Coagulation Profile of Convalescent Plasma Donors and Recipients

Convalescent plasma (CP) therapy for COVID-19 infection may have favorable safety but varying efficacy, with concerns about its procoagulant impact. We investigated whether administration of CP to hospitalized patients affects their coagulation profile. Fifty-four patients randomized in a double-blinded fashion received either placebo, low-titer CP (LCP) or high-titer CP (HCP). Donor blood samples were obtained at the time of the plasmapheresis, while recipient blood samples were collected before infusion, one day post-infusion and between two and six days after infusion. Routine laboratory follow-up, coagulation biomarkers, antiphospholipid antibodies, and thrombin generation (TG) were assessed. CP donors had normal blood cell counts and coagulation profiles, without differences between LCP and HCP donors at the baseline. All CP recipients were on low-molecular-weight heparin thromboprophylaxis at the time of the infusion. Despite randomization, the HCP group had lower baseline (p = 0.004) and Day 1 platelet counts (p = 0.019) than the LCP group. Von Willebrand antigen (VWF:Ag) levels clearly exceeded normal without differences at baseline. At Day 1, LCP recipients had higher VWF:Ag (mean ± SD 224 ± 15%) than HCP recipients (210 ± 8%) (p = 0.012). In all groups, overall 80% lupus anticoagulant was positive. Baseline TG variables were comparable, but again LCP recipients exhibited higher endogenous thrombin potential (ETP) (1313 ± 535 nM.min) (p = 0.038) and peak TG (184 ± 106 nM) (p = 0.037) than the HCP group (870 ± 425 nM.min and 86 ± 54 nM). Our findings show that LCP increases VWF:Ag levels and enhances TG despite the thromboprophylaxis. These results suggest that HCP induces less hypercoagulability than LCP, which may contribute to the variability in CP efficacy.

Hydroxyurea therapy in sickle cell disease: knowledge and prescription patterns among care providers in a low-and middle-income setting

Background

Hydroxyurea is a safe, effective, and well-tolerated disease-modifying therapy for patients with sickle cell disease (SCD), leading to reduced morbidity, mortality, and an improved quality of life. However, its underutilization, driven by inadequate knowledge and variability in use among SCD care providers, may limit its benefits. This study assessed the knowledge and prescription patterns of hydroxyurea among SCD care providers in Jos, Nigeria.

Methodology

A cross-sectional survey of 132 physicians managing SCD was conducted to collect data on socio-demographics, hydroxyurea knowledge, and prescription patterns using a proforma. Knowledge was assessed using 17 questions (maximum score: 17). Scores above 12 (50th percentile) were classified as "good," while scores of 12 or below were categorized as "poor." Prescription patterns were evaluated against the National Institutes of Health (2014) and British Society for Haematology (2018) guidelines. Data were analyzed using descriptive and inferential statistics.

Results

Sixty-seven (50.8%) of the 132 physicians had inadequate knowledge of hydroxyurea's clinical benefits and safety. Only 35 (26.5%) were aware of available treatment guidelines, and 32 (24.2%) had ever prescribed hydroxyurea. Among prescribers, nine (28.1%) used inappropriate criteria to initiate treatment and six (18.8%) prescribed below recommended doses. The median maximum daily prescribed dose was 750mg, whereas five (15.6%) physicians did not exceed 200mg, irrespective of patient weight. Treatment guidelines were not followed by 25 (78.1%) of prescribers.

Conclusion

This study revealed a high prevalence of inadequate knowledge and inconsistent hydroxyurea prescription practices among SCD care providers. Targeted training is essential to enhance hydroxyurea utilization and ensure adherence to standardized treatment guidelines, ultimately improving patient outcomes.

