bluuebunny/crossref_metadata_2025 huggingface dataset:
Spur Cell Anemia: A Rare and Under-Diagnosed Cause of Anemia in Alcoholic Patients with Advanced Liver Disease
Authors: Hajiabbasi Maryam
Published: December 2023

Anemia in patients with alcohol use disorder (AUD) has a wide range of differential diagnoses, which can be challenging to interpret. It is often multifactorial, such as due to blood loss with or without coagulopathy, direct toxic effect of alcohol on hematopoietic cells, chronic inflammation, abnormalities in red blood cells (RBC) membranes, and nutritional deficiencies. Alcohol-induced liver disease may contribute to anemia through coagulopathy, splenomegaly, and hypersplenism. Macrocytosis is a common finding in patients with AUD due to B12 or folate deficiency or RBC membrane abnormality due to changes in lipid composition of RBC membranes. Patients with cirrhosis may have low haptoglobin due to impaired synthetic liver function. However, non-autoimmune hemolytic anemia and concomitant alcohol-induced liver damage should raise suspicion for spur cell anemia (SCA) and Zieve's syndrome. These medical conditions tend to be underreported or misdiagnosed.

We describe a 44 year old male patient with a past medical history of AUD who presented with alcohol intoxication and was found to have newly diagnosed decompensated cirrhosis with severe macrocytic anemia with Hgb of 5.9 g/dl. Patient denied overt bleeding. Initial workup revealed high absolute reticulocyte count of 10.8% with retic index of 3, low haptoglobin of <15 mg/dl, elevated LDH of 275 u/l, negative Coombs test consistent with non-autoimmune hemolytic anemia, normal folate and B12 levels, and mixed direct and indirect hyperbilirubinemia. Peripheral blood smear showed anisopoikilocytosis, macrocytes, many spur cells, increased reticulocytes, but no schistocytes. Endo-colonoscopy showed grade 1 esophageal varices without evidence of recent bleeding. Given the history of heavy alcohol intake and cirrhosis, combined with Coombs-negative hemolytic anemia and peripheral blood smear findings of numerous spiculated red cells, our patient was diagnosed with SCA. At the time, due to active alcohol use, the patient was deemed not to be a candidate for liver transplant.

This case report aims to aid physicians with the recognition of acute hemolytic anemia in patients with alcoholic liver injury and consideration of SCA and Zieve's syndrome as potential underlying causes. Prompt recognition and differentiation between these medical conditions are crucial as prognosis and treatment are different. Early recognition of SCA and timely consideration of liver transplantation can significantly improve patient outcomes.
Characterizing Hereditary Hemolytic Anemias in a Hispanic Cohort Using Next Generation Sequencing
Authors: Chang Simone , Kasianchyk Mariia , Velazquez Vanessa , Borrego Andre , Maharaj Satish
Published: December 2023

Background:

Hereditary hemolytic anemias (HHA) are a heterogeneous group of nonimmune disorders characterized by increased red blood cell (RBC) destruction due to abnormalities of hemoglobin stability, defects of RBC metabolism, and disorders of RBC hydration. Although uncommon, they comprise important causes of anemia in children and adults by causing chronic or episodic hemolysis. Clinical, laboratory, and genetic heterogeneity characterize this group of disorders and make recognition challenging. The advent of next generation sequencing (NGS) has made accurate genetic diagnoses attainable, with an increasing number of studies reporting clinical utility in HHA. For patients with suspected HHA, multigene testing is available incorporating an NGS panel associated genes. However, there is limited data on the use of multigene NGS to characterize HHA in the Hispanic population. Herein, we describe results from NGS testing of a pilot cohort referred for HHA investigation to hematology clinics along the US/Mexico border.

Methods:

Pediatric and adult hematology clinics at Texas Tech University in El Paso, TX collaborated for testing on HHA referral and clinical case review. The diagnostic panel (AnemiaID/PerkinElmer/Revvity®) included 51 genes encoding RBC cytoskeletal proteins, membrane transporter, RBC enzymes, and certain bilirubin metabolism genes. The complete coding region, splice site junctions, and, where appropriate, deep intronic or regulatory regions were covered. Targeted gene capture and library construction for NGS were performed using a Whole Blood and Saliva kit and 150 base pair paired-end sequencing was done on Illumina® NGS systems at target average coverage of 80×. NGS output data were summarized descriptively for all patients and clinically correlated for diagnosis.

Results:

In this pilot cohort, 11 patients were tested during September 2022 to June 2023, age ranging 7-75 years, with females accounting for 64% of the group. Findings are reported in the Table below; Pathogenic variants leading to a definitive diagnosis were identified in 8 of 11 cases (73%). The most frequently mutated genes were SPTA1 followed by PIEZO1, SPTB, RHAG, GSR, SLC4A1 and TPI1. Approximately 58% of the mutations were reported as novel. Diagnoses included, most commonly, Hereditary Spherocytosis followed by Hereditary Pyropoikilocytosis and Congenital Dyserythropoietic Anemia. Compound heterozygosity leading to complex interactions was noted in 4 cases (36%), involving SPTA1 low expression alleles in trans (alpha-LELY and alpha-LEPRA) in 2 cases.

