bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of Early Factor VIII Exposure, Prophylaxis and Prenatal/Perinatal Events on Inhibitor Risk in Children with Hemophilia A: A Case-Control Study.
Authors: Santagostino Elena , Rocino Angiola , Mancuso Maria E. , Mazzucconi Maria G. , Mancuso Giacomo , Messina Maria , Tagliaferri Annarita , Luciani Matteo , Boeri Elio , Mannucci Pier M.
Published: October 2019

In a multicenter case-control study we investigated the impact of prenatal/perinatal events and early FVIII exposure on the inhibitor risk in hemophiliacs. Patients: 102 children (age:13–196 months) with hemophilia A (FVIII≤2%) exclusively treated with recombinant FVIII and evaluated for inhibitors every 3 months were included. Forty-seven patients who developed inhibitors at the median age of 26 months (4–80) after a median of 16 exposure days (ED, 5–150), 37 high-responders (6–500 BU/mL) and 10 low-responders (<5 BU/mL), were compared with 55 children who did not develop inhibitors after at least 20 ED (5<50, 4<100, 10<200 and 36>200 ED). Results: by univariate analysis, family history of inhibitors, intron 22 inversion and prophylaxis started after the first 20 ED were significantly associated with an increased risk of inhibitor development (OR 9.5, 95%CI 1.1–79.9; OR 2.7, 95%CI 1.1–6.6; OR 3.7, 95%CI 1.1–12.1, respectively). No statistically significant differences were found for variables such as villocentesis/amniocentesis, premature/caesarian birth, breast-feeding, surgery, central venous devices and FVIII infusions associated with infections/vaccinations. By multivariate analysis, the inhibitor risk was 2.8-folds (95%CI 1.1–7.3) in children with intron 22 inversion and 4.5-folds (95%CI 1.1–17.5) in patients who started prophylaxis after the first 20 ED. By univariate and multivariate analysis, there was not a linear trend in the inhibitor development according to the age at first FVIII exposure (≤6, 7–12, 13–18, 19–24, >24 months). Conclusions: this study showed that starting prophylaxis within the first 20 ED had a favourable impact on the inhibitor risk independently from the age at first FVIII exposure.
Pulmonary Hypertension in Pediatric Patients with Sickle Cell Disease; a Retrospective Study.
Authors: Young Eric M. , Zilberman Mark V. , Du Wei , Sarnaik Sharada A.
Published: October 2019

Background: While pulmonary hypertension (PHT) contributes significantly to the morbidity and mortality of adults with sickle cell disease (SCD), it has not been studied in pediatric SCD patients. We sought to evaluate the prevalence and significance of PHT in pediatric SCD population.

Methods: From May 1999 to July 2004, 123 echocardiograms were performed in SCD patients. Utilizing the tricuspid valve regurgitant jet, right ventricular systolic pressure (RVSP) was estimated in 56 studies (47 patients, aged 0 to 18 years). PHT was defined as RVSP >30 mmHg.

Mean steady-state as well as the most recent white blood count (WBC), hemoglobin (Hb) level, reticulocyte count, ferritin level, and number of red cell units transfused in the year prior to the study were noted. In addition, all chest X-ray readings were reviewed to determine the number and type of life-time pulmonary events (effusions, infiltrates, pneumonia, atelectasis or CHF) in each patient. Acute chest syndrome (ACS) was determined to be any effusion, infiltrate or pneumonia.

Statistical analysis included Fisher’s exact test and Spearman’s correlation coefficients.

Results: Eleven patients were acutely ill at the time of the echocardiogram and were excluded from the analysis. Of the remaining 36 patients, pulmonary hypertension was present in 24 (66%). There was a significant difference in RVSP between younger (0 to 9 years) and older (10 to 18 years) groups of patient (p<0.004). There was a positive correlation between the age and RVSP (r = 0.36; p = 0.031).

A significant negative correlation was shown between RVSP and most recent Hb (r = −0.41; p = 0.012) as well as RVSP and the mean steady state platelet count (r = −0.35; p = 0.035). A positive correlation was found between RVSP and the number of ACS episodes (r = 0.37; p = 0.024), RVSP and mean steady state reticulocyte count (r = 0.51; p = 0.002) as well as the most recent reticulocyte count (r = 0.42; p = 0.012). There was however, no correlation found between RVSP and the number of episodes of CHF, collapse or atelectasis separately or grouped together. No correlation was found between RVSP and the number of units transfused or ferritin level.

Conclusion: Pulmonary Hypertension is highly prevalent in the pediatric SCD population and its prevalence increases with age. It correlates with indicators of acute and chronic hemolysis as well as the number of ACS events. Our study did not demonstrate correlations between PHT and iron overload indices. Prospective clinical trials monitoring PHT in SCD pediatric patients are indicated.
In Vitro Modulation of Cellular Immunity with Antioxidants in Patients with Thalassemia Major.
Authors: Atasever Belkis , Kuruca Serap Erdem , Karakas Zeynep , Agaoglu Leyla
Published: October 2019

Immunological disturbances have been reported in thalassemia and the possibility has been raised that these may be consequences of blood transfusion and iron overload. These disturbances are augmentation of the number of supressor T cells (CD8), decreased number and activity of helper T cells (CD4) and impaired activity of NK (natural killer) cells. Iron overload causes toxic tissue changes through the release of free radicals and induces oxidative stress. According to Fenton and Haber-Weiss reactions, iron plays a catalytic role occuring hydroxyl radicals (OH*) which are very reactive free radicals. Antioxidants, like vitamin E, vitamin C and selenium, may modulate oxidative damage.

