bluuebunny/crossref_metadata_2025 huggingface dataset:
Costliness of Iron Repletion Methods in Iron Deficient Adolescent Females Depends on Patient-Specific Factors
Authors: Mamauag Erica , McCormick Meghan , Smith Kenneth
Published: December 2023

Background: Iron deficiency anemia is common in adolescent females. Treatment is possible with either enteral (PO) or intravenous (IV) formulations. The cost-effectiveness of each method is unknown. In addition, treatment cost-effectiveness likely differs between three distinct adolescent female subgroups with iron deficiency: average BMI with moderate anemia, average BMI with severe anemia, and obese BMI with moderate anemia.

Methods: A decision analysis model evaluated PO ferrous sulfate, IV iron sucrose, and IV ferric carboxymaltose use in adolescent female subgroups, comparing costs associated with each treatment strategy from a healthcare perspective. In the PO iron strategy, initial PO therapy failure prompted conversion to IV iron sucrose use. Literature review was performed to obtain model parameters. The effectiveness term in the model was the likelihood of successful iron repletion, which was assumed to be identical for each strategy in the base case analysis. Model time horizon was three months. One-way sensitivity analyses evaluated model uncertainty.

Results: In moderate anemia and average BMI, IV iron sucrose was least costly at $531.79 (compared to $592.12 for PO iron and $855.78 for IV ferric carboxymaltose). Varying the PO iron success likelihood and clinic visit frequency could favor the PO iron strategy. With severe anemia and average BMI, IV ferric carboxymaltose was least costly at $855.78 (vs. $1013.44 for IV iron sucrose and $902.78 for PO iron). Variation in infusions needed for IV iron sucrose (and therefore anemia severity) alters the preferred strategy, with IV iron sucrose favored if 1-4 infusions are required, PO iron favored if 5-6 infusions required, and IV ferric carboxymaltose preferred if 7 or more infusions are needed. In the moderately anemic obese group, PO iron was preferred, costing $763.90 compared to $798.12 for IV iron sucrose and $855.78 for IV ferric carboxymaltose. In a one-way sensitivity analysis, PO iron was favored at a weight >74kg (base case value 90); below this weight, IV iron sucrose was preferred.

Conclusion: The cost-effectiveness of different iron repletion strategies depends on the adolescent female subgroup affected. Patient weight and anemia severity are important clinical characteristics to consider when assessing which method is the most cost-effective.
Development of a Risk Assessment Model for Cardiac Injury in Patients Newly Diagnosed with Acute Myeloid Leukemia Based on a Multicenter, Real-World Analysis in China
Authors: Ma Linlu , Wang Qian , Li Xinqi , Zhang Nan , Liang Yuxing , Wu Jinxian , Yuan Guolin , Zhou Fuling
Published: December 2023

Studies have revealed that acute myeloid leukemia (AML) patients are prone to combined cardiac injury. We aimed to identify hematological risk factors associated with cardiac injury in newly diagnosed AML patients before chemotherapy and develop a personalized predictive model. The population baseline, blood test, electrocardiogram, echocardiograph, and genetic and cytogenetic data were collected from 499 newly diagnosed AML patients. The data were subdivided into training and validation cohorts. After univariate logistic regression, least absolute shrinkage and selection operator regression, and multivariate logistic regression analysis, abnormal NT-proBNP, NPM1 mutation, WBC, and RBC were independent risk factors for cardiac injury in AML patients (all p<0.05). The nomogram was constructed based on the above four variables with high accuracy. The area under the curve was 0.742, 0.750, and 0.706 in the training, internal validation, and external validation cohort, respectively. The calibration curve indicated that the model has good testing capability. The Kaplan-Meier curve showed that the higher the risk of combined cardiac injury in AML patients, the lower their probability of survival. This prediction nomogram identifies hematological risk factors associated with cardiac injury in newly diagnosed AML patients and can help hematologists identify the risk and provide precise treatment options.

Key words: acute myeloid leukemia, risk factor, prediction model, inflammation, cardiac injury
Role of the S1P Signaling Pathway in the Pathogenesis of Angioimmunoblastic T-Cell Lymphoma
Authors: Lin Wen-Hsuan Wendy , Rodriguez Cortes Jose , Aitken Mick , Reglero Clara , Laurent Anouchka , Cooke Anisha , Belver Laura , Bhagat Govind , Rabadan Raul , Ferrando Adolfo A. , Palomero Teresa
Published: December 2023

Peripheral T cell lymphomas (PTCLs) are a group of aggressive lymphoid malignancies originating from mature T cells. Angioimmunoblastic T-cell lymphomas (AITL) represent 20% to 30% of all PTCL diagnoses and are associated with autoimmune features, poor response to chemotherapy, and dismal prognosis. Molecular profiling of AITL has identified T-follicular helper (TFH) cells as the cell of origin of AITL, while mutational analysis has identified frequent alterations in epigenetic regulators ( TET2, DNMT3A, and IDH2) and elements of the TCR pathway as drivers of AITL transformation. Our group identified the highly recurrent RHOA G17V mutation as a defining hallmark of AITL and other T-cell lymphomas of TFH-cell origin (Palomero et al., 2014). Using a novel conditional knockin mouse model, we demonstrated that expression of Rhoa G17V in CD4+ T-cells induces TFH cell specification and promotes AITL lymphomagenesis in the context of loss of Tet2 (Cortes et al., 2018).