Conclusion:

Hereditary hemolytic anemia in the Hispanic population is characterized by complex molecular interactions and a high prevalence of novel mutations in RBC cytoskeleton/enzyme genes. NGS has clinical utility and should be considered for accurate diagnosis. Further research into the molecular basis and genetic spectrum of HHA in the Hispanic population is needed.
Stage-Specific Erythropoietic Regulation By Long Non-Coding RNAs (lncRNAs) in Patients with Monge's Disease
Authors: Azad Priti , Zhou Dan , Rana Tariq M , Haddad Gabriel
Published: December 2023

Background: Approximately 20% of individuals living in Andean mountains suffer from Chronic Mountain Sickness, CMS, or Monge's disease. They manifest the disease in adulthood and often die because of excessive erythropoiesis (EE) (Hematocrit of >65%, averaging 72%, mostly occurring in males), an extreme phenotype that can often lead to myocardial infarction or stroke. The uniqueness of this Andean population is even more significant when we realize that there are individuals who live side by side at the same altitude as those with CMS but do not suffer from the same extreme phenotype (non-CMS).

Methods: To understand the mechanistic basis of EE in these patients, we performed RNA seq of cells from both CMS and non-CMS populations. We further utilized an in-vitro human iPS-derived model system to study the functional role of genes at various erythroid stages.

Results: Interestingly, we discovered a unique non-overlapping profile of differentially expressed long non-coding RNA (lncRNAs) between CMS and non-CMS cells. Among these lncRNAs, LINC00431 was significantly downregulated in non-CMS cells as compared to CMS in hypoxia (mimicking high altitude). We further validated the expression of LINC00431 and found it to be significantly downregulated under hypoxia in the non-CMS cells as determined by the qPCR (P<0.01). We hypothesized that this lncRNA plays a role in regulating EE response at high altitude. Knock-down of LINC00431in the CMS cells did not affect the early stages of erythroid proliferation (such BFU-E) but there was a large effect in the later erythroid stages such as the CFU-E and reticulocyte stages (CD71+, CD235a+ cells). Particularly, KD of LINC00431 resulted in a major reduction (from ~60% to ~7%, p<0.0001) of CD235a+ erythroid cells (Reticulocyte stage-a later erythroid stage). In contrast, we have also shown that the knock-down of LINC02228 has a large impact at the early erythropoietic stage BFU-E of the CMS cell reducing by 50% when we KD LINC00228.

Conclusion: These results show a stage-specific erythropoietic regulation by lncRNAs in the CMS and non-CMS patients. LINC02228 plays a critical role at the BFU stage and LINC00431 plays an important role particularly at later erythroid stages (CD71+, CD235+ Reticulocyte stage). This stage specificity also suggests distinct mechanisms for each lncRNAs and their downstream targets.
Automated Preselection of Regions of Interest By Deep Learning Facilitates Rapid Whole Slide Image Analysis of Bone Marrow Smears
Authors: Schneider Martin M. K. , Schulze Freya , Schmittmann Tim , Riechert Sebastian , Gediga Miriam Eva Helena , Sockel Katja , Kroschinsky Frank P. , Wendt Karsten , Bornhaeuser Martin , Middeke Jan Moritz , Eckardt Jan-Niklas
Published: December 2023

The analysis of bone marrow smears (BMS) serves as a critical diagnostic tool in hematology, offering valuable insights into the cellular composition and distinctive morphology of bone marrow cells. It enables the accurate diagnosis, classification, and monitoring of various hematologic diseases. Currently, both clinical routine diagnostics and scientific research, especially for the implementation of digital technologies, rely heavily on the manual selection of regions of interest (ROI) suitable for cell-level evaluation. Current guidelines recommend the manual evaluation of up to 500 cells per sample making the process time-consuming, cost-ineffective, subjective, and prone to human error. Consequently, significant inter-observer variability and inconsistencies in diagnosis often arise.

Automated analysis of BMS using whole slide images (WSI) offers a promising approach to alleviate financial and time-related burdens while promoting standardization and streamlining of routine diagnostics. We have developed a machine learning approach utilizing a fully convolutional neural network (CNN) specifically designed for semantic segmentation based on the algorithm by Long et al. (IEEE Computer Society, 2015). The model is capable of learning deep semantic representations in its classification backbone combined with shape features in a shallow layer to produce detailed segmentations. The classification backbone consists of an adapted residual neural network with 50 layers (Resnet50) by He et al. (arXiv:1512.03385, 2015). To train the model, we curated a diverse dataset consisting of 60 different WSI BMS, each manually and independently annotated by at least two experts providing a robust ground truth (figure 1). Data augmentation was performed via horizontal flipping, random resizing, and random cropping. A train-test split of 80:20 was implemented with 5-fold internal cross-validation. The model's accuracy was evaluated as mean intersection-over-union ratio yielding high congruency between ground truth and model prediction (figure 2). The final model uses downscaled images effectively reducing data storage size and data transfer time decreasing fully automated ROI prediction time to <300 ms for one WSI.

The model allows for in-depth examination at the cellular level, harnessing the potential of thousands of relevant cells present in a WSI, in contrast to the limited range of 200 to 500 cells typically examined in conventional clinical routine diagnostics. Thereby, the model solves an essential bottleneck in computer vision in microscopy minimizing human manual labor and standardizing BMS processing results.
Mitochondrial Fission Protein Drp1 Regulates Platelet Function
Authors: Jacob Shancy , Tistao Marina , Ajanel Gomez Abigail , Denorme Frederik , Kosaka Yasuhiro , Manne Bhanu Kanth , Guo Li , Campbell Robert A. , Rondina Matthew T. , Rowley Jesse W
Published: December 2023

Background: Mitochondria in platelets contribute to platelet function and are altered by diseases that involve dysregulated hemostasis or thrombosis. Mitochondrial integrity, governed by its size, number and distribution is modulated by fusion and fission proteins. Pharmacological inhibition of the mitochondrial fission protein Dynamin-related protein 1 (Drp1) has been shown to inhibit granule release in human platelets and impair thrombus formation in a murine model of thrombosis. However, the mitochondrial roles for Drp1 in platelet function are still largely unknown.

