bluuebunny/crossref_metadata_2025 huggingface dataset:
Winrho: Safety and Efficacy during Pregnancy
Authors: Cromwell Caroline , Tarantino Michael , Aledort Louis M.
Published: April 2020

Anti-D (WinRho SDF Baxter) immune globulin is approved in the United States for the treatment of chronic and acute ITP in adult and children. It is also approved for the suppression of Rh isomimmunization in pregnant women. The use of Anti-D for ITP during pregnancy is not licensed in the United States. In pregnant patients in particular, treating physicians are wary of the use of a drug in an off-label setting given the fear of increased risk to the mother and fetus. To assess its use in pregnant patients a surveillance questionnaire was sent to over 700 practicing adult or pediatric hematologists and obstetricians in the United States. A computer based literature search using the search terms “ITP and pregnancy” and “Anti-D and pregnancy” was also conducted.

Patient Age Gestational Age Number of doses Concomitant meds Maternal Platelet Response* Maternal adverse events Fetal adverse events *Response is defined as a platelet count greater than 30,000 1 35 38 1 Unknown Y N N 2 28 15 7 Y Y Y N 3 23 38 1 Y Y N N 4 36 38 1 N Y N N 5 36 34 1 Y Y N N 6 37 14 4 Unknown Y Y N 7 37 37 1 N Y Y Y 8 31 36 1 Y Y Y N 9 46 20 1 Y Y N N 10 38 37 2 Y Y N N

Very few pregnant patients with ITP appear to have been treated with Anti-D. Information on 10 cases were obtained for review related to the efficacy and safety of Anti-D to mother and child.

Maternal Adverse Events included: headache (2 patients), nausea (1 patient), hemolysis (1 patient), and myalgias (1 patient). Fetal adverse events included fetal jaundice in one child. Concomitant medications included prednisone and IVIG.

A majority of these patients were treated during the third trimester of pregnancy. Out of the 10 patients, all patients achieved a platelet count greater than 30,000. Many of these patients were on concomitant medications for ITP, and were initiated on Anti-D in an attempt to raise the platelet count. There were no episodes of DIC, renal failure, fetal death, neonatal hemolysis or spontaneous abortion. One child had jaundice, which resolved with phototherapy and there was no long-term sequelae. This review provides some data for the efficacy and safety of anti-D for pregnant patients with ITP. Further investigation of its use during pregnancy is on-going. These data should encourage larger studies so this indication can be considered for approval
A SCID Mouse Model for Monitoring in Vivo Viability of Human Platelet Concentrates Using Flow Cytometry
Authors: Ding Jia-hua , Huang Cheng-yin , Xu Shiyun
Published: April 2020

Objective To develop an animal test method for evaluating the in vivo quality of human platelet concentrates.

Methods Human platelets were transfused to mice by tail vein with a 1mL insulin syring fitted with a 29-gauge ultra-fine needle. Blood samples were taken at 30 minutes,2,4,6,8,12, and 24hours after infusion with a tail vein nick technique, whole blood was collected into heparinized capillary tubes. Human platelets in mouse whole blood were detected by flow cytometry with monoclonal anti-human CD61-PE–conjugated antibodies. All subsequent recoveries were calculated as a percentage of the initial collection.

Results The survival time of human platelets were significantly prolonged in SCID than in BALB/c,FVB mice. Recoveries at 4 hours after transfusion in SCID, BALB/c,FVB mice were 68.6%±8.1%(n =10),29.9%±6.5%(n =8),28.1%±5.5%(n =8), respectively, and with a T½ estimate of 8 hours for SCID, 2.5 hours for BALB/c and 2 hours for FVB mice. platelet storage lesions either by chemical treatment or by suboptimal conditions storage exhibited decreased recoveries in SCID mice.

Conclusion The quality of platelet Products can be evaluated by assessing the survival of human platelets in SCID mice using flow cytometry.
Immature Platelet Fraction (IPF) as Novel Laboratory Parameter for Managing Early Onset Thrombocytopenia in Very Low Birth Weight Infants
Authors: Weimann Andreas , Lun Andreas , Gaedicke Gerhard , Cremer Malte
Published: April 2020

Thrombocytopenia (platelet count <150/nl) is one of the most common hematologic problems in preterm and term neonates and affects 18 to 35% of all patients admitted to neonatal intensive care units (NICU). Thrombocytopenia is more than twice common in extremely low birth weight infants (ELBW; <1000g) as reported among the general NICU population. Among thrombocytopenic ELBW infants almost 40% suffer from severe thrombocytopenia as defined by a platelet count <50nl. The risk for hemorrhage, which may cause acute life-threatening complications and/or life-long disability in more than 15%, is difficult to assess, because it is closely related to the gestational and postnatal age of the neonate as well as the cause of the thrombocytopenia and the severity of concurrent conditions. From routine full blood counts of premature (birth weight <1500g) and full term babies we additionally determined platelet counts, IPF, MPV, NRBC and reticulocyte counts. On the basis of individual IPF and platelet counts we were able to predict the platelet counts of the following day. In non-thrombocytopenic preterm and term neonates no significant changes in IPF values were found during the first week of life. In the first week, thrombocytopenic neonates displayed higher IPF values than neonates with normal plaletet counts. We hypothesize that IPF is higher in neonates with chronic hypoxia as leading cause for thrombocytopenia and lower in case of perinatal infections. IPF could be a novel parameter in routine diagnostics available at a 24/7 basis in VLBW infants and may be valuable in identifying the underlying pathomechanism of various thrombocytopenias and in clinical decision making on platelet transfusions.
TTP, ET, and ITP Sequential Occurrence in a Single Patient: a Case Report
Authors: Farhat Mirna H , Hanbali Amr
Published: April 2020

INTRODUCTION: Thrombotic thrombocytopenic purpura (TTP), essential thrombocythemia (ET) and idiopathic thrombocytopenic purpura (ITP) are three separate disease entities that affect the platelets. Each has a different pathophysiology clinical presentation and consequences. We present a case where TTP, ET, and ITP were diagnosed in the same patient at different times of her clinical course with the aim of drawing the attention to this undocumented occurrence which remains under investigation.