Hematolymphoid neoplasm mimicking endodontic lesions: case series and review of the literature

Hematolymphoid neoplasms originating in the periapical region of a tooth are rare occurrences. Their signs, symptoms, and radiographic findings can also mimic lesions of endodontic origin. History-taking and clinical examination provide clues to determine the possibility of a non-endodontic lesion, although the definitive diagnosis can only be rendered based on histologic examination. In our case series, we present four cases of hematolymphoid neoplasms that radiographically mimicked endodontic lesions. All the cases initially underwent endodontic treatment, but the lesions failed to resolve. In one case, the clinician suspected a diagnosis of lymphoma based on the patient's history. In the other cases, the clinicians' impression was that the lesions originated from endodontic issues. We present two cases of diffuse large B-cell lymphoma, a case of a plasma cell neoplasm, and a case of Langerhans cell histiocytosis, along with a literature review of three entities when found in the oral cavity as well as review of hematolymphoid neoplasm mimicking endodontic lesion previously reported in literature.

Flow cytometry in acute myeloid leukemia and detection of minimal residual disease

Acute myeloid leukemia (AML) is a common type of acute leukemia (AL), belonging to malignant tumors of the hematopoietic system with the characteristics of rapid disease development, control with extreme difficulties, easy recurrence, poor prognosis, and incidence rate increasing with age. The traditionally diagnostic standard of French American British (FAB), being based on the morphological examination with high human subjectivity, can no longer meet the demand of clinical diagnosis and treatment of AML. Requirements of objective accuracy and low-dose sample, have become the indispensable method for AML diagnosis and monitoring prognosis. Flow cytometry is a modern technology that can quickly and accurately detect the series, antigen distribution, differentiation stage of AML cells, minimal residual lesions after AML therapy, so as to provide the great significance in guiding clinical diagnosis, hierarchical treatment, and prognosis judgement. This article will systematically elaborate on the application of flow cytometry in the diagnosis and classification of AML, and the detection of minimal residual lesions, thereby providing reference significance for dynamic monitoring and prognostic observation of AML with different immune subtypes of FAB.

Myeloid sarcoma: Experience from a tertiary care center in southern India - A series of eight unusual cases

BACKGROUND

Myeloid sarcoma (MS) is a tumor mass comprising myeloid blasts with or without maturation occurring in any site other than bone marrow. It is a rare and distinct clinical presentation of myeloid neoplasm.

MATERIALS AND METHODS

This is a retrospective study over 7 years (2015-2022) comprising a series of eight cases, which includes clinical details, morphology, immunohistochemistry (IHC) markers, cytogenetics, and molecular details.

RESULTS

These cases showed up as an isolated MS (3/8), as an initial clinical presentation in acute myeloid leukemia (1/8), as acute myeloid leukemia (1/8), as a disease progression in primary myelofibrosis (1/8), as chronic myeloid leukemia (1/8), and as BCR-ABL-negative myelodysplastic syndrome/myeloproliferative neoplasm (1/8). One of the three isolated MS was incorrectly identified as having Ewing's sarcoma. One case each presented at the cervical lymph node, mediastinum, skin, sacral soft tissue, maxillary sinus, and perinephric fat, and two cases presented at the hard palate.

CONCLUSION

Four of the cases in our study were clinically thought of as lymphoma/sarcoma, which was a major diagnostic challenge. All but one case succumbed to their disease. Without adequate clinical history and appropriate use of ancillary techniques such as IHC in tissue biopsies, flow cytometry, cytogenetics, and molecular studies, these cases have a high chance of being misdiagnosed as non-Hodgkin lymphoma, small round blue cell tumor, or undifferentiated carcinomas, which can complicate patient management and prognosis.

Outcomes in patients with acute myeloid leukemia older than 70 years within the last 30 years, a single center experience

As median age of patients with acute myeloid leukemia is 72 years, older patients continue to be a vulnerable cohort representing significant challenges in clinical practice. Patient-specific comorbidities as well as leukemia-specific unfavorable molecular- and cytogenetics confer even poorer outcomes. Treatment of AML therefore needs to be less toxic to prevent harm while lowering or eradicating leukemic burden to prolong survival. In this retrospective analysis we included 365 older AML patients from the Düsseldorf registry who were diagnosed and treated in our department of hematology over a period of 31 years. Most patients were treated with HMA (37.3%) followed by 35.3% of patients who received either low dose chemotherapy or BSC. 9% of patients were treated with induction chemotherapy while 8.5% of patients received a combination of HMA with venetoclax. 4.1% of patients underwent allografting. At the time of last follow up, 35 patients (9.6%) were still alive. Of those patients who were treated with induction chemotherapy or HMA + venetoclax, 18.2% and 29.0% were still alive, whereas 60% of the patients who underwent allogeneic stem cell transplantation were still alive (p < 0.001). Median overall survival of the entire patient population was 6 months. Longest survival was observed in patients who underwent aHSCT with an unreached median overall survival followed by patients who were treated with induction chemotherapy (21 months) or HMA plus venetoclax (11 months). The implementation of HMA + venetoclax and increasing numbers of aHSCT improved prognosis and survival even in older AML patients.