In the present study; firstly, normal lymphocytes mitogen responses and NK activity were investigated by colorimetric MTT test in 26 thalassemia patients and 10 healthy volunteers as control. Secondly, lymphocytes were incubated with vitamin E ( 150, 50, 15 mg/ml), vitamin C (200, 100, 20mg/ml) and selenium (10−5, 10−6, 10−7 M). Finally, lymphocytes mitogen responses and NK activity are investigated. The results were statistically analyzed comparing with controls and healthy volunteers.

It was found decreased NK activity of thalassemia patients in comparison with healthy volunteers. The concentration of 10−7 M of selenium enhanced NK activity at the E:T (effector/target) ratio of 50:1 The concentration of 200 mg/ml of vitamin C enhanced NK activity at the E:T ratio of 10:1, 25:1 and 50:1. However, vitamin E decreased NK activity of both thalassemia patients and healhty volunteers. The concentration of 50 mg/ml vitamin E decreased NK activity at the E:T ratio of 5:1 in thalassemia patients and the concentration of 15 mg/ml of vitamin E decreased NK activity at the E:T ratio of 5:1 in healhty volunteers.

It was not found any differences between thalassemia patients and healthy volunteers in lymphocytes mitogen responses. The concentration of 200 mg/ml of vitamin C decreased lymphocytes mitogen response against PHA.

In conclusion, we suggest that vitamin C and selenium supplementation are required in patients with thalassemia for augmentation of NK cell activity.
Novel Dombrock Blood Group Genetic Variants in Different Ethnic Groups Identified by High Throughput Beadchip DNA Analysis.
Authors: Reid Marion E. , Vissavajjhala Prabhakar , Palacajornsuk Poosub , Velliquette Randall W. , Chaudhuri Asok , Hashmi Ghazala P. , Shariff Tasmia , Seul Michael
Published: October 2019

Background : Modern bioarray chip technology enables rapid allele determination in a large number of donors by DNA typing when compared to classical serological methods. We analyzed five single nucleotide polymorphisms (SNPs) associated with Dombrock (DO) alleles in blood samples from donors of different ethnic groups, and found new genetic variants.

Method : The BeadChip™ technology used primers for a single multiplex PCR reaction, and allele-specific oligonucleotides with variable 3′-terminal nucleotide for elongation-mediated multiplex analysis (eMAPTM) of the DO polymorphisms. Color-encoded beads displaying the elongation probes were assembled into planar arrays of small footprint on semiconductor chips, permitting the instant imaging of fluorescent elongation products from the entire array. Five SNPs of DO blood group antigens DOA/DOB (nt 378 C>T, 624 T>C, 793 A>G), Hy+/Hy− (nt 323 G>T) and Jo(a+)/Jo(a−)(nt 350 C>T) were analyzed simultaneously. Blood samples from a total of 445 donors, comprising of 100 Thai, 69 Jewish, 58 Chinese and 218 random New York City donors were analyzed.

Results : As shown in the table below, the predominant diploid allelic combinations observed in all the groups were DOB/DOB followed by DOA/DOB and then DOA/DOA. In the random donor group, we also observed several less prevalent allele combinations: DOB/HY (14.2%), DOB/JO (1.4%), DOA/HY (0.5%), DOA/JO (2.3%), HY/HY (1.4%), JO/JO(1.8%), and HY/JO (0.9%). Interestingly, two novel alleles in trans with the known alleles: DOB/HA (11% in Thai, 2.9% in Jewish, 6.9% in Chinese and 2.8% in random donors), DOA/HA (1.8% in random donors, 1.7% in Chinese and 1.4% in Jewish), DOB/SH (0.5% in random donors) and HY/SH (1.4 % in random donors) were also detected. HA allele is 378T, 624T, 793A (like JO but with 350C). Hemagglutination studies showed that HA, as predicted from the nucleotide at position 793, encoded Doa antigen. SH allele is 378C, 624C, 793C (like HY but with 323G) and is predicted to encode Dob antigen.

Conclusion: The BeadChip™ technology facilitated the identification of novel genetic variants, in addition to accelerating blood group typing.

Most prevalent DO allele combinations (in %)

Ethnic Group DOB/DOB DOA/DOB DOA/DOA Thai 73 14 2 Jewish 52.2 30.4 9 Chinese 79.3 12.1 0 Random 38.5 21.6 11
Peripheral Blood Lymphocytes Subpopulations and Apoptotic Markers in Patients with Lymphoid Malignancies and in Controls: An Epidemiologic Case-Control Study.
Authors: Maynadie Marc M. , Casey Romain , Piazzon Karine , Capiod Jean Claude , Carli Paule-Marie
Published: October 2019

Few references ranges of normal peripheral blood lymphocytes subpopulations are available in the literature and fewer data were available regarding activation, proliferation and apoptosis antigen expression on such populations. We studied these parameters in patients included in an epidemiologic case-control study on risk factors of lymphoid malignancies conducted within European countries.

Cell surface staining of peripheral blood lymphocyte antigens were analysed by multicolour flow cytometry in 300 cases and 300 controls. We determined CD3+, CD3+/CD4+, CD3+/CD8+, CD3−/CD56+CD16+, CD19+, CD19+/CD5+, CD19+/CD5− and CD57+ populations. Expression of CD25, CD16, CD40, CD154, CD95 and CD178 were studied on these populations. CD expressions were compared by multiple regressions between controls and diseases, after stratification on circulating phase. In controls we observed a significant decrease of B cells and an increase of NK cells with age. No difference was found according to sex, smoking status and Body Mass Index. In Follicular Lymphoma, Diffuse Large B Cell Lymphoma and Marginal Zone Lymphoma (MZL) without circulating phase cases, we observed a decrease of the B cell subset and an increase of the NK cell subset instead of only a trend was found in Multiple Myeloma, Mycosis Fongoides, Hodgkin Disease and Lymphoplasmacytic Lymphoma. CD95 expression was increased in HD, DLBCL, MZL without circulating phase and Hairy Cell Leukemia but decreased in B-cell Chronic Lymphocytic Leukemia and MZL with circulating phase. CD40 was decreased on B cells in HD, FL, MZL, B-ALL and CLL.