CASE REPORT: A 42 year old African American female was diagnosed in 1994 with TTP after she presented with slurring of speech and left upper extremity weakness. Her hemoglobin was 9.7 g/dL, creatinine of 1.3 mg/dL, LDH of 448 IU/L and her peripheral smear showed schistocytes. She was diagnosed with TTP and was treated with plasma exchange with improvement in the platelet count. In March 2001, she presented with purple toe syndrome and a platelet count of 877,000. Bone marrow biopsy revealed panmyeloid hyperplasia, clustering of megakaryocytes, and stainable iron. She was then diagnosed to have essential thrombocythemia and was started on Anagrelide, which was later switched to Hydroxyurea. In October 2001, Hydroxurea was stopped and two weeks later, her platelet count dropped to 12,000. Investigations including a bone marrow biopsy were done which showed megakaryocytes in atypical clusters. No schisocytes were seen on peripheral smear. The patient’s platelet count dropped to 7,000 and she was transfused with 12 units of platelets. Post transfusion her count was 90,000 but dropped to 25,000 in less than 12 hours. She was then started on IV immunoglobulins and steroids for a presumptive diagnosis of ITP and her platelet count subsequently improved. Subsequent outpatient evaluation was negative for ANA, C3, C4, and HIV

CONCLUSION: The fact that both immune and thrombotic thrombocytopenic purpura occur with increased frequency among persons with systemic lupus erythematosus, HIV disease, or pregnancy supports the hypothesis that some pathophysiologic factors are shared. As the three conditions have different natural histories and require different treatment modalities, it is important to recognize that these diseases may be seen sequentially and here comes the importance of reviewing peripheral blood smears for evaluation of thrombocytopenia and bone marrow aspirations for diagnosis of thrombocythemia in order to reach an accurate diagnosis and tailor therapy accordingly. This case demonstrates the variability and complexity of platelet disorders. Platelets may go one way or another and can even go in opposite directions in the same person. After reviewing the literature, there are no reported cases of TTP, ET, and ITP diagnosed in the same patient. Our aim is to draw the attention to this rare case which is still under investigation.
Invasive Streptococcus Pneumoniae infection Associated with Hemolytic Uremic Syndrome in Chinese Pediatric Patients
Authors: So Jason Chi Chiu , Leung Yuk-Yan , Yip Sze Fai , Lam Clarence CC , Chan Li Chong
Published: April 2020

Hemolytic uremic syndrome (HUS) associated with pneumococcal pneumonia is rarely reported in the Western literature, in contrast to classical HUS associated with Escherichia coli (E. coli) (O157:H7). We conducted a retrospective review over a 2-year period from 2006 to 2008 in a large tertiary teaching hospital. Five cases were identified. All patients were Chinese children with a median age of 3 years (range: 2 – 4 years). No documented case of E. coli (O157:H7) infection was seen in the same hospital over the past 5 years from 2003 to 2008. Streptococcus pneumoniae (S. pneumoniae) infection was confirmed by positive blood and/or pleural fluid culture. Four of 5 patients developed empyema requiring decortication. HUS was diagnosed as early as 3 days after onset of febrile illness and was apparent within 2 weeks in all patients. The mean nadir for hemoglobin and platelet was 41 g/L (range: 13 – 55 g/L) and 7 ×109/L (range: 4 – 9 ×109/L), respectively. None of them had significant bleeding. All patients received red cell transfusion and 4 of 5 patients received platelet transfusion for prophylaxis or for coverage of invasive procedures. T activation on red cells was documented in all cases. Washed red cells and concentrated pooled platelet-rich plasma were transfused, except for 1 case when transfusion took place before a diagnosis of HUS was made. All patients had impaired renal function as evident by a raised serum creatinine level (range: 101– 756 umol/L). Only 1 patient required dialysis. One patient deteriorated rapidly and died of refractory septicemic shock and multi-organ failure 30 hours after admission. Her hemoglobin and platelet on admission was 106 g/L and 115 ×109/L, respectively. She received unwashed red cells and ordinary platelet concentrate upon clinical deterioration. Blood smear examination and T activation study subsequently confirmed a diagnosis of S. pneumoniae associated HUS. All surviving patients had full renal and hematological recovery with a median follow up of 11 months (range: 3 – 28 months). Invasive S. pneumoniae infection is a relatively common association in Chinese pediatric patients with HUS. This condition can be fatal in the acute state but the medium to long term prognosis is favorable. Transfusion of washed red cells and plasma-reduced platelets is a routine practice in this group of patients, although the efficacy and necessity of this practice has not been formally studied.
Early Hb Response to ESA Treatment May Be An Indicator of Better Survival Prognosis
Authors: Berlin Jesse A , Bowers Peter , Rao Sudhakar , Aravind Suresh , Sun Steven , Liu Kevin
Published: April 2020

Chemotherapy induced anemia patients who respond to ESA treatment have hemoglobin increases within 4–8 weeks. Patients with inadequate Hb response after several weeks treatment often have their ESA dose escalated.. We conducted an exploratory analysis to test the hypothesis that safety outcomes in randomized studies of epoetin alfa might differ depending on the Hb response after 4–8 weeks of treatment.