A literature review of major surgery experience with emicizumab in people with hemophilia A without factor VIII inhibitors

People with hemophilia A have a total or partial deficiency of factor (F)VIII, causing spontaneous and/or traumatic bleeding into the joints, muscles, and soft tissues. Major surgery may be required to restore joint mobility or treat the symptoms of common comorbidities in people with hemophilia A. Additional factor replacement is recommended during the perioperative period; collated information on the experience of emicizumab-treated people with hemophilia A during major surgery is currently lacking. To provide a consolidated narrative summary of the experience with emicizumab in people with hemophilia A without FVIII inhibitors undergoing major surgery, a comprehensive literature search was performed using PubMed/MEDLINE (cut-off date: March 31, 2024); the abstract books for applicable congresses (2016-2024) were searched manually. Studies were included if reporting original data on people with hemophilia A of all ages and hemophilia A severities without FVIII inhibitors on emicizumab prophylaxis who had undergone major surgery. Outcomes collected included perioperative surgical management, adverse events, and bleeding events. Twenty publications were included; 72 procedures were reported. Twenty-two orthopedic and 34 other major procedures were specifically described. FVIII replacement was used to manage 66 procedures perioperatively, and 25 procedures were managed in conjunction with antifibrinolytics. Fifteen procedures resulted in a bleeding event, and one individual experienced a thrombotic event. No deaths were reported. This review provides a consolidated narrative of the currently reported experiences of emicizumab-treated people with hemophilia A without FVIII inhibitors undergoing major surgery, helping to support the future management decisions of emicizumab-treated people with hemophilia A during surgery.

Follicular Lymphoma of the Gallbladder in an Octogenarian: A Case Report and Literature Review

Primary follicular lymphoma (PFL) is an indolent subtype of non-Hodgkin lymphoma that typically involves lymphoid tissues. Gallbladder involvement is exceedingly rare and poses significant diagnostic challenges. Few cases in the literature describe gallbladder follicular lymphoma, particularly in elderly male patients, leaving notable gaps in clinical understanding and management. Herein, we present the case of an 82-year-old male who presented with acute abdominal pain and unintentional weight loss. Initial imaging, including contrast-enhanced computed tomography, ultrasound, and magnetic resonance imaging, revealed a suspicious gallbladder mass with wall thickening and regional lymphadenopathy, raising concern for malignancy. Endoscopic ultrasound-guided fine needle aspiration and subsequent immunophenotyping confirmed a diagnosis of PFL. The patient underwent radical cholecystectomy with lymphadenectomy, and histopathological examination corroborated the diagnosis of gallbladder follicular lymphoma. During follow-up, the patient developed complications, yet no evidence of lymphoma recurrence was observed. A literature review identified 8 similar cases, further emphasizing the rarity of this presentation. Future research should focus on optimizing diagnostic techniques, refining therapeutic strategies, and conducting longer-term follow-up studies to better assess patient outcomes in such a rare disease. This case highlights the need for heightened clinical suspicion and comprehensive evaluation in atypical presentations of extranodal lymphoma.

