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Rationale for revision and proposed changes of the WHO diagnostic criteria for polycythemia vera, essential thrombocythemia and primary myelofibrosis. Blood Cancer J 2015; 5:e337. [PMID: 26832847 PMCID: PMC4558589 DOI: 10.1038/bcj.2015.64] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 06/30/2015] [Indexed: 12/19/2022] Open
Abstract
The 2001/2008 World Health Organization (WHO)-based diagnostic criteria for polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF) were recently revised to accomodate new information on disease-specific mutations and underscore distinguishing morphologic features. In this context, it seems to be reasonable to compare first major diagnostic criteria of the former WHO classifications for myeloproliferative neoplasm (MPN) and then to focus on details that have been discussed and will be proposed for the upcoming revision of diagnostic guidelines. In PV, a characteristic bone marrow (BM) morphology was added as one of three major diagnostic criteria, which allowed lowering of the hemoglobin/hematocrit threshold for diagnosis, which is another major criterion, to 16.5 g/dl/49% in men and 16 g/dl/48% in women. The presence of a JAK2 mutation remains the third major diagnostic criterion in PV. Subnormal serum erythropoietin level is now the only minor criterion in PV and is used to capture JAK2-unmutated cases. In ET and PMF, mutations that are considered to confirm clonality and specific diagnosis now include CALR, in addition to JAK2 and MPL. Also in the 2015 discussed revision, overtly fibrotic PMF is clearly distinguished from early/prefibrotic PMF and each PMF variant now includes a separate list of diagnostic criteria. The main rationale for these changes was to enhance the distinction between so-called masked PV and JAK2-mutated ET and between ET and prefibrotic early PMF. The proposed changes also underscore the complementary role, as well as limitations of mutation analysis in morphologic diagnosis. On the other hand, discovery of new biological markers may probably be expected in the future to enhance discrimination of the different MPN subtypes in accordance with the histological BM patterns and corresponding clinical features.
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102
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Keohane C, Kordasti S, Seidl T, Perez Abellan P, Thomas NSB, Harrison CN, McLornan DP, Mufti GJ. JAK inhibition induces silencing of T Helper cytokine secretion and a profound reduction in T regulatory cells. Br J Haematol 2015; 171:60-73. [DOI: 10.1111/bjh.13519] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 03/24/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Clodagh Keohane
- Department of Haematology; Guy's and St Thomas’ NHS Foundation Trust; London UK
- Department of Haematological Medicine; Kings College London; London UK
| | - Shahram Kordasti
- Department of Haematological Medicine; Kings College London; London UK
- Department of Haematological Medicine; Kings College Hospital NHS Foundation Trust; London UK
| | - Thomas Seidl
- Department of Haematological Medicine; Kings College London; London UK
| | | | | | - Claire N. Harrison
- Department of Haematology; Guy's and St Thomas’ NHS Foundation Trust; London UK
| | - Donal P. McLornan
- Department of Haematology; Guy's and St Thomas’ NHS Foundation Trust; London UK
- Department of Haematological Medicine; Kings College Hospital NHS Foundation Trust; London UK
| | - Ghulam J. Mufti
- Department of Haematological Medicine; Kings College London; London UK
- Department of Haematological Medicine; Kings College Hospital NHS Foundation Trust; London UK
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103
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Harrison CN, McLornan DP, Francis YA, Woodley C, Provis L, Radia DH. How We Treat Myeloproliferative Neoplasms. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2015; 15 Suppl:S19-S26. [PMID: 26297273 DOI: 10.1016/j.clml.2015.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 02/06/2015] [Accepted: 02/26/2015] [Indexed: 06/04/2023]
Abstract
The present report focuses on management strategies for the myeloproliferative neoplasm according to the structure and processes we use within our center, a large tertiary unit in central London. The standard procedures for achieving an accurate diagnosis and risk stratification and therapeutic strategies for these diseases with a detailed focus on contentious areas are discussed. In the 9 years after the description of the Janus kinase 2 mutation, this field has altered quite radically in several aspects. For example, a new therapeutic paradigm exists, especially for myelofibrosis. We share how our unit has adapted to these changes.
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Affiliation(s)
- Claire N Harrison
- Department of Haematology, Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom.
| | - Donal P McLornan
- Department of Haematology, Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Yvonne A Francis
- Department of Haematology, Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Claire Woodley
- Department of Haematology, Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Lizzie Provis
- Pharmacy Service, Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Deepti H Radia
- Department of Haematology, Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom
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104
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Lee G, Arcasoy MO. The clinical and laboratory evaluation of the patient with erythrocytosis. Eur J Intern Med 2015; 26:297-302. [PMID: 25837692 DOI: 10.1016/j.ejim.2015.03.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 03/14/2015] [Accepted: 03/16/2015] [Indexed: 12/19/2022]
Abstract
Erythrocytosis is frequently encountered as an incidental abnormality on laboratory testing that reveals persistent elevation of the hematocrit level (>52% in men and >48% in women). In many cases, erythrocytosis is the manifestation of an underlying cardiopulmonary process, drug-induced due to androgens, or secondary to smoking, rather than a primary bone marrow disorder such as polycythemia vera. A systematic approach to the clinical and laboratory evaluation of each patient is indicated to consider diverse differential diagnosis possibilities and to identify the underlying etiology of erythrocytosis in order to formulate appropriate subspecialist referral and management plans. A thorough medical history and meticulous physical examination supplemented by a focused initial laboratory evaluation will enable the general practitioner to ascertain the etiology of erythrocytosis in the majority of cases. Patients with clinical and laboratory features suggestive of polycythemia vera and those patients without an apparent underlying condition known to cause erythrocytosis benefit from early referral to a hematologist for further specialized diagnostic evaluation and therapy considerations.
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Affiliation(s)
- Grace Lee
- Division of Hematology, Department of Medicine, Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
| | - Murat O Arcasoy
- Division of Hematology, Department of Medicine, Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA.
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105
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Yasuda W, Jackson JE, Layton DM, Shovlin CL. Hypoxaemia, sport and polycythaemia: a case from Imperial College London. Thorax 2015; 70:601-3. [PMID: 25855611 PMCID: PMC4453632 DOI: 10.1136/thoraxjnl-2014-206381] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 02/25/2015] [Indexed: 11/24/2022]
Affiliation(s)
| | - James E Jackson
- Department of Imaging, Imperial College Healthcare NHS Trust, London, UK
| | - D Mark Layton
- Department of Haematology, Imperial College London, London, UK
| | - Claire L Shovlin
- NHLI Cardiovascular Sciences, Imperial College London, London, UK Department of Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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106
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Erythrocytosis, methemoglobinemia, and the saturation gap. Ann Hematol 2015; 94:509-10. [DOI: 10.1007/s00277-014-2179-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 07/26/2014] [Indexed: 11/30/2022]
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107
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Gheshlaghi F, Piri-Ardakani MR, Masoumi GR, Behjati M, Paydar P. Cardiovascular manifestations of anabolic steroids in association with demographic variables in body building athletes. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2015; 20:165-8. [PMID: 25983770 PMCID: PMC4400712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 10/04/2014] [Accepted: 01/07/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND The most common drug abuse among athletes is anabolic steroids which lead to the development of cardiovascular diseases and sudden death. Thus, the aim of this study was to evaluate cardiovascular outcomes of anabolic consumption in body building athletes. MATERIALS AND METHODS Totally, 267 male athletes at the range of 20-45 years old with the regular consumption of anabolic steroids for >2 months with at least once weekly. High-density lipoprotein (HDL), low-density lipoprotein (LDL), triglyceride (TG), and hematocrit (Hct) levels were measured after 10 h of fasting. Data analysis was performed using K2, t-test, ANOVA and correlation coefficient through SPSS 17. RESULTS There was a nonsignificant difference between groups regarding HDL, TG, and total cholesterol. There was a significant decrease in the total and categorized LDL and Hct levels in consumers of anabolic steroid versus nonusers (P = 0.01 and P = 0.041, respectively). Results showed a significant increase in systolic and diastolic blood pressure (SBP and DBP) in anabolic steroid users which associates with duration of abuse (P = 0.02 and P = 0.03, respectively). No significant electrocardiography changes were found within the follow-up period. CONCLUSION Increase in SBP or DBP is a common complication of these drugs which can lead serious vascular disorders. The lower LDL cholesterol level might be due to the higher amounts of lipid consumption in these athletes.