Objective: To determine the mitochondrial roles of Drp1 in regulating platelet function.

Methods: PF4-Cre mediated MK/platelet specific Drp1 null mice (Drp1 -/-) were used. Platelet morphology in Drp1 -/- and wild type (WT) platelets was analyzed by confocal microscopy. Procoagulant platelet formation (PS +ve platelets) after thrombin and the GPVI agonist convulxin (THR+CVX) stimulation was measured using Annexin V staining. Mitochondrial potential (ΔΨm) and mass at baseline and after stimulation was measured using TMRM and mitotracker green. Washed platelet activation in WT and Drp1 -/- platelets in response to convulxin was measured by flow cytometry. Platelet cytoplasmic calcium transients were measured using FURA-2AM after stimulation with THR+CVX. Phosphorylation of Drp1 (pDrp1 S616) in washed WT platelets in response to dual agonist THR+CVX was measured by western blotting.

Results: Drp1 -/- platelets were bigger in size than WT platelets as measured by microscopy and had increased mitochondrial mass as determined by flow cytometry. Absence of Drp1 reduced activation of the αIIb/β3 fibrinogen binding receptor (P=0.035; n=5-6 per group) and reduced alpha granule release (P=0.025; n=5-6 per group) in response to CVX.Dual agonist stimulation resulted in reduced PS +ve platelets in Drp1 -/- compared to WT platelets (P=0.0035; n=7 per group). Since depolarization precedes PS exposure, we measured ΔΨm using TMRM in resting and dual agonist stimulated WT and Drp1 -/- platelets. No difference in ΔΨm was observed in resting Drp1 -/- vs WT platelets whereas, stimulated Drp1 -/- platelets exhibited significantly higher ΔΨm (P=0.038; n=4 per group) than stimulated WT platelets. Interestingly, in response to dual agonists, Drp1 -/- platelets also showed a significant increase (P<0.001) in cytoplasmic calcium transients than WT platelets. Western blot analyses of washed WT platelets stimulated with dual agonist showed phosphorylation of Drp1 at S616 (S616), indicating Drp1 activation.

Conclusion: These findings highlight a role for Drp1 in murine platelet mitochondrial function, GPVI activation, and procoagulant platelet formation.
A Prospective, Observational Study of Bleeding and Quality of Life in Patients with Glanzmann Thrombasthenia in the United Kingdom: Updated Results
Authors: Rea Catherine , York Thomas , Lorch Ulrike , Khair Kate , Pembroke Luke , Amin Jigar
Published: December 2023

Glanzmann thrombasthenia (GT) is a rare bleeding disorder characterized by impaired platelet function. Recent studies suggest that patients with GT experience high-frequency bleeds, often access medical care, and have a significant burden of disease. There are no detailed, prospective studies characterizing bleeds and associated patient-reported impacts in GT.

We conducted a prospective diary study characterizing bleeds and associated patient-reported impacts in 30 patients with GT over 3 months. Patients record bleed events daily in a custom-designed electronic bleed diary. At approximately the same time each day, they answer the question, “Have you had a bleed?” If the answer is yes, they also include the anatomical site of the bleed. Female patients are asked to record menstrual bleeding. For each bleed reported, patients can document symptoms, treatments received, and the location where the treatment was received (e.g., at home or in the hospital). They are also asked to record the socioeconomic impacts of individual bleeds, such as missed social or leisure activities, missed work, and missed education.

The updated results confirm the high frequency of bleeds in patients with GT. Key variables will include diary completion compliance, mean monthly bleed rate (excluding menstrual bleeding), as well as detailed recordings of types and anatomical locations of bleed events. Further details will include patient reported, bleed-associated symptoms and socioeconomic impacts. In addition, a thorough description of menstrual bleeds and the impacts reported by women will be presented.

This study provides further evidence of the high frequency and significant impact of bleeds in patients with GT. These prospective data establish a direct link between bleed events and the corresponding impact on QOL (quality of life) in patients with GT. In addition, the findings of this study suggest that there is a need for new treatments for GT that can reduce the frequency of bleeds and improve the quality of life for patients.
Impact of COVID 19 on Patients with Multiple Myeloma : A National Inpatient Sample Analysis
Authors: Sanghvi Ankushi , Patel Sagar , Nanavaty Dhairya , Nadeem Ahmed
Published: December 2023

Introduction:

Multiple myeloma (MM) is characterized by the proliferation of clonal immunoglobulins and suppression of normal immunoglobulins. These patients are susceptible to infections due to multiple factors such as hypogammaglobulinemia, impaired lymphocyte function, steroid-related immunosuppression, and neutropenia secondary to chemotherapy. There is limited data on the association of COVID-19 infection with in-hospital outcomes of MM. We hypothesize that COVID-19 infection is associated with adverse outcomes.

Methodology:

We queried the National Inpatient Sample (NIS) Database 2020 for adult (aged ≥ 18 years) hospitalizations with a primary diagnosis of MM. The cohort was subcategorized based on the presence of COVID-19 infection. The primary outcome studied was in-hospital mortality. Multiple secondary outcomes were analyzed including length of stay, cost of hospital stay, and individual organ system failures. Multivariable logistic regression was performed adjusting for patient and hospital level characteristics to evaluate outcomes. An alpha error of 0.05 was accepted for all analyses.