Rapid Identification of β-Thalassemia, Hb E, and High Hb F Determinants Using a High-Resolution Melting Analysis: Application in Prenatal Diagnosis in Southern Thailand

β-thalassemia (thal), hemoglobin (Hb) E, and high Hb F determinants, which are caused by mutations in the β-globin gene cluster, are common genetic disorders in Thailand and Southeast Asia. Prenatal diagnosis is essential for couples at risk to identify severe forms, including homozygous β-thal and Hb E/β-thal. Conventional methods, including reverse dot-blot hybridization and gap-polymerase chain reaction (PCR) for genotyping of point and large deletion mutations, require post-PCR steps, which are time-consuming and costly. This study aimed to develop a rapid and efficient method using monoplex high-resolution melting (HRM) analysis for genotyping of Hb E and 11 β-thal mutations; multiplex HRM analysis for identifying six deletional mutations, including two β0-thal mutations (3.5 and 45 kb deletion); and a novel method for detecting four high Hb F determinants, namely, δβ0-thal (12.5 kb deletion), HPFH6, Indian inv-del (Aγδβ)0-thal, and Thai del-inv-ins (Aγδβ)0-thal. The developed assays were validated using 182 blinded fetal DNA samples with 41 β-thal genotypes. Different HRM patterns were observed among wild-type, heterozygote, homozygote, and compound heterozygote genotypes. Six deletional mutations showed specific melt curves. This technique demonstrated 100% concordance with conventional methods. The assay showed 100% sensitivity, specificity, and positive and negative predictive values within the limit of detection at DNA concentrations of 8.0 ng/reaction. Finally, this developed assay was efficient in identifying both point mutations and large deletion, convenient, rapid, and cost-effective and did not require post-PCR steps. Thus, this technique has potential for application in prenatal diagnosis of thal and can inform prevention and control programs.

The role of ABCG2 in health and disease: Linking cancer therapy resistance and other disorders

All biological systems have adenosine triphosphate (ATP) binding cassette (ABC) transporters, one of the significant protein superfamilies involved in transport across membranes. ABC transporters have been implicated in the etiology of diseases like metabolic disorders, cancer, and Alzheimer's disease. ATP-binding cassette superfamily G member 2 (ABCG2), one of the ABC transporters, is necessary for the ATP-dependent efflux of several endogenous and exogenous substances. Consequently, it maintained cellular homeostasis and shielded tissue from xenobiotic substances. ABCG2 was initially identified in an Adriamycin-selected breast cancer cell line (MCF-7/AdrVp) and was linked to the emergence of multidrug resistance (MDR) in cancerous cells. Under many pathophysiological conditions, including inflammation, disease pathology, tissue injury, infection, and in response to xenobiotics and endogenous substances, the expression of ABCG2 undergoes alterations that result in modifications in its function and activity. Genetic variants in the ABCG2 transporter can potentially impact its expression and function, contributing to the development of many disorders. This review aimed to illustrate the impact of ABCG2 expression and its variants on oral drug bioavailability, MDR in specific cancer cells, explore the relationship between ABCG2 expression and other disorders such as gout, Alzheimer's disease, epilepsy, and erythropoietic protoporphyria, and demonstrate the influence of various synthetic and natural compounds in regulating ABCG2 expression.

The Correlation between Reticulocyte Hemoglobin Equivalent (RET-He), Iron Status, and Erythrocyte Indices in Chronic Kidney Disease Patients at Prof. Dr. R.D. Kandou Manado Hospital

Background: Chronic Kidney Disease (CKD) is a public health concern with anemia being a major complication. RET-He is a cost-effective parameter to assess iron status in CKD, but further research is necessary to assess its correlation with existing parameters. This study attempted to investigate the correlation between RET-He, iron status, and erythrocyte indices among CKD patients. Materials and Methods: A cross-sectional study involving 110 CKD patients who underwent routine hematology and iron profile tests (serum iron/SI, total iron binding capacity/TIBC, transferrin saturation/TSAT, and ferritin). RET-He was then measured using a Sysmex XN-1000 hematology analyzer. Statistical tests were used to define the correlation between RET-He), iron status, and erythrocyte indices. Results: There was a significant positive correlation between RET-He and SI (r = 0.349; p = 0.000), TSAT (r = 0.393; p = 0.000), and ferritin (r = 0.279; p = 0.003). Among CKD patients with excess iron levels, there was a moderate correlation between RET-He and TSAT (r = 0.404; p = 0.000). Conclusion: The study found a significant correlation between RET-He levels and iron status markers in CKD patients. RET-He is recommended as an additional parameter to assess iron status and as an additional method to estimate TSAT and ferritin levels, especially in settings where chemistry analyzers are unavailable. Further research is required to establish RET-He cut-off values for identifying excessive iron levels in CKD patients.