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Affiliation(s)
- Farzad Gheshlaghi
- Department of Clinical Toxicology and Forensic Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Isfahan Clinical Toxicology Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Gholam Reza Masoumi
- Department of Clinical Toxicology and Forensic Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Isfahan Clinical Toxicology Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohaddaseh Behjati
- Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Parva Paydar
- Pharmaceutical Students Research Committee, School of Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
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Hasan T, El Makki E. Unusual involvement of the portal vein in polycythemia vera-genetic perspective. ACTA MEDICA INTERNATIONAL 2015. [DOI: 10.5530/ami.2015.5.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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109
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Shovlin CL. Pulmonary arteriovenous malformations. Am J Respir Crit Care Med 2014; 190:1217-28. [PMID: 25420112 PMCID: PMC4315816 DOI: 10.1164/rccm.201407-1254ci] [Citation(s) in RCA: 143] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 10/20/2014] [Indexed: 11/16/2022] Open
Abstract
Within the past decade, pulmonary arteriovenous malformations (PAVMs) have evolved from rare curiosities to not uncommon clinical states, with the latest estimates suggesting a prevalence of ~1 in 2,600. PAVMs provide anatomic right-to-left shunts, allowing systemic venous blood to bypass gas exchange and pulmonary capillary bed processing. Hypoxemia and enhanced ventilatory demands result, although both are usually asymptomatic. Paradoxical emboli lead to strokes and cerebral abscesses, and these commonly occur in individuals with previously undiagnosed PAVMs. PAVM hemorrhage is rare but is the main cause of maternal death in pregnancy. PAVM occlusion by embolization is the standard of care to reduce these risks. However, recent data demonstrate that currently recommended management protocols can result in levels of radiation exposure that would be classified as harmful. Recent publications also provide a better appreciation of the hematologic and cardiovascular demands required to maintain arterial oxygen content and oxygen consumption in hypoxemic patients, identify patient subgroups at higher risk of complications, and emphasize the proportion of radiologically visible PAVMs too small to treat by embolization. This review, therefore, outlines medical states that exacerbate the consequences of PAVMs. Chief among these is iron deficiency, which is commonly present due to concurrent hereditary hemorrhagic telangiectasia: iron deficiency impairs hypoxemia compensations by restricting erythropoiesis and increases the risk of ischemic strokes. Management of periodontal disease, dental interventions, pulmonary hypertension, and pregnancy also requires specific consideration in the setting of PAVMs. The review concludes by discussing to what extent previously recommended protocols may benefit from modification or revision.
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Affiliation(s)
- Claire L. Shovlin
- NHLI Cardiovascular Sciences, Imperial College, London; and
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
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110
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Kreher S, Ochsenreither S, Trappe RU, Pabinger I, Bergmann F, Petrides PE, Koschmieder S, Matzdorff A, Tiede A, Griesshammer M, Riess H. Prophylaxis and management of venous thromboembolism in patients with myeloproliferative neoplasms: consensus statement of the Haemostasis Working Party of the German Society of Hematology and Oncology (DGHO), the Austrian Society of Hematology and Oncology (ÖGHO) and Society of Thrombosis and Haemostasis Research (GTH e.V.). Ann Hematol 2014; 93:1953-63. [PMID: 25307456 DOI: 10.1007/s00277-014-2224-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Accepted: 09/25/2014] [Indexed: 01/28/2023]
Abstract
Patients with Philadelphia chromosome-negative myeloproliferative neoplasms (MPN) like polycythemia vera and essential thrombocythemia are at increased risk of arterial and venous thrombosis. Strategies of prevention may consist of platelet aggregation inhibitors and/or cytoreductive agents depending on the underlying disease and the individual risk. Clinical evidence for management of acute venous thromboembolic events in MPN patients is limited. Modality and duration of therapeutic anticoagulation after venous thrombosis has to be evaluated critically with special regard to the increased risk for spontaneous bleeding events associated with the underlying diseases. Both for therapy of the acute event and for secondary prophylaxis, low-molecular-weight heparins should preferentially be used. A prolongation of the therapeutic anticoagulation beyond the usual 3 to 6 months can only be recommended in high-risk settings and after careful evaluation of potential risks and benefits for the individual patient. New direct oral anticoagulants (NOAC) should not preferentially be used due to lack of clinical experience in patients with MPN and potential drug interactions (e.g. with JAK inhibitors). Consequent treatment of the underlying myeloproliferative disease and periodical evaluation of the response to therapy is crucial for optimal secondary prophylaxis of thromboembolic events in those patients.
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Affiliation(s)
- Stephan Kreher
- Department of Hematology and Oncology, Charite Berlin, Berlin, Hindenburgdamm 30, 12200, Berlin, Germany,
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111
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Barbui T, Thiele J, Kvasnicka HM, Carobbio A, Vannucchi AM, Tefferi A. Essential thrombocythemia with high hemoglobin levels according to the revised WHO classification. Leukemia 2014; 28:2092-4. [DOI: 10.1038/leu.2014.175] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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112
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El Sayed SM, Abou-Taleb A, Mahmoud HS, Baghdadi H, Maria RA, Ahmed NS, Nabo MMH. Percutaneous excretion of iron and ferritin (through Al-hijamah) as a novel treatment for iron overload in beta-thalassemia major, hemochromatosis and sideroblastic anemia. Med Hypotheses 2014; 83:238-46. [PMID: 24857772 DOI: 10.1016/j.mehy.2014.04.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 09/25/2013] [Accepted: 04/01/2014] [Indexed: 11/24/2022]
Abstract
Iron overload is a big challenge when treating thalassemia (TM), hemochromatosis and sideroblastic anemia. It persists even after cure of TM with bone marrow transplantation. Iron overload results from increased iron absorption and repeated blood transfusions causing increased iron in plasma and interstitial fluids. Iron deposition in tissues e.g. heart, liver, endocrine glands and others leads to tissue damage and organ dysfunction. Iron chelation therapy and phlebotomy for iron overload have treatment difficulties, side effects and contraindications. As mean iron level in skin of TM patients increases by more than 200%, percutaneous iron excretion may be beneficial. Wet cupping therapy (WCT) is a simple, safe and economic treatment. WCT is a familiar treatment modality in some European countries and in Chinese hospitals in treating different diseases. WCT was reported to clear both blood plasma and interstitial spaces from causative pathological substances (CPS). Standard WCT method is Al-hijamah (cupping, puncturing and cupping, CPC) method of WCT that was reported to clear blood and interstitial fluids better than the traditional WCT (puncturing and cupping method, PC method of WCT). In other word, traditional WCT may be described as scarification and suction method (double S technique), while Al-hijamah may be described as suction, scarification and suction method (triple S technique). Al-hijamah is a more comprehensive treatment modality that includes all steps and therapeutic benefits of traditional dry cupping therapy and WCT altogether according to the evidence-based Taibah mechanism (Taibah theory). During the first cupping step of Al-hijamah, a fluid mixture is collected inside skin uplifting due to the effect of negative pressure inside sucking cups. This fluid mixture contains collected interstitial fluids with CPS (iron, ferritin and hemolyzed RBCs in thalassemia), filtered fluids (from blood capillaries) with iron and hemolyzed blood cells (hemolyzed RBCs, WBCs and platelets). That fluid mixture does not contain intact blood cells (having diameters in microns) that are too big to pass through pores of skin capillaries (6-12nm in diameter) and cannot be filtered. Puncturing skin upliftings and applying second cupping step excrete collected fluids. Skin scarifications (shartat mihjam in Arabic) should be small, superficial (0.1mm in depth), short (1-2mm in length), multiple, evenly distributed and confined to skin upliftings. Sucking pressure inside cups (-150 to -420mmHg) applied to skin is transmitted to around skin capillaries to be added to capillary hydrostatic pressure (-33mmHg at arterial end of capillaries and -13mmHg at venous end of capillaries) against capillary osmotic pressure (+20mmHg). This creates a pressure gradient and a traction force across skin and capillaries and increases filtration at arterial end of capillaries at net pressure of -163 to -433mmHg and at venous end of capillaries at net pressure of -143 to -413mmHg resulting in clearance of blood from CPS (iron, ferritin and hemolyzed blood cells). Net filtration pressure at renal glomeruli is 10mmHg i.e. Al-hijamah exerts a more pressure-dependent filtration than renal glomeruli. Al-hijamah may benefit patients through inducing negative iron balance. Interestingly, Al-hijamah was reported to decrease serum ferritin significantly (by about 22%) in healthy subjects while excessive traditional WCT was reported to cause iron deficiency anemia. Al-hijamah is a highly recommended treatment in prophetic medicine. In conclusion, Al-hijamah may be a promising adjuvant treatment for iron overload in TM, hemochromatosis and sideroblastic anemia.