Recently, we have identified that Rhoa G17V regulates the expression of the sphingosine-1-phosphate (S1P) receptor 1 (S1PR1) one of the five members of the receptor family of S1P, which plays an essential role in immune response and lymphocyte trafficking. During thymic T-cell development, expression of Rhoa G17V in CD4+ cells inhibited S1PR1 downregulation after the double positive stage leading to altered positive selection, reduced CD4+ single positive cell numbers and premature thymic egress of autorreactive T-cells which results in the development of systemic inflammation and autoimmunity. In our Tet2 −/− RHOA G17V AITL tumor model, constitutive activation of S1P receptors supported activation of the STAT3 and NFkB pathway and enhanced migration of malignant cells to peripheral organs. Mechanistically, expression of Rhoa G17V in mature CD4+ T-cells impaired re-phosphorylation of the Ezrin-Radoxin-Moesin (ERM) complex independently of ROCK signaling and led to the activation and increased migration of CD4+ T-cells. Importantly, blockade of S1PR1 signaling by fingolimod induced anti-tumor activity in Tet2 −/− RHOA G17V lymphoma-bearing mice in vivo with significant reductions in tumor burden associated with increased apoptosis and decreased STAT3 phosphorylation. Furthermore, analysis of a panel of primary tumors from AITL patients using a multiplexed staining panel and PhenoImager platform revealed significantly higher S1PR1 expression in AITL tumor cells than normal TFH cells from benign reactive lymph nodes. Our findings highlight the role of S1P signaling pathway in the pathogenesis of RHOA G17V-driven AITLs and the potential therapeutic benefit of targeting this pathway.
Bone Health of Hemophilia Ａ Patients Using Emicizumab
Authors: Lyu Ting-Wei , Sun Ting , Chou Sheng-Chieh
Published: December 2023

Background:

Hemophilia patients have been observed to exhibit a higher prevalence of osteoporosis compared to age-matched general population. However, the underlying mechanism responsible for this association remains poorly understood. One hypothesis proposes that factor VIII itself may possess additional physiological functions that contribute to bone health. Conversely, alternative viewpoints suggest that overall coagulation function or thrombin generation may play a pivotal role in maintaining optimal bone health. The introduction of emicizumab, a bispecific antibody that mimics the coagulation function of factor VIII but possesses a structurally distinct composition, presents an opportunity to shed light on this matter. Therefore, the primary objective of this study is to explore and compare the bone health status of hemophilia patients, distinguishing between those utilizing emicizumab and those who are emicizumab-naïve.

Method:

From June 2019 to June 2023, at the hemophilia center of National Taiwan University Hospital, additional examinations to assess the patients' bone health were performed with routine annual joint health evaluations for patients with hemophilia A (PwHA) and B (PwHB). This included the use of dual-energy X-ray absorptiometry scan (DEXA) to measure the bone mineral density (BMD) of the lumbar spine, hip, and femur. Furthermore, the serum levels of procollagen type 1 N-terminal propeptide (P1NP) and C-terminal telopeptide (CTX) were measured as reference markers for bone formation and bone resorption, respectively. The Kruskal-Wallis test was utilized to statistically evaluate the observations among the three groups.

Results:

The study population was divided into three distinct groups based on their hemophilia subtype and treatment: PwHA who had been utilizing emicizumab for more than one year (n=8), PwHA individuals receiving regular factor VIII treatment (n=16), and PwHB (n=10). The analysis of the collected data, as presented in the accompanying table, revealed that the three groups exhibited similar characteristics in terms of age, annual bleeding rate, and joint conditions. Moreover, no statistically significant differences were detected in the measurements of bone mineral densities (BMDs) and biomarkers. However, it is worth noting that there appeared to be a potential trend toward higher levels of P1NP in the PwHB group.In the case of PwHA patients using emicizumab, we examined the longitudinal changes in T-score of BMD over time. Notably, three PwHA patients with baseline T-scores below zero demonstrated improvements in their T-scores after one year of emicizumab treatment.

Conclusion:

The results of this study indicate a lack of significant disparities in bone health between individuals utilizing emicizumab and those who are not. Furthermore, our findings suggest that emicizumab usage does not lead to a decline in bone health over the observed period.
Management and Evolution after VTE Recurrence and/or Bleeding in Cancer Patients Receiving Anticoagulant Therapy for VTE: A Nationwide Cohort Study in France
Authors: Mahe Isabelle , Gusto Gaelle , Quignot Nadia , Khachatryan Artak , Chaves José , Moniot Audrey , André Lucas , Van Roy Sylvain , Mokgokong Ruth , Bertoletti Laurent
Published: December 2023

CONCLUSION

Until recently, the standard of care for treatment of venous thromboembolism ( VTE) in cancer patients was low molecular weight heparins (LMWH). Despite anticoagulation therapy (AC), patients remain at high risk of treatment failure (VTE recurrence and/or bleeding).

To determine the characteristics, management and the course of treatment after experiencing a recurrent VTE and/or bleeding event in VTE cancer patients receiving LMWH.

A nationwide retrospective cohort study of all adult patients (identified via the French national health data system: SNDS) with VTE and active cancer prescribed LMWH from 2013 to 2018.

Of 31,771 patients administered LMWH, 1,256 patients (mean age 64.1 years) experienced a recurrent VTE (median time to the first recurrent VTE event: 1.2 months) and 1,129 patients (mean age 67.5 years) experienced a bleeding event leading to hospitalization (median time to the first bleeding event: 1.5 months) during the first six months, and among them 46.7% and 40.9% patients experienced the event within the first month.

The proportion of patients with recurrent VTE and bleeding varied according to cancer sites (7.3%, 6.5% and 5.1% for recurrent VTE and 5.0%, 6.1% and 4.1% for bleeding, respectively in lung, colorectal and breast cancer) (Figure 1).