Sickle cell trait in non-firearm arrest-related deaths of Black persons

The role of sickle cell trait (SCT) in sudden exertional death is well-recognized in sports and military training. However, it is not yet studied for non-firearm arrest-related death (NF-ARD). With extensive multi-pronged searches, a large database (n = 1389) of NF-ARDs was established. For the years 2006-2021 (inclusive) there were 50 NF-ARDs of Black persons in which postmortem evidence of SCT was found. A control cohort consisted of 414 NF-ARDs of Black persons with no reported SCT. The mean age for SCT cases was 33.1 ± 10.4 years versus 37.0 ± 10.4 years for the control group (p = 0.01). The body-mass index for SCT cases was 28.3 ± 6.6 kg/m2 versus 30.7 ± 7.6 kg/m2 for the control group (p = 0.03). The prevalence of cardiomegaly was 21% for SCT cases versus 39% in the control cohort (p = 0.008). The postmortem prevalence of SCT in NF-ARDs of Black persons (n = 50, 10.7%) was higher than the prevalence of SCT in the US Black population, which is 7.1% (p = 0.003). In this study of NF-ARDs in Black persons, the prevalence of SCT and the differences between the SCT cases and the control cohort suggest that exertional collapse associated with sickle cell trait may be a contributory factor in NF-ARDs.

Pegcetacoplan: the first and only C3-targeted therapy for the treatment of adults with paroxysmal nocturnal hemoglobinuria

INTRODUCTION

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired disorder of hematopoietic stem cells, characterized by somatic mutations of the Phosphatidylinositol Glycan Class A Gene, resulting in increased hemolysis. The advent of complement inhibitors has since changed the way clinicians approach treating PNH. Pegcetacoplan is a C3 inhibitor that has shown promise in this field and improved outcomes for patients who have been diagnosed with PNH.

AREAS COVERED

This review article will aim to examine the pathophysiology of PNH and the current treatments available, with a focus on pegcetacoplan. It will focus on the pharmacodynamics, pharmocokinetics and evidence in the use of pegcetacoplan in PNH. Electronic sources including PubMed, MEDLINE, were utilized with studies in the last 5 years prioritized, especially the phase 3 Prince and Pegasus studies.

EXPERT OPINION

The results from phase 3 studies for pegcetacoplan have been promising, showing good efficacy and improvements in patients' conditions. More research is required to evaluate the use of pegcetacoplan, especially in combination with existing treatment in patients who are having suboptimal results. Nonetheless, with more results on the way and new agents to treat PNH in the vicinity, this remains a very exciting time for both clinicians and patients.

Splenic rupture in dairy cattle: Report of 24 cases

Splenic rupture in cattle is scarcely described in the literature. The aim of this work was to report the occurrence of splenic rupture in cattle in southern Brazil as well as to describe the causes of the condition. Between 2013 and 2022, 24 of the 1769 bovine necropsies performed in southern Brazil were due to splenic rupture, accounting for 1.36% of the diagnoses. Animals died due to hemoperitoneum caused by a rupture in the splenic capsule, typically associated with marked splenomegaly and a large hematoma between the capsule and the parenchyma. Clinical signs were described in a subset of cases (11 of 24 cases, 46%) and included apathy, abdominal pain, mucosal pallor, tachycardia, and respiratory distress. However, the majority (13 of 24 cases, 54%) presented as sudden death. The underlying cause of splenic rupture was established as follows: 16 cases (67%) secondary to babesiosis, 4 cases (17%) due to lymphoma, 1 case (4%) due to a thrombus, 1 case (4%) due to external trauma, 1 case due to a ruptured nodular lymphoid hyperplasia (4%), and 1 case of undetermined cause (4%). Hypovolemic shock caused by splenic rupture is an important cause of death of dairy cattle, and babesiosis and bovine leukemia virus-associated lymphoma are among the most common etiologic diagnoses (84% of cases). The description of the causes of this condition is important to clarify the pathogenesis and occurrence of splenic rupture in dairy cattle.