Methods: The analysis compared the survival across subsets of epoetin-alfa treated patients. Specifically, a landmark analysis was used, which defines a hemoglobin responder at a pre-specified point in time (in this case 4 & 8 weeks post treatment), and then examines survival subsequent to that point in time.Patients were categorized as “Hb responder” when their Hb increased by >0.5 g/dL; “Hb stable” when Hb change within ≤ 0.5g/dL; “Hb non-responder” when the Hb decreased >0.5 g/dL, compared to the value prior to epoetin-alfa treatment. Survival was estimated using the Kaplan-Meier method and comparisons were made between the responders and non-responders versus the stable group. Cox’s proportional hazards model was used to adjust for the following baseline covariates: hemoglobin prior to treatment, baseline performance status, and advanced disease at baseline. All analyses were stratified by study to account for any differences in the study populations and study conduct.

Results: These exploratory findings suggest the possibility that patients identified as non-responders to ESAs after 4 or 8 weeks of ESA treatment may be at increased risk of death, and that this effect is most pronounced in the studies that treated patients beyond the correction of anemia. Although these analyses were adjusted for several key baseline covariates, it is unclear whether these effects result from treatment, or whether patients who fail to respond to epoetin alfa are inherently at increased risk of death (e.g., due underlying malignancy), regardless of their treatment status.
Costimulatory Blockade Enhances Engraftment and Prevents Anti-Donor Antibody Generation in Nonmyeloablative Conditioned Prediabetic NOD Mice
Authors: Bozulic Larry D , Xu Hong , Huang Yiming , Ildstad Suzanne T
Published: April 2020

Chimerism induces tolerance to organ and tissue grafts. Although the toxicity of conditioning has been significantly reduced with nonmyeloablative approaches, it would be beneficial to further reduce the intensity of conditioning in organ transplant recipients. Studies in normal mice and autoimmune NOD mice have revealed that the primary role for conditioning is to control host-versus-graft alloreactivity, allowing for immune-based conditioning to establish chimerism. Recent insights into the mechanism of interaction and crossregulation between innate and adaptive immune responses have led to the development of new approaches for immune-based conditioning. We previously demonstrated that preconditioning of diabetes-prone NOD mice with anti-CD8 monoclonal antibody (mAb) combined with anti-CD154 mAb allowed chimerism to be established with 550 cGy total body irradiation (TBI). Here we investigated whether combined costimulatory blockade can improve the nonmyeloablative regimen and enhance bone marrow chimerism in autoimmune recipients. Prediabetic NOD (H-2d) mice were treated with anti-CD8 antibody (day -3). After 500 cGy TBI (day 0), recipient NOD mice were transplanted with 30 × 106 B10.BR (H-2k) bone marrow cells (day 0) and received anti-CD154, anti-OX40L, and anti- inducible co-stimulatory molecule (ICOS) mAbs intraperitoneally (IP) (day 0, 1, 2, 3). Chimerism and multilineage analysis were quantitated by flow cytometry. Chimeric animals produced multilineage donor chimerism. While 18 prediabetic NOD mice demonstrated an average PB chimerism of ~37% at 1 month and 61% engraftment, 15 of 18 mice lost PB chimerism by 6 months. NOD mice were then transplanted with B10.BR donor skin grafts 1 month post BM transplant. Flow cytometry cross-match assays were performed to detect anti-donor antibody (Ab) in the sera collected 1 month post skin grafting. 44% of chimeric NOD mice (n=9) accepted their skin grafts for over 90 days, while 100% of non-chimeric animals (n=4) rejected their grafts within 60 days. NOD mice transplanted with B10.BR skin grafts alone rejected their grafts within 2 weeks and generated significantly higher levels of donor-specific Abs (mean fluorescence intensity: 251.2 ± 61.5, P<0.0001, n=6) compared to chimeric NOD (4.5 ± 0.6, P<0.0005, n=17) or non-chimeric NOD (12.6 ± 2.4, P<0.0005, n=10). Both chimeric NOD and non-chimeric NOD mice transplanted with 3rd party B6 skin grafts rejected their grafts within 30 days. These results suggest that rejection of skin grafts in chimeric and nonchimeric animals is not associated with anti-donor antibody generation in preconditioned animals. Studies are currently underway to determine if impaired generation of effector/memory T cells (CD44high/CD62Llow/−) is responsible for enhanced engraftment and to determine the potential mechanisms that promote tolerance in prediabetic NOD mice after loss of PB chimerism.
Establishment of a Murine Model of Allogeneic Umbilical Cord Blood Transplantation
Authors: Wang Yi , Depei Wu , Chen Guanghua , Sun Aining
Published: April 2020

This study was undertaken to establish a murine model of unrelated allogeneic umbilical cord blood transplantation (UCBT). To investigate the potential possibility to reconstitute the immunohematopietic system in adult mice recipients across major histocompatibility complex by mixed 2 near term cord blood transplantation: 1×106 umbilical cord blood mononuclear cells from 20 day old C57BL/6 (H2b) pups and 1×106 umbilical cord blood mononuclear cells from 20 day old C3H (H2k) mixed pups delivered by cesarean were injected into lethally irradiated (8.0Gy) BALB/c (H2d) adult mice in the same time. After one month, anti-H2b and anti-H2k antibody were used to investigate donor chimera in recipients. Results showed that all of the control mice that reconstituted with only 1×106 umbilical cord blood mononuclear cells from 20-day-old C57BL/6 (H2b) pups died with in three weeks after radiation. 70% recipients that reconstituted with mixed umbilical cord blood mononuclear cells survived in the observation period of three months. Two donors mixed chimera was demonstrated by using anti-H2b and anti-H2k antibody in the same recipient. In vitro mixed lymphocyte response showed immune tolerance. The results confirmed that two kinds of umbilical cord blood can form mixed chimera in the same adult mice recipients. Mixed umbilical cord blood transplantation can reconstitute the immunohematopietic system in adult mice recipients without causing serious GVHD. This model may be suitable to address many questions raised in clinical mixed umbilical cord blood transplantation.
Blood Cell Versus Vascular Endothelial Cell Contributions to Nitrite Homeostasis and Blood Pressure Regulation
Authors: Wood Katherine C , Liu Virginia B , Noguchi Audrey , Wang Xunde , Raghavachari Nalini , Gladwin Mark T.
Published: April 2020