The management of patients with recurrent VTE consisted of a switch to another AC treatment in 370 patients, in whom 262 switched to an oral AC (179 to a DOAC and 83 to a VKA), the remaining continuing LMWH.

The management of patients with bleeding consisted of a switch to another AC treatment in 159 patients. Among the 159 switched patients, 94 switched to an oral AC (73 to a DOAC and 21 to a VKA), <10 stopped AC (Figure 2).

Our results indicate that recurrent VTE and bleeding events lead to a heterogenous switch of AC therapy. Further research is needed to optimize secondary AC management in VTE cancer patients.

This study was sponsored by Pfizer and Bristol Myers Squibb

Keywords : venous thromboembolism; cancer; anticoagulants; bleeding; low molecular weight heparin; treatment pattern
Primary Effusion Lymphoma (PEL) and Primary Effusion-like Lymphoma (PEL-LL): A Comparative Study of Clinicopathologic Features and Outcomes
Authors: Gupta Supriya , Graham Christopher , Haddad Philip A
Published: December 2023

Background:

While PEL is a well-established distinct WHO entity, PEL-LL is poorly defined and has been characterized differently by different researchers. Over the years, it encompassed PEL that expressed mature B-cell markers, extra-cavitary solid PEL, and recently the HHV8-unrelated PEL-like lymphomas. For this study, we defined PEL-LL as PEL-like lymphomas expressing mature B-cell phenotype. We conducted this study to compare the clinicopathological characteristics of PEL and PEL-LL and their impact on clinical outcomes.

Methods:

To study the clinicopathologic characteristics, therapeutic interventions, overall survival (OS), disease-free survival (DFS), and prognostic factors, we compiled a pooled database of 381 cases of PEL and PEL-LL. Chi-square and t-test were used to test the statistical significance of differences in parameters. Kaplan-Meier survival curves were constructed. Cox proportional hazards model and Log-rank tests were used to assess the influence of clinicopathologic factors on OS and DFS.

Results:

A total of 381 (268 PEL, 113 PEL-LL) patients were identified. PEL and PEL-LL median ages were 51 and 74 (p < 0.0001), respectively. There was a male preponderance with M:F of 7 with PEL versus 2 with PEL-LL (p < 0.0001). The median OS was 6 months for PEL and 16 months for PEL-LL (p = 0.006). Compared to the thoracic cavity, involvement of the peritoneal cavity was associated with worse OS in both PEL and PEL-LL. Still, PEL-LL maintained better outcomes for each risk group (24 and 7 vs. 11 and 4 months, p < 0.0001). In the absence of HIV infection, PEL-LL has a superior OS to PEL (19 vs. 6 months, p = 0.002). However, HIV infection erases this survival advantage (6 vs. 6.5 months). In both entities, active treatment was associated with better OS (19 vs. 10 and 9 vs. 2 months, p < 0.0001). However, the untreated PEL-LL arm did as well as the treated PEL arm. Achieving CR as the best response to therapy in both PEL-LL and PEL was associated with superior OS (108 vs. 7 and 70 vs. 2 months, p < 0.0001). While dose-intense chemotherapy regimens did not impact OS in PEL-LL, they were associated with better OS in PEL (22 vs. 18 and 15 vs. 8 months, p = 0.03).

Conclusions:

This is the first study to compare PEL and PEL-LL expressing mature B-cell phenotype. It identifies key factors that impact OS that vary between the two entities. It also supports that PEL and PEL-LL represent two different disease entities regardless of their similar presentation.
Incidence and Predictive Factors of Heparin-Induced Thrombocytopenia: A Comprehensive Analysis Using National Inpatient Data
Authors: Al-Alwan Ahmad , Awidi Muhammad , Vyas Charmee , Singh Vinit , Khalid Farhan , Du Doantrang , Eltoukhy Hussam
Published: December 2023

Introduction:

Heparin-induced thrombocytopenia (HIT) is a serious complication associated with heparin therapy, characterized by an immune reaction involving antibodies against heparin-platelet factor 4 (PF4). This immune complex formation triggers platelet activation, blood clotting, and reduced platelet counts. Several factors, including previous heparin exposure, duration of exposure, and certain comorbidities, have been examined as potential risk factors for HIT development. In this study, our objective was to determine the incidence of HIT and identify predictive factors associated with its occurrence.

Methods:

We conducted an analysis using the National Inpatient Sample (NIS) data from 2020 to investigate the incidence of HIT during that year and its correlation with specific comorbidities. Patient identification was based on the International Classification of Diseases (ICD-10) code D75.82. The incidence and associated comorbidities were evaluated using multivariate logistic analysis with Stata 17.

Results:

Among the 32,355,827 adult patients admitted throughout the United States in 2020, a total of 11,380 cases of HIT were identified. The incidence of HIT was significantly higher in male patients, obese individuals, those with acute kidney injury (AKI), chronic kidney disease (CKD), type II diabetes mellitus (DMII), heart failure (HF), primary hypercoagulable states, and autoimmune diseases such as systemic lupus erythematosus (SLE). The highest risk of developing HIT was observed in patients with thrombophilia (OR 4.17, 95% CI 3.66-4.75, P = .000), AKI (OR 3.53, 95% CI 3.19-3.91, P = .000), and HF (OR 2.10, 95% CI 1.90-2.33, P = .000). Among autoimmune diseases studied, only SLE was associated with an increased odds ratio for developing HIT (OR 1.60, 95% CI 1.06-2.41, P = .026).