Results:

A total of 111,540 MM hospitalizations were included in the study, of which 2,195 (1.96%) had concomitant COVID-19 infection. The mean age was almost similar in both groups. Patients with MM and concurrent COVID-19 infection, had significantly higher in-hospital mortality [adjusted odds ratio (aOR) 6.54, 95% CI 5.25-8.20, p<0.001], length of stay [aOR 4.12 (2.92-5.32), p<0.001] and hospitalization cost [$54,940 ($34,688-$75,191), p<0.001]. They had higher rates of cardiac arrest (2.9% vs 1.1%, p<0.001), acute renal failure (48.8% vs 31.3%, p<0.001), acute liver failure (2.5 % vs 1.1%, p<0.001), acute respiratory failure (50.8% vs 17.3%, p<0.001). They also required higher levels of care in terms of hemodialysis (14.8% vs 8.8%, p<0.001), non-invasive ventilation (8.4% vs 3.3%, p<0.001), and invasive ventilation (1.6 % vs 0.3%, p<0.001).

Discussion:

Patients with MM who were admitted with COVID-19 had higher odds of in-hospital mortality, and developing (end-organ)complications such as cardiac arrest, respiratory failure, renal failure, and liver failure. They also had longer and costlier stays. The development of COVID-19 in patients with MM causes such poor outcomes likely due to shared endothelial dysfunction, thrombosis, and hyperinflammation. Prior studies have also shown impaired response to mRNA vaccination in this population. Thus, as COVID-19 restrictions are now at ease, increased vigilance is required in this vulnerable population. The limitations of our study are retrospective use of the administrative database with a potential of missing or inaccurate data, lack of information on specific treatments in MM patients limiting the ability to assess treatment-related outcomes, and unknown vaccination status.
Machine Learning Can Outperform Ann Arbor Staging in Predicting Survival in Patient with Diffuse Large B-Cell Lymphoma: Analysis of a Large National Cancer Database
Authors: Kumar Madhan Srinivasan , Gujju Veena , Park Ji Hwan , Hogue Debra , Naqash Abdul Rafeh , Al-Juhaishi Taha Mahdi Salih
Published: December 2023

Introduction:

Diffuse Large B-cell Lymphoma (DLBCL) is the most common lymphoma in the world with usually an aggressive clinical course. The Ann Arbor staging system and International Prognostic Index (IPI) commonly utilized in clinical practice for risk stratification have known limitations. Machine learning (ML) has emerged as a promising tool for more comprehensive and deeper data analysis. We sought to utilize the ability of ML to predict survival in DLBCL compared to Ann Arbor staging system using a large national database.

Methodology:

We employed the ML algorithm XGBoost on the National Cancer Institute's Surveillance, Epidemiology and End Result (SEER) database to predict overall survival (OS) and the lymphoma specific survival (LSS). For prediction analysis, we transformed the survival labels into a simple Boolean format: “alive” represented as 0, “dead” as 1, and “dead (attributable to this cancer diagnosis)” also as 1. We utilized one-hot encoding to convert categorical features and variables into binary vectors. The data set was divided into two parts: training (80%) and test (20%). Further, we split the training set into the actual training set and validation set by using stratified 5-fold cross validation. Hyper-parameter optimization was done within the validation set. A broad range of attributes were utilized by the model for its prediction algorithm. To understand how each attribute contributes to predictions, we calculated its importance score in XGBoost.

Results:

A total of 64,912 patients with DLBCL were found and their data were extracted. The majority were Caucasian (78.9%) with a median age range of 60 to 69. The model was able to predict OS and LSS, with an area under the curve (AUC) of 0.89 and 0.75 (Figure 1), respectively. Factors selected by the model for survival prediction included presence or absence of B-symptoms, treatment status, and disease stage. For OS and LSS, the model found B symptoms to be the highest contributing factor with an importance score of 0.205 and 0.167, respectively. Other important factors incorporated by the model included age and stage IV for OS, and stage IV and clinically asymptomatic status for LSS. The least important factors were location of the primary lymphoma site and year of diagnosis (Table 1).

Conclusion:

Machine learning tools can help predict survival in patients with DLBCL and able to challenge current staging systems. Our results warrant validation in future prospective studies.
Comparison of Non-Myeloablative Conditioning Regimens Flu/Bu2, Flu/Mel 100 and Flu/TBI in Patients with AML and MDS
Authors: McKiernan Phyllis , Gelman Simon , Rowley Scott D , Kaur Sukhdeep , Cho Christina , Suh Hyung C , Boonstra Michele S , Georgantzis Addi , Baker Melissa , Einstein Amy , Donato Michele L.
Published: December 2023

Allogeneic hematopoietic stem cell transplantation (HSCT) is a potentially curative treatment modality for patients with myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). Non-myeloablative (NMA) conditioning regimens are used to decrease toxicity, making HSCT more tolerable and available to older patients or patients with co-morbidities. It remains unclear as to which NMA regimen leads to superior outcomes.

Methods: We retrospectively compared outcomes of 3 NMA regimens in 98 patients with AML or MDS undergoing allogeneic HSCT from January 2017 to December 2021. The 3 regimens were: Flu/Mel 100: fludarabine 40 mg/m2 days -5 to -2, melphalan 100 mg/m2 day -2; Flu/Bu2: fludarabine 30 mg/m2 days -6 to -2, busulfan 130 mg/m2 days -3 to -2; Flu/TBI: fludarabine 30 mg/m2 days -4 to -2, total body irradiation 200-300 cGY on day-1. Patients conditioned with Flu/Mel 100 or Flu/Bu2 also received rabbit anti-thymocyte globulin 4-6 mg/kg. Graft versus host disease (GVHD) prophylaxis consisted of tacrolimus and low dose methotrexate for patients receiving Flu/Mel 100 or Flu/Bu2, and sirolimus, cyclosporine and mycophenolate mofetil for patients conditioned with Flu/TBI.