Mice genetically deficient in constitutive nitric oxide synthase (eNOS) are hypertensive compared to normal C57Bl6 (wild type) mice, indicating the importance of constitutively produced nitric oxide (NO•) to blood pressure regulation and vascular homeostasis. The objective of this study was to use molecular methodologies to determine the contribution of eNOS in circulating blood cells to the intravascular pool of nitrite, a metabolite and storage form of nitric oxide (NO•) with powerful vasorelaxant activity, and to the regulation of blood pressure under physiological conditions. We used bone marrow transplant to create chimeric mice genetically deficient in eNOS in either circulating blood cells (−/+) or vascular endothelium (+/−), confirmed by flow cytometry, western blot, RT-PCR and immunohistochemistry. Nitrite concentrations in whole blood and plasma of chimeras were quantified using ozone-based reductive chemiluminescence. Mean arterial and diastolic blood pressures of chimeras were assessed in the absence/presence of NOS stimulation with oral L-Arginine or NOS inhibition with oral L-Name. A highly significant inverse correlation between plasma nitrite concentrations and blood pressures was noted across all groups of chimeric mice. Importantly, in agreement with higher blood pressures in −/+ chimeras compared to eNOS positive controls (+/+ chimeras globally competent for eNOS), significantly reduced whole blood and plasma nitrite concentrations were also measured. Blood pressure responses to NOS inhibition or stimulation were intact in all chimera groups except eNOS negative controls (−/− chimeras globally deficient for eNOS) and, importantly, blunted in −/+ chimeras compared to eNOS positive controls. These findings indicate a functional blood cell eNOS that is a major contributor to circulating nitrite concentrations and plays a critical role in vascular homeostasis.
Characterization of NK1.1+ CD8 T Cells in Allogeneic Hematopoietic Cell Transplantation Recipients
Authors: Wang Yi , Wang Hui , Wang Shumei , Sykes Megan , Yang Yong-Guang
Published: April 2020

NKT cells from naïve mice are mainly CD4+ or CD4−CD8−. However, it has been reported that CD8+ NKT cells can be expanded in vitro from splenocytes, bone marrow cells and thymocytes of C57BL/6 (B6) mice by stimulation with anti-CD3 mAb and cytokines, and that the expanded CD8+ NKT cells mediate strong graft-vs.-leukemic (GVL) effects without severe GVHD after adoptive transfer into allogeneic mice. We now describe the presence of CD8+NK1.1+ cells in recipient livers (approximately 2–6%), but not in other tissues (spleen, lung, bone marrow, thymus and PBMC), in various allogeneic hematopoietic cell transplantation (allo-HCT) models. The generation of CD8+NK1.1+ cells is likely a consequence of alloresponses, as these cells were not detected in the liver of syngeneic HCT controls. Flow cytometric analysis confirmed that these cells are CD1d-independent, TCRαβ+ T cells with a memory phenotype (CD44+ and CD62L−), and do not express CD49b, Ly-49C/I, Ly-49G2, or Ly-49D. In a sublethally (6 Gy)-irradiated B6-to-B6D2F1 allo-HCT model, NK1.1+ CD8 T cells became detectable by week 2, increased in number until approximately week 8, and gradually declined thereafter but were still detectable in the liver at day 100 after allo-HCT. By using CD45.1 and CD45.2 congeneic donors, we determined that the majority of NK1.1+ CD8 T cells were derived from the donor splenocytes. Furthermore, depletion of CD8+, but not NK1.1+, cells from the donor splenocytes prior to transplantation prevented the generation of NK1.1+ CD8 T cells, indicating that these cells were derived from donor NK1.1−CD8+ splenic T cells. Our data demonstrate that donor CD8 T cells can acquire NK1.1 expression upon activation in allo-HCT recipients, and that these NK1.1+ CD8 T cells maintain a memory phenotype and persist in the recipients with preferential accumulation in the liver. Studies are currently in progress to determine the role of activated donor NK1.1+ CD8 T cells in GVHD and GVL effects.
Mesenchymal Stem Cell Therapy in a Rat Model for GvHD
Authors: Zinöcker Severin , Wang Mengyu , Nestvold Janne , Vaage John Torgils , Kvalheim Gunnar , Rolstad Bent
Published: April 2020

Graft-vs-host-disease (GvHD) is an important hindrance for the usage of allogeneic bone marrow cell transplantation (alloBMT) as a treatment strategy for leukemias and other hematopoietic malignancies. Mesenchymal stem cells (MSC) can interact with the immune system and inhibit alloreactive cells. Infusions of MSC into GvHD patients have alleviated disease severity and overall survival and in recent clinical trials.