This study was one of the most important, in term of number of patients included, particularly concerning data on activation, proliferation and apoptosis markers in normal subjects but also in several lymphoid malignancies.
Multiple Cycles of Recombinant Human Thrombopoietin Therapy in a Patient with Chronic Refractory Idiopathic Thrombocytopenic Purpura.
Authors: Zhao Yongqiang , Hua Baolai , Zou Nong , Wang Shujie , Zhu Tienan
Published: October 2019

Thrombopoietin (TPO) is the key regulator of megakaryocytepoiesis and platelet production. TPO binds to its specific receptor, c-Mpl, on the surfaces of megakaryocytes, and may promote the proliferation, differentiation and maturation of megakaryocytes, and finally increase the circulating platelet count. The role of TPO in the pathogenesis of idiopathic thrombocytopenic purpura (ITP) is not certain. Plasma concentrations of TPO in ITP patients were similar to or little lower than that in healthy subjects. Therefore it is possible that supplemental TPO could significantly promote platelet production and increase platelet counts in ITP patients. Here, we report the result of multiple cycles of recombinant human thrombopoietin (rhTPO) therapy in a patient with refractory ITP. The patient, a 42-year-old woman, was admitted to our department on December 30, 2003. She had suffered from chronic ITP for more than 4 years. The patient had been treated with glucocorticosteroids, immunosuppressive agents and splenectomy. No sustained response could be achieved. The diagnosis of chronic refractory ITP was made. There were petechiae and gingival bleeding on admission. Liver and spleen were not palpable. Hemoglobin was 142g/L, white blood cell count 7.6×10 9/L, platelet count 15×10 9/L. Bone marrow aspiration revealed that erythroid and myeloid development were normal, megakaryocytes were increased in number and no dysplastic features. After an informed consent was obtained from the patient, rhTPO (Sunshine Pharmaceutical Corporation, China) was administrated subcutaneously at dosage of 1.0 μg/kg, daily for 14 days or until platelet count sustained more than 50×109/L. Anti-rhTPO antibodies were determined weekly by ELISA. Three cycles of rhTPO therapy was given with 6, 13 and 8 dosing for each cycle. The platelet counts before each cycle were all less than10×109/L and increased above 50×109/L on day 5, 11 and 8 of rhTPO administration, respectively. The peak platelet counts of 456, 130 and 82×109/L were reached on day 9, 15 and 13 for each cycle. Then platelet count decreased gradually. The durations of platelet count more than 50×109/L in 3 cycles were 13, 7 and 10 days respectively. No increase of WBC count and Hb level occurred. No liver and kidney function damage, abnormal coagulation functions or thrombosis developed during the treatment. rhTPO antibodies were not detectable. The result indicated that rhTPO could transiently increase peripheral platelet counts of the patient with chronic refractory ITP. It was uncertain why peak platelet counts declined and durations of platelet count more than 50×109/L shortened when multiple cycles of rhTPO were given.
An Open Label, Multi Center Study on the Efficacy and Safety of a Liquid, Ready-to-Use Intravenously Administered Anti-D Immunoglobulin in Patients with Chronic Immune Thrombocytopenic Purpura.
Authors: Aledort Louis M. , Salama Abdulgabar , Kovaleva Lidia , Robak Tadeusz , Brenner Benjamin , Newland Adrian , Davies Simon , Nugent Diane J. , Hubsch Alphonse , Andresen Irmgard , Zenker Othmar
Published: October 2019

Introduction

Intravenous anti-Rh0(D) immune globulin (anti-D) is used as a platelet enhancing therapy in patients with ITP. The following study was designed to assess the efficacy, tolerability and safety of a new, liquid anti-D (ZLB Behring).

Methods

This multicenter study was an open-label, single arm, phase III trial of 98 Rh0(D)-positive patients with chronic ITP and a platelet count < 30x109/L. Exclusion criteria included previous splenectomy, HIV infection, pregnancy, anemia (hemoglobin < 100 g/L), and positive Coombs test. The study medication was a chromatographically purified, solvent detergent treated and nanofiltered (15 nm) anti-D. This manufacturing process results in a product with a high purity (particularly a very low IgA content) and an excellent viral safety. Anti-D was provided in pre-filled, ready-to-use syringes and administered at a dose of 50 μg/kg body weight as a single intravenous injection.

The primary endpoint was the response rate, defined by the percentage of patients reaching an increase of their platelet count by at least 20x109/L to at least 30x109/L within 15 days. Secondary endpoints included time to platelet response, duration of response and the regression of hemorrhages. For the safety evaluation, blood hemoglobin, serum creatinine and bilirubin levels were closely monitored, in addition to the recording of all adverse events (AE).

Results

The overall response rate was 66 % (95 % CI: 57 to 75 %). The median time to response was 3 days and the median duration of response was 22 days. A regression of hemorrhages was seen in 88 % of the 50 patients having bleeding at baseline. The most frequent drug related AEs were chills, pyrexia, increase in bilirubin levels and headache. They were generally mild or moderate. A slight decrease in hemoglobin levels (median: -8 g/L) and a slight, transient elevation of bilirubin (median: +0.6 mg/dL) were seen in most patients as expected due the mode of action of anti-D. Clinically relevant elevations in serum creatinine level did not occur (median change: < 0.02 mg/dL).

