/Q-TOF and IFE.

Active and ongoing results

The LC/Q-TOF was able to isotype M-proteins similarly to IFE but with a mass accuracy approximately 1 Da. The LC/Q-TOF LOD was ~35 mg/L. 183 patient serum samples were analyzed. 134 were QTOF+/IFE+, 23 were QTOF-/IFE-, 23 were QTOF+/IFE-, and 3 were QTOF-/IFE+. When QTOF+/IFE- results were excluded due to the improved sensitivity of the LC/Q-TOF method, the concordance of LC/Q-TOF with IFE was ~98%.

Conclusions

Accurate mass determination of the M-protein intact light chain can readily differentiate daratumumab from IgG-kappa M-proteins. Excluding QTOF+/IFE-, the concordance rate was 98% between IFE and QTOF. QTOF demonstrated a LOD for IgG-kappa ~ 35 mg/L which is ~ 5-10x lower than most IFE estimated LODs. Future samples will compare QTOF to MRD assessments using next generation flow cytometry at a detection level of 10-5.
Congenital Hemolytic Anemias Presenting As Severe Anemia in Older Patients
Authors: Khosla Meera , Hassanain Hala S , Rice Lawrence
Published: December 2024

Mild congenital hemolytic anemias can become worse with aging and co-morbidities. We currently care for four patients in whom we established the diagnosis of Hereditary Spherocytosis (HS) or Hereditary Elliptocytosis (HE) after age 70. All had received multiple red blood cell transfusions. One had “failed” hypomethylating agent therapy for misdiagnosed myelodysplastic syndrome. Another patient (after three bone marrow exams) was about to start treatment for multiple myeloma (he had a small monoclonal gammopathy); he now has a normal hemoglobin after splenectomy for HS. The peripheral blood smear was strongly suggestive of the diagnosis in all patients. In three of the four, the diagnosis was confirmed by genetic testing and first-degree relatives were identified who also were affected. In the fourth patient, genetic and family studies are planned. Hematologists and hematopathologists should be vigilant for congenital hemolytic anemias becoming symptomatic in older people, sparing them misdiagnosis and mistreatment. With the de-emphasis on microscopic morphology skills in modern medical curriculae, this may be becoming a larger problem.
Jobelyn, a Sorghum Bicolor Exract-Based Oral Supplement Reduces Oxidative Stress in School Aged Children with Sickle Cell Disease
Authors: Diaku-Akinwumi Ijeoma Nnenna , Olajide Deborah , Adekunle Motunrayo B , Adebayo Adekunle B , Bamiro Saka , Ofakunrin Akinyemi O.D. , Ajonuma Louis C
Published: December 2024

Introduction:

Sickle cell disease (SCD) is highly prevalent in Sub-Saharan Africa, contributing to 16% of mortality in Nigerian and Ghanaian children under 6 years of age. School-aged children with SCD experience recurrent illness, hospitalization, and disability due to complications. Oxidative stress contributes significantly to SCD pathophysiology. This study investigated Jobelyn®, a sorghum bicolor-based herbal supplement, for its effect on oxidative stress markers in SCD children. Jobelyn is available over the counter and is use by people living with SCD in Nigeria.

Methods:

This non-randomized, quasi-experimental study included 87 Jobelyn-naïve children with SCD (aged 5-17 years). Ethics approval was granted by the Lagos State University Teaching Hospital health research ethics committee. Parents and participants gave written consent and assent. Demographic data, full blood counts, and oxidative stress markers (Glutathione, superoxide dismutase, catalase, and malondialdehyde) were measured at baseline, 6 weeks, and 12 weeks after commencing Jobelyn supplementation. Children receiving hydroxyurea were not excluded.

Results:

Significant increases in Glutathione levels (p<0.0001) and decreases in superoxide dismutase, catalase, and malondialdehyde levels (p<0.0001) were observed at 6 and 12 weeks. Hemoglobin concentrations rose significantly (p<0.001) at 6 weeks, while white cell counts fell below steady state values (p<0.001). Both hydroxyurea-naïve and the near equal number of hydroxyurea-treated children all responded with statistically significant changes in oxidative stress markers.

Conclusion:

Jobelyn significantly reduced oxidative stress and improved hematological indices in school-aged Nigerian children with SCD. Further longitudinal studies and Jobelyn trials in children with SCD are recommended to determine its benefits and safety profile.
Genetic Insights into Myeloid Malignancies: A Comparative Analysis of NCCN Guidelines, the World Health Organization Classification, and the ICC System
Authors: Puentes Roisin , Feld Jonathan , Smith Christopher G. , Lyle Derek D
Published: December 2024

Background: The 2023/2024 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for myeloid malignancies, alongside the 5th edition of the World Health Organization (WHO) Classification of Haematolymphoid Tumours: Myeloid and Histiocytic/Dendritic Neoplasms, and the 2022 International Consensus Classification of Myeloid Neoplasms and Acute Leukemias (ICC), provide comprehensive frameworks for understanding the genetic landscape of these diseases. This study aims to compare the genetic references in these guidelines to highlight the breadth of genetic markers implicated in myeloid malignancies.