We are studying the immunoregulatory potential of MSC as a putative therapy for GvHD in an experimental animal model. Bone marrow-derived MSC from PVG rats are highly efficient in blocking PVG lymphocytes stimulated by allogeneic BN lymphocytes in mixed lymphocyte reactions. We have found a substantial contribution of indirect (without cell contact) inhibition of allostimulation by MSC in vitro, and have examined some of the possible mediating factors among rat cytokines. In our in vivo model we have transplanted BN host rats with 30×106 PVG donor bone marrow (depleted for T cells), and induced GvHD by injection of 1×106 peripheral T cells from PVG donors two weeks later. We have successfully reversed the lethality of GvHD in a number of diseased animals by pre-emptive and repeated infusions of MSC, improving the overall survival rate by 30%. We are furthermore able to trace injected MSC in vivo, and thereby hope to obtain important information on the migration and behaviour of those cells in the development of GvHD. Additional transplantation experiments to improve the effectiveness of the cellular treatment and test more MSC lines from different MHC-congenic rat strains are underway. Moreover, we will include a rat myelogenic leukemia (BNML) in our GvHD model based on our existing protocols and investigate the long-term outcome of MSC therapy (mortality and disease recurrence) with respect to both graft-versus-leukemia and graft-versus-host immunity.
Significant Expansion of Myeloid Derived Suppressor Cells in Patients with High- Risk Breast Cancer Treated with Dose Dense Adjuvant Chemotherapy
Authors: Talmadge James E , Reed Elizabeth , Cowan Kenneth , Gabrilovich Dmitry , Warkentin Phyllis , Janssen William E. , Wisecarver James , Anderson James , Mailliard Mary , Maas Sarah , Turken Orhan , Coskun Uger
Published: April 2020

Myeloid derived suppressor cells (MDSCs) have been reported to be expanded in cancer patients, following growth factor administration and after chemotherapy. These cells have been associated with a loss of T-cell number and function and provide one mechanism of immune evasion. We examined the effect of dose dense chemotherapy on immune phenotypes and function in patients with breast cancers 4 cms or larger and/or four or more involved nodes. The adjuvant therapy was dose-dense doxorubicin, cyclophosphamide (AC) followed by paclitaxel (P), then 33 doses of radiation (R). Blood samples were obtained and studied prior to therapy, 1 week post AC and 1, 15 and 21 weeks post P and then 3, 6 and 12 months later. Flow cytometric analyses of cellular phenotypes were done on these blood specimens and compared to the levels prior to therapeutic intervention and to normal age and sex matched donors. Twenty-three pts have been followed a median of 29 months (range 5.5–50.5 months) from study entry. Two patients relapsed 8 and 23 months after diagnosis. T-cell CD-4 numbers declined following AC from an average of 4.9±0.5 ×106/ml to 1.7±0.3×106/ml, but increased to an average of 2.7± 0.3 × 106/ml, 21 weeks after P or 12 weeks after R. In this study the MDSCs were defined as Lin- (CD3, CD19, CD14 and CD13), HLA-DR- and CD33+. The numbers of MDSCs, which in normal donors were 0.62±0.16×106/ml and in the cancer patients at diagnosis were 11.8±9.6×106/ml increased to 58.4±25.9×106/ml 15 weeks after R. They remained significantly elevated through one year after diagnosis when they were 27.3±12.3×106/ml. The majority of the MDSCs had a high side scatter and forward scatter by flow analysis suggesting a granulocytic commitment rather than a monocytic commitment. The increase in MDSC numbers was apparently associated with R as the numbers of MDSCs were not significantly increased by AC (15.7±13.5×106/ml) or P (10.9±6×106/ml) one week following completion of each cycle of dose dense therapy. In association with the increase in MDSCs there was a significant decrease in PHA proliferation by the peripherial blood mononuclear cells (MNCs) and suppressive activity by irradiated MNC for allergenic lymphocytes.
Hemophagocytic Lymphohistiocytosis (HLH) in Adults Should Be Treated through Intensive Immune Suppression: 2 Case Reports
Authors: Xie Shuangfeng , Yin Songmei , Ma Liping , Nie Danian , Li Yiqing , Wang Xiuju , Liang Dongmei
Published: April 2020

Background: HLH includes the great majority of patients with macrophage-related disorders. Although HLH is considered as a reactive disease, it is an invariably fatal disease. HLH have 2 types: familial hemophagocytic lymphohistiocytosis and secondary hemophagocytic syndrome. The HLH-2004 protocol made by Histiocytosis Association of America (HAA) was for patients aged <18 years. There was no standard protocol for adults patients with HLH. But the HLH cases was not rare in patients aged >18 years, especially in China. We had 2 HLH cases recently, the 2 patients had different prognosis through different treatment.

Patients and treatment: Case 1, a 20 years old man, he had mild infection 3 weeks ago, and was cured by antibiotics. Then 2 weeks ago, he got persistent fever, lymphadenectasis, hepatosplenomegaly and pancytopenia. Bone marrow smear discovered 3.5% hematophagocyte, no malignant cells. His direct bilirubin (DBIL) increased to 229.9μmol/L, fibrinogen decreased to 0.14g/L, albumin decreased to 24.6g/L in 5 days. Then he was treated with the HLH-2004 protocol (VP-16+dexamathsone+ciclosporin A). After 10 days treatment, his DBIL became 149.7μmol/L, fibrinogen increased to 1.73g/L, albumin increased to 31.2g/L, The pancytopenia was improved too. Now he was still in recover state. Case 2, a 33 years old woman, she was diagnosed enteric T-cell Non- Hodgkin’s Lymphoma 3 weeks ago. She had normal blood cell analysis and liver function at that time. She had colon perforation because of the lymphoma before the diagnosis and the abdominal inflammatory was severe. Also 1 week after her diagnosis, she had HLH. We try to improve her state by supportive treatment. No chemotherapy was used. Soon, severe pancytopenia appears, her fibrinogen decreased to 0.84g/L, albumin decreased to 23.1g/L, alanine transarninase (AST) increased to 201U/L. Her state aggravated very fast and died of hemorrhea and shock. Almost all adult patients with HLH had poor prognosis without the HLH-2004 protocol treatment. HLH-2004 protocol might be a hope for adult patients with HLH. We need to investigate the effects of HLH-2004 protocol through treating more adult patients with HLH. Also, after the diagnosis of HLH, the patient should be treated as soon as possible, because the multi-organ failure could be developed very fast. The chance of treatment might be lost because of multi-organ failure.
Twenty Units of Blood and Counting
Authors: Brownrigg Emma , Carr Debbie , Copeman Michael C. , Creighton Kim , Demasi Catherine , Domanski Julie , Harrison Susan , Hodges Cherry , Kanakis Joanne , Kelleher Sharyn , McCosker-Rees Joanna , Prall Rachel , Richardson Dawn , Ryan Patricia , Swan Craig , Terry Susan , Tovey Julie , Van Kuilenberg Rosita , Wills Melissa , Slader Cassandra
Published: April 2020

Iron overload is a condition seen in patients who have received multiple packed red cell transfusions. Generally, patients who have received >20 transfused units will be at risk. Currently in Australia there is no universal method of tracking the number of transfusions a patient has received, and a cumulative figure requires manual calculation. Therefore, identification of at-risk patients is not straightforward.

Aim: Firstly, to review the primary diagnosis of transfused patients in haematology day units. Secondly, to quantify number of transfusions received and serum ferritin levels of transfused patients. Thirdly, to review the use of iron chelation in these patients and document potential reasons for non-chelation including co-morbidities and concomitant medications.

Method: Medical records for outpatients transfused during the 12-week index period (12 consecutive weeks from Human Research and Ethics Commitee/institution approval) were reviewed in this retrospective multicentre audit. Data were captured using a piloted data collection form. Non-parametric statistical test have been used.

Results: To date, 237 patients, aged 0–95 have been reviewed from 10/20 centres. Common underlying conditions necessitating transfusion were: MDS(35%), chemotherapy-induced anaemia(21%) and thalassaemia(14%). The medical record of 26% patients indicated that transfusions had also been given elsewhere. In total, 119 had received >20units, 58(49%) had been prescribed chelation therapy. Fourteen patients who had received >20units had no documented serum ferritin. Patients receiving iron chelation were younger (median 42 cf.73 years, p=0.0004), had received more transfusions(median 60 cf.18, p<0.0001) and more units(median 187 cf.37, p<0.0001). There was no difference in number of concurrent medical conditions(p=0.73) or concomitant medications(p=0.14). Life expectancy was documented for 6 patients only, 3 were chelated.

Conclusion: There is variability in the monitoring and treatment of iron overload in Australian hospitals, with not all at-risk patients receiving chelation. The development and implementation of universal tracking tools for transfusion nurses and patients may be one means of improving identification of at-risk patients.
Characterization and Development of Genomic DNA Quality Controls for Thrombophilia and Warfarin Sensitivity Testing
Authors: Anekella Bharathi , Wu Jainlei , Huang Catherine , Dryga Sergy , Smith Tamara , Howell Renee , Manak Mark
Published: April 2020

Background: Genetic tests for diagnosis of clotting disorders and monitoring their treatment are based on identification of single nucleotide polymorphisms (SNPs) that are related respectively to clotting and to drug metabolism crucial to the effectiveness of therapy. Thrombophilia, an inherited condition which predisposes to thromboembolism, is due in part to genetic factors, such as the presence of SNPs in the genes encoding clotting factors. Hyperhomocysteinemia, which poses an extremely elevated risk of thromboembolism to the patient, can be caused by certain mutations to the MTHFR (677CT, 1298AC) gene; genotyping all genes involved in thrombophilia concurrently can offer a more complete picture of the genetic component of thrombophilic risk. Warfarin is the most frequently used oral anticoagulant for treatment and prevention of thromboembolism and requires careful adjustment of therapeutic dose and close monitoring because of its narrow therapeutic index and wide individual variability in response and therapeutic dose. Genetic variations in two genes, CYP2C9 and vitamin K epoxide reductase (VKORC1), have been shown to have a profound effect on warfarin sensitivity. Using genetic tests for identification of these variants clinicians to better estimate the appropriate starting dose for therapy, which may improve drug safety. Currently a number of test systems detect these SNPs. Use of a well-characterized independent quality control sample is important to monitor the accuracy and reproducibility of these tests. We have developed multi-analyte quality controls that contain major SNP variants for both thrombophilia MTHFR and warfarin sensitivity.

Methods: PBMCs from multiple donors were screened for mutations for MTHFR for Thrombophilia and for CYP2C9 and VKORC1 for warfarin sensitivity. Mutations were identified using the Third Wave Technologies INVADER® and Autogenomics INFINITI™ platforms; and ABI TaqMan® SNP assay. All mutations were confirmed by sequencing on an ABI 3130 instrument.

Results: PBMC samples were screened for CYP2C9, VKORC1, and MTHFR mutations. The mutation frequency for CYP2C9*2, CYP2C9*3 and VKORC1 1639GA variants was 28%, 7% and 63% respectively. 100% genotyping concordance was observed in all testing. In addition, heterozygotes for additional VKORC1 SNPs 5808TG, 6484CT, 6853GC, 7566CT, and 9041GA were present in one sample bearing VKORC -1639GA. The mutation frequency for MTHFR 677CT and 1298AC was 17% wt and 29% het for both SNPs. The identification of heterozygotes in several SNPs allowed development of multi-analyte controls for both genes. Data showing reproducibility and accuracy in SNP call rate on various test platforms will be presented.