Discussion

The present study has demonstrated that the tested anti-D is safe and efficacious in chronic ITP. Response rate, time to response and duration of response were similar to those reported for other platelet enhancing treatments, including high dose corticosteroids, IVIG and other anti-D products. The increase in platelet count was accompanied by a substantial regression of hemorrhages. Drug related adverse events were mainly mild and expected and no cases of severe hemolysis or deterioration of renal function occurred. The liquid, ready-to-use anti-D is an attractive treatment alternative in ITP, offering the convenience of a fast and easy administration.
High Altitude: A Hyper Coagulable State: Results of a Prospective Cohort Study.
Authors: Kotwal Jyoti , Chopra G. S. , Kotwal A. , Sharma Y. V. , Bhardwaj J. R.
Published: October 2019

Thrombosis has been recognized as a complication of rapid ascent as well as long-term stay at high altitude (HA). Researchers have presented conflicting results and majority of them studied only short-term stay. A prospective cohort study was carried out at a height of 3500 m to study the hematological factors, which may lead to increased propensity to thrombosis on prolonged stay at HA. The subjects were healthy low landers (initial N=38, complete follow up N=32) in age group of 20–40 years, inducted to HA and investigated at induction and subsequently at 3 and 8 months. The comparison cohort was age and sex matched low landers not inducted to HA. Bleeding time, clotting time, hemoglobin (Hb), HCT, platelet count, prothrombin time, APTT, fibrinogen, d-dimers. Protein C, protein S, anti-thrombin III levels, APC resistance, PAI-1, Beta thromboglobulin (BTG) and PF4 were estimated. On induction to HA the mean Hb, platelet count, fibrinogen levels, PAI-1 levels and levels of platelet activation factors were in normal range and not statistically different from those at low altitude (P>0.05). None of the subjects had thrombophilia. There was no statistically significant change in Protein C, Protein S, AT III levels, APC resistance, BT, CT, PT and APTT. The mean values were: Hb (13.9, 15.6, 16.6 gm/dl); platelet count (255, 309, 343 x 103/mm3); fibrinogen (253, 304, 346 mg/dl); BTG (30.3, 38.5, 47.3 IU/ml); PF 4 (3.9, 7.6, 13.7 IU/ml) and; PAI-1 (23.7, 40.1, 49.3 ng/ml), at (induction, 3 months, 8 months) respectively. The P value for all was 0.000 by repeated measure analysis. The high Hb itself is unlikely to be the single cause of the thrombotic tendency at HA as its maximum value was 18.0 gm/dl. Erythrocytosis and hyper viscosity are known to activate platelets, however, platelet activation may be the result of hypoxic stress and injury to platelets or endothelium. An important finding of the study was the rise in PAI-1 levels that correlated with rise in fibrinogen levels and duration of stay at HA (Figure 1 and 2). The endothelial injury and clotting activation followed by increased fibrinolysis maintains homeostasis. We hypothesize that increased PAI-1 level tilts the balance by decreasing fibrinolytic activity and increasing propensity to thrombosis. Hypoxia during surgery is known to cause raised postoperative PAI-1 levels leading to a tendency of postoperative thrombosis. The prolonged hypoxia in a lowlander staying in HA may have a similar effect. By virtue of increased platelet count, hematocrit, platelet activation factors, PAI-1 and fibrinogen, prolonged stay at HA is a pro thrombotic state. Thus, there may be a role for antiplatelet drugs in prevention in view of the platelet hyperactivity and interventional trials with homocysteine lowering vitamins or aspirin also need to be considered.
Is Cladribine, a Treatment for Chronic Lymphocytic Leukemia, a DNA Methylation Inhibitor?.
Authors: Yu Margaret K. , Wade Mark , Moore Brent C. , Fitzpatrick Frank A.
Published: October 2019

Chronic lymphocytic leukemia is a heterogenous B lymphocyte disorder with a variable natural history. Like other Malignancies, key regulatory genes like the tumor suppressor, p16, and the mismatch repair gene, hMLH1, are frequently silenced by DNA methylation in patients with chronic lymphocytic leukemia (CLL). Although focal hypermethylation is found, global genomic DNA is hypomethylated compared to genomic DNA from healthy volunteers. Inhibition of DNA methylation may help CLL cells regain normal cellular function. Few studies have been done evaluating DNA methylation of CLL cells likely in part due to the difficulty in establishing a CLL cell line without altering DNA methylation. In addition, the primary cells do not divide in vitro, making the assessment of effect of a DNA methylation inhibitor very difficult. Of the ten samples tested from patients with CLL, we have not found p16 or hMLH1 expression by western blotting. Since 2-Chlorodeoxyadenosine (Cladribine) is already used clinically for treatment of CLL and may deplete available methyl donors, we asked if Cladribine is effective because of its inhibitory effect on DNA methylation in leukemia cells. To further evaluate the role of DNA methylation in CLL, we assessed the effect of 5-aza-2′-deoxycitidine (Decitabine), a DNA methyltransferase inhibitor compared to Cladribine in HT-29 cells. HT-29 cells do not express p16 and MAGE because of DNA methylation of the promoters. Assessment of global DNA methylation is done using reversed-phase high-performance liquid chromatography. Our results reveal that daily doses of 300nM Cladribine modestly inhibited global DNA methylation by 20+/−14% at 72 hours (n=3), while daily doses of 500nM Decitabine inhibited global DNA methylation by 75+/−9% at 72 hours (n=3). This results in re-expression of MAGE-1, a gene silenced by DNA methylation in all somatic tissues and p16, only in the Decitabine treated cells. We also evaluated the Cdx-2 promoter, an intestinal restricted gene silenced by DNA methylation in HT-29 cells. Decreased methylation of two regions of the Cdx-2 promoter was seen in the cells treated with Decitabine compared to the control cells. Cladribine treated cells had no effect on the Cdx-2, and may actually increase DNA methylation (result of 20 sequences). These results could be explained by the marked growth inhibitory effect of Cladribine at 300nM. We chose to evaluate Cladribine at 300nM because this plasma concentration is obtainable in patients treated with 0.1mg/kg of Cladribine, a dose frequently used in treatment of hairy cell leukemia. Cells with decreased DNA methylation after treatment with Cladribine may have died at the 72 hour time point.
Natural History of 656 Patients with Non IgM MGUS.
Authors: Nobile Carolina , Petrucci Maria T. , Bartolozzi Francesco , Levi Anna , De Muro Marianna , Tirindelli Maria C. , Del Bianco Patrizia , Gallucci Cristiano , Mandelli Franco , Avvisati Giuseppe
Published: October 2019