Methods: We systematically reviewed the NCCN guidelines, the WHO, and the ICC system for references to genes relevant to myeloid neoplasms. The myeloid neoplasms assessed included chronic myeloid leukemia (CML), polycythemia vera (PV), essential thrombocythemia (ET), myeloproliferative neoplasms (MPN), myelodysplastic syndromes (MDS), MDS/MPN overlap syndromes, chronic neutrophilic leukemia (CNL), and chronic eosinophilic leukemia (CEL).

Results: A total of 185 unique genes were identified as relevant to myeloid malignancies within the guidelines, 87 of which were fusions. 89 genes were mentioned in the NCCN guidelines, 74 in the WHO classification, and 143 in the ICC. Some genes were uniquely associated with specific disease states, while others were relevant across various myeloid malignancies. An overlap of 76 genes, including 32 fusions was noted across all guidelines.

Conclusion: The findings underscore the critical role of comprehensive genetic testing in the diagnosis and management of myeloid malignancies. The overlap and unique genetic markers identified in the NCCN, WHO, and ICC guidelines emphasize the need for large panel testing across myeloid malignancies to ensure precise genetic characterization of the relevant genes, enabling accurate diagnosis, risk stratification, prognostication, and the tailoring of therapeutic strategies to the patient, including the use of drugs targeted for only certain mutations. The high gene count captured within the treatment guidelines emphasizes the necessity for comprehensive genetic testing to enhance clinical outcomes and advance personalized medicine in the management of myeloid neoplasms.
Hemoglobin A2 Values in Sickle Cell Disease Patients Reveal Alarming Heterozygosity
Authors: Pendharkar Dinesh , Nirmal Garima
Published: December 2024

Sickle cell disease (SCD) is one of the most common genetic diseases, affecting more than 300000 patients in India. It is characterized by homozygous hemoglobin S or other HbS-associated variants. However, large datasets have not been reported. The prevalence of thalassemia is equally high in the Indian population. High-performance liquid chromatography data are now available. However, heterozygosity has not been well studied. HbA2 values require further consideration.

We conducted a prospective observational study to collect data from large cohorts and analyze HbA2 % in relation to hematological parameters in one geographical tribal district. A total of 691 patients, including 575 homozygous (HbSS) and 116 patients with HbS > 50% and HbA2 values ≥ 4%, were reviewed. High-performance liquid chromatography charts were used to differentiate the Hb variants.

The median age of SCD was was16 (interquartile range {IQR] 9-25) years, and 360 (52.1 %)were males. The median A2 was 1.9% (IQR 1.4-2.7) Hb S was 67.9 % (IQR,62.9-72.7), Hb F was 26.2% (IQR 21.5-30.9).There were 116 (16.68 %) patients with HbA2 levels of 4 and above, with a median age of 16.5 (IQR 9-27) years and 59.5 % males. The value of HbA2 % ranged from to 4-8 in 100 patients; one had a value of 37, and remaining between 9-22. This group had median Hb A2 % of median 5.1 (IQR 4.5-6.3) , HbS % of 65.4 (IQR 65.0-70.2) , HbF% of 23.25 (IQR 16.8-29.3)and A0 of 6.6 (IQR 4.4-8.2).The median hematological parameters were Hb 7.8 g/dL (IQR 6.0-9.1), MCV 71.4 fL (IQR 66.8-76.6) , MCH 22.6 pg (IQR 21.1-24.4) , MCHC 31.3 g/dL (IQR 29.9-32.9) Total count 14.4 x103 /µL (IQR 8.6-18.8).A higher HbA2 level was associated with higher MCV (Spearman's rho value 0.008; p =0.01) and positively correlated with MCH (Spearman's rho value=0.003; p =0.01).

In conclusion,the data showed a strikingly high incidence of elevated Hb A2 (16% of the SCD population). Considering the higher-than-normal values of HbA2 in the sickle population in India, it is important to generate even larger data. For better understanding, the molecular classification of patients should be incorporated. Therefore, there is a need to reclassify the levels of HbA2 to qualify for heterozygosity.
Advancing agriculture with functional NM: “pathways to sustainable and smart farming technologies”
Authors: Alam Mir Waqas , Junaid Pir Mohammad , Gulzar Yonis , Abebe Buzuayehu , Awad Mohammed , Quazi S. A.
Published: December 2024

The integration of nanotechnology in agriculture offers a transformative approach to improving crop yields, resource efficiency, and ecological sustainability. This review highlights the application of functional NM, such as nano-formulated agrochemicals, nanosensors, and slow-release fertilizers, which enhance the effectiveness of fertilizers and pesticides while minimizing environmental impacts. By leveraging the unique properties of NM, agricultural practices can achieve better nutrient absorption, reduced chemical runoff, and improved water conservation. Innovations like nano-priming can enhance seed germination and drought resilience, while nanosensors enable precise monitoring of soil and crop health. Despite the promising commercial potential, significant challenges persist regarding the safety, ecological impact, and regulatory frameworks for nanomaterial use. This review emphasizes the need for comprehensive safety assessments and standardized risk evaluation protocols to ensure the responsible implementation of nanotechnology in agriculture.