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Affiliation(s)
- Salah Mohamed El Sayed
- Department of Clinical Biochemistry and Molecular Medicine, Taibah Faculty of Medicine, Taibah University, Al-Madinah Al-Munawwarah, Saudi Arabia. Department of Medical Biochemistry, Sohag Faculty of Medicine, Sohag University, Egypt
| | - Ashraf Abou-Taleb
- Department of Pediatrics, Sohag Faculty of Medicine, Sohag University, Egypt
| | - Hany Salah Mahmoud
- World Federation of Alternative and Complementary Medicine, Cairo Regional Headquarter, Cairo, Egypt
| | - Hussam Baghdadi
- Department of Clinical Biochemistry and Molecular Medicine, Taibah Faculty of Medicine, Taibah University, Al-Madinah Al-Munawwarah, Kingdom of Saudi Arabia
| | - Reham A Maria
- Department of Clinical Biochemistry and Molecular Medicine, Taibah Faculty of Medicine, Taibah University, Al-Madinah Al-Munawwarah, Kingdom of Saudi Arabia; Department of Medical Biochemistry, Tanta Faulty of Medicine, Tanta University, Egypt
| | - Nagwa Sayed Ahmed
- Department of Medical Biochemistry, Sohag Faculty of Medicine, Sohag University, Egypt
| | - Manal Mohamed Helmy Nabo
- Department of Pediatrics, Sohag Teaching Hospital, Sohag, Egypt; Division of Pediatric Cardiology, Department of Pediatrics, Maternity and Children Hospital, King Abdullah Medical City, Al-Madinah Al-Munawwarah, Kingdom of Saudi Arabia
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113
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Santhirapala V, Williams LC, Tighe HC, Jackson JE, Shovlin CL. Arterial oxygen content is precisely maintained by graded erythrocytotic responses in settings of high/normal serum iron levels, and predicts exercise capacity: an observational study of hypoxaemic patients with pulmonary arteriovenous malformations. PLoS One 2014; 9:e90777. [PMID: 24637882 PMCID: PMC3956463 DOI: 10.1371/journal.pone.0090777] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 02/04/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Oxygen, haemoglobin and cardiac output are integrated components of oxygen transport: each gram of haemoglobin transports 1.34 mls of oxygen in the blood. Low arterial partial pressure of oxygen (PaO2), and haemoglobin saturation (SaO2), are the indices used in clinical assessments, and usually result from low inspired oxygen concentrations, or alveolar/airways disease. Our objective was to examine low blood oxygen/haemoglobin relationships in chronically compensated states without concurrent hypoxic pulmonary vasoreactivity. METHODOLOGY 165 consecutive unselected patients with pulmonary arteriovenous malformations were studied, in 98 cases, pre/post embolisation treatment. 159 (96%) had hereditary haemorrhagic telangiectasia. Arterial oxygen content was calculated by SaO2 x haemoglobin x 1.34/100. PRINCIPAL FINDINGS There was wide variation in SaO2 on air (78.5-99, median 95)% but due to secondary erythrocytosis and resultant polycythaemia, SaO2 explained only 0.1% of the variance in arterial oxygen content per unit blood volume. Secondary erythrocytosis was achievable with low iron stores, but only if serum iron was high-normal: Low serum iron levels were associated with reduced haemoglobin per erythrocyte, and overall arterial oxygen content was lower in iron deficient patients (median 16.0 [IQR 14.9, 17.4]mls/dL compared to 18.8 [IQR 17.4, 20.1]mls/dL, p<0.0001). Exercise tolerance appeared unrelated to SaO2 but was significantly worse in patients with lower oxygen content (p<0.0001). A pre-defined athletic group had higher Hb:SaO2 and serum iron:ferritin ratios than non-athletes with normal exercise capacity. PAVM embolisation increased SaO2, but arterial oxygen content was precisely restored by a subsequent fall in haemoglobin: 86 (87.8%) patients reported no change in exercise tolerance at post-embolisation follow-up. SIGNIFICANCE Haemoglobin and oxygen measurements in isolation do not indicate the more physiologically relevant oxygen content per unit blood volume. This can be maintained for SaO2 ≥78.5%, and resets to the same arterial oxygen content after correction of hypoxaemia. Serum iron concentrations, not ferritin, seem to predict more successful polycythaemic responses.
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Affiliation(s)
- Vatshalan Santhirapala
- Imperial College School of Medicine, Imperial College, London, United Kingdom
- National Heart and Lung Institute (NHLI) Cardiovascular Science, Imperial College, London, United Kingdom
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Louisa C. Williams
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Hannah C. Tighe
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - James E. Jackson
- Department of Imaging, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Claire L. Shovlin
- National Heart and Lung Institute (NHLI) Cardiovascular Science, Imperial College, London, United Kingdom
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- * E-mail:
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Abstract
INTRODUCTION Polycythemia vera (PV) patients suffer from disease-related constitutional symptoms, cardiovascular complications and risk of transformation into myelofibrosis and acute leukemia. AREAS COVERED Clinical and molecular aspects and current therapies will be described to provide clinical and molecular background to understand the natural history and treatment strategies in PV. Pertinent ongoing research questions, challenges arising out of the specific disease course and biology of PV as well as challenges and opportunities for new agents in PV are addressed. A focus is placed on pegylated interferon-α formulations (PEG-INFa2a) and JAK2 inhibitors. Newest data on symptom burden and incidence and prevalence of PV and MPNs are highlighted in the context of development of PV therapies. EXPERT OPINION Therapeutic goals in PV are to prevent vascular events, reduce symptoms and for future therapies delay/prevent disease progression. Currently available treatments such as phlebotomy, antiplatelet therapy, managing risk factors and cytoreductive therapies such as hydroxyurea (HU) and PEG-INFa2a are effective. JAK2 inhibitors recently have shown promising activity in reducing PV symptoms and spleen size and improving blood counts. Yet the influence of long-term outcome and delaying disease progression is unknown. Thus, there still remains an unmet medical need for improved therapy and symptom management in PV.
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Affiliation(s)
- Raoul Tibes
- Mayo College of Medicine, Mayo Clinic, Mayo Clinic Cancer Center, Division of Hematology & Medical Oncology, 13400 E. Shea Boulevard, Scottsdale, AZ 85259, USA.
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115
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Barbui T, Thiele J, Carobbio A, Gisslinger H, Finazzi G, Rumi E, Luigia Randi M, Vannucchi AM, Gisslinger B, Müllauer L, Ruggeri M, Rambaldi A, Tefferi A. Masked polycythemia vera diagnosed according to WHO and BCSH classification. Am J Hematol 2014; 89:199-202. [PMID: 24166817 DOI: 10.1002/ajh.23617] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 10/21/2013] [Indexed: 11/08/2022]
Abstract
Polycythemia vera (PV) is currently diagnosed by the World Health Organization (WHO) criteria regarding hemoglobin (HB) levels and JAK2V617F and related mutations or by the British Committee for Standards in Haematology (BCSH) guidelines predominantly based on hematocrit (HCT) values (>52% in men and >48% in women) in JAK2 mutated patients. We examined clinical features at diagnosis and outcome in 397 mutated PV patients showing a bone marrow (BM) morphology conforming with the WHO descriptions but including also cases with a HB level <18.5 g/dL in males (range 16.0-18.4) and <16.5 g/dL in females (range 15.0-16.4). These patients were regarded as masked PV (mPV) comprising 140 (35%) cases of our cohort. A comparison with the BCSH criteria based on HCT levels revealed a decrease of mPV patients to 59 (15%). In both classification systems, mPV patients were more males, presented more frequently with higher platelet counts, and increased BM reticulin fibrosis. A worsening of overall survival was documented in mPV patients in comparison with overt PV following the WHO (P = 0.011) as well as the BCSH (P = 0.0019) criteria. Risk factors for inferior survival in mPV were age >65 years and white blood cell count >15 × 10(9) /L. Without these risk factors mPV patients had the same survival as overt PV suggesting that a fraction of patients with HB lower than that required for WHO diagnosis should still be considered as overt PV. This study has established the existence of mPV by two different classification systems based on either HB or HCT threshold values.