Conclusion:

The incidence of HIT varies and is influenced by the presence of specific comorbidities. Further studies are recommended to investigate additional factors that may increase the likelihood of HIT development. This information could aid in validating and implementing standard precautionary measures in patients at higher risk of developing HIT.
Zanubrutinib, Lenalidomide Combined with R-CHOP As the Frontline Treatment for Mantle Cell Lymphoma
Authors: Zeng Zhiyong , Yang Apeng
Published: December 2023

Objectives

Mantle cell lymphoma (MCL) has poor prognosis with existing available therapies. Zanubrutinib, a novel BTK inhibitor, has shown promising outcomes in relapsed/refractory MCL. The aim of this retrospective study was to evaluate the efficacy and safety of zanubrutinib combined with R2-CHOP (lenalidomide, rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) in newly diagnosed MCL.

Methods

We retrospectively analyzed newly diagnosed MCL between September 2020, to March 2023 in a single-center in China. All patients received zanubrutinib 160 mg twice daily, lenalidomide 25 mg daily (days 1 to day 14), rituximab 375 mg/m 2, cyclophosphamide 750 mg/m 2 (day 1), doxorubicin 50 mg/m 2 or liposome doxorubicin 40 mg (day 1), vincristine 1.4 mg/m 2 (day 1), and prednisone 100 mg (day 1 to day 5) every 3 weeks. After 4 cycles, autologous hematopoietic stem cell transplantation (ASCT) was performed according to the patient's condition. After 6 cycles of induction or ASCT, patients with an objective response (complete or partial response) continued to receive zanubrutinib twice daily plus rituximab maintenance therapy, administered every 12 weeks for up to 8 additional doses. All patients underwent CT or PET-CT scans to evaluate mid-term efficacy. After 6 cycles, PET-CT scans were evaluated for patients whose mid-term efficacy did not achieve complete metabolic response (CMR).

Results

All of 5 patients treated with ZR2-CHOP were enrolled. The median age was 50 years (range: 44-66 years), 3 patients were females, 2 patients were males. 3 patients were classical MCL, 1 patient was pleomorphic MCL, and 1 patient was blastoid-variant MCL. The overall response rate was 100% (5 of 5), and all of them achieved CMR (Figure 1). Three patients achieved CMR after 4 cycles received ASCT, two received 6 cycles. At the mid-term evaluation after 4 cycles, 4 patients achieved CMR, 1 patient achieved PR but achieved CMR after 6 cycles. At data cutoff (22 March 2023), the median follow-up time was 26.1 (range, 12.5-32.4) months. The median PFS and OS rates were not reached. The 2-year PFS rate and the 2-year OS rates were both 100% (Figure 2). The most common grade 3/4 adverse events were neutropenia (60%) and thrombocytopenia (40%), all of which were controllable and resolved. The results of WES analysis showed that the most common gene mutations were KMT2D (frequency, 60%) and DDR2 (frequency, 40%). ctDNA was dynamically detected in four patients. Matched analysis of WES and ctDNA showed that gene mutations detected by these two methods were highly consistent, with 3 out of 4 patients being consistent. Among them, one showed negative ctDNA before and after treatment, while the other three patients indicated a decreasing trend in ctDNA mutation rate after 4 or 6 cycles, including a 50% decline or a change from baseline to negative.

Conclusions:

ZR2-CHOP showed promising preliminary efficacy and acceptable safety in previously untreated patients with MCL.
Burden of Chemotherapy-Related Myelodysplastic Syndrome/Acute Myeloid Leukemia in the Chemotherapeutic Armamentarium
Authors: Gaddam Shiva Jashwanth , Grewal Udhayvir , Thevuthasan Sindhu , Ramadas Poornima
Published: December 2023

Introduction:

Therapy related Myelodysplastic Syndrome and Acute Myeloid Leukemia (t-MDS/AML) is a well-established adverse event (AE) associated with conventional chemotherapy drugs and has historically carried a poorer prognosis when compared to de novo disease. Newer chemo medicines like PARP inhibitors have also been implicated in developing this complication. However, comprehensive real-world data is lacking pertaining to the AE burden relative to individual drug classes.

Methods:

We used the FDA Adverse Events Report System (FAERS) public dashboard to obtain the data. Data was available for the years 1970 - 2023. We retrieved the number of events that were reported as “Myelodysplastic Syndrome” or “Acute Myeloid Leukemia” for individual chemotherapy classes that have historically been known to cause t-MDS/AML. Disproportionality analysis was performed by calculating the reporting odds ratio (ROR) with its 95% confidence interval (CI).

Results:

The drug class with the highest ROR of MDS/AML was the topoisomerase inhibitors - ROR 2.38 (95% CI 2.27-2.49). Intercalating agents like anthracyclines and mitoxantrone had the next highest ROR of 2.12 (95% CI 2.04 - 2.21). The novel drug class PARP inhibitors had the third most burden of t-MDS/AML with an ROR of 1.57 (95% CI 1.46 - 1.69). Table 1. depicts the individual drug classes and their ROR for associated MDS/AML. Table 1 depicts the individual drug classes and their ROR for associated MDS/AML.

Conclusions:

From this retrospective analysis, we identified that among all the chemotherapy drug classes, the topoisomerase II inhibitors were associated with the highest burden of t-MDS/AML, followed by intercalating agents and PARP inhibitors. Further data is essential to identify the patient characteristics associated with higher risk of developing this dreaded complication. This could improve patient-counseling prior to treatment initiation, assist with alternate drug choices when applicable, and perhaps also aid in developing strategies for closer monitoring in high-risk patients.
Keeping up with the Cartashians - Classical Hematology Drug Approvals over Past 5 Years
Authors: Shah Surbhi , Padrnos Leslie , Pruthi Rajiv K. , Go Ronald S.
Published: December 2023

Classical hematological disorders encompass a broad array of congenital and acquired blood conditions, ranging from thrombotic and hemorrhagic disorders, hemoglobinopathies such as sickle cell disease/thalassemia, abnormalities in blood counts, disorders of iron metabolism, obstetric hematologic conditions, and rare genetic hematologic diseases. The past decade has seen a revolution in research and therapeutic development for these disorders. It has led to FDA approval of novel therapies such as gene therapies for hemophilia and hemoglobinopathies, targeted therapies for coagulation and complement disorders, factor VIII mimetics, new immunotherapeutic targets for cytopenia and genomic-directed diagnosis and therapy for a wide range of blood disorders.

Between January 2018 and July 2023, 34 new drugs have been approved for different classical hematological disorders, and several more have received approval for new or expanded indications. This is changing how we treat patients with classical hematological conditions. Most classical hematological disorders have an impact on patients' quality of life as well as life span, and for decades, many of these disorders were managed with limited therapy options with variable efficacy.

Rare hemolytic disorders such as cold agglutinin disease, paroxysmal nocturnal hemoglobinuria, thrombotic thrombocytopenic purpura, atypical hemolytic uremic syndrome, sickle cell disease, thalassemia, porphyria all have expanded options. Newer agents for the management of anemia, thrombocytopenia and leukopenia in different clinical settings are available. Lastly, management of hemophilia is being revolutionized by extended half-life products, non-factor options and gene therapy. Hemophilia care has always been deemed to be costly, but gene therapy is getting additional attention due to the high price tag.

We have compiled the list of all new drugs that got FDA approval for classical hematological disorders over past 5 years and plan to present this in the form of an infographic providing details on the drug along with its indication, trial leading to approval and cost implications of each therapy. Our intention is to summarize the drug development for classical hematology and highlight “not so benign” nature of these disorders and related therapy particularly in terms of financial toxicity for the patients.
Development of Best-in-Class Gene Editing Therapy for β-Hemoglobinopathies Using Innovative Transformer Base Editor (tBE)
Authors: Wang Lijie , Li Peixue , Wang Yichuan , Lan Kewei , Zheng Huiming , Zhu Di , Zhang Yan , Guo Runni , Ma Hongxia , He Jing , Su Qing , Gao Runze , Zhang Lang , Bao Zhiwei , Hou Jianxia , Ji Letu , Zhang Jian , Wu Sijia , Li Yaliang , Luo Bei , Wu Bingbing , Mou Susan , Chen Jia
Published: December 2023

β-thalassemia and sickle cell disease (SCD) are among the most prevalent monogenic disorders worldwide and both these β-hemoglobinopathies are caused by mutations in the β-globin gene HBB. Reactivating the expression of the γ-globin genes ( HBG1/2) mimicking the naturally occurring hereditary persistence of HbF (HPFH) is expected to be a universal strategy to treat β-thalassemia and SCD by the induction of fetal hemoglobin (HbF). To achieve this goal, CorrectSequence Therapeutics' first pipeline, CS-101, uses transformer Base Editor (tBE) to precisely edit human hematopoietic stem cells (HSC) ex vivo to induce the expression of γ-globin for treatment of β-thalassemia and sickle cell disease. Compared with the commonly used gene editing methods such as CRISPR/Cas nucleases or other base editors, tBE is a base editing system that avoids to cause DNA double strand breaks or off-target mutations. With the safety advantages of tBE, CS-101 targets one of the most potent targets to activate γ-globin expression without causing unexpected off-target mutations. A commercial scale manufacturing process to ex vivo edit HSC has been developed and validated with more than 10 batches of commercial scale production, all of which exhibited consistent process performance and product quality. Pre-clinical in vivo studies showed that while tBE-mediated editing of HSC induces robust γ-globin expression, tBE did not cause adverse effect on the engraftment or differentiation of the HSC in mice after transplantation. Clinical study for CS-101 is underway and it holds great promise to become the best-in-class gene editing treatment for β-hemoglobinopathies.
Lung Megakaryocytes Arise from a Flt3 - Cell Lineage and Contribute to Recovery of Platelet Counts in Thrombocytopenic States
Authors: Livada Alison C. , McGrath Kathleen E. , Blick-Nitko Sara , Li Chen , Kingsley Paul D. , Vit Leah A. , Ture Sara , Koniski Anne , Palis James , Morrell Craig
Published: December 2023

Platelet-producing megakaryocytes (Mks) are present in the lung, and we have described an immune modulatory phenotype of lung Mks. It is assumed that the extravascular lung Mks are ‘seeded’ from the bone marrow (BM). To investigate lung Mk origin and how origin may impact function, we used complementary models to lineage trace lung Mks and their platelets.

FlkSwitch mTmG mice label all progeny from Flt3 + progenitors with GFP while all other cells are labeled with Tomato. We leveraged the FlkSwitch mouse model to compare BM and lung Mk origins. In 18 week old mice, the vast majority of BM and spleen Mks were GFP +, while lung Mks were largely Tomato + (Figure 1A). These data implied that in the adult mouse lung Mks arise from a Flt3 - pathway that is distinct from BM megakaryopoiesis in homeostatic conditions.

We next used a lineage tracing model (MDS1-Cre-ERT2 Tomato) where tamoxifen (TAM) administration induces a Tomato reporter in hematopoietic stem cell (HSC)-derived cells. Mice were dosed with TAM at 18 weeks and sacrificed at 32 weeks. Lung and BM Mks were largely Tomato + (~75%) and matched Tomato levels of BM Lineage - Sca1 + c-Kit + (LSK). Next, we dosed mice with TAM at 8 weeks, sacrificed the mice at 14 weeks and found similarly high levels of Tomato in BM LSK, BM Mk, and lung Mk. In MDS1-Cre-ERT2 Tomato mice, both BM and lung Mks were Tomato +/HSC-dependent, suggesting that lung Mks arise from HSCs in adult mice.

Next, we used CFSE dye given oropharyngeal (OP) to label only lung cells. We detected CFSE + lung Mks for up to 120 days post administration without any CFSE + Mks in BM or spleen. These data suggested there is a long-lived Mk population in the lung. Taken together, these complementary models imply that lung Mks arise from a Flt3 - lineage that is HSC-dependent, which yields Mks that can live in the lung for extended periods of time.

The CFSE OP method labeled only lung cells, which enabled us to track lung Mk-derived platelets. We found that about 10% of the steady-state circulating platelet pool is lung derived. In a model of thrombocytopenia using diphtheria toxin mediated platelet depletion in PF4-Cre-iDTR mice, we observed a doubling of CFSE + lung-derived circulating platelets (about 20%). We also used Plasmodium yoelli murine malaria as a model of infection associated with more chronic thrombocytopenia. Using CFSE OP labeling of lung Mk-derived platelets, we saw a marked increase in CFSE + lung-derived platelets early post- P. Yoelli infection (Figure 1B).

Our studies suggest that lung Mks arise from a Flt3 - HSC-dependent pathway and contribute relatively more platelets during acute and chronic thrombocytopenia. Ongoing work aims to describe the role of lung megakaryopoiesis via a Flt3 - HSC-dependent pathway in early development and in models of thrombocytopenia.
Influence of Human and Viral IL-6 on KSHV Infection in Human Tonsil Lymphocytes
Authors: Zakir Wajd , Osborn Jessica , Totonchy Jennifer
Published: December 2023

Background: Infection of B cells by lymphotropic gamma-herpesvirus Kaposi sarcoma-associated herpesvirus (KSHV) causes Multicentric Castleman Disease, Primary Effusion Lymphoma, and the newly-identified inflammatory syndrome designated KICS.1 Despite proven connections to lymphoproliferative disorders, little is known about how KSHV invades the human immune system or the early events governing infection in B lymphocytes. IL-6 signaling plays a critical role in KSHV-mediated disease, where elevated hIL-6 levels are positively associated with KSHV viral load and disease progression.2 This dynamic is even more complex due to the co-existence of human IL-6 (hIL6) and KSHV-encoded viral IL-6 (vIL6) in these diseases. Although the impact of IL-6 signaling is well-established in the context of KSHV disease, its role in the early stages of infection in B cells remains undefined.

Hypothesis: We hypothesize that hIL6 and vIL6 play critical roles in the early stages of KSHV infection in B cells and the establishment of KSHV-infected plasma cells.

Method: In this study, we use ex vivo infection of tonsil lymphocytes with recombinant KSHV as a model to investigate early infection events. Our main objective is to utilize multiple approaches, including molecular knockout of vIL6 from the KSHV genome, knockout of human IL6 through CRISPR-Cas9 gene editing as well as recombinant proteins and neutralizing antibodies to manipulate signaling from hIL6 and vIL6. We will examine how these manipulations affect the viability, differentiation, and proliferation of tonsil lymphocyte cultures as well as the magnitude and distribution of KSHV infection via flow cytometry analysis.

Results: In our investigations, successful knockdown of hIL-6 in non-B cells resulted in reduced B cell viability, with IL6 knockdown correlating with decreased B cell survival in the cultures as well as decreased KSHV infection, particularly in plasma cells. Neutralization of hIL6 reduced proliferation in B cell cultures and this effect was more profound when hIL6 was neutralized in the context of infection with the vIL6 mutant virus. Moreover, hIL-6 neutralization had little effect on total infection in the context of WT KSHV, but vIL6 mutant virus had a reduced ability to establish infection when hIL6 was neutralized. We will also present results showing the effects of vIL6 and hIL6 on B cell differentiation in response to KSHV infection. Overall, our findings suggest that hIL6 and vIL6 have complementary but separable roles in the early stages of KSHV infection in B cells.

References:

1. Thakker S, Verma SC. Co-infections and Pathogenesis of KSHV-Associated Malignancies. Front Microbiol. 2016;7. Accessed July 20, 2023. https://www.frontiersin.org/articles/10.3389/fmicb.2016.00151

2. N, Totonchy J. Cytokine-Targeted Therapeutics for KSHV-Associated Disease. Viruses. 2020;12(10):1097. doi:10.3390/v12101097
NK Cells Contribute to Therapeutic Effects of Type I Interferons in Polycythaemia Vera
Authors: Muth Sabine , Lossa Johanna , Schnöder Tina , Bartneck Joschka , Marini Federico , Ries Frederic , Lindhauer Nora Sophia , Klein Matthias , Bopp Tobias , Schild Hansjörg , Heidel Florian H , Probst Hans Christian , Radsak Markus P.
Published: December 2023