Conclusion: We have developed multi-analyte controls for thrombophilia and warfarin sensitivity that can monitor extraction, amplification and detection, and evaluated their performance with several test methods.
ENACCTing WELLNESS- a Community Centered Intervention to Enhance Treatment Option Decision- Making among Newly Diagnosed and Recurrent Hematologic Cancer Patients
Authors: Michaels Margo , Golant Mitch , Belkora Jeff , Miller Melissa F , Blakeney Natasha
Published: April 2020

Background: Less than three percent of adult cancer patients participate in cancer clinical trials. This rate is even lower among people of color and the medically underserved who tend to have higher cancer mortality rates than the population as a whole. With timely diagnosis and enhanced access to clinical trials, more patients with blood cancers will have expanded options for treatment and the opportunity to receive quality cancer care.

Methodology: ENACCTing WELLNESS is a pilot project with the Education Network to Advance Cancer Clinical Trials (ENACCT) and The Wellness Community (TWC), which seeks to demonstrate how community-centered education, outreach and support services can both address informational needs and enhance access to care among those living with blood cancers in four communities nationwide. Using an innovative ecological framework directing educational efforts at the intrapersonal, interpersonal, institutional and community perspectives, ENACCTing WELLNESS:

Provides one-on-one treatment decision support with a trained facilitator, using an evidence-based decision-making model, SCOPED (Situation-Choices-Objectives-People-Evaluation-Decisions), to prompt newly diagnosed/newly recurred patients to list questions about their diagnosis and treatment, including the option of receiving their treatment though a clinical trial; Increases awareness of support services for patients, their family members, friends, and caregivers; Educates primary care providers, especially those caring for the medically underserved, about options to refer patients to local clinical trials for first line treatment; and Enhances cultural competency skills of local clinical trial investigators and their teams.

Results: This session will discuss the use of the SCOPED model in the conceptual framework of ENACCTing WELLNESS, and the collaborative effort between two community-centered organizations to enhance patient treatment decision-making options through provider training, referral, and one-on-one patient counseling. We will report lessons learned from phase I of the pilot study and preliminary evaluation data from health care provider training.

Implications: The framework implemented in this pilot may result in increased and timely primary care referral of patients with a suspected hematologic cancer and may assure decision quality as measured by high levels of decision self-efficacy and low levels of decision regret among patients contemplating treatment choices.
The Importance of Clinical Variables for Propensity Score Matching When Comparing Costs: The Case of ESA Treatments for Chemotherapy Induced Anemia
Authors: Polsky Daniel , Eremina Daria , Hess Gregory P. , Hill Jerrold , Hulnick Scott , Roum Adam , Whyte Joanna , Kallich Joel
Published: April 2020

Background: The erythropoiesis-stimulating agents (ESAs) epoetin alfa (EA) and darbepoetin alfa (DA) are treatments for chemotherapy-induced anemia. Therapy choice depends on many factors, including cost. Previous analyses have demonstrated differences in the characteristics of patients receiving EA vs. DA. We estimated cost differences between DA and EA in patients with cancer receiving chemotherapy using a propensity score matched analysis of baseline patient characteristics with and without hemoglobin (Hb) values.

Methods: Data were extracted from electronic medical records in two US databases between January 2004 and December 2006. The study sample included 6743 patients receiving chemotherapy, with ≥ 1 visit during the study period, who received an ESA during a chemotherapy episode. Episodes of chemotherapy care were constructed using a 90 day gap in administration to identify the start and end. Patients receiving both, or neither, DA and EA during their initial chemotherapy episode, or with missing descriptive data were excluded. Drug costs were calculated from cumulative dose multiplied by 106% of the average sales price (ASP) for DA or EA. Two propensity score matches were conducted: first using variables available in administrative billing claims systems, then adding the baseline Hb test result. Regression-adjusted cost differences were estimated with and without baseline Hb, using generalized linear models.

Results: Using baseline Hb as a variable resulted in a better match of the baseline characteristics for the EA and DA treatment groups compared to the original sample or the matched sample without baseline Hb. Mean ESA costs for the original sample were $4171 for EA and $3811 for DA (mean difference: $360; P <0.001, SE $99). With propensity score matching without baseline Hb, mean estimated costs were $3836 for EA and $3599 for DA (mean difference: $237; P = 0.053, SE $123). With propensity score match including baseline Hb, mean costs were $3965 for EA and $3536 for DA (mean difference: $429; P = 0.001, SE $125).

Conclusions: Addition of baseline Hb as a variable in propensity score and ESA cost models affects ESA treatment cost estimates in patients with cancer receiving chemotherapy. Cost comparisons based on observational data should use analytical methods that account for differences in clinical variables between treatment groups.
Outpatient Treatment with Intravenous Antimicrobial Therapy in Patients with Febrile Neutropenia and Hematologic Malignancies
Authors: Bellesso Marcelo , Pracchia Luis Fernando , Dias Lucia , Chamone Dalton , Dorlhiac-Llacer Pedro
Published: April 2020

OBJECTIVES: The purpose of this study is to evaluate outcomes like success of the initial therapy; failure of outpatient treatment and death in outpatient treatment with intravenous antimicrobial therapy in patients with febrile neutropenia (FN) and hematologic malignancies. In addition, it was compared clinics, laboratory data and Multinational Association for Supportive Care of Cancer index (MASCC) with failure of outpatient treatment and death.