COVID-19 induced thrombotic thrombocytopenic purpura in a patient with systemic lupus erythematosus: A rare case report

RATIONALE

Thrombotic thrombocytopenic purpura (TTP) is a severe and rare disease, and its complexity increases in the presence of underlying autoimmune disease and COVID-19 infection, making differential diagnosis and treatment more challenging.

PATIENTS CONCERNS

A 43-year-old patient presented with high fever, intermittent cough, and tea-colored urine.

DIAGNOSES

The patient had a long-term history of systemic lupus erythematosus (SLE) and lupus nephritis (LN). The nasopharyngeal swab confirmed the diagnosis of COVID-19 by RT-PCR, and plasma ADAMTS-13 activity was completely deficient (0%). It was considered that COVID-19 infection occurred on the basis of SLE disease and was then complicated with TTP.

INTERVENTIONS

The patient was successfully treated with plasma exchange, followed by a combination of biologics and immunosuppressants.

OUTCOMES

After 1 year of follow-up, the patient had completely recovered from COVID-19 infection and TTP, meeting the cure criterion. In addition, the LN was in remission, with an SLEDAI-2K score of 0, indicating a low disease activity state.

LESSONS

This article indicates that the patient suffers from both long-standing underlying diseases and the sudden occurrence of SARS-CoV-2 infection, which complicates the determination of the etiology and diagnosis of TTP. Consequently, after thorough analysis of the disease progression, clinical manifestations, laboratory results, and treatment outcomes, it was primarily concluded that COVID-19 was the catalyst for the onset of TTP in this patient.

Cholecystectomy-induced thrombotic microangiopathy (TMA) in a postpartum patient successfully treated with eculizumab: a case report

BACKGROUND

Thrombotic microangiopathy (TMA) is a rare, life-threatening disorder characterized by microangiopathic hemolytic anemia, thrombocytopenia, and end-organ damage. Atypical hemolytic uremic syndrome (aHUS) is even less common, comprising less than 10% of hemolytic uremic syndrome (HUS) cases. aHUS in postpartum is associated with poor maternal outcomes, with the majority of cases resulting in end-stage renal disease. aHUS, unlike other types of TMA, is related to complement dysregulation. Thus, the current treatment of choice for aHUS is complement blockade, which limits unregulated activation of complement and complement-mediated end organ damage.

CASE PRESENTATION

We present a rare case of a previously healthy, postpartum, 20-year-old Hispanic female patient who underwent a laparoscopic cholecystectomy and subsequently developed complement-mediated TMA, successfully treated with eculizumab. Unique to our case was renal failure owing to multiple insults and partial resolution of hematologic TMA findings prior to initiation of eculizumab.

CONCLUSION

Our case emphasizes the importance of clinicians possessing a high degree of clinical awareness and judgement surrounding complement-mediated TMA, aHUS and its subsets, and surgery as a precipitator, regardless of safety, particularly during the postpartum period.

Vascular injury in glomerulopathies: the role of the endothelium

In glomerulopathies, endothelial dysfunction and the presence of histological vascular lesions such as thrombotic microangiopathy, arteriolar hyalinosis, and arteriosclerosis are related to a severe clinical course and worse renal prognosis. The endothelial cell, which naturally has anti-inflammatory and anti-thrombotic regulatory mechanisms, is particularly susceptible to damage caused by various etiologies and can become dysfunctional due to direct/indirect injury or a deficiency of protective factors. In addition, endothelial regulation and protection involve participation of the complement system, factors related to angiogenesis, the renin-angiotensin system (RAS), endothelin, the glycocalyx, the coagulation cascade, interaction between these pathways, interactions between glomerular structures (the endothelium, mesangium, podocyte, and basement membrane) and interstitial structures (tubules, arterioles and small vessels). Dysregulation of those components is also associated with the progression of renal fibrosis, since endothelial cell damage promotes endothelial-to-mