bluuebunny/crossref_metadata_2025 huggingface dataset:
Prevalence of Pulmonary Embolism Among Patients with Acute Exacerbations of Chronic Obstructive Pulmonary: Data from Nationwide Inpatient Sample
Authors: Pathak Ranjan , Giri Smith , Karmacharya Paras , Donato Anthony
Published: October 2019

Background

Patients suffering from acute exacerbation of chronic obstructive pulmonary disease (AECOPD) are thought to be at a higher risk of developing venous thromboembolism due to various reasons such as smoking, immobilization and a transient procoagulant state. However, clinical diagnosis of acute pulmonary embolism (PE) in patients with AECOPD is often difficult due to the similarity in the presenting symptoms of the two conditions. Literature regarding the true prevalence of PE among patients with AECOPD and the role of routine screening for PE in these patients with imaging is controversial. Although some studies have suggested prevalence rates to be as high as 20-25%, thus justifying a routine CT pulmonary angiography (CTPA) to evaluate for PE in these patients, other studies have refuted such findings.

Methods

We used the 2011 Nationwide Inpatient Sample database to identify patients aged ≥18 years admitted with AECOPD (International Classification of Diseases, 9th Revision, Clinical-Modification [ICD-9-CM] code 491.21). Patients with AECOPD with co-existing PE were identified using the ICD-9-CM codes 415.1x and 673.2x. Prevalence of PE in patients with AECOPD was calculated. Similarly, in-hospital mortality, length of stay and mean hospital charge was derived for patient with AECOPD, with and without PE. Statistical analysis was performed using Stata 13.1 (STATA Corp, College Station, TX), which accounted for the complex survey design and clustering of the database.

Results

A total of 1,187,808 admissions with AECOPD were identified, of which 1.18% (n=13,988) patients were found to have co-existent PE. On Univariate analyses, no differences were seen in the demographic characteristics (mean age, sex, race, primary payer, region, bed-size, teaching status) of AECOPD patients with and without PE. However, diagnosis of concurrent PE in patients with AECOPD was associated with higher in-hospital mortality (10.6% vs. 3.81%, p<0.001), mean length of stay (9.38 vs. 5.92 days, p<0.001) and mean total hospital charges ($74,234 vs. 40,424, p<0.001).

Conclusion

In this study of large national database, we found the prevalence of PE in patients admitted for AECOPD to be much lower than reported in literature, suggesting that routine imaging to rule out PE is unlikely to be cost effective. Furthermore, routine screening of AECOPD patients for PE with CTPA might actually result in more untoward effects such as incidental pulmonary nodules and PEs with further unnecessary testing and treatment.

Disclosures

No relevant conflicts of interest to declare.
A Successful Model for Adult Emergency Medicine Protocol Implementation for Sickle Cell Disease
Authors: Desai Payal C. , Delatore Luca , Hanes Deborah , Rettig Amy , Gill Miranda , Walsh Jason , Graham Emily , Adkins Eric
Published: October 2019

Introduction: Sickle Cell Disease (SCD) affects approximately 1 in 350 African American newborn infants each year in the United States and 70,000-100,000 people in the United States. Vaso-occlusive pain crisis is the most common complication that results in patients seeking emergency care for sickle cell disease. In the US in 2006, an estimated 232,381 emergency department (ED) visits were related to sickle cell disease, which resulted in approximately $356 million of ED health care costs and $2.6 billion of combined ED and inpatient costs. Initial pediatric data suggests that time to opiate initiation effectively decreased the total ED length of stay, and total intravenous opiates. While adult ED protocols have been implemented, results on time to first opiate as well as health care utilization has been variable.

Methods: A multidisciplinary quality improvement group was formed to improve emergency room department care delivery for patients with sickle cell disease. The existing NIH 2014 sickle cell guideline and Tanabe protocol was modified to include individualized pain plans (Figure 1). The primary goal was defined as average time to first opiate of < 60 minutes. The secondary goal was to improve long term health care utilization as measures by length of ED stay and readmission rates for patients with sickle cell disease. The data was compared to a year prior to protocol implementation given the seasonal variations observed in patient admissions and encounter volumes. For reporting, those patients that require a toxicology screen prior to opiate administration were excluded from the data analysis.

Results: There were a total of 352 encounters from 102 unique patients that occurred time of protocol initiation (January 2015-June 2015). The average time to first opiate in January 2014 was 170 min and June 2014 was 166min. After protocol implementation, the average time to first opiate in January 2015 was 123 min and June 2015 62 min (Figure 2). The readmission rate compared to May and June 2014 was decreased by 43% and 20% in May and June 2015, respectively. The average length of ED stay decreased from 9.4 hrs in June 2014 to 5.0 hrs in June 2015 (Figure 3).

Conclusion: With a collaborative multi-disciplinary approach, successful ED protocol implementation is feasible. The collaboration can lead to better patient care with improvement in time to analgesia. The model may also contribute to reduction in health care utilization.