Continuous variables were compared between conditioning regimens using Pearson's Chi-squared test or Fisher's exact test. PFS and OS survival probability and survival times were estimated with Kaplan-Meyer(K-M) procedure. To compare survival distributions between conditioning regimens, a log-rank test was used. We report 24-month survival probabilities in months with corresponding 95% confidence intervals.

Results: Patient demographics were balanced between the 3 groups including age (range 54-80), gender, disease risk and cell source (Table 1). 24-month progression free survival (PFS) was not different between the groups: Flu/Mel 100 was 70% (47%-100%), Flu/Bu2 was 49% (39%-63%), and Flu/TBI was 33% (18%-61%) (p=0.3). For Flu/Mel 100 the 24-month overall survival (OS) was 70% (47%-100%), Flu/Bu2 was 53% (42%-66%), Flu/TBI was 32% (17%-61%) which was not statistically different ( p=0.3) (Figure 1). There was no difference between the 3 groups for non-relapse mortality (NRM) ( p=0.46). The incidence of all grade acute GVHD was 70% for Flu/Mel 100, 66% for Flu/Bu2 and 76% for Flu/TBI ( p=0.70). There was no difference in the incidence of chronic GVHD between the groups; Flu/Mel 100 50%, Flu/Bu2 55%, Flu/TBI 57% (p>0.99).

Conclusions: All three NMA regimens were found to be statistically equivalent. NRM, PFS, OS and the incidence of acute and chronic GVHD was not statistically different between the groups. A limitation of the study is the relatively small number of patients in the Flu/Mel 100 group. Further study with a larger sample size is needed to evaluate for small differences between the regimens.
Ixazomib, Pomalidomide and Dexamethasone (IxaPD) Pan-Oral Regimen in the Treatment of Refractory and Relapsed Multiple Myeloma
Authors: Chen Miao , Fu Rong , Chen Wenming , Wang Wei , Ma Yanping , Zhuang Junling
Published: December 2023

Aim To analyze the efficacy and safety of Ixazomib, pomalidomide and dexamethasone (IxaPD) regimen in patients with refractory and relapsed multiple myeloma（RRMM）.

Methods Clinical data of RRMM patients were collected from 5 centers in north China from Jan 2021 to Aug 2023, who were treated by IxaPD regimen for at least two courses. Response, time to next treatment and overall survival were analyzed as end points.

Results A total of 34 patients were enrolled, including 21 in multicenter real-world study and 13 in investigator initiated IxaPD trial (NCT04989140) who were naïve to ixazomib or pomalidomide with previous treatment of 1 to 3 lines. There were 18 males and 16 females with the median age 65.5 (range 41-81) years old. The median duration from diagnosis to enrollment was 31 months (range 1-117), including 23/34 (67.3%) of patients were in first relapse. Thirteen in 24 (54.2%) patients had high-risk cytogenetic abnormalities. Regarding previous history, 20.6% presented renal insufficiency, 3 cases (8.8%) had extramedullary diseases, and 5 cases (14.7%) received autologous hematopoietic stem cell transplantation. After median 5 courses (range 2-24) of IxaPD chemotherapy, the overall response rate (ORR) was 64.7%, with 47.1% VGPR or better. The median time to achieve the best response was 2 months (range 1-6). After a median follow-up of 13 months (range 2-28), 52.9% of patients progressed and the median time to next treatment was 7 months (range 3-21). The mortality rate was 17.6%, and the median overall survival was not reached. In the multivariate analysis, response to first-line induction therapy significantly affected the time to next treatment(P<0.05), while age, first relapse, R-ISS stage, high-risk cytogenetics abnormalities, and renal insufficiency did not impact significantly. Neither did those factors also have significant impact on overall survival. Most of the adverse effects (AEs) were grade 1-2, mainly skin rash, peripheral neuropathy, constipation, diarrhea, edema, arthralgia, herpes zoster, and shortness of breath. Only one case of grade 3 pulmonary infection occurred.

Conclusion The pan-oral IxaPD regimen showed anticipated effect and good tolerance for RRMM patients, especially appropriate for patients achieving deep response in first-line therapy. More patients are being enrolled and update data will be reported.
Effectiveness and Safety of a Cmop±R Regimen for the Initial Treatment of Patients with NHL
Authors: Duan Yishan , You Tao , Xu Peng , Ma Xiao , Wu Depei , Huang Haiwen
Published: December 2023

Introduction

Non-Hodgkin's lymphoma (NHL) is a globally prevalent cancer with a high mortality rate. Although advances in treatment have improved patient survival, patients with high International Prognostic Index (IPI) scores continue to face challenges. The CMOP regimen (cyclophosphamide, mitoxantrone, vincristine, and prednisone) has shown promising efficacy in peripheral T-cell lymphomas with an overall response rate of 84%, but there is a lack of evidence in other NHL subtypes. In this study, we present preliminary results of a CMOP±R (CMOP±rituximab) regimen for the initial treatment of patients with NHL. The study is registered at ClinicalTrials.gov (NCT 2300074073).