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Affiliation(s)
| | | | | | | | | | - Elisa Rumi
- University of Pavia; I.R.C.C.S. Policlinico San Matteo Pavia Italy
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116
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Vannucchi AM, Guglielmelli P, Pieri L, Antonioli E, Bosi A. Treatment options for essential thrombocythemia and polycythemia vera. Expert Rev Hematol 2014; 2:41-55. [DOI: 10.1586/17474086.2.1.41] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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117
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Barbui T, Thiele J, Gisslinger H, Finazzi G, Carobbio A, Rumi E, Luigia Randi M, Betozzi I, Vannucchi AM, Pieri L, Carrai V, Gisslinger B, Müllauer L, Ruggeri M, Rambaldi A, Tefferi A. Masked polycythemia vera (mPV): results of an international study. Am J Hematol 2014; 89:52-4. [PMID: 23996471 DOI: 10.1002/ajh.23585] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 08/27/2013] [Indexed: 01/30/2023]
Abstract
We examined the baseline features and clinical outcomes of 140 patients presenting with JAK2V617F positivity and a bone marrow morphology conforming with WHO criteria of polycythemia vera (PV), but a hemoglobin level of <18.5 g/dL in males (range 16.0-18.4) and <16.5 g/dL in females (range 15.0-16.4). This cohort operationally referred to as masked PV (mPV) was compared with 257 patients with overt PV and displayed male predominance, a more frequent history of arterial thrombosis and thrombocytosis. Incidence of thrombosis was similar between the two groups but mPV displayed significantly higher rates of progression to myelofibrosis and acute leukemia and inferior survival. In multivariable analysis mPV diagnosis was an independent predictor of poor survival along with age >65 years and leukocyte count >10 × 10(9) /L. Our data suggest that mPV is a heterogeneous myeloproliferative neoplasia and not necessarily an early/ pre-polycythemic form of classical PV that at onset in a small fraction of patients clinically may mimic essential thrombocythemia. On the other hand, the majority mPV may have a longer prodrome of undiagnosed PV or a disease biology akin to primary myelofibrosis-post PV myelofibrosis that could explain the worsening of outcome in comparison to overt/classical manifestations.
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Affiliation(s)
| | | | | | | | | | - Elisa Rumi
- University of Pavia; I.R.C.C.S. Policlinico San Matteo Pavia Italy
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118
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de Lacerda JF, Oliveira SN, Ferro JM. Chronic myeloproliferative diseases. HANDBOOK OF CLINICAL NEUROLOGY 2014; 120:1073-81. [PMID: 24365372 DOI: 10.1016/b978-0-7020-4087-0.00072-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The chronic myeloproliferative disorders are a group of diseases in which there is an increased proliferation of one or more subtypes of myeloid cells; they include essential thrombocythemia (ET), polycythemia vera (PV), and primary myelofibrosis (PMF). In ET and PV the main neurologic manifestations are headaches, dizziness and macro- and microvascular, both venous and arterial, thrombosis and intracranial hemorrhages. Paresthesias and chorea also occur in PV. In PMF neurologic complications are very rare and consist predominantly of spinal cord compression by extramedullary hematopoiesis tissue.
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Affiliation(s)
- João Forjaz de Lacerda
- Department of Hematology and Bone Marrow Transplantation, Hospital de Santa Maria, Lisbon, Portugal
| | | | - José M Ferro
- Neurology Service, Department of Neurosciences, Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal.
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119
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Assi TB, Baz E. Current applications of therapeutic phlebotomy. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2014; 12 Suppl 1:s75-83. [PMID: 24120605 PMCID: PMC3934278 DOI: 10.2450/2013.0299-12] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 05/20/2013] [Indexed: 12/19/2022]
Affiliation(s)
- Tarek Bou Assi
- Department of Pathology and Laboratory Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
| | - Elizabeth Baz
- Department of Pathology and Laboratory Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
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120
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JAK2 or CALR mutation status defines subtypes of essential thrombocythemia with substantially different clinical course and outcomes. Blood 2013; 123:1544-51. [PMID: 24366362 DOI: 10.1182/blood-2013-11-539098] [Citation(s) in RCA: 446] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Patients with essential thrombocythemia may carry JAK2 (V617F), an MPL substitution, or a calreticulin gene (CALR) mutation. We studied biologic and clinical features of essential thrombocythemia according to JAK2 or CALR mutation status and in relation to those of polycythemia vera. The mutant allele burden was lower in JAK2-mutated than in CALR-mutated essential thrombocythemia. Patients with JAK2 (V617F) were older, had a higher hemoglobin level and white blood cell count, and lower platelet count and serum erythropoietin than those with CALR mutation. Hematologic parameters of patients with JAK2-mutated essential thrombocythemia or polycythemia vera were related to the mutant allele burden. While no polycythemic transformation was observed in CALR-mutated patients, the cumulative risk was 29% at 15 years in those with JAK2-mutated essential thrombocythemia. There was no significant difference in myelofibrotic transformation between the 2 subtypes of essential thrombocythemia. Patients with JAK2-mutated essential thrombocythemia and those with polycythemia vera had a similar risk of thrombosis, which was twice that of patients with the CALR mutation. These observations are consistent with the notion that JAK2-mutated essential thrombocythemia and polycythemia vera represent different phenotypes of a single myeloproliferative neoplasm, whereas CALR-mutated essential thrombocythemia is a distinct disease entity.
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121
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Barbui T, Thiele J, Vannucchi AM, Tefferi A. Rethinking the diagnostic criteria of polycythemia vera. Leukemia 2013; 28:1191-5. [DOI: 10.1038/leu.2013.380] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 12/04/2013] [Indexed: 12/19/2022]
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122
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Cario H, McMullin MF, Bento C, Pospisilova D, Percy MJ, Hussein K, Schwarz J, Aström M, Hermouet S. Erythrocytosis in children and adolescents-classification, characterization, and consensus recommendations for the diagnostic approach. Pediatr Blood Cancer 2013; 60:1734-8. [PMID: 23776154 DOI: 10.1002/pbc.24625] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 05/16/2013] [Indexed: 11/11/2022]
Abstract
During recent years, the increasing knowledge of genetic and physiological changes in polycythemia vera (PV) and of different types of congenital erythrocytosis has led to fundamental changes in recommendations for the diagnostic approach to patients with erythrocytosis. Although widely accepted for adult patients this approach may not be appropriate with regard to children and adolescents affected by erythrocytosis. The "congenital erythrocytosis" working group established within the framework of the MPN&MPNr-EuroNet (COST action BM0902) addressed this question in a consensus finding process and developed a specific algorithm for the diagnosis of erythrocytosis in childhood and adolescence which is presented here.