Myeloproliferative neoplasms (MPN) are clonal hematopoietic stem cell (HSC) disorders resulting in massive overproduction of mature peripheral blood cells, e.g. myeloid cells in chronic myeloid leukemia (CML), erythrocytes in polycythemia vera (PV) or platelets in essential thrombocythemia (ET), eventually occurring with myelofibrosis (MF). The JAK2V617F mutation is highly abundant in PV and has triggered the development of JAK inhibitors relieving PV induced symptoms and splenomegaly. However, neither JAK inhibitors nor phlebotomy or chemotherapy as other treatment options affect the allelic burden of mutated JAK2 as indicator of the clone size of malignant HSCs and thus cannot alter the natural course of the disease. In contrast, interferon alpha (IFNa) is well known to be effective in all MPNs and can even induce long-term remissions but have only been recently approved in the EU for the treatment of PV. Concerning the mode of action, type I interferons (IFNs) can directly inhibit proliferation of the malignant hematopoietic stem cell (HSC) clone. As being an immune stimulatory, type I IFNs drive the activation of immune and stromal cells in general. Thus, it is reasonable to assume that indirect effects of IFNs may also contribute to therapeutic effects. However, the cell specific contribution of type I IFNs on normal and malignant HSCs is unexplored so far. To investigate the immunological mechanisms by which type I IFNs attack malignant HSCs in MPNs, we use a mouse model for PV, in which mice suffer from increased hematocrit and enlarged spleens and in which we can reduce disease symptoms by the injection of IFNa. Performing high-dimensional flow cytometry and single cell sequencing we show here a comprehensive analysis of the contribution of cells and pathways in the therapeutic effect of IFNa in P. vera mice. We identified NK cell frequencies and numbers to be increased in the bone marrow of P. vera mice upon IFNa therapy. In the absence of NK cells after antibody mediated depletion the reduced disease symptoms in IFNa treated P. vera mice were completely reversed, indicating that NK cells play a critical role in the beneficial effects of IFNa treatment of P. vera mice. Thus, NK cells may represent a previously unexplored target in the development of future treatments of MPNs.
Racial Differences in the Association of Glucagon-like Peptide 1 Agonist Use and the Progression of Monoclonal Gammopathy of Undetermined Significance to Multiple Myeloma in US Veterans with Diabetes Mellitus
Authors: Grandhi Nikhil , Liu Lawrence , Wang Mei , Thomas Theodore , Kumar Akhil , Gao Feng , Sanfilippo Kristen M. , Colditz Graham , Chang Su-Hsin
Published: December 2023

Background: Glucagon-like peptide 1 (GLP-1) agonists are antidiabetic medications that exert cardiac and renal benefits in addition to their well-established antihyperglycemic effects. A prior analysis has shown that GLP-1 agonist use is associated with a 65% reduction in the risk of progression from monoclonal gammopathy of undetermined significance (MGUS) to multiple myeloma (MM) in US Veterans with diabetes mellitus (DM). However, it is unknown whether there are racial differences to this effect of GLP-1 agonists. We aimed to assess the racial differences in the association between GLP-1 agonist use and the progression risk in diabetic patients with MGUS.

Methods: Patients diagnosed with MGUS in the Veterans Health Administration (VHA) database from 10/1/99-12/31/21 were identified using ICD codes. A natural language processing algorithm was used to confirm MGUS diagnosis and progression to smoldering MM or MM. Patients diagnosed with MGUS before DM and those who experienced progression within 1 year of MGUS diagnosis or within 2 years of DM diagnosis were excluded. For each race, we performed 1:2 matching for patients with and without GLP-1 agonist use based on follow-up time. The outcome was progression to smoldering MM or MM. Cumulative incidence functions stratified by GLP-1 agonist use (ever vs. never use) were plotted and a Gray's test was performed to detect the difference between the functions. The association between time-varying GLP-1 agonist use and MGUS progression was estimated using a multivariable Fine-Gray subdistribution hazard model with death as a competing event.

Results: Our NLP algorithm confirmed 20,832 patients with DM and MGUS. After applying our inclusion and exclusion criteria, we had 9,294 white patients and 4,981 black patients, of which 909 and 403, respectively, were GLP-1 agonist users. After matching, our analytic cohort included 2,718 white patients (33.3% with GLP-1 agonist use) and 1,191 black patients (33.3% with GLP-1 agonist use). GLP-1 agonist use was associated with a dramatically significant reduction in progression rate in white patients (aHR 0.25; 95% CI 0.09-0.68), while the association was not shown in black patients (aHR 1.01; 95% CI 0.36-2.90).

Conclusion: For patients with MGUS and DM, GLP-1 agonist use is associated with a 75% reduction in progression risk in white patients and no significant reduction in black patients. This highlights a racial disparity in the potential role of GLP-1 agonist for chemoprevention in the management of MGUS.
A Cytochrome c Variant Enhances Megakaryocytic Maturation
Authors: Shafaei Pishabad Zahra , Wan Yuen On Anna , Ledgerwood Elizabeth
Published: December 2023

Mutations in genes which play a role in the processes of megakaryopoiesis and platelet production cause thrombocytopenia. Five pathogenic variants in the gene encoding cytochrome c ( CYCS) associated with mild autosomal dominant thrombocytopenia have been reported. The role of cytochrome c in megakaryopoiesis and platelet formation is unknown, and it is unclear how mutations in cytochrome c cause thrombocytopenia. The goal of this project is to understand how CYCS mutations cause thrombocytopenia.

We are using the human leukemic K562 cell line as a model system to study the impact of CYCS mutations on megakaryocyte differentiation and mitochondrial function. One of the CYCS pathogenic variants (c.145T>C; p.Tyr49His) was introduced into K562 cells using the CRISPR-Cas9 base-editing method. K562 cells have three copies of CYCS-containing chromosome 7 and we isolated CYCSWT/WT/WT, CYCSWT/WT/Y49H, CYCSWT/Y49H/Y49H, CYCSY49H/Y49H/Y49H clonal lines, confirmed by sequencing and mass spectrometry. K562 cells undergo megakaryocyte differentiation in response to PMA. We monitored the expression of megakaryocyte markers CD61 and CD41a by flow cytometry in response to PMA in all clonal lines. The K562- CYCSY49H/Y49H/Y49H line showed faster maturation compared to all other clonal lines and the parental K562 cells. We assessed mitochondrial function using the Seahorse XFe96 Analyzer. Our results show that the mutation does not impact mitochondrial respiratory function. Finally, we have introduced the Y49H mutation into WTC11 iPSCs. Investigations of the impact of the Y49H variant on apoptosis showed that there is no significant differences in apoptosis between WT and the clonal line carrying the Y49H variant. Our results suggest that the pathogenic c.145T>C; p.Tyr49His CYCS variant enhances megakaryocyte maturation.
Comparison of the Efficacy between 81 Mg Bid of Aspirin and 162 Mg Od of Aspirin in Splenectomized Thalassemic Patients with Aspirin Resistance
Authors: Kaokunakorn Thanapon , Ruchutrakool Theera , Suwanawiboon Bundarika , Hantaweepant Chattree , Rungjirajittranon Tarinee , Nakkinkun Yupa , Binhama Tasneem , Chinthammitr Yingyong
Published: December 2023