PATIENTS AND METHODS: In a retrospective study we evaluated FN following chemotherapy events that were treated initially with Cefepime, with or without Teicoplanin.

RESULTS: Of the 178 FN episodes in 128 patients, it was observed success of initial therapy in 63.5% events, failure of outpatient treatment in 20.8% and death in 6.2%. In multivariate analysis, significant risks of failure of outpatient treatment were smoking (OR: 3.14, IC: 1.14 – 8.66, p=0.027) and serum creatinine > 1.2mg/dL (OR: 7.97, IC: 2.19 – 28.95, p = 0.002). About death, the risk was pulse oximetry < 95% (OR: 5.8, IC: 1.50 – 22.56, p = 0.011). Analyzing MASCC index, 165 events were classified as low risk and 13 as high-risk. Failure of outpatient treatment were reported in connection with 7 (53.8%) high-risk episodes and 30 (18.2%) low-risk, p=0.006. In addition, death in 7 (4.2%) lowrisk and 4 (30.8%) high-risk events, p=0.004.

CONCLUSIONS: The outpatient treatment with intravenous antibiotic was satisfactory. The risks: smoking, serum creatinine elevated and pulse oximetry should be considered in FN evaluation. It was validated MASCC index in Brazilian population.
Persistence of Human Parvovirus B19 in Multipotent Mesenchymal Stromal Cells Expressing the Erythrocyte P antigen: Implications for Transplantation
Authors: Sundin Mikael , Lindblom Anna , Örvell Claes , Barrett A. John , Sundberg Berit , Watz Emma , Wikman Agneta , Broliden Kristina , Le Blanc Katarina
Published: April 2020

Multipotent mesenchymal stromal cells (MSC) are used to improve the outcome of hematopoietic stem cell transplantation (HSCT) and in regenerative medicine. However, human MSC may harbor persistent viruses that may compromise their clinical benefit. Parvovirus B19, known to cause the childhood disease erythema infectiosum (“fifth disease”), can be hazardous to HSCT recipients due to development of a virus mediated severe pancytopenia. Retro spectively screened, 1 of 20 MSC from healthy donors contained B19 DNA. The donors exhibited a seroprevalence of anti-B19 IgG comparable to the reported normal level. Using flow cytometry, we found that human MSC (n=6) expressed the erythrocyte P antigen (also called globoside), reported as the B19 receptor, and Ku 80, a reported B19 co-receptor. After in vitro exposure to plasma derived from B19 viremic patients, MSC (n=3) were found positive for intracellular B19 proteins as determined by immunofluorescence. This demonstrates that MSC can be infected by B19. Further studies revealed that MSC could transmit B19 to bone marrow cells in vitro, suggesting that the virus can persist in the marrow stroma of healthy individuals. Two HSCT patients received the B19 positive MSC as treatment for graft-versus-host disease. Neither developed viremia nor symptomatic B19 infection, even though they where severely immunocompromised by means of subnormal Ig levels, low leukocyte counts and poor responses in mixed lymphocyte cultures. These results demonstrate for the first time that persistent B19 in MSC can infect hematopoietic cells and underscore the importance of monitoring B19 transmission by MSC products.
Role of Homing Regulation in Coculturing Human Cord blood–derived Mesenchymal Stem cells with CD34-Positive Cells from Umbilical Cord Blood
Authors: Lee Mark , Hong Heesun , Kim Sung Yong , Cho Yo Han , Yoon So Young
Published: April 2020

Background and Objectives Mesenchymal stem cells plays an important role in the hematopoietic stem cell engraftment condition with SDF-1 (CXCL12)-CXCR4 signaling and in their homing in various tissues. In this study, we evaluated that the regulation of homing efficiency for mesenchymal stem cells to support ex vivo expansion of hematopoietic stem cells from umbilical cord blood.

Methods We investigated the expression of CXCR4 and Stromal-Derived Factor-1 (SDF-1) in cocultured mesenchymal stem cell with umbilical cord blood-derived CD34-positive cell, which stimulated with granulocyte macrophage-colony stimulating factor (GM-CSF) and stem cell factor (SCF) cytokine.

Results In this study, we evaluated that coculturing of SDF-1+ mesenchymal stem cells with stimulated CD34+ cells significantly increased the expression of CD34, CD45, and CD19 for myeloid surface marker and intracellular CXCR4 within a few hours as compared with culturing of CD34-positive cells alone or with SDF-1− mesenchymal stem cells or untreated mesenchymal stem cells by Flow cytometre. In the result of stimulation for 48 hours with various cytokines in CD34-positive cells, CXCR4 gene and ERK-1,2 protein up-regulated, and increased in vitro migration capacity of cocultured SDF-1+ mesenchymal stem cell with CD34+ cells as examined by quantitative RT-PCR of human GAPDH. To enhance homing effect by mesenchymal stem cell, we maintained expanded mesenchymal stem cells for up to 5–10 passages with monitoring of the expression of various tissue surface antigens, such as skeletal muscle, neural, liver, and endothelial cells. SDF-1+ mesenchymal stem cells induced the homing of cellular products of stimulated cord blood-derived CD34-positive cells for 10 days. Moreover, the tranfected SDF-1+ cells with a green fluorescent protein gene using lentivirus maintained their capacities of protein release and homing in culture system. SDF-1− mesenchymal stem cells reduced CXCR4 expression in cocultured CD34-positive cells.

Conclusions: These results demonstrate that the role of the SDF-1/CXCR4 axis is an important rold in the regulation of homing and engraftment of mesenchymal and hematopoietic stem cells. SDF-1+ mesenchymal stem cells have clinical potential to regulate homing and short-term engraftment for hematopoietic stem cell transplantation.