Aim

This prospective, single-arm, open-label, multicenter phase 2 clinical trial was designed to evaluate the efficacy and safety of a CMOP±R regimen including mitoxantrone hydrochloride liposome in patients with newly diagnosed NHL.

Method

Adult patients with a confirmed diagnosis of NHL (predominantly DLBCL, MZL, FL, and AITL), ECOG performance status ≤1, normal organ and bone marrow function, and at least one measurable or evaluable lesion were enrolled in this study. Patients with significant cardiac dysfunction or uncontrolled cardiovascular disease were excluded. Treatment with the CMOP±R regimen was administered every 4 weeks for up to 6 cycles until disease progression or an intolerable toxic response. The primary endpoint was the objective response rate (ORR), which was assessed by the investigators. Secondary endpoints included duration of response (DoR), progression-free survival (PFS), overall survival (OS), and safety. Adverse events were graded using NCI Common Terminology Criteria for Adverse Events (CTCAE) 5.0. The study was approved by the Institutional Ethics Committee (IRB number: 2022021).

Results

From November 26, 2022 through May 19, 2023, 17 Chinese patients with various NHL subtypes who were eligible for enrollment were treated with the CMOP±R regimen. Nine of these patients were eligible for efficacy evaluation. Results showed that 100% of evaluable patients achieved an objective response and 66.7% achieved a complete response. Hematological toxicity was the most common treatment-related adverse reaction, with leukopenia (100%) and neutropenia (100%) being the most common grade ≥3 toxic reactions.

Conclusions

The CMOP±R regimen using mitoxantrone hydrochloride liposome showed efficacy in the initial treatment of NHL with acceptable and manageable adverse effects. The role of this regimen in the treatment of NHL warrants further exploration.
RDW As a Predictor of Adverse Outcomes: A Systematic Review and Meta-Analysis of Frailty and Mortality Risk
Authors: Keesari Praneeth Reddy , Vegivinti Charan Thej Reddy , Ganampet Narendranath Reddy , Guna Sowmya Durga Subhasri , Venugopalan Sruthi , Edusa Samuel , Manaktala Pritika Singh , Palisetti Spandana , Muslehuddin Zainab , Theik Nyein Wint Yee , Salibindla Divya , Desai Rupak
Published: December 2023

Introduction

Red cell distribution width(RDW) is a measure of variation in red blood cell size. Although not very sensitive or specific to diagnose anemia, RDW is identified as a marker of inflammation and oxidative stress. Multiple studies in recent times have evaluated its association with overall mortality, frailty, venous thromboembolism, chronic kidney disease, and liver disease. Identifying frailty and risk of mortality is crucial and may help curtail adverse health outcomes in the aging population. We conducted a systematic review and meta-analysis to identify if high RDW serves as an indicator of frailty and mortality.

Methods

We performed a comprehensive review of Pubmed, Scopus, and Google Scholar until June 2023 using appropriate keywords to identify studies evaluating the risk of frailty and mortality in patients with high RDW. Binary random-effects model was used to estimate pooled odds ratios (OR) and 95% confidence intervals (CI). Leave one out sensitivity analysis was performed. Heterogeneity was assessed using I2 statistics. A p<0.05 was considered statistically significant.

Results

A total of 9 studies were included with data spreading across 9 countries. Sample size included 881 and 1180 individuals with high RDW that reported frailty and mortality as an outcome respectively, and 5919 and 4426 individuals with normal RDW that reported frailty and mortality as an outcome respectively. Unadjusted odds for frailty were 2.10 (95% CI, 1.78 - 2.47; p-value < 0.01) with heterogeneity of 0%(I2) whereas adjusted odds were 2.257 (95% CI, 1.510 - 3.373; p-value < 0.001) and heterogeneity of 0%(I2). Similarly, unadjusted odds for mortality were 3.30 (95% CI, 2.21- 4.94; p-value < 0.01) with heterogeneity of 75.16%(I2) and adjusted odds for mortality were 2.75 (95% CI, 1.24 - 6.08; p-value 0.01) with heterogeneity of 79.8%(I2). Sensitivity analysis using leave one out method demonstrated similar results.

Conclusion

This study concludes that there is a significantly higher risk of frailty (125%) and mortality (175%) in individuals with high RDW. RDW is a readily available and a cost effective tool. Consequently, there is a need for additional research to investigate the potential of RDW as a predictor for morbidity and mortality in various settings, such as patients undergoing targeted interventions, pre-procedural assessments, and in specific disease populations.
Reducing DNA Damage Associated with Endogenous Genotoxic Stress in Hematopoietic Stem Cells
Authors: Singh Brijendra , Salinas Carlo Salas , Hossain Md Akram , Millington Christopher , Patel Ketan , Tong Wei
Published: December 2023