Backgroud: Currently, aspirin is widely used in splenectomized thalassemic patients. Despite taking 81 mg of aspirin daily, some patients develop venous thromboembolic complications, and these patients are referred to as “aspirin-resistance”. Then, increasing dose of aspirin to 162 mg/day is one of treatment options. It is not known if which regimen of aspirin at dose of 162 mg/day (1 tab po bid VS 2 tabs po once daily) is more effective in these patients.

Methods: This is a prospective randomized cross-over study in splenectomized thalassemic patients between 2022 and 2023 at Siriraj Hospital. All splenectomized thalassemic patients aged from 18 to 60 years who have been taking aspirin of 81 mg/day were enrolled and evaluated for aspirin resistance (ASA-resist) by platelet aggregation test using arachidonic acid as agonist (PAT-AA). Patients with 81-mg aspirin resistance were randomly assigned to the following 7-day regimens in a crossover design: aspirin 81 mg twice daily (ASA1x2) or aspirin 162 mg once daily (ASA2x1), and their PAT-AA was assessed after each regimen.

Results: A total of 64 patients (41 women) with a median age of 32.5 years were mostly Hb E/beta-thalassemia (86%) whereas 53% were transfusion-dependent thalassemia (TDT). ASA-resist was found in 24 patients (37.5%). The 'ASA1x2' showed a higher prevalence of ASA-resist than 'ASA2x1' but no statistical significance (52.4% vs.35%; OR 2.0; 95%CI, 0.58-7.17; p=0.265). For 'ASA1x2' regimen, serum ferritin level of ≥1200 ng/mL was significantly associated with ASA-resist (OR 10.7; 95%CI, 1.4-82.0; p=0.030). For 'ASA2x1' regimen, ASA-resist was significantly associated with TDT (p=0.015) and serum ferritin level of ≥1200 ng/mL (OR 20.0; 95%CI, 1.7-238.6; p=0.017).

Conclusions: The “aspirin 81 mg twice daily” regimen showed a higher prevalence of aspirin resistance than “aspirin 162 mg once daily” regimen in splenectomized thalassemic patients with aspirin resistance, and an elevated serum ferritin level was significantly associated with aspirin resistance in both regimens.
Targeting B-Cell Malignancies with Anti-ROR1 CAR T-Cell Therapy
Authors: Weng Jinsheng , Le Cao Cuong , Pan Yong , Perutelli Francesca , Cheng Xiaoyun , Cao Jingjing , Agbedia Owhofasa , Kuang Shao-Qing , Liu Jingwei , Chu Fuliang , Patchva Sridevi , Saini Neeraj Y. , Neelapu Sattva S.
Published: December 2023

Anti-CD19 chimeric antigen receptor (CAR) T cell therapy has been shown to induce high

complete response rates in the majority of B-cell lymphoma patients. However, over 50% of

patients relapse within one year. A major cause of failure appears to be due to loss of CD19

expression on the tumor cell surface. This indicates that novel therapeutic strategies are still

needed in clinic. Receptor tyrosine kinase like orphan receptor 1(ROR1) is an oncofetal receptor

for Wnt5α that is expressed in multiple embryotic tissues but absent in virtually all adult tissues.

However, ROR1 is expressed at high levels in chronic lymphocytic leukemia (CLL), mantle cell

lymphoma (MCL), diffuse Large B-Cell Lymphoma (DLBCL), and several solid tumors. The high

expression level of ROR1 in tumor cells is associated with adverse clinical prognosis. In

addition, a small percentage of cancer cells with characteristics of undifferentiated leukemia

cells or cancer stem cells were found to overexpress ROR1. Using hybridoma technology, we

generated an anti-ROR1 monoclonal antibody that specifically recognized ROR1 protein. The

antibody bound to ROR1-expressing MCL cell lines but not to normal donor T cells, B cells, or

monocytes, indicating the specificity of the antibody. Lentiviral transduction of a CAR molecule

derived from the anti-ROR1 antibody into primary human T cells redirected their specificity

against B-cell lymphoma cell lines. We found the anti-ROR1 CAR T cells specifically lysed B-

cell lymphoma tumor cells at high efficiency but not normal B cells. At an effector: target ratio of

1:1, the anti-ROR1 CAR T cells lysed over 95% of B-cell lymphoma tumor cells during 3-days of

coculture. To determine the optimal CAR construct, we evaluated various hinge

transmembrane, and costimulatory domains in the CAR molecule. We found that incorporation

of the CD28 hinge and transmembrane domain in the CAR construct dramatically enhanced the

in vitro lysis efficiency of anti-ROR1 CAR-T cells. In conclusion, we developed a novel and

potent anti-ROR1 CAR T-cell therapy product that may be used for treatment of various B-cell

malignancies and ROR1-expressing solid tumors.