A monoclonal gammopathy of undetermined significance (MGUS) occurs in about 1% of the population over 50 years of age. Of these, about 20% evolves in Multiple Myeloma (MM); however, so far, predictive parameters of progression have not yet been identified.The aim of this study was to analyse the natural history of a cohort of non IgM MGUS and to identify whether or not there were laboratory parameters at diagnosis which can be utilized as prognostic markers of stable MGUS or progression to MM. From February 1974 to July 2001, 656 non IgM MGUS, whose clinical history was concluded (lost to follow up or died), have been followed at the Hematology of the University “La Sapienza” in Rome. The duration of follow up ranged from 2 months to 324 months, male/female ratio was 1.14, median age was 65 years (range 19–92). In each patient we evaluated: hemoglobin, platelet count, serum protein electrophoresis, serum concentration of monoclonal protein, serum calcium, creatinine, uric acid, BUN and percentage of bone marrow plasma cells.A monoclonal component (MC) of IgG type was documented in 543 patients (83%) while in 106 (16%) it was of IgA type, 6 patients had biclonal MC and 1 had a λ light chain MC; BJ proteinuria was detected in 78 (11%) patients at diagnosis.

After a median follow up of 60.1 months (range 2–324) the MC remained stable in 496 patients (75%), whereas in 160 cases (25%) increased to evolve in MM. According to the literature, cumulative probability of progression to MM was 3%, 7% and 17% at 5, 10 and 15 years respectively. Differently from what observed by other investigators, in this cohort of pts, the MGUS of IgA type was not associated with a higher risk of progression to MM. The median time of progression to MM was 60.7 months (range 3–256) and factors associated with a more rapid progression to MM were advanced age and a higher number of bone marrow plasmacells. At diagnosis of MM, the concentration of the serum MC was significantly higher (P<0.003) in patients who evolved from MGUS than in those with a newly diagnosed MM. None of the studied parameters at diagnosis of MGUS were predictive of evolution to MM even though, levels of MC <2.4 g/dl and bone marrow plasmacell infiltration <9% indicated a slower progression to overt MM.
Significant and Morbid Changes in Heart Rate Variability Precedes and Complicates Symptomatic Hypotension in Peripheral Blood Stem Cell Apheresis.
Authors: Nakamae Hirohisa , Terada Yoshiki , Akahori Mika , Nakane Takahiko , Hagihara Kiyoyuki , Takeoka Yasunobu , Hasegawa Taro , Ohta Kensuke , Yamane Takahisa , Hino Masayuki
Published: October 2019

Peripheral blood stem cell harvest (PBSCH) has been widely performed for rescue following high-dose chemotherapy or as an alternative to BMT for allogeneic stem cell transplantation. However, severe complications, which caused sudden death, were reported in PBSCH from healthy donors. Recent cumulative evidence shows that decrease in cardiovascular signal variability of the R-R period (heart rate variability, HRV) is strongly associated with sudden death and/or cardiac event after a myocardial infarction. Furthermore, usefulness of HRV as a clinical tool has been explored in numerous conditions such as hypertrophic cardiomyopathy, obstructive sleep apnea, diabetic neuropathy, and various neurological alterations. Two types, time domain and frequency domain, are included in HRV analysis. In this study, we investigated HRV during and after apheresis for PBSCH in 23 cases [8 autologous transplant patients, 15 allogeneic transplant donors; 8 men, 15 women; median age 47 years (27–55)]. Date from 24-hour ambulatory ECG recordings were analyzed with R-R data analysis software (MemCalc/CHIRAM version 1, Suwatrust, Tokyo, Japan). Acknowledged simple markers in time domain analysis are the standard deviation of all normal beats (SDNN) and the square root of the mean of the sum of squared differences between adjacent normal-to-normal intervals (r-MSSD). On the other hand, markers in frequency domain analysis include LH, low frequency power (0.04–0.15Hz); HF, high frequency power (0.15–0.4 Hz); LH/HF ratio; VLF, very low frequency power (0.003–0.04 Hz); and ULF, ultra low frequency power (<0.0033 Hz). These power spectrum analyses of HRV are used to investigate sympathovagal balance, autonomic cardiovascular control and/or target function impairment. Among frequency domain analysis markers, VLF or ULF reportedly have particular prognostic value in all causes of mortality after myocardial infarction. In our study, SDNN, r-MSSD, HF, VLF, and ULF significantly and markedly decreased to morbid levels during apheresis (all P<0.001). Of 23 harvest cases, symptomatic hypotension occurred during apheresis in 2 cases and after apheresis in one case. Notably, in these 3 cases, SDNN and VLF had already begun to decrease about 5–10 minutes before significant symptomatic hypotension occurred (P=0.03, P=0.04, respectively). Our results suggested that morbidly decreased HRV indicates serious cardiovascular load and suppression of the parasympathetic nervous system in apheresis for PBCSH. HRV analysis might be a useful tool to prevent donors from severe autonomic cardiovascular complications in PBCSH.
Valgancyclovir Significantly Reduced Reactivation of CMV Following Mini-Transplantation with MAP (Mitoxantrone, Ara-C, and Pentostatin) Regimen.
Authors: Qureshi Anila , Seiter Karen , Ahmed Tauseef , Nelson John , Liu Delong
Published: October 2019