Figure 1. ED Pain Protocol Algorithm Figure 1. ED Pain Protocol Algorithm Figure 2. Time to First Opiate (mins) Figure 2. Time to First Opiate (mins) Figure 3. Length of Stay in the Emergency Department (Hrs) Figure 3. Length of Stay in the Emergency Department (Hrs)

Disclosures

Desai: Pfizer: Consultancy.
Metabolomic Profiling Identifies Hypoxia-Induced Imbalanced Lands' Cycle Promotes Sickling and Disease Progression
Authors: Wu Hongyu , Bogdanov Mikhail , Zhang Yujin , Sun Kaiqi , Song Anren , Liu Hong , Adebiyi Morayo G, , Alexander Danny C. , Milburn Michael V. , Idowu Modupe , Juneja Harinder S. , Xia Yang
Published: October 2019

Sickle cell disease (SCD) is a prevalent hemolytic genetic disorder with high morbidity and mortality affecting millions of individuals worldwide. Although it is well accepted that deoxygenation and polymerization of sickle hemoglobin (HbS) are initial triggers for sickling, it has been known for more than three decades that abnormal membrane lipid organization and composition are found in sickle erythrocyte. Early studies showed some lipids are altered in sickle erythrocytes, however, no studies have identified overall membrane lipid alteration and functional role of those altered specific lipids in SCD. Using unbiased metabolomic profiling, we found that lysophospholipids (LPLs), particularly lysophosphocholines (LysoPCs), were significantly elevated inside erythrocytes of mice with SCD due to imbalanced Lands' cycle. Lands' cycle containing two concerted enzymes: phospholipases A2 (PLA2s) and lysophospholipid acyltransferases (LPLATs) was initially discovered in 1958. However, its function and cellular regulation in membrane homeostasis in SCD remain unrecognized prior to our metabolomics screening. Here, we demonstrated that enhancing imbalanced Lands' cycle promotes a process of sickling and disease progression in mice by inducing LysoPC content inside erythrocytes. Significantly, correcting impaired Lands' cycle reduced LysoPC levels within erythrocytes and attenuated sickling and disease progression in mice. Mechanistically, we revealed that hypoxia-mediated MEK/ERK activation underlies imbalanced Lands' cycle by preferentially inducing activity of PLA2 but not LPCAT1 in mouse sickle erythrocytes. Additionally, the detrimental role of impaired Lands' cycle-induced LysoPC production in sickling via MEK/ERK-dependent activation of PLA2 in SCD patients mirrors our mouse finding. Overall, our studies have identified a pathological role of imbalanced Lands' cycle in SCD, revealed molecular basis regulating Lands' cycle and immediately provided novel therapeutic possibilities for the disease.

Disclosures

No relevant conflicts of interest to declare.
Barth Syndrome: An Under-Recognized Cause of Chronic Neutropenia
Authors: Steward Colin G. , Groves Sarah J. , Taylor Carolyn L. , Maisenbacher Melissa K. , Versluys Birgitta , Newbury-Ecob Ruth , Ozsahin Hulya , Hamilton Leo , Damin Michaela K. , Bowen Valerie M. , McCurdy Katherine R. , Mackey Michael C. , Bolyard Audrey Anna , Dale David C.
Published: October 2019

Barth syndrome is an X-linked disease characterized by defective remodeling of phospholipid side chains in mitochondrial membranes. Major features include neutropenia, fetal or childhood onset dilated cardiomyopathy, motor delay and proximal myopathy, feeding problems and constitutional growth delay. Improved diagnostic testing, recognition of the wide disease phenotype and a worldwide patient/family support network have recently facilitated much more rapid ascertainment, now with at least 186 living males diagnosed worldwide. We provide a comprehensive survey of neutropenia seen in Barth syndrome and its management based on the study of 90 patients. Neutropenia (i.e. at least one count less than 1.5 x 109/L) was detected in 74 of 90 (82%) patients; 28 of 90 (31%) patients had a mean neutrophil count less than 1.5 x 109/L; 13 of 90 (14%) had a mean count less than 0.5 x 109/L. Neutropenia may be the sole presenting feature in Barth syndrome. Importantly, it can take on any form: intermittent and unpredictable, chronically severe or cyclical, thus mimicking other diseases. Eighty-seven patients had reported monocyte data. Monocytosis was seen in 65 of 87 (75%) patients with at least one monocyte count greater than 1.0 x 109/L and 23 of 87 (26%) had at least one monocyte count greater than 3.0 x 109/L.

Some patients who were neutropenic and had a bone marrow evaluation showed myelocyte arrest. Neutropenic Barth patients are highly responsive to granulocyte colony-stimulating factor, although dosing can be challenging because of innate variations in their neutrophil counts. Clinical improvement with reduced signs and symptoms of infections is the usual response to this treatment. Barth syndrome should be considered in any male with neutropenia accompanied by any of the characteristic features of Barth syndrome and in those with idiopathic neutropenia.

Disclosures

Dale: Amgen: Consultancy, Honoraria, Research Funding.
Erythropoietin Mediated Increase in Monocyte-Derived Liver Macrophages; A Role for Kupffer Cells?
Authors: Gilboa Dafna , Haim-Ohana Yasmin , Ben-Califa Nathali , Deshet-Unger Naamit , Bab-Hiram Sahar , Gassmann Max , Mittelman Moshe , Neumann Drorit
Published: October 2019

Erythropoietin (EPO) is the major hormone that drives mammalian erythropoiesis, via its surface receptor, EPO-R. It is mainly used for treating anemia associated with chronic renal failure and certain malignancies, although this latter indication is currently disputed. EPO-Rs were also found in non-erythroid cells, including dendritic cells and bone marrow macrophages (Lifshitz, 2008; 2010). Here we addressed the effect of EPO on hepatic-macrophages, namely resident liver macrophages (Kupffer cells) and liver monocyte-derived macrophages (MFs). Utilizing the rat Kupffer cell line (RKC-2) we demonstrate that these cells express EPO-R transcripts and cell surface EPO-R, as detected by our novel EPO-R antibody (GM1012; Maxwell 2015). EPO treatment of the RKC-2 cells led to a 1.5±0.06 fold increase (p<0.05) in EPO-R mRNA levels and a 2±0.01 fold decrease (p<0.01) in surface EPO-R levels. Stimulation of the cells with EPO induced a 15%±0.06 (p=0.01) increase in transcript levels of CCL-2 (a chemo attractant for monocytes) and a 15%±0.6 (p<0.05) increase in the levels of the secreted chemokine. EPO treatment also enhanced cellular activity of the RKC-2 cells as manifested in a 50%±0.13 (p<0.01) increase in cell migration, an increase in phagocytosis of microbeads (40%±0.08, p<0.01) and of E.coli (13%±0.05, p<0.01).