Fanconi anemia (FA) is a bone marrow failure (BMF) syndrome that arises from mutations in a network of FA genes essential for DNA interstrand crosslink (ICL) repair and replication stress tolerance. Endogenous formaldehyde is ubiquitous within cells as it is produced as a byproduct during normal cellular metabolism such as histone, RNA and DNA demethylation. Previous studies show that endogenous formaldehyde is a hematopoietic stem cell (HSC) genotoxin and metabolic carcinogen. We previously showed that endogenous formaldehyde is removed by the enzyme alcohol dehydrogenase 5 (ADH5), and Adh5-deficient mice therefore accumulate formaldehyde adducts in DNA that require the FA pathway to repair. Mice lacking Adh5 together with the FA pathway central component Fancd2 exhibit bone marrow failure and early lethality. Adh5 haploinsufficiency combined with Fancd2 deficiency, or Fancd2-/-Adh5+/- mice, demonstrates severely compromised HSC activity. However, the contributing factors that cause DNA damage and the protective mechanisms by which cells reduce DNA damage during endogenous genotoxic stress are not fully understood. Here, we show that the genetic inactivation of Lnk/Sh2b3 in Fancd2-/-Adh5+/- mice restores HSC function. Adh5 haploinsufficiency exacerbated Fancd2 deficiency, while Lnk deficiency rescued HSC homeostasis and transplantability of Fancd2-/-Adh5+/- mice. Moreover, Lnk deficiency increased HSC quiescence and reduced endogenous DNA damage in Fancd2-/-Adh5+/- mice. Importantly, Lnk deficiency does not participate in repairing formaldehyde-induced DNA damage, nor does it metabolize formaldehyde or reduce genomic formaldehyde-deoxyguanine adduct in vivo. Rather, Lnk deficiency reduced single-strand DNA (ssDNA) breaks and ssDNA binding protein RPA in HSCs during the cell cycle, thereby suppressing the ATR pathway activation upon endogenous replication stress. Moreover, loss of Lnk increased S-phase progression and fork recovery in Fancd2-/-Adh5+/- HSPCs at the stressed replication fork upon HU treatment, thereby preventing replication fork collapse and DNA damage. These findings highlight a new mechanism by which Lnk deficiency mitigates replication stress-induced DNA damage in response to endogenous genotoxic insult from cellular metabolism during HSC regeneration.
Incidence of Parkinsonism As a Complication of Anti-BCMA CAR-T Cell Therapy in Multiple Myeloma
Authors: Singh Vaishnavi , Master Samip
Published: December 2023

Introduction: B-cell maturation antigen (BCMA)-directed chimeric antigen receptor T-cell (CAR T) therapy has revolutionized the treatment for relapsed/refractory multiple myeloma (RRMM). Two BCMA-directed CAR T products, Idecabtagene Vicleucel (ide-cel) and Ciltacabtagene Autoleucel (cilta-cel), have received approval from the U.S. Food and Drug Administration (FDA). While these therapies have demonstrated remarkable efficacy, concerns regarding treatment-related neurotoxicities have emerged. The specific adverse effect of Parkinsonism associated with BCMA-directed CAR T therapy has not been adequately studied.

Methods: We conducted an analysis utilizing the FDA Adverse Events Reports System (FAERS) database, covering the years 2021-2023. Our search focused on the reported incidence of Parkinsonism associated with BCMA-directed CAR T therapy.

Results: Upon reviewing the FDA data, we identified a total of 177 patients with reported nervous system disorders related to Ide-cel therapy. Out of these patients, 2 had reported incidents of Parkinsonism. Similarly, for Cilta-cel therapy, there were 81 patients with reported nervous system disorders, with 5 reported incidents of Parkinsonism. Out of the total 7 reported patients with Parkinsonism, 5 were males, 2 were females, the average age was 67, the average weight was 68.9 kg, and 3 patients were also noted to have associated cytokine release syndrome.

Conclusion: Our analysis of FAERS data highlights the occurrence of Parkinsonism associated with BCMA-directed CAR T-cell therapy. Further studies are required to quantify the need for neurological surveillance after initiating treatment with these novel agents.
Quantification of ADA of Humanized CD19 CAR-T Cell Therapy in R/R LBCL
Authors: Huang Zhongpei , Mei Heng , Li Chenggong , Hu Yu
Published: December 2023

Purpose: Humanized CD19 chimeric antigen receptor (CAR) T-cell therapy results in a high response rate in patients with relapsed/refractory (R/R) large B-cell lymphoma (LBCL). And many clinical trials have discovered the impact of anti-drug antibody (ADA) on CAR-T efficacy. But the ADA has yet been quantified. And its influence in patients with CAR-T infusion is still unknown.

Patients and methods: We enrolled 30 patients with R/R LBCL treated with humanized CD19 CAR-T cells between April, 2022 and July, 2023, and collected their plasma at pre-FC, day7, 14, and follow up months for ADA testing using flow cytometry.

Results: The detection of ADA within plasma of humanized CAR-T was performed using flow cytometry, and the relative quantification of ADA was achieved by setting up a calibration curve with CD19 protein as a standard. R 2 of the calibration curve can be 0.999 (Figure 1a). The physiologic threshold was determined as 0.1nM (95%CI) by using plasma from 10 normal subjects.

27/30 patients who experienced only one infusion and did not relapse had mostly low ADA (<3nM). Only one exception having a maximum value higher than 5nM with PFS maintained 1 year. All of the 27 patients had ADA presence before FC, but it did not affect CAR-T amplification.

3/30 patients who received second CAR-T cell infusion, 2 of which had 2 infusions of the same product, and 1 of which relapsed after relma-cel infusion and followed by the humanized product. 2 of the 3 patients (P08 and P09) who had a high ADA before the second infusion (of 3.52 and 3.27) had extremely limited CAR-T expansion after the second infusion (maximum CAR copies of 470 and 3950, respectively), and both relapsed 1 month after the second infusion (Figure 1b-1c). The other one patient (P18) had a low ADA both before and after the second infusion (maximum is before infusion, 0.65 nM), and had normal subsequent CAR copies amplification (maximum 60800 and minimum 10850), and did not relapse during the follow-up period (Figure 1d). We consider that ADA >3nM suggests poor CAR-T amplification and poor prognosis, but further validation is needed due to the small number of patients.