CMV reactivation remains a significant morbidity following allogeneic transplantation. IV gancyclovir may cause myelosuppresion and renal toxicity. It is reserved for the therapy of CMV reactivation. We initiated prophylaxis with Valgancyclovir (Valcyte, manufactured by Hoffman-LaRoche), an oral pro-drug of gancyclovir, against CMV reactivation in patients with CMV exposure history. The Valgancyclovir was given as 450 mg po BID three times a week when post-transplant WBC exceed 1500. In this study, 50 patients who received mini-allogeneic hematopoietic stem cell transplantation following MAP regimen (mitoxantrone, AraC, pentostatin) were included for analysis. 30 patients had prior exposure to CMV (pre-transplant CMV IgG + for patient and /or donor), 20 patients had no evidence of prior exposure. Among the 30 patients who had exposure, 10 patients had antigenemia. Among the 20 patients who did not have exposure history, 2 had CMV antigenemia. Among the 30 patients who had exposure, 19 received Valgancyclovir prophylaxis, 10 received acyclovir, and 1 received gancyclovir. 2 of 19 patients (10%) among the valgancyclovir group had CMV antigenemia, whereas 8 of 11 (72%) who did not receive valgancyclovir prophylaxis had CMV antigenemia (table 1). We conclude that valgancyclovir prophylaxis significantly reduced CMV reactivation (p=0.0009) in patients who had history of CMV exposure and received mini-transplantation after MAP conditioning regimen.

CMV reactivation post-minitransplantation with MAP regimen

*CMV-Ag + CMV-Ag − *p=0.0009 Valgancyclovir n=19 2 17 Acyclovir /Gancyclovir n=11 8 3
Successful Re-Engraftment after Second Allogeneic Transplantation for Graft Failure in Patients with Refractory Hematologic Malignancies.
Authors: Gabriel Don A. , Coghill James , Shea Thomas C. , Comeau Terrance , Irons Robert , Krasnov Carol
Published: October 2019

Graft failure (GF), either primary or after transient engraftment, following matched, related allogeneic hematopoetic stem cell transplantation (HSCT) without T-cell depletion is usually less than 3% for hematological diseases. Graft failure using non-T-cell depleted unrelated donors in chronic myelogenous leukemia (CML) as reported by the national marrow registry is approximately 9.7%. For aplastic anemia, the incidence of graft failure is estimated to be 10%. In this report, we present 3 patients (Pts) with GF following unrelated ablative allogeneic HSCT (two with peripheral blood stem cells and one with bone marrow). Pt. 1 had transient engraftment and Pts 2 & 3 had primary GF. Their relevant demographics are as follows:

TABLE 1

Disease Unrelated Donor Age/Sex GVHD: BMT1 GVHD: BMT2 PTLD Pt1 CML, 1st Chronic Phase Matched 29/F None Grade II Yes Pt2 MDS Matched 57/M None None No Pt3 MDS/AML 1ag Mismatched 55/M None None No

All patients were initially conditioned with alemtuzumab (A) 30mg/day on days −8 to −6, fludarabine (F) 30mg/m2/day on days −7 to −3, and busulfan .8mg/kg x 16 doses (two patients) or x 8 doses (one patient) on days −5 to −2. Conditioning for HSCT #2 included cyclophosphamide 50mg/kg/day, Mesna 50mg/kg/day, and thymoglobulin 2.5mg/kg/day on days −5 to −2. Graft versus host disease (GVHD) prophylaxis included tacrolimus for both HSCT transplants, and low dose methotrexate (3 doses) combined with prednisone (2mg/kg) on days 0–18 followed by a two week taper for HSCT #2. The stem cell product and engraftment kinetics are shown below.

Significant toxicities after HSCT#2 have included successful resolution of PTLD in patient #1 (who also experienced infection with pulmonary respiratory syncitial virus, BK viruria, and fatty infiltration of the liver). BK viruria was noted in patient #2, as well as hypertension and a modest pericardial effusion with global hypokinesis (but with a normal ejection fraction). Hepatomegaly was documented, but no vaso-occlusive disease was established. Patient #3 developed a cardiac arrhythmia, hypertension, and BK viruria and remains Plt transfusion dependent. Patient #1 had grade II GVHD of the skin and gut, but patients 2 and 3 had none. GVHD has been <grade II. GF occurred in 3/17 Pts with MUD transplants that included alemtuzamab in the conditioning regimen. While GF is unacceptably high, it is encouraging that all 3 Pts. successfully completed 2nd MUD transplant with transfusion and cytokine independence using same donor preceded in Pts. 1 & 2 by depletion of anti-ABO incompatible antibodies in the recipient.[table2]
Correlation of Clinical Features with the Mutational Status of GM-CSF Signaling Pathway-Related Genes in Children with Juvenile Myelomonocytic Leukemia
Authors: Yoshida Nao , Yagasaki Hiroshi , Yoshimi Ayami , Takahashi Yoshiyuki , Xu Yinyan , Tanaka Makito , Watanabe Nobuhiro , Matsumoto Kimikazu , Kato Koji , Ueyama Junichi , Inada Hiroko , Goto Hiroaki , Yabe Miharu , Mimaya Junichi , Kikuchi Akira , Manabe Atsushi , Kojima Seiji
Published: October 2019