Finally, in vivo experiments in which C57BL/6 mice were injected 3 times a week with 180U recombinant Human EPO (rHuEPO), demonstrated an EPO-induced selective increase in MFs (19.5%±0.01, p=0.05), but not in Kupffer cells. Elevated CCL-2 in sera of EPO-injected mice (2.1 fold increase, p<0.01) supports a mechanism by which EPO stimulates Kupffer cells to increase secretion of CCL-2, which in turn enhances recruitment of monocytes to the liver and their subsequent differentiation into MFs.

The present study points to a new as hitherto unexplored action of EPO on two separate liver macrophage populations (Kupffer cells and MFs) which play crucial and distinct roles in liver homeostasis and immunity as well as in liver pathologies. EPO selective actions on liver macrophages thus call for future studies on the effects of this hormone on inflammation in the liver with a therapeutic goal to enhance liver immunity.

Disclosures

Mittelman: Celgene: Research Funding, Speakers Bureau; GlaxoSmithKline: Research Funding; Johnson & Johnson: Research Funding, Speakers Bureau; Novartis Pharmaceuticals Corporation: Research Funding; Roche: Research Funding; Amgen: Research Funding.
Staged Interventions to Improve Quality and Reduce Cost of Care in Patients with Suspected Heparin-Induced Thrombocytopenia
Authors: Samuelson Bethany T , Holmes Meredith , White Andrew , Glynn Emily , Martin Daniel B , Garcia David , Kelly Janet , Wittkowsky Ann Kathryn
Published: October 2019

Background

Heparin induced thrombocytopenia (HIT) is a rare but often considered diagnosis that requires treatment, in the form of costly parenteral anticoagulants, while awaiting the results of confirmatory testing. We hypothesized that improving the accuracy and consistency with which a patient's risk of HIT was determined, through the use of Computer-based Provider Order Entry (CPOE) interventions, would lead to decreased cost of care.

Methods

This study was conducted out of two affiliated US academic medical centers with a shared electronic medical record (EMR). A series of staged interventions, including provider and pharmacist education, real-time alerts and a CPOE based decision support tool were implemented as part of a multidisciplinary quality improvement project between January 1, 2013 and December 31, 2013. All inpatients ³18 years of age who underwent laboratory testing for HIT and/or were started on bivailrudin therapy for suspected HIT between January 1, 2012 and December 31, 2014 were included. For the purposes of our study, we defined the pre-intervention period as January 1 through December 31, 2012 and the post-intervention period as January 1 through December 31, 2014. The primary outcome was mean monthly bivalirudin expenditure at each institution. The secondary outcomes were number of HIT enzyme-linked immunosorbent assay (ELISA) and serotonin release assay (SRA) tests sent per month.

Results

We observed a statistically significant reduction in mean monthly bivalirudin expenditures from $64,178 to $17,704 (p = 0.0002) at one of the included centers and a decrease that approached significance from $28,275 to $16,708 (p = 0.100) at the other. Statistically significant reductions were also noted in mean monthly ELISA testing rates from 38.1 to 19.8 (p=0.01) and mean monthly SRA testing rates from 9.4 to 3.1 (p=0.0001) across both centers.

Discussion

Our findings suggest that the use of a computer-based order entry intervention, as part of a multidisciplinary quality improvement effort, can effectively reduce cost and decrease rates of lab testing in the management of heparin-induced thrombocytopenia. Such interventions are relatively low cost and of low complexity in institutions with established order entry systems and have the potential for a lasting impact on cost and quality of care.

Disclosures

No relevant conflicts of interest to declare.
Protein S As a Potential Treatment for FIX-Derived Deep Vein Thrombosis
Authors: Pilli Vijaya Satish Sekhar , Plautz Willium , Majumder Rinku , Simioni Paolo
Published: October 2019

Background: Every year, 0.1-0.2% of the USA population experiences deep vein thrombosis (DVT). Two causes of DVT are increased Factor IX (FIX) levels and hyperactivating mutations in FIX (FIX Padua variant- R338L and Malmo variant T148A). In principle, inhibition of activated FIX (FIXa) should alleviate DVT. Previous in vitro studies demonstrated that the anticoagulant Protein S (PS) inhibits the intrinsic pathway mediated by wild type FIXa, making PS an attractive candidate to treat DVT.

Aims: To establish Protein S as a remedy for FIX-mediated DVT/Padua/Malmo

Methods: Anisotropy, clotting assays, thrombin generation assays, co-localization, co-immunoprecipitation, and bleeding assays.

Results: We further explored the physiological relevance of the PS-FIXa interaction and PS-mediated inhibition of FIXa by ex vivo (co-immunoprecipitation) and in vivo (co-localization) studies. Because PS can inhibit FIXa in vivo, we used competitive, direct anisotropy assays and co-immunoprecipitation assays to measure the efficiency PS and hyperactive FIXa (R338L) interaction. Interestingly, the results demonstrated that FIXa R338L has lost its affinity towards PS compared with wild type FIXa. The same finding was obtained by ex vivo thrombin generation assays and FXa generation assays supplemented with various concentrations of PS. Thus, to be inhibited, hyperactive FIX requires a greater amount of PS compared with wild type FIXa. We are further confirming this finding with mouse models.

Conclusion: Addition of PS to plasma inhibits both wild type and R338L FIXa and extends clotting time. Previous studies showed that the addition of PS has no significant negative effects. Thus, we conclude that PS supplementation potentially constitutes a novel and effective treatment for FIX-mediated DVT.