Conclusions: The quantification of ADA is essential and credible, which contributes to the unification of standard. Pre-existing ADA does not affect CAR-T amplification for the first infusion but possibly suggests a negative impact on CAR-T efficacy and amplification of multiple-infusion. However, further research is needed.
Recombinant Human Thrombopoietin Reduces the Risk of Acute Graft-Versus-Host-Disease and Its Mechanisms
Authors: Rong Fei , Zhao Chunting , Liu Xiaodan , Ma Xiaolin , Jiang Erlie , Feng Sizhou
Published: December 2023

Objective: Acute graft-versus-host-disease (aGVHD) is an important complication that is observed after allogeneic hematopoietic stem cell transplantation (allo-HSCT). We aimed to evaluate the effects of recombinant human thrombopoietin (TPO; rhTPO) on aGVHD using clinical data, mice models, and peripheral blood mononuclear cells (PBMCs). Methods: From 2016 to 2018, 162 cases of allo-HSCT in our hospital were recruited in this study. The correlation between TPO use and aGVHD was analyzed. After a GVHD model was constructed in Balb-C mice, HE staining was performed to compare the pathophysiological changes of the liver, intestine, lung, kidney, and other organs of the mice. The levels of lymphocyte subsets and cytokines in the mice spleens in the different groups were detected. PBMCs were isolated from the peripheral blood of healthy persons and patients with allo-HSCT via Ficoll gradient centrifugation and treated with different concentrations of rhTPO. The proliferation of PBMCs was detected via the CCK8 method, and the differentiation of PBMCs into lymphocytes was analyzed via flow cytometry. Results: 1) The occurrence of aGVHD was observed in 10 patients (47.6%) in the control group and 27 (23.1%) in the treatment group. The difference between the two groups was statistically significant (χ2=5.465, P=0.019). 2) The results of the aGVHD mice proved that rhTPO decreased the damage to the mouse liver, intestine, lung, and kidney tissues. In addition, splenic cell subpopulations CD4+cells, CD8+cells, T cells, and NK cells increased in the GVHD group but decreased due to rhTPO (P<0.05). After rhTPO treament, T cell subpopulations Th2 and Th17 cells decreased in the GVHD mice (P<0.05). Cytokines CD8+IL-17A+ and CD8+IL-4+IFNγ showed no difference between the four groups (P>0.05). Compared to GVHD mice, CD8+IL-4+ decreased in TPO-treated GVHD mice, and the effect of TPO at a high dose was more significant (P<0.05). 3) The results of the PMBCs suggested that a low dose of rhTPO could promote the proliferation of PMBCs, while a high dose could inhibit the proliferation. rhTPO promoted the differentiation of PBMCs into the CD3-PC5 subset. Conclusions: Altogether, this study indicates that rhTPO reduces the risk of aGVHD and is a protective factor against the occurrence of aGVHD.
Outcomes of Paediatric Acute Promyelocytic Leukaemia in the UK
Authors: Vedi Aditi , Memon Irum , Van Risjik Else , Uparkar Urmila , Shenton Geofffrey , Trinquand Amélie , Clesham Katherine , Mclelland Vanessa , Campbell Helen Jane , Patrick Katharine , Thompson Lyndsey , Baird Susan , Connor Philip , James Beki
Published: December 2023

Acute Promyelocytic Leukaemia (APL) is characterized by unique genetic and molecular abnormalities, clinical features, and treatment strategies. It accounts for 5-10% of paediatric acute myeloid leukaemia (AML) cases. APL is defined by the t(15;17)(q24;q21) chromosomal translocation, leading to the formation of the PML-RARA fusion protein, which plays a crucial role in leukemogenesis. All-trans retinoic acid (ATRA) has revolutionized APL management by targeting the PML-RARA fusion protein and inducing complete remission in the majority of patients. Arsenic trioxide (ATO) has emerged as an effective therapeutic agent, particularly in cases with ATRA resistance or relapse. ATO is now widely recommended as part upfront treatment. However, access to ATO has been limited by funding sources in certain countries.

This retrospective national study presents the treatment strategies, complications, and survival outcomes of 50 paediatric patients, aged 1 to 18 years, diagnosed with APL in the UK over an 8-year period, between 1 st November 2014 and 31 st October 2021. There were 21 (42%) high risk (HR) patience and 29 (58%) non-HR patients in the cohort. The majority of patients received a chemotherapy-free regimen comprising ATRA and ATO, with additional agents used selectively. Chemotherapy was usually given to patients in the event of lack of access to ATO or clinical urgency. Availability to ATO varied between countries within the UK.

Event-free survival (EFS) and overall survival (OS) were evaluated, with a minimum 2 years follow up from diagnosis and median follow-up of 8 years. Overall, the cohort demonstrated a high OS of 94%, with no significant difference observed between HR and non-HR patients. However, HR patients experienced significantly lower EFS, with all relapses occurring in this group. Relapsed patients received varied treatment regimens, including ATRA, ATO, and chemotherapy, with favourable outcomes.

This study contributes valuable insights into the management and outcomes of paediatric APL in the UK, emphasizing the importance of early diagnosis and risk stratification for optimal treatment decisions. Addressing disparities in ATO availability and promoting consistent funding across NHS Trusts will be crucial in further improving patient outcomes and reducing relapse rates in APL. Future research should focus on refining treatment protocols and exploring novel therapeutic strategies to enhance the long-term survival of paediatric APL patients. The study highlights the challenges associated with ATO availability across NHS Trusts, impacting treatment decisions and outcomes for APL patients.