Juvenile myelomonocytic leukemia (JMML) is a rare clonal myeloproliferative disorder that affects young children. It is characterized by specific hypersensitivity to granulocyte-macrophage colony-stimulating factor (GM-CSF) in vitro. Mutations in RAS, NF1, or PTPN11 positioned in the GM-CSF signal pathway, are thought to be involved in the pathogenesis of JMML. However, no information is available on the relationship between these mutations and clinical features of JMML. The impacts of these mutations on clinical outcome also remain unclear. We tested 49 Japanese children with JMML for N-RAS, K-RAS, and PTPN11 mutations and evaluated their clinical significance. We also assessed correlations between mutational status and clinical and laboratory findings, including age at diagnosis, fetal hemoglobin (HbF), platelet count, and cytogenetic abnormality, all which have been proposed as prognostic factors for JMML. Of the 49 JMML patients, cytogenetic abnormalities were detected in 13, including 8 with monosomy 7. For 2 patients, a clinical diagnosis of neurofibromatosis type 1 (NF1) was confirmed. PTPN11 and N-/K-RAS mutations were found in 22 (45%) and 8 (16%) patients, respectively. Neither PTPN11 nor RAS mutations nor NF1 were present in 17 (35%) patients, and no simultaneous aberrations in these genes were found. In patients with the PTPN11 mutation, age at diagnosis was older (35 vs 11 months; P=0.001, or 12 months; P<0.01) and HbF level was higher (31 vs 10%; P=0.03, or 16%; P<0.01) than for patients with the RAS mutation or without any aberration, suggesting that the clinical outcome for patients with the PTPN11 mutation might be poorer, because a higher HbF level and older age have been reported to be poor prognostic factors. In fact, overall survival (OS) at 5 years was lower for patients with the PTPN11 mutation than for those without (20±9% vs 58±9%; P=0.02). In addition to PTPN11 mutation, age older than 24 months (P<0.01) and abnormal karyotype (P=0.02) were also associated with poor prognosis for OS. Of the 49 patients, 33 received stem cell transplantation (SCT). OS probabilities for patients with and without a mutation in PTPN11 at 5 years after SCT were 25±10% and 64±12%, respectively (P=0.04). More importantly, mutation in PTPN11 was the only unfavorable factor for relapse after SCT (P<0.01). Seven patients died owing to relapse and 12 from complications. All patients who died after relapse had a PTPN11 mutation. In summary, our results suggest that PTPN11-mutated JMML might be a distinct subgroup with specific clinical characteristics and a poor outcome.
HIV-Associated Non-Hodgkin Lymphoma in 114 Patients with Undetectable HIV Viral Load at NHL Diagnosis.
Authors: Oksenhendler Eric , Gerard Laurence , Galicier Lionel , Leturque Nicolas , Janin Anne , Meignin Veronique
Published: October 2019

Although the incidence of HIV-associated Non-Hodgkin lymphoma (NHL) has decreased since the use of combination antiretroviral therapy (cART) and survival has improved, NHL still represents one of the most frequent and severe complications in HIV-infected patients. Out of the 361 patients included in a cohort of HIV-NHL from 1996 to 2006, 114 patients had undetectable (? 500 copies/ml) plasma HIV-RNA. These patients were included in a study to analyze the characteristics of NHL over time according to the duration of HIV infection control. All available histological samples were reviewed by a single pathologist. Tumor was defined as virus-associated (VposNHL) if EBV (ISH, IHC or PCR) or HHV-8 (IHC or PCR) were detected in the tumor cells, and not virus-associated (VnegNHL) if nor EBV nor HHV8 were detected. Comparisons were performed using non parametric tests. All patients were treated with cART, with a median duration of 24 months (IQR, 2–119). The median duration of HIV replication control was 9.3 months (IQR, 0.13–90.5). Most cases (63%) had occurred within 18 months of HIV control versus only 37% after M18. When comparing characteristics of NHL in patients with less or more than 18 months of HIV control, the patients were older (52 years versus 41 years, P<10–4), have a longer median duration of HIV infection (4 years versus 2.4 years, P=.006), and a higher median CD4 cell count (346 × 106/L versus 275 × 106/L, P=.03) when HIV control was >18 months versus ?18 months. None of the NHL features (histology, phenotype, staging, ECOG, LDH, B symptoms) were different between the 2 groups. Virus-association could be assessed for EBV and HHV-8 in 96 cases (84%): 52 patients presented with a virus-associated tumor (31 EBV+, 13 HHV-8+, 8 both) and 43 tumors were not virus-associated. There was no difference in this repartition according to the duration of HIV control (P=.62).

VposNHL VnegNHL VundeterNHL HIV-RNA <500 cop/ml < 18 months 30 28 14 HIV-RNA <500 cop/ml > 18 months 16 13 4 Median CD4 cell count (×106/L) 280 290 317

Virus-associated tumors were neither associated with CD4 cell count (P=.86), nor with CD8 cell count (P=.78). In conclusion, NHL still occur in patients with HIV controled infection (30% of HIV-NHL), but within the first 18 months after plasma HIV-RNA becomes undetectable in most patients. After 18 months, the incidence dramaticaly decreased. However, characteristics of NHL and specifically the association with EBV and/or HHV-8 were not different according to the duration of control of HIV infection.
Natural History of Transfusion-Independent Non-Severe Aplastic Anemia in Children.
Authors: Nishio Nobuhiro , Yagasaki Hiroshi , Takahashi Yoshiyuki , Hama Asahito , Muramatsu Hideki , Kojima Seiji
Published: October 2019