Disclosures

No relevant conflicts of interest to declare.
Donor-Derived B Cells Produce Potent AML-Specific Antibodies That Recognize Novel Tumor-Specific Antigens and Mediate Graft-Versus-Leukemia Immunity
Authors: Gillissen Marijn Aletta , Kedde Martijn , Yasuda Etsuko , Levie Sophie E. , Bakker Arjen Q. , Claassen Yvonne B. , Bohne Martino , Speijer Dave , Picavet Daisy I. , Stap Jan , van Oers Marinus H. J. , Beaumont Tim , van Helden Pauline M. , Spits Hergen , Hazenberg Mette D.
Published: October 2019

Unleashing the tumor-specific immune response by immunotherapies such as checkpoint inhibitors or allogeneic stem cell transplantation can result in long lasting tumor regression. While the role of T cells in such graft versus leukemia (GvL) immune responses has been established, the contribution of B cells to GvL responses is less clear. Using SEREX and other techniques, the presence of antibodies directed against established tumor antigens following allogeneic hematopoietic stem cell transplantation (HSCT) has been demonstrated. The function of these antibodies remains to be established though. Here we tested the hypothesis that B cells contribute to GvL.

We selected three patients with high-risk AML who mounted potent GvL responses after allogeneic HSCT. Of these patients we established antibody-producing clonal B cell lines following transduction of memory B cells from the peripheral blood of these patients with Bcl-6 and Bcl-xL and screened those for producing antibodies specifically binding to surface antigens on AML cell lines and AML blasts. A number of antibodies were identified that recognized primary AML blasts isolated from newly diagnosed AML patients, but did not bind to healthy bone marrow, peripheral blood mononuclear cells or tissues such as liver, skin and colon. Target identification analyses revealed two novel, AML-specific surface proteins as primary targets of these antibodies. These newly identified AML-specific antigens are widely expressed on different types of AML, including blasts of the last 17 AML patients that entered our clinic of whom diagnosis material was made available for this project.

Strikingly, antibody binding to one of these targets induced direct cell death of cultured AML cell lines and of primary AML blasts. Cytotoxicity of the antibodies was rapid, occurred both at 37o C and 4o C and could be prevented by Cytochalasin D, an actin polymerization inhibitor that stabilizes the cytoskeleton. This, in combination with the observation that cell death could not be prevented by apoptosis inhibitors indicated that the tumor cells were killed through a necrotic pathway like oncosis. Other antibodies induced antibody-dependent cell-mediated cytotoxicity (ADCC) and complement-dependent-cytotoxicity (CDC).

Together these data indicate that tumor selective antibodies are elicited following allogeneic HSCT in AML patients with a strong GvL response. The direct and indirect cytotoxic activities against tumor cells of these antibodies suggest that they contribute to the GvL response.

Disclosures

No relevant conflicts of interest to declare.
Impact of Bone Marrow Plasmacytosis on Outcome in Patients with AL Amyloidosis Following Autologous Stem Cell Transplant
Authors: Hwa Yi L. , Kumar Shaji K. , Lacy Martha Q. , Gertz Morie A. , Buadi Francis , Rajkumar S. Vincent , Go Ronald S. , Leung Nelson , Kapoor Prashant , Dingli David , Russell Stephen J. , Lust John A. , Hayman Suzanne R. , Kourelis Taxiarchis , Dispenzieri Angela
Published: October 2019

Background: Previous studies have demonstrated inferior overall survival (OS) among patients with AL amyloidosis who have bone marrow plasmacytosis (BMPC) >10%. It is well recognized that AL patients who achieve the deepest hematologic responses have superior organ response and OS rate.

Methods: We designed a study to determine if BMPC% affects CR rate post ASCT and whether pre-transplant induction therapy improves response rate and OS among patients with a higher baseline BMPC burden.

Results: Among 415 AL patients who underwent ASCT at Mayo Clinic, Rochester within 12 months of diagnosis, 116 (28%) had BMPC>10% at diagnosis. The median age was 57.2 years. The median follow up for surviving patients was 67.3 months. There was no statistically significant difference in age, gender, time from diagnosis to transplant, or use of attenuated conditioning regimen between groups with high (>10%) and low (≤ 10%) bone marrow involvement. The high BMPC group tended to receive more induction chemotherapy before ASCT, and presented with greater value of albumin, beta-2 microglobulin and difference in serum free light chain (dFLC). A higher CR rate was observed in low BMPC group (44.6% versus 26.7%, p=0.0013). In patients with high BMPC, a higher CR rate (33.9% versus 17.7%, p<0.05) was seen in those who received pre-ASCT induction therapy compared with no induction therapy. Among 3 groups of patients who had: no pre-ASCT therapy; steroid only as induction; and induction chemotherapy, the 5-year OS rates were 50.5%, 40% & 67.5%, respectively, p<0.03.

Conclusions: Lower bone marrow burden at diagnosis yielded a deeper response following ASCT. Compared to no therapy, patients who were treated with steroid only pre-ASCT had an inferior OS, but other induction regimens appeared to improve survival. These data would support the concept that using induction therapy prior to ASCT conditioning among patients with higher tumor burden may be of value.

Figure 1. In BMPC > 10% at diagnosis, OS comparison between induction therapies pre-ASCT Figure 1. In BMPC > 10% at diagnosis, OS comparison between induction therapies pre-ASCT Figure 2. Figure 2. Figure 3. Figure 3.