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Affiliation(s)
- Holger Cario
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
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123
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Bento C, Percy MJ, Gardie B, Maia TM, van Wijk R, Perrotta S, Della Ragione F, Almeida H, Rossi C, Girodon F, Aström M, Neumann D, Schnittger S, Landin B, Minkov M, Randi ML, Richard S, Casadevall N, Vainchenker W, Rives S, Hermouet S, Ribeiro ML, McMullin MF, Cario H, Chauveau A, Gimenez-Roqueplo AP, Bressac-de-Paillerets B, Altindirek D, Lorenzo F, Lambert F, Dan H, Gad-Lapiteau S, Catarina Oliveira A, Rossi C, Fraga C, Taradin G, Martin-Nuñez G, Vitória H, Diaz Aguado H, Palmblad J, Vidán J, Relvas L, Ribeiro ML, Luigi Larocca M, Luigia Randi M, Pedro Silveira M, Percy M, Gross M, Marques da Costa R, Beshara S, Ben-Ami T, Ugo V. Genetic basis of congenital erythrocytosis: mutation update and online databases. Hum Mutat 2013; 35:15-26. [PMID: 24115288 DOI: 10.1002/humu.22448] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 09/13/2013] [Indexed: 12/15/2022]
Abstract
Congenital erythrocytosis (CE), or congenital polycythemia, represents a rare and heterogeneous clinical entity. It is caused by deregulated red blood cell production where erythrocyte overproduction results in elevated hemoglobin and hematocrit levels. Primary congenital familial erythrocytosis is associated with low erythropoietin (Epo) levels and results from mutations in the Epo receptor gene (EPOR). Secondary CE arises from conditions causing tissue hypoxia and results in increased Epo production. These include hemoglobin variants with increased affinity for oxygen (HBB, HBA mutations), decreased production of 2,3-bisphosphoglycerate due to BPGM mutations, or mutations in the genes involved in the hypoxia sensing pathway (VHL, EPAS1, and EGLN1). Depending on the affected gene, CE can be inherited either in an autosomal dominant or recessive mode, with sporadic cases arising de novo. Despite recent important discoveries in the molecular pathogenesis of CE, the molecular causes remain to be identified in about 70% of the patients. With the objective of collecting all the published and unpublished cases of CE the COST action MPN&MPNr-Euronet developed a comprehensive Internet-based database focusing on the registration of clinical history, hematological, biochemical, and molecular data (http://www.erythrocytosis.org/). In addition, unreported mutations are also curated in the corresponding Leiden Open Variation Database.
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Affiliation(s)
- Celeste Bento
- Department of Hematology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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124
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Evers D, Kerkhoffs JL, Van Egmond L, Schipperus MR, Wijermans PW. The efficiency of therapeutic erythrocytapheresis compared to phlebotomy: A mathematical tool for predicting response in hereditary hemochromatosis, polycythemia vera, and secondary erythrocytosis. J Clin Apher 2013; 29:133-8. [DOI: 10.1002/jca.21303] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 08/22/2013] [Accepted: 09/10/2013] [Indexed: 11/07/2022]
Affiliation(s)
- Dorothea Evers
- Department of Haematology; Hagaziekenhuis; Leyweg 275 The Hague The Netherlands
| | | | - Liane Van Egmond
- Department of Haematology; Hagaziekenhuis; Leyweg 275 The Hague The Netherlands
| | | | - Pierre W. Wijermans
- Department of Haematology; Hagaziekenhuis; Leyweg 275 The Hague The Netherlands
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125
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Turkington RC, Arnold EC, Percy MJ, Ranaghan LA, Cuthbert RJG, McMullin MF. Comparison of diagnostic criteria for polycythaemia vera. Hematology 2013; 12:123-30. [PMID: 17454193 DOI: 10.1080/10245330601111797] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Three sets of diagnostic criteria for polycythaemia vera (PV); the Polycythaemia Vera Study Group (PVSG) criteria (1975), the British Committee for Standards in Haematology (BCSH) criteria (1996) and the World Health Organisation (WHO) criteria (2001) have been described. We compared the ability of each set of criteria to accurately diagnose PV and differentiate it from secondary, apparent and idiopathic erythrocytosis. A cohort was drawn from a clinical database of erythrocytosis patients currently attending the Belfast City Hospital and the relevant information from the time of diagnosis for each patient was assessed according to each set of criteria, with the BCSH criteria used as a comparator. Sufficient data was available on 71 patients: 46 PV, 8 idiopathic, 8 apparent and 9 secondary erythrocytosis. The BCSH criteria classified 34 of 46 patients (73.9%) as PV and the WHO criteria had a sensitivity and specificity of 100% for classifying PV. For idiopathic and apparent erythrocytosis, the specificity of the WHO criteria, compared to the BCSH criteria, declined to 66.7 and 87.5%, respectively. The PVSG criteria were limited by the unavailability of required data for some patients resulting in a sensitivity and specificity of 50% for PV and specificity of 100% for all other groups. The Janus kinase 2 (JAK2) V617F mutation was present in 34 (85.3%) PV, 2 (50%) IE, 1 (50%) apparent and no secondary erythrocytosis cases. We concluded that the BCSH criteria were the most accurate diagnostic criteria for PV as they had an acceptable level of sensitivity and could differentiate between PV and other erythrocytoses.
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Affiliation(s)
- Richard C Turkington
- Department of Haematology, Queen's University Belfast, Belfast City Hospital, Lisburn Road, Belfast, Northern Ireland, BT9 7AB. UK
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126
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Bento C, Almeida H, Maia TM, Relvas L, Oliveira AC, Rossi C, Girodon F, Fernandez-Lago C, Aguado-Diaz A, Fraga C, Costa RM, Araújo AL, Silva J, Vitória H, Miguel N, Silveira MP, Martin-Nuñez G, Ribeiro ML. Molecular study of congenital erythrocytosis in 70 unrelated patients revealed a potential causal mutation in less than half of the cases (Where is/are the missing gene(s)?). Eur J Haematol 2013; 91:361-8. [PMID: 23859443 DOI: 10.1111/ejh.12170] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2013] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Congenital erythrocytosis can be classified as primary, when the defect is intrinsic to the RBC progenitors and independent of the serum erythropoietin (Epo) concentration, or secondary, when the erythrocytosis is the result of an upregulation of Epo production. Primary erythrocytosis is associated with mutations in the EPOR gene, secondary CE can de due to mutations that stabilize the hemoglobin in the oxygenated form or to mutations in the genes that control the transcriptional activation of the EPO gene - VHL, EGLN1, EPAS1. Chuvash polycythemia, caused by mutations in VHL gene, shares features of both primary and secondary erythrocytosis, with increased Epo production but also hypersensitivity of progenitors to Epo. MATERIAL AND METHODS With the main objective of describing the etiology and molecular basis of CE, we have studied 70 consecutive unrelated patients presenting with idiopathic erythrocytosis from our hematology clinic or referred from other centers. According to a study algorithm, we have sequenced all the genes described as associated with CE. RESULTS AND DISCUSSION Erythrocytosis molecular etiology was identify in 25 (36%) of the 70 subjects. High-affinity Hb variants were the most common cause, present in 20% of the cases. New mutations were identified in the JAK2, EPOR, VHL, and EGLN1 genes. CONCLUSIONS High-affinity hemoglobin variants are a very rare cause of secondary CE, but it seems likely that their incidence may be underestimated. Our experience shows that in erythrocytosis with a dominant inheritance and normal or inappropriate high Epo levels, the HBB and HBA genes should be the first to be studied. In spite of the seven genes known to be involved in CE, the majority of the cases have unknown etiology.
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Affiliation(s)
- Celeste Bento
- Serviço de Hematologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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127
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Sonmez M, Saglam F, Karahan SC, Erkut N, Mentese A, Sonmez B, Ucar F, Topbas M, Ovali E. Treatment related changes in antifibrinolytic activity in patients with polycythemia vera. Hematology 2013; 15:391-6. [DOI: 10.1179/102453310x12719010991740] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Affiliation(s)
- Mehmet Sonmez
- Department of HaematologySchool of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Fatma Saglam
- Department of Internal MedicineSchool of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - S. Caner Karahan
- Department of BiochemistrySchool of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Nergiz Erkut
- Department of HaematologySchool of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Ahmet Mentese
- Department of BiochemistrySchool of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Bircan Sonmez
- Department of Nuclear MedicineSchool of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Fahri Ucar
- Department of Medical Biology and GeneticsSchool of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Murat Topbas
- Department of Public HealthSchool of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Ercument Ovali
- Department of HaematologySchool of Medicine, Karadeniz Technical University, Trabzon, Turkey
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128
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Musallam KM, Porter JB, Sfeir PM, Tamim HM, Richards T, Lotta LA, Peyvandi F, Jamali FR. Raised haematocrit concentration and the risk of death and vascular complications after major surgery. Br J Surg 2013; 100:1030-6. [DOI: 10.1002/bjs.9176] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2013] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Preoperative anaemia is associated with adverse postoperative outcomes. Data on raised preoperative haematocrit concentration are limited. This study aimed to evaluate the effect of raised haematocrit on 30-day postoperative mortality and vascular events in patients undergoing major surgery.
Methods
This was a cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Thirty-day mortality and vascular events, demographics and perioperative risk factors were obtained for adults undergoing major surgery. The adjusted effect of raised (over 0·50) compared with normal (0·41–0·50, American Medical Association reference range) preoperative haematocrit concentration on postoperative outcomes was assessed. Separate sex-specific analyses were also conducted, using haematocrit concentration thresholds commonly used in the diagnosis and management of apparent or absolute erythrocytosis.
Results
Some 3961 (2·0 per cent) of 197 469 patients had a raised haematocrit concentration before surgery. After adjustment, the 30-day postoperative mortality rate was higher in patients with raised haematocrit than in those without (odds ratio (OR) 2·23, 95 per cent confidence interval 1·77 to 2·80). Thirty-day rates of deep vein thrombosis (OR 1·95, 1·44 to 2·64) and pulmonary embolism (OR 1·79, 1·17 to 2·73), but not myocardial infarction or stroke, were also higher in patients with a raised haematocrit concentration. The effect on mortality was noted beyond the haematocrit thresholds of 0·48 in women and 0·52 in men; the effect estimates were considerably higher for values exceeding 0·54. Values between 0·41 and 0·45 were not associated with increased mortality risk. Similar observations were noted for venous thrombosis, although with apparent sex differences.
Conclusion
A raised haematocrit concentration was associated with an increased risk of 30-day mortality and venous thrombosis following major surgery.
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Affiliation(s)
- K M Musallam
- Department of Internal Medicine, UK
- Angleo Bianchi Bonomi Haemophilia and Thrombosis Centre, Department of Medicine and Medical Specialties, Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy
| | - J B Porter
- Department of Haematology, University College London, UK
| | - P M Sfeir
- Department of Surgery, American University of Beirut Medical Centre, Beirut, Lebanon
| | | | - T Richards
- Division of Surgery and Interventional Science, University College Hospital, London, UK
| | - L A Lotta
- Angleo Bianchi Bonomi Haemophilia and Thrombosis Centre, Department of Medicine and Medical Specialties, Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy
| | - F Peyvandi
- Angleo Bianchi Bonomi Haemophilia and Thrombosis Centre, Department of Medicine and Medical Specialties, Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy
| | - F R Jamali
- Department of Surgery, American University of Beirut Medical Centre, Beirut, Lebanon
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129
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Abstract
An erythrocytosis occurs when there is an increased red-cell mass. The causes of erythrocytosis are divided into primary, when there is an intrinsic defect in the erythroid cell, and secondary, when the cause is extrinsic to the erythroid cell. An idiopathic erythrocytosis occurs when the increased red-cell mass has no identifiable cause. Primary and secondary defects can be further classified as either congenital or acquired causes. The diagnostic pathway starts with a careful history and examination followed by measurement of the erythropoietin (EPO) levels. This allows a division of those patients with a low EPO level, who can then be investigated for primary causes of erythrocytosis, and those with a normal or high EPO level, where the oxygen-sensing pathway needs to be explored further. Physiological studies in those with congenital defects in the oxygen-sensing pathway show many changes in the downstream metabolism adapting to the defect, which has a bearing on the management of the disorders. Low-dose aspirin and venesection to an achievable target are the main therapeutic options that can be considered in the management of erythrocytosis. Specific guidance on venesection options should be considered with certain causes such as high oxygen-affinity hemoglobins.
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Affiliation(s)
- Mary Frances McMullin
- Department of Haematology, 'C' Floor, Belfast City Hospital, Queen's University Belfast, Lisburn Road, Belfast, BT9 7AB, Northern Ireland, UK
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130
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Rai R, Pieters T. An unusual psychiatric presentation of polycythaemia 'Difficulties lie in our habits of thought rather than in the nature of things' Andre Tardieu. BMJ Case Rep 2013; 2013:bcr-2012-008215. [PMID: 23576647 DOI: 10.1136/bcr-2012-008215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Psychiatric symptoms are not always best explained in the context of psychological stress. The same mental, emotional and behavioural changes also arise from various medical conditions. For a clinician this dual origin of psychiatric symptoms creates an ongoing diagnostic challenge. Our patient is a 50-year-old gentleman who had been working in a company for around 33 years and always had good appraisals. He presented to mental health services with a 5-year history of persecutory beliefs, convinced that his employers were out to damage his reputation. Apart from a diagnosis of polycythaemia, a few months before the onset of abnormal beliefs, there is no personal or family history of psychiatric disorder or medical illness. His delusions did not respond to conventional treatment with psychotropic medication possibly due to non-adherence because of side effects. However, a series of venesections lead to an improvement in mental state.
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Affiliation(s)
- Rahul Rai
- CPFT, Newtown Centre, Huntingdon, UK.
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131
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132
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Abstract
The myeloproliferative neoplasms that are associated with the JAK2 mutation are a heterogeneous group of disorders. The additional mutations that result in the clinical phenotype are still the subject of research. As more than one mutation is involved, and as JAK2 has a necessary physiological role (unlike BCR-ABL), the development of targeted therapy remains a challenge. Although new drugs are being developed, treatment at present is predominantly with agents that have been in use for many years. An understanding of the need to control the thrombotic risk has, however, led to improved survival rates such that ET and PV can be seen as chronic diseases.
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Affiliation(s)
- Amy Publicover
- Department of Haematology, University Hospital Southampton. UK
- Department of Haematology, Derriford Hospital, Plymouth, UK
| | - Patrick Medd
- Department of Haematology, University Hospital Southampton. UK
- Department of Haematology, Derriford Hospital, Plymouth, UK
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133
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Bento C, Almeida H, Fernandez-Lago C, Ribeiro ML. Primary familial congenital erythrocytosis: two novel EPOR mutations found in Spain. Int J Lab Hematol 2013; 35:e27-8. [DOI: 10.1111/ijlh.12061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- C. Bento
- Laboratório de Anemias Congénitas e Hematologia Molecular; Centro Hospitalar e Universitário de Coimbra; Coimbra Portugal
| | - H. Almeida
- Laboratório de Anemias Congénitas e Hematologia Molecular; Centro Hospitalar e Universitário de Coimbra; Coimbra Portugal
| | | | - M. L. Ribeiro
- Laboratório de Anemias Congénitas e Hematologia Molecular; Centro Hospitalar e Universitário de Coimbra; Coimbra Portugal
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Sugiura Y, Nemoto E, Shinoda H, Nakamura N, Kaseda S. Surgery for lung adenocarcinoma with smokers' polycythemia: a case report. BMC Res Notes 2013; 6:38. [PMID: 23374961 PMCID: PMC3571947 DOI: 10.1186/1756-0500-6-38] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 01/30/2013] [Indexed: 12/20/2022] Open
Abstract
Background Smoking is a cause of cancer and polycythemia. Therefore, surgeons who treat patients with cancer may also encounter patients with polycythemia. However, few cases of surgical patients with polycythemia have been reported; in particular, a surgical case involving smokers’ polycythemia has never been reported. We herein report a patient with lung cancer and smokers’ polycythemia who successfully underwent lobectomy with control of hematocrit based on a modified formula in the perioperative period. Case presentation A 67-year-old man underwent abdominoperineal resection for rectal carcinoma in June 2008. A ground glass opacity had been identified in the upper lobe of the right lung and was gradually enlarging. In March 2012, bronchoscopic cytology for investigation of the mass revealed non-small cell lung cancer, suggesting primary lung non-small cell carcinoma (T1bN0M0, Stage IA). When he was referred to our hospital for surgery, his complete blood count showed a red blood cell level of 6.50×106/μL, hemoglobin of 21.0 g/dL, and hematocrit of 60.1%. The hematologists’ diagnosis was secondary polycythemia due to heavy smoking (smokers’ polycythemia) because the white blood cell and platelet counts were within normal limits and the erythropoietin was not increased. We calculated the appropriate phlebotomy and infusion volumes based on a formula that we modified. After 550 g of blood was phlebotomized to reduce the hematocrit to approximately 55%, video-assisted right lung upper lobectomy with lymph node dissection was performed in April 2012. The hematocrit was maintained at <50% postoperatively, and the patient was uneventfully discharged on postoperative day 7. The predictive hematocrit and measured hematocrit were very closely approximated in this case. Conclusion We experienced a patient with smokers’ polycythemia who underwent right upper lobectomy for adenocarcinoma. The findings in this case report are meaningful for surgeons treating cancer patients because there are few reports discussing the perioperative care of surgical patients with polycythemia.
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Affiliation(s)
- Yasoo Sugiura
- National Hospital Organization, Kanagawa National Hospital, Pulmonary and Thoracic Surgery, 666-1 Ochiai, Hadano, Kanagawa, 257-8585, Japan.
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135
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Does venous blood gas analysis provide accurate estimates of hemoglobin oxygen affinity? Ann Hematol 2013; 92:517-21. [PMID: 23307600 DOI: 10.1007/s00277-012-1667-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 12/23/2012] [Indexed: 12/28/2022]
Abstract
Alterations in hemoglobin oxygen affinity can be detected by exposing blood to different PO2 and recording oxygen saturation, a method termed tonometry. It is the gold standard to measure the PO2 associated with 50 % oxygen saturation, the index used to quantify oxygen affinity (P50Tono). P50Tono is used in the evaluation of patients with erythrocytosis suspected to have hemoglobin with abnormal oxygen affinity. Since tonometry is labor intensive and not generally available, we investigated whether accurate estimates of P50 could also be obtained by venous blood gas analysis, co-oximetry, and standard equations (P50Ven). In 50 patients referred for evaluation of erythrocytosis, pH, PO2, and oxygen saturation were measured in venous blood to estimate P50Ven; P50Tono was measured for comparison. Agreement among P50Ven and P50Tono was evaluated (Bland-Altman analysis). Mean P50Tono was 25.8 (range 17.4-34.1) mmHg. The mean difference (bias) of P50Tono-P50Ven was 0.5 mmHg; limits of agreement (95 % confidence limits) were -5.2 to +6.1 mmHg. The sensitivity and specificity of P50Ven to identify the 25 patients with P50Tono outside the normal range of 22.9-26.8 mmHg were 5 and 77 %, respectively. We conclude that estimates of P50 based on venous blood gas analysis and standard equations have a low bias compared to tonometry. However, the precision of P50Ven is not sufficiently high to replace P50Tono in the evaluation of individual patients with suspected disturbances of hemoglobin oxygen affinity.
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136
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Bai J, Zhang L, Hu X, Xue Y, Long F, Zhang B, Yan S. Investigation of the influence of body weight index to the result of therapeutic erythrocytapheresis in patients with polycythemia vera. Transfus Apher Sci 2012; 47:295-9. [DOI: 10.1016/j.transci.2012.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Accepted: 07/31/2012] [Indexed: 11/17/2022]
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137
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Ballen KK, Woolfrey AE, Zhu X, Ahn KW, Wirk B, Arora M, George B, Savani BN, Bolwell B, Porter DL, Copelan E, Hale G, Schouten HC, Lewis I, Cahn JY, Halter J, Cortes J, Kalaycio ME, Antin J, Aljurf MD, Carabasi MH, Hamadani M, McCarthy P, Pavletic S, Gupta V, Deeg HJ, Maziarz RT, Horowitz MM, Saber W. Allogeneic hematopoietic cell transplantation for advanced polycythemia vera and essential thrombocythemia. Biol Blood Marrow Transplant 2012; 18:1446-54. [PMID: 22449610 PMCID: PMC3499973 DOI: 10.1016/j.bbmt.2012.03.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 03/19/2012] [Indexed: 11/20/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is curative for selected patients with advanced essential thrombocythemia (ET) or polycythemia vera (PV). From 1990 to 2007, 75 patients with ET (median age 49 years) and 42 patients with PV (median age 53 years) underwent transplantations at the Fred Hutchinson Cancer Research Center (FHCRC; n = 43) or at other Center for International Blood and Marrow Transplant Research (CIBMTR) centers (n = 74). Thirty-eight percent of the patients had splenomegaly and 28% had a prior splenectomy. Most patients (69% for ET and 67% for PV) received a myeloablative (MA) conditioning regimen. Cumulative incidence of neutrophil engraftment at 28 days was 88% for ET patients and 90% for PV patients. Acute graft-versus-host disease (aGVHD) grades II to IV occurred in 57% and 50% of ET and PV patients, respectively. The 1-year treatment-related mortality (TRM) was 27% for ET and 22% for PV. The 5-year cumulative incidence of relapse was 13% for ET and 30% for PV. Five-year survival/progression-free survival (PFS) was 55%/47% and 71%/48% for ET and PV, respectively. Patients without splenomegaly had faster neutrophil and platelet engraftment, but there were no differences in TRM, survival, or PFS. Presence of myelofibrosis (MF) did not affect engraftment or TRM. Over 45% of the patients who undergo transplantations for ET and PV experience long-term PFS.
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Affiliation(s)
- Karen K Ballen
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts 02214, USA.
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138
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Sun T, Zhang L. Thrombosis in myeloproliferative neoplasms with JAK2V617F mutation. Clin Appl Thromb Hemost 2012; 19:374-81. [PMID: 22826442 DOI: 10.1177/1076029612453761] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Myeloproliferative neoplasms (MPNs) are clonal hematopoietic stem cell disorders and are characterized by advanced proliferation and survival advantage. These abnormalities are considered to derive from the point mutation in exon 14 of the Janus kinase 2 genes (JAK2 V617F). The thrombosis rate and the high prevalence of JAK2V617F in patients with MPN suggest that there is an association between the 2 in MPN. Apart from the mutation, other variables are documented to cause endothelial dysfunction and involve in thrombotic tendency. Endothelial progenitor cells differentiated from hematopoietic stem cell in patients with JAK2V617F MPN play an indispensable role in initiating and modulating neoangiogenesis. Although a risk-oriented therapeutic approach has been applied to MPN treatments, the further study on pathogenesis of MPN may provide more novel preventions and therapies for MPN.
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Affiliation(s)
- Tiantian Sun
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
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139
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Choe WH, Park BG, Lee KH, Lee JH, Lee JH, Kwon SW. Automated double red-cell phlebotomy for the treatment of erythrocytosis. J Clin Apher 2012; 27:255-9. [DOI: 10.1002/jca.21241] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 06/14/2012] [Indexed: 01/19/2023]
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140
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Ghazali N, Collyer JC, Tighe JV. Hemimandibulectomy and vascularized fibula flap in bisphosphonate-induced mandibular osteonecrosis with polycythaemia rubra vera. Int J Oral Maxillofac Surg 2012; 42:120-3. [PMID: 22520725 DOI: 10.1016/j.ijom.2012.03.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Revised: 01/11/2012] [Accepted: 03/16/2012] [Indexed: 11/16/2022]
Abstract
This report presents the successful management of an advanced and refractory bisphosphonate-related osteonecrosis of the jaws (BRONJ) by hemimandibulectomy and an osteocutaneous fibula flap reconstruction in a patient with polycythaemia rubra vera, a rare haematological condition in which there is increased risk of thrombosis and haemorrhage. Union of the vascularized bone with the mandible depends on obtaining a BRONJ-free margin and rigid fixation of the bony ends. Magnetic resonance imaging can provide accurate delineation of necrotic bone and area of osteomyelitis. Placement of a 1cm margin beyond this can envisage a BRONJ-free margin. Aggressive medical management of polycythaemia rubra vera by venesection, asprin and cytoreduction therapy along with anticoagulant prophylaxis against thromboembolic events in the first 2 weeks following major surgery can provide the basis of a good surgical and flap outcome. Nevertheless, the possibility of unpredictable haemorrhage must be considered throughout.
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Affiliation(s)
- N Ghazali
- Maxillofacial Unit, Queen Victoria Hospital, East Grinstead, United Kingdom.