The known clinical courses of non-severe aplastic anemia (NSAA) in children are spontaneous resolution, persistent NSAA, or progression to severe aplastic anemia (SAA). A few published reports have indicated the outcome of transfusion-independent NSAA. We performed a retrospective analysis of transfusion-independent NSAA to evaluate the incidence and time of progression to transfusion-dependent NSAA or SAA. We reviewed the records of 70 children with acquired aplastic anemia referred to Nagoya University Hospital between September, 1986 and August, 2006. Transfusion-independent NSAA was defined as hypocellular marrow and at least 2 cytopenias that persisted for several weeks, without meeting the criteria for SAA (neutrophil count less than 500/μl, a platelet count less than 20,000/μl, and an absolute reticulocyte count less than 20,000/μl). We included only children (aged less than 18 years) with transfusion-independent NSAA at diagnosis who were treated with supportive care alone. The median ages of the 23 patients who met the criteria were 7.7 years (range, 3.0–15.2 y) and 15 were female. The etiology of the aplastic anemia was unknown in all patients. At diagnosis, median neutrophil, platelet and reticulocyte counts were 1,040/μl (range, 380–3,200/μl), 41,000/μl (range, 20,000–126,000/μl) and 63,000/μl (range, 10,000–120,000/μl), respectively. Of 22 patients for whom chromosomal data were available, none had chromosomal abnormalities at diagnosis. Patients were followed for a median of 89 months (range, 11–198 months). Transfusion-independent NSAA persisted in 10 (43%) patients at a median of 30 months (range, 11–117 months) after diagnosis. On the other hand, 13 (57%) progressed to transfusion-dependent NSAA or SAA at a median of 53 months (range, 9–175 months) after diagnosis and required some treatment. Of these 13 patients, 4 received androgens, 2 received high-dose methylprednisolone, 1 received immunosuppressive therapy (IST) with anti-thymocyte globulin and cyclosporine, and 4 underwent hematopoietic stem cell transplantation (HSCT) from HLA-matched siblings. The Kaplan-Meier estimate for progression-free survival was 64%±11% at 5 years and 25%±12% at 10 years, respectively. None of the patients treated with supportive care alone had hematological improvement. None developed paroxysmal nocturnal hemoglobinuria or myelodysplastic syndrome, and all patients are currently alive. In conclusion, NSAA did not spontaneously resolve in any of the 23 patients and the incidence of disease progression was high. Whether early intervention with IST or supportive care alone is preferable should be compared.
The Protective Role of Protein C in Endotoxin-Induced Shock.
Authors: Lay Angelina J. , Donahue Deborah , Tsai Meng-Ju , Castellino Francis J.
Published: October 2019

The serine protease, activated Protein C (aPC) plays an important role in the maintenance of vascular hemostasis. Besides its ability to regulate coagulation and fibrinolysis, aPC also possesses antiinflammatory and antiapoptotic properties. Severe depletion of plasma PC and aPC contributes to sepsis pathogenesis. Although treatment with recombinant aPC benefits a subset of patients with severe sepsis, mechanisms by which aPC improves survival in these patients remain largely unknown. Using mice genetically predisposed to a severe PC deficiency, we initiated studies to further elucidate the mechanistic relationships between very low endogenous PC levels and inflammatory disease pathogenesis. Here, we show for the first time, that novel genetic dosing of PC strongly correlates with survival outcome following endotoxin (LPS) challenge in mice. Our findings provide evidence that very low endogenous levels of PC predispose mice to early onset of disseminated intravascular coagulation, thrombocytopenia, hypotensive shock, organ damage, and reduced survival after LPS challenge. Furthermore, an excessive inflammatory response is observed in very low-PC mice, but is greatly reduced in WT cohorts. Administration of recombinant human aPC to low-PC mice significantly prevents endotoxin-induced hypotensive shock and prolongs survival. This study highlights the importance of host endogenous levels of PC in predicting survival outcome following a severe acute inflammatory challenge.
Antithrombin Deficiency in Pregnancy.
Authors: Andrew Retter J. , Beverley Hunt J.
Published: October 2019

Background: During pregnancy untreated antithrombin deficiency is associated with up to a 50% risk of venous thromboembolism (VTE) and a relative risk of pregnancy loss of 2.1 with a 5-fold increase in stillbirths. Thus thromboprophylaxis is widely used, but little data is available to select type, dose & duration of anticoagulation.

Method: We performed a retrospective, single centre observational study of our antithrombin deficient pregnancies since 1996.

Results: There were 9 pregnancies in 8 women; median age at conception 33 (age-range 19–37). They separated into 3 groups (1) 4 asymptomatic patients diagnosed on family screening. They received unmonitored enoxaparin 40mg until 16 weeks then 40mg BD. (2) 2 with previous VTE, received intermediate dose enoxaparin (1mg/kg), increased to BD at 16 weeks. Monitoring was done to maintain an anti-Xa trough of <0.12 iu/ml and peak <0.8iu.ml. (3) 2 referred after presenting with VTE in pregnancy. They received enoxaparin 1mg/kg BD and the same monitoring These included a known antithrombin deficient woman, referred in her second pregnancy at 26weeks gestation with premature rupture of the membranes and an iliofemoral deep vein thrombosis which developed on enoxaparin 60mg OD. Enoxaparin was increased to 1mg/kg BD and an IVC filter inserted. Despite the filter however she had a pulmonary embolism. The filter was removed after Caesarean section at 31 weeks. Two had sagittal sinus thromboses in the first trimester associated with severe hyperemesis requiring IV fluids. One was our only thromboprophylaxis failure, receiving enoxaparin 40mg OD, she weighed 80Kg. The second presented at 11weeks gestation. She was intolerant of self injecting and so switched to warfarin at 15 weeks until 35 weeks as did one other mother. All mothers had close feto-maternal monitoring with uterine artery Doppler at 24 weeks if possible and then monthly growth scans thereafter.

Delivery: Thromboprophylaxis was stopped at labour initiation or 12hrs prior to Caesarean section (3 women) and 50iu/kg of antithrombin concentrate was given. Anticoagulation was restarted 24hrs after delivery. Six weeks enoxaparin post-partum thromboprophylaxis was given or the women converted back to warfarin. Estimated blood loss at delivery was a median of 200ml (range 200–500ml), no transfusions were required. There were no post partum VTEs. Nine births occurred at a median gestation of 38weeks (range 31–41), median birth weight 3045g (range 1420–4120g). One child has West’s syndrome.

Conclusion: This is the largest case series on the management of antithrombin deficiency in pregnancy. The combined use of enoxaparin in pregnancy and post partum combined with antithrombin concentrate during labour appears to improve pregnancy outcome and reduce the rate of VTE. Larger studies are required to confirm this finding.