Disclosures

Kumar: Celgene: Research Funding; Celgene, Millenium, Sanofi, Skyline, BMS, Onyx, Noxxon,: Other: Consultant, no compensation,; Sanofi: Research Funding; AbbVie: Research Funding; Millenium/Takeda: Research Funding; Onyx: Research Funding; Skyline, Noxxon: Honoraria; Janssen: Research Funding. Gertz:Celgene: Honoraria; millenium: Consultancy, Honoraria; Onyx: Honoraria; Novartis: Honoraria; Smith Kline: Honoraria.
Measuring Quality of End-of-Life Care for Blood Cancers: A National Survey of Hematologic Oncologists
Authors: Odejide Oreofe O. , Cronin Angel M. , Condron Nolan B. , Fletcher Sean A. , Earle Craig , Abel Gregory A.
Published: October 2019

Background: Hematologic malignancies have been associated with poor performance on standard measures of quality of end-of-life (EOL) care in oncology (eg, Hui, Cancer, 2014); however, these measures were originally developed primarily for solid tumors, and they may not appropriately address EOL quality issues for patients with blood cancers. We sought to explore hematologic oncologists' perspectives regarding the acceptability of current oncology EOL quality measures, hypothesizing that they would report them to be largely unacceptable.

Methods: In 2014, we mailed a 30-item survey to a national sample of hematologic oncologists randomly selected from the American Society of Hematology clinical directory. The survey was developed through focus groups (n=20) and cognitive debriefing (n=5) with hematologists whose practices focus on patients with blood cancers. In the resulting survey, we provided a list of standard EOL quality measures (Earle, JCO, 2003; Keating, Cancer, 2010; Phelps, JAMA, 2009; see table) and two novel hematology-based measures (no red cell transfusions ≤ 7 days before death, and no platelet transfusions ≤ 7 days before death) and asked "Please indicate whether or not you feel each is an acceptable indicator of good quality EOL care for patients with hematologic malignancies." We decided a priori that we would consider a measure to be "highly acceptable" if there were at least 75% agreement among hematologic oncologists on its acceptability. Worrying that they might reject them all, we also asked them to identify three measures they would choose in a scenario where three had to be adopted.

Results: We received 349 surveys from 48 states (response rate: 57.3%). Non-responders were not significantly different across known variables (gender and region of practice). Among respondents, median age was 52 years, median time in practice was 25 years, and 43% practiced primarily in tertiary centers. Eighty-seven percent were board-certified in oncology, 81% in hematology, and 71% in both specialties. The table below shows acceptability of the quality measures as rated by respondents.

In the exercise where three measures had to be chosen, the one chosen most often was no CPR within 30 days of death (54%), followed by enrollment in hospice >7 days before death (46%).

Conclusions: In contrast to our hypothesis, all of the measures we presented were considered acceptable by a substantial proportion of the hematologic oncologists in our national cohort. Moreover, while four of the measures reached our a priori designation of being highly acceptable, the two hematology-focused measures did not meet this same threshold. These data suggest that in hematologic oncology, resources should be directed towards addressing barriers to performance on established EOL quality measures in addition to creating new ones.

Figure 1. Figure 1.

Disclosures

No relevant conflicts of interest to declare.
Fertility Preservation for Women with Sickle Cell Disease (SCD)
Authors: Plowden Torie C , Millan Nicole M , Owen Carter M , Healy Mae W , Banks Nicole K , Hsieh Matthew , Fitzhugh Courtney D. , Witmyer Jeannine , Peak Doug , Frankfurter David , DeCherney Alan H , Tisdale John F , Wolff Erin F
Published: October 2019

Objective: Peripheral blood stem cell transplant (PBSCT) can now cure SCD in adults, but may result in a loss of future fertility. Little is documented regarding fertility preservation in women with SCD. The aim of this study was to perform fertility preservation for women with SCD scheduled for PBSCT.

Design: Prospective cohort of women with SCD undergoing fertility preservation prior to PBSCT at a large research hospital.

Materials and Methods: Patients underwent standard controlled ovarian hyperstimulation (COH) using an antagonist protocol cycle with leuprolide trigger under close multidisciplinary (including reproductive endocrinologists and hematologists) monitoring. All patients were continued on therapeutic or started on prophylactic anticoagulation prior to beginning COH, and maintained on hydroxyurea.

Results: Nine reproductive aged women were screened; 1 declined participation, 1 was diagnosed with unrecognized premature ovarian insufficiency, 1 had her fertility preservation cycle canceled due to poor response to fertility medications and 2 patients are scheduled for upcoming cycles. The remaining four women (ages 20, 34, 24, 27) successfully underwent COH, transvaginal oocyte retrieval and cryopreservation of mature eggs (n= 8, 13, 15, 21 oocytes, respectively). The third patient underwent two cycles due to low mature oocyte yield from her initial cycle. Headaches were reported by patients 1 and 2 following gonadotropin injections, with a negative neurologic workup including MRI in patient 2. Patient 3 underwent an exchange transfusion on day 10 of stimulation, which did not adversely impact serum reproductive hormone levels. Patients 3 and 4 reported an acute exacerbation of their chronic pain during COH, which responded well to intravenous fluids, IV and oral pain medications. Therefore, despite severe SCD and co-morbid conditions, the side effects were manageable. There were no venous thrombotic events.

Conclusion: These results provide support that fertility preservation can be safely performed in women with SCD under the care of a multidisciplinary team. The safest stimulation protocol (i.e. antagonist cycle with leuprolide trigger for final oocyte maturation) was successful in all patients despite multiple risk factors for failed leuprolide trigger. Fertility preservation is important not only before PBSCT to cure their underlying disease, but also because of high rates of premature ovarian insufficiency in the SCD population post-transplant.

Support: Intramural NICHD and NHLBI, NIH.