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141
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Kremyanskaya M, Mascarenhas J, Hoffman R. Why Does My Patient Have Erythrocytosis? Hematol Oncol Clin North Am 2012; 26:267-83, vii-viii. [DOI: 10.1016/j.hoc.2012.02.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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142
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Chambellan A, Coulon S, Cavailles A, Hermine O, Similowski T. BPCO et érythropoïèse : interactions et conséquences. Rev Mal Respir 2012; 29:213-31. [DOI: 10.1016/j.rmr.2011.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Accepted: 04/21/2011] [Indexed: 11/15/2022]
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143
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Patel ARC, Hurst JR. Extrapulmonary comorbidities in chronic obstructive pulmonary disease: state of the art. Expert Rev Respir Med 2012; 5:647-62. [PMID: 21955235 DOI: 10.1586/ers.11.62] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Extrapulmonary comorbidities are common and significant in chronic obstructive pulmonary disease (COPD), often contributing to symptoms, exacerbations, hospital admissions and mortality. Cardiovascular, musculoskeletal and psychological conditions are among the most prevalent and important of these. In particular, ischemic heart disease is a leading cause of death in the COPD population as a whole. Here, we provide a state-of-the-art summary of key comorbidities observed in COPD patients in terms of their prevalence, impact, pathophysiology and prognosis. In addition, we review clinical, diagnostic and management strategies that may differ in COPD patients from the rest of the population.
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Affiliation(s)
- Anant R C Patel
- Academic Unit of Respiratory Medicine, Royal Free Campus, UCL Medical School, London, NW3 2PF, UK.
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Abstract
SummaryThe term myeloproliferative disorders (MPDs) describes a group of conditions in which an intrinsic stem cell defect is present in the bone marrow. This leads to hypercellularity in one or more of the myeloid cell lines (red blood cells, platelets, granulocytes and their precursors), or increased bone marrow fibrosis. MPDs are rare; combined annual incidence is 6 per 100,000.MPDs may present in asymptomatic patients as an incidental finding, or may be associated with constitutional features such as weight loss, sweats or lethargy. Splenomegaly is common but lymphadenopathy is not a feature. The most significant complications are: arterial thrombosis, venous thrombosis, secondary marrow fibrosis and transformation to acute myeloblastic leukaemia (AML). Treatment aims to reduce the risk of such complications.Recent advances in the understanding of the pathogenesis of these disorders have radically changed the approach to the diagnosis of MPD and are the focus of new treatment developments.
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146
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McMullin MF, Wu C, Percy MJ, Tong W. A nonsynonymous LNK polymorphism associated with idiopathic erythrocytosis. Am J Hematol 2011; 86:962-4. [PMID: 21990094 DOI: 10.1002/ajh.22154] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Mary Frances McMullin
- Department of Haematology, Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Northern Ireland, United Kingdom.
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147
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Kiladjian JJ, Chevret S, Dosquet C, Chomienne C, Rain JD. Treatment of polycythemia vera with hydroxyurea and pipobroman: final results of a randomized trial initiated in 1980. J Clin Oncol 2011; 29:3907-13. [PMID: 21911721 DOI: 10.1200/jco.2011.36.0792] [Citation(s) in RCA: 182] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE The overall impact of hydroxyurea (HU) or pipobroman treatments on the long-term outcome of patients with polycythemia vera (PV) has not been assessed in randomized studies. We report final analyses from the French Polycythemia Study Group (FPSG) study, which randomly assigned HU versus pipobroman as first-line therapy in 285 patients younger than age 65 years. PATIENTS AND METHODS The full methodology has been described previously. FPSG results were updated with a median follow-up of 16.3 years. Statistical analysis was performed by using competing risks on the intention-to-treat population and according to main treatment received. RESULTS Median survival was 17 years for the whole cohort, 20.3 years for the HU arm, and 15.4 years for the pipobroman arm (P = .008) and differed significantly from that in the general population. At 10, 15, and 20 years, cumulative incidence of acute myeloid leukemia/myelodysplastic syndrome (AML/MDS) was 6.6%, 16.5%, and 24% in the HU arm and 13%, 34%, and 52% in the pipobroman arm (P = .004). Cumulative myelofibrosis incidence at 10, 15, and 20 years according to main treatment received was 15%, 24%, and 32% with HU versus 5%, 10%, and 21% with pipobroman (P = .02). CONCLUSION Data from this unique randomized trial comparing HU with another cytoreductive drug in PV showed that (1) survival of patients with PV treated with conventional agents differed from survival in the general population, (2) evolution to AML/MDS is the first cause of death, (3) pipobroman is leukemogenic and is unsuitable for first-line therapy, and (4) incidence of evolution to AML/MDS with HU is higher than previously reported, although consideration should be given to the natural evolution of PV.
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148
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Tripathy S, Panda SS, Rath B. Phlebotomy for rapid weaning and extubation in COPD patient with secondary polycythemia and respiratory failure. Lung India 2011; 27:24-6. [PMID: 20539767 PMCID: PMC2878708 DOI: 10.4103/0970-2113.59264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The increased incidence of ventilator-associated complications in patients with chronic obstructive pulmonary disease (COPD) necessitates rapid weaning and extubation. The presence of secondary polycythemia in this subgroup increases the incidence of stroke and myocardial infarction due to hyperviscosity and tissue hypoxia. We present a 58-year-old male patient of COPD with secondary polycythemia (hematocrit 64%) who had possible hyperviscosity-related complications leading to cardiac arrest after a minor surgical procedure. The patient developed ventilator dependence after recovery. Phlebotomy was done to remove 10% of total blood volume. Symptomatic improvement was dramatic. Improvement in weaning indices like rapid shallow breathing index and PaO2/PAO2 was observed facilitating rapid weaning and early extubation. Monitored, acute phlebotomy is safe and cost-effective. It decreases blood volume and viscosity, increases cardiac output and improves exercise tolerance in patients.
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Affiliation(s)
- Swagata Tripathy
- Department of Kalinga Institute of Medical Sciences, Bhubaneswar, India
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149
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The CYTO-PV: A Large-Scale Trial Testing the Intensity of CYTOreductive Therapy to Prevent Cardiovascular Events in Patients with Polycythemia Vera. THROMBOSIS 2011; 2011:794240. [PMID: 22084668 PMCID: PMC3200258 DOI: 10.1155/2011/794240] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Accepted: 02/22/2011] [Indexed: 01/14/2023]
Abstract
Polycythemia vera (PV) is a chronic myeloproliferative disorder whose major morbidity and mortality are thrombohaemorragic events. Current guidelines advise maintaining hematocrit (HCT) level below 45% in males and 42% in females. Such targets lean on pathophysiological reasoning, while evidence from ECLAP and PVSG-01, the two largest prospective studies in this disease, suggests no difference in the rate of thrombosis in patients maintained at different HCT values below 50%-52%. Cytoreductive therapy in PV (CYTO-PV) is a multicenter, randomized, and controlled trial assess the benefit/risk profile of cytoreductive therapy with phlebotomy or HU aimed at maintaining HCT < 45% versus maintaining HCT in the range 45%-50%. CYTO-PV is being conducted in the framework of the Gruppo Italiano Malattie Ematologiche nell'Adulto (GIMEMA) and is funded by the Italian Drug Agency (AIFA). It is an independent trial with broad recruitment criteria to mimic clinical practice. We describe here the study and its advancement status. Conclusions. Clinical research in rare disease can be carried out with limited funds, provided a research hypothesis is felt as clinically relevant by a scientific community willing to share knowledge on the outcome of clinical practice, thus producing scientific results useful to improve treatment and prognosis of patients.
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150
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Lee FS, Percy MJ. The HIF pathway and erythrocytosis. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2011; 6:165-92. [PMID: 20939709 DOI: 10.1146/annurev-pathol-011110-130321] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Because of the central role that red blood cells play in the delivery of oxygen to tissues of the body, red blood cell mass must be controlled at precise levels. The glycoprotein hormone erythropoietin (EPO) regulates red blood cell mass. EPO transcription, in turn, is regulated by a distinctive oxygen-sensing mechanism. In this pathway, prolyl hydroxylase domain protein (PHD) site-specifically hydroxylates the α-subunit of the transcription factor hypoxia-inducible factor α (HIF-α), thereby targeting the latter for degradation by the von Hippel-Lindau tumor-suppressor protein (VHL). Under hypoxic conditions, this posttranslational modification of HIF-α is inhibited, which stabilizes it and promotes the transcriptional activation of genes, including that for EPO. Rare patients with erythrocytosis have mutations in the genes encoding for PHD2, HIF-2α, and VHL, which implicates these proteins as critical to the proper control of red blood cell mass in humans.
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Affiliation(s)
- Frank S Lee
- Department of Pathology and Laboratory Medicine, University of Pennsylvania School of Medicine, Philadelphia, 19104, USA.
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