Disclosures

No relevant conflicts of interest to declare.
CD44 and PSGL-1 Collaborate in Controlling the Migration of Human Activated T-Cells
Authors: Ali Amal J. , Merzaban Jasmeen S. , Abuelela Ayman F.
Published: October 2019

Selectins play a central role in the trafficking of activated T cells by mediating tethering and rolling on vascular endothelium, acting as a beacon to help navigate them to the site of infection. Here we present a comprehensive binding and in vitro functional analysis of E-selectin ligands expressed on human activated T cells. Using a mass-spectrometric approach we identified a number of glycoproteins that may act as physiological E-selectin ligands on human activated T cells and focused on comparing the role the previously identified well-known E-selectin ligands, PSGL-1 (P-selectin glycoprotein ligand 1) to the newly identified ligand CD44. We show that CD44 from human activated CD4+ and CD8+ T cells binds E-selectin, and that immobilized CD44 mediates tethering and rolling of E-selectin expressing CHO cells via sialylated N-linked glycans. By knocking down CD44 and/or PSGL-1 in primary human activated T cells, our data demonstrate for the first time that CD44 is essential for mediating the rolling over E-selectin and thereby cooperates with PSGL-1 as a major E-selectin ligand on human activated T cells. This has major implications in the development of targeted therapies to combat inflammatory diseases and in transplantation settings.

Disclosures

No relevant conflicts of interest to declare.
Species-Specific Roles for a2,3- and a2,6-Linked Sialic Acid Residues in PECAM-1-Mediated Homophilic Interactions
Authors: Lertkiatmongkol Panida , Paddock Cathy , Newman Peter J.
Published: October 2019

PECAM-1 is a 130 kDa type 1 transmembrane glycoprotein belonging to the immunoglobulin gene (Ig) superfamily, and is constitutively expressed on the surface of circulating blood cells and endothelial cells. In platelets, PECAM-1 serves as an inhibitory receptor to limit thrombus growth, while on endothelial cells, PECAM-1 is a major junctional protein that functions to sense flow, mediate leukocyte transendothelial migration, and regulate vascular permeability. Previous studies have shown that PECAM-1/PECAM-1 homophilic interactions, mediated by amino-terminal Ig-homology domain 1 (IgD1), are required for its functions on endothelial cells. Interestingly, PECAM-1 is a heavily glycosylated receptor, with two of its nine N -linked glycans present in IgD1. Murine PECAM-1 is modified by addition of α2,6-linked sialic acid residues, and studies performed using recombinant murine PECAM-1 protein have shown that PECAM-1/PECAM-1 homophilic interactions are abrogated upon removal of sialic acid, and inhibited by α2,6- sialylated oligosaccharides, suggesting that these glycans may be important in PECAM-1 homophilic binding. Murine PECAM-1, however, does not bind human PECAM-1. A chimeric protein comprised of the human PECAM-1 extracellular domain fused with human Fc (PECAM-1/IgG) produced by Chinese Hamster Ovary (CHO) cells, which are able to add only α2,3-linked sialic acid residues, has been successfully used to study PECAM-1-mediated adhesive interactions for many years. Taken together, these data suggest that the mechanisms by which PECAM-1 interacts with itself may differ between species. The purpose of the present investigation, therefore, was to examine the role of glycans, specifically terminal sialic acid residues, in human PECAM-1 homophilic interactions. To determine whether the specific linkage of sialic acid affects human PECAM-1 homophilic interactions, we examined the relative ability of α2,3-sialylated PECAM-1/IgG - produced in wild-type CHO cells which lack α2,6-sialyltransferase activity - and α2,6-sialylated PECAM-1/IgG - produced in CHO cells that had been stably transfected with ST6Gal-1, to bind to PECAM-1-transfected REN cells. We found that α2,3-sialylated PECAM-1/IgG bound more than twice as well as α2,6-sialylated PECAM-1/IgG (mean fluorescence intensity (MFI) of 457,250 ± 33,049 versus 280,333 ± 78,589; normal human IgG bound with an MFI of 158,550 ± 62,133). These findings were further supported by molecular docking studies, which showed a preferential orientation for interactions between α2,3-linked sialic acid and amino acid K89 within PECAM-1 Ig homology domain 1 - a residue known to be important in PECAM-1 homophilic interactions. Taken together, these data provide important new conceptual information that improves our understanding of the role of glycosylation in PECAM-1 homophilic adhesive interactions.

Disclosures

No relevant conflicts of interest to declare.
Heart Failure Related Hospitalizations Are Associated with Increased Morbidity and Mortality in Pediatric Oncology Patients
Authors: Keeshan Britton , Lin Kimberly Y , O'Connor Matthew J , Ginsberg Jill P , Aplenc Richard , Shaddy Robert , Rossano Joseph
Published: October 2019

Introduction: Cardiomyopathy is a well-described complication of cancer therapy in pediatric patients. However, the prevalence and outcomes of heart failure related hospitalizations in these patients are unknown. We hypothesize that while heart failure related hospitalizations are uncommon in pediatric oncology patients, they are likely associated with increased morbidity and mortality.

Methods: We performed retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database, a nationwide database of pediatric hospitalizations in the United States, for oncology patients with and without heart failure for years 2000, 2003, 2006, and 2009.

Results: Heart failure was identified in 914 of 259,432 (0.4%) pediatric oncology admissions. Patients with heart failure were more likely to be non-white (52.2 vs 43%, p<0.001), less likely to be in the highest income bracket (23.9 vs 27.5%, p=0.014), more likely to have leukemia (40.7 vs 31.3%, p<0.001), and more likely to undergo bone marrow transplantation on admission (5.0 vs 1.6%, p<0.001). Several morbidities were significantly more common in patients with heart failure including respiratory failure [16.4% vs 1.3%, odds ratio (OR) 14.6, 95% CI 12.2-17.4), sepsis (21.9% vs 7.2%, OR 3.6, 95% CI 3.1-4.3), stroke (1.5% vs 0.6%, OR 2.5, 95% CI 1.5-4.3), and renal failure (11.7% vs 1.2%, OR 10.9, 95% CI 8.9-13.3). Length of stay (LOS) and hospital charges were also significantly greater in oncology patients with heart failure patients compared to those without; median LOS 9 (IQR 4-25) vs 4 days (IQR 2-6); median hospital charges $58,023 (IQR 18,835-169,826) vs $18,161 (IQR 8,860-39,640); p<0.001 for both. Hospital mortality was significantly greater in oncology patients with heart failure compared to those without (13.3% vs 1.3%; OR 11.5, 95% CI 9.5-14.0). On multivariable analysis, heart failure was independently associated with hospital mortality in pediatric oncology patients (OR 2.21, 95% CI 1.63-3.00).

Conclusion: Heart failure is an uncommon but serious complication in hospitalized pediatric oncology patients. The presence of heart failure was associated with increased morbidities, resource utilization, and mortality. Further study is needed for the prevention and treatment of heart failure in this population.

Disclosures

Aplenc: Sigma Tau: Honoraria.
Isolation and Characterization of Mesenchymal Stromal Cells Derived from Paediatric Patients with B Acute Lymphoblastic Leukemia
Authors: Dander Erica , Palmi Chiara , Portale Federica , Beneforti Linda , Biondi Andrea , Cazzaniga Giovanni , D'Amico Giovanna
Published: October 2019

PURPOSE: Several studies reported the importance of tumor microenvironment in the development and progression of hematological disorders. The identification of key factors involved in the crosstalk between the malignant cells and the bone marrow Mesenchymal Stromal Cells (BM-MSCs) may provide a tool for interfering with the protective BM niche. The purpose of our work was to isolate and characterize morphologically, phenotypically and functionally MSCs derived from pediatric patients with B Acute Lymphoblastic Leukemia (B-ALL).

METHODS: MSCs were isolated from BM-MNCs obtained from 10 B-ALL children (n=5 non-traslocated high risk patients and n=5 t(12;21) patients) and from 6 healthy donors (HDs) and cultured in DMEM 10% FCS. MSCs were characterized at fourth passage in terms of morphology, immunophenotype (FACS analysis) and in vitro adipogenic and osteogenic differentiation potential. Chromosomal translocations detected in leukemia cells were investigated in B-ALL-MSCs by fluorescence in situ hybridizations (FISH) or polymerase chain reaction (PCR).

RESULTS: Both HD-MSCs and B-ALL-MSCs resulted comparable in terms of morphology. They both expressed the typical MSC markers CD73, CD90 and CD105, while lacked the expression of the hematopoietic markers CD14, CD34, CD45 and MHC-II. HD-MSCs as well as B-ALL-MSCs were able to differentiate, under appropriate stimuli, into adipogenic and osteogenic lineages as showed by Oil Red O liphophilic dye and Alizarin Red staining of calcium deposits. In addition, MSC from all investigated ALL patients did not present the chromosomal translocations that had been detected in leukemia cells (1 patient BCR-ABL p210, 5 patients TEL-AML1).

CONCLUSIONS: We found that B-ALL-MSCs resulted similar in terms of morphology, phenotype and differentiation ability to HD-MSCs. Furthermore, MSCs from patients did not reveal the chromosomal translocations present in leukemia blasts. Functional characterization of MSCs in terms of soluble molecule production is needed to identify altered cellular pathways.

Since emerging evidence supports the importance of the MSCs in the leukemic niche, we will focus on the potential functional alterations of ALL-MSCs. Our purpose is to understand the mechanisms underlying the support of leukemic cells by the BM microenvironment. The discovery of altered molecular pathways will pave the way for the development of new immunotherapy strategies for targeting the leukemic niche.

Disclosures

No relevant conflicts of interest to declare.
The Expression and Effect of B7-H3 in Mantle Cell Lymphoma
Authors: Wang Jing , Zhang Wei , Wang Yanfang , Dong Fei , Zhu Mingxia , Wan Wenli , Li Haisheng , Wu Feifei , Yan Xinxing , Yang Xiao-Feng , Ke Xiaoyan
Published: October 2019

Objective : To investigate the effects of B7-H3 (CD276) on oncogenesis and chemosensitivity in mantle cell lymphoma (MCL).

Methods : The B7-H3 expression was detected by flow cytometry in cell lines, 20 patients with MCL and 20 volunteers. B7-H3 knockdown was performed using lentivirus transduction in the Maver and Z138 mantle cell lymphoma cell lines, respectively. The effects of B7-H3 on cell proliferation, cycle, migration and invasion were investigated by CCK-8 assay, methyl cellulose colony forming assay, PI staining, and Transwell assays in vitro. By establishing Maver and Z138 xenograft models, the effects of B7-H3 on tumourigenicity were observed, and Ki-67 and PCNA was detected through immunohistochemical. Moreover, the impacts of B7-H3 RNAi on the anti-tumor effect of chemotherapy drugs were determined with CCK-8, Annexin V-FITC/PI and Hoechst 33342 staining assays in vitro and with xenograft models in vivo.

Results: The frequency of B7-H3positive expression cases was 65.0% (13/20) in MCL patients and 10.0% (2/20) in volunteers. The down-regulation of B7-H3 significantly decreased tumor proliferation in MCL in vitro and in vivo. In the B7-H3 knockdown groups of Maver and Z138 xenograft models, the mean inhibition rate of tumor growth was 59.1% and 65.0% (p = 0.010 and 0.003), and the expression of both Ki-67 and PCNA were significantly lower, respectively. After B7-H3 silencing, the cell cycles of Maver and Z138 were both arrested at G0/G1 phase, and the expression of cell cycle-related proteins Cyclin D1 and CDK4 was lower. The cell migration rates and invasion capacity were decreased, and the rates of distant metastasis in B7-H3 knockdown both Maver and Z138 xenografts were significantly declined as well. The expression of invasion-related proteins MMP-2 and MMP-9 was lower in B7-H3 knockdown cells and xenografts. The silencing of B7-H3 increased the sensitivity of Maver and Z138 cells to Rituximab and Bendamustine and enhanced the drug-induced apoptosis, respectively. The activity of caspase-3 in vitro and the expression of caspase-3 in both Maver and Z138 xenografts was significantly increased in the B7-H3 shRNA combined with chemotherapy drugs groups.

Conclusions: B7-H3 levels in MCL patients were signifiantly higher than that in volunteers. Our study demonstrates for the first time that B7-H3 promotes mantle cell lymphoma progression and B7-H3 knockdown significantly enhances the chemosensitivity. This may provide a new therapeutic approach to mantle cell lymphoma.

Disclosures

No relevant conflicts of interest to declare.
Dynamic Variation and Clinical Significance of the Cytokine Level Changes in Children with Acute Leukemia during Chemotherapy
Authors: Wu Xuedong , Jing Yuanfang , Wen Jianyun , Chen Libai , Li Chunfu
Published: October 2019

Background:

Cytokines and infection are closely related. One of the hot spots is the indexes which can early diagnose and predict prognosis of febrile neutropenia patients with acute leukemia. It is importment to find predictors of infection in febrile neutropenia patients.

Aim:

To investigate the variation of CRP(C-reactive protein), IL-6(interleukin 6), IL-8(interleukin 8) and IFN-γ (interferon γ) in children with acute leukemia before and after febrile neutropenia, and evaluate the reliability of plasma interleukin (IL) and CRP levels as indicators of febrile neutropenia patient.

Methods:

We selected 40 cases of children with acute leukemia from Pediatric department of Nanfang Hospital,Southern Medical University,including 27 cases of acute lymphoblastic leukemia(67.5%),13 cases of acute myeloid leukemia(32.5%). The mean age was 7 years(range:1-14).We used Luminex immunoassay to detected levels of cytokines, which include CRP, IL-6, IL -8 and IFN-γ. Serum samples were collected before chemotherapy(T0),3 days after chemotherapy(T1), 1 day after confirmation of febrile neutropenia, (T2), 3 days after febrile neutropenia (T3), 7 days after febrile neutropenia (i.e. the use of antibiotics 7 days,T4), recovery after chemotherapy(T5).

Results: Compared T1、T5 to T0, the levels of CRP, IL-6 were no statistically significant(P>0.05). Compared T1 to T0, the levels of IFN-γ and IL -8 were statistically significant(P=0.005 and P=0.002); Compared T5 to T0 and T5 to T1, the levels of IFN-γ and IL-8 were no statistically significant(P>0.05). In T0, T1 and T5 phase, the levels of IL-6, IL-8, IFN-γ and CRP were not correlated (P>0.05). Compared T2, T3 to T0, the level of CRP increased significantly after infection early in the fever, and the level of CRP increased in 24 hours.Compared T2, T3 to T0, the levels of IL-6, IL-8 were statistically significant, the level of IL-8 decreased after infection, but the level of IL-6 level increased in 24 hours.There were significant positive correlation between CRP and IL-6 in T2, T3 and T4 phase.

Conclusions.

The level of CRP increased significantly after infection early in the fever, and the level of CRP increased in 24 hours. the level of IL-8 decreased after infection,but the level of IL-6 level increased in 24 hours.The levels of CRP, IL-8 and IL-6 can be useful markers to identify febrile neutropenia in children with acute leukemia.

Disclosures

No relevant conflicts of interest to declare.
Low Incidence of V617FJAK2 Mutation in Acute Myeloid Leukemia and Myelodysplastic Syndromes
Authors: Balatzenko Gueorgui , Spassov Branimir , Georgieva Yanica , Hrischev Vasil , Guenova Margarita
Published: October 2019

Background: V617F JAK2 mutation is a typical molecular finding in BCR-ABL-negative myeloproliferative neoplasms (MPN). The same abnormality has also been reported in other myeloid malignancies. However, the data regarding the incidence and clinical relevance of V617F JAK2 in acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) are conflicting.

Aim: To establish the incidence and clinical significance of V617F JAK2 mutation in AML and MDS patients in our institution.

Materials and Methods : AML and MDS patients with isolated bone marrow mononuclear cells were included in this study, as follows: (i) 139 AML patients (71 females; 68 males; mean age of 57.5±15.3 years), including: 122 - de novo AML, 7 - therapy related AML (t-AML) and 10 - secondary AML (sAML) after primary MPN [3 V617F JAK2(+), 2 V617F JAK2(-) and 5 with unknown initial V617F JAK2 status]; (ii) 35 MDS patients. V617F JAK2 mutation status was determined using allele-specific polymerase chain reaction (PCR) and PCR RFLP (Restriction Fragment Lenght Polymorphism) analysis.

Results: V617F JAK2 mutation was detected in 3 AML patients: (i) in 1/122 (0.8%) de novo AML patients - male patient with minimally differentiated AML, with no antecedent MPN and the leukemic population showed aberrant myeloid phenotype with co-expression of CD7 and overexpression of EVI1 gene, (ii) in 2/10 (20.0%) patients with sAML after MPN and both patients had V617F JAK2(+) sAML after V617F JAK2(+) primary myelofibrosis. Interestingly; in the same group, a female patient with V617F JAK2(+) essential thrombocythemia developed 5 years later V617F JAK2(-) sAML with an aberrant myelomonocytic phenotype and co-expression of CD56. None of the patients with t-AML or MDS tested positive for V617F JAK2.

Conclusion: V617F JAK2 mutation is a rare finding in AML and MDS patients. Higher incidence was observed in sAML after MPN. However, the mutation status at the AML stage may not be identical as that detected during the primary MPN.

Disclosures

No relevant conflicts of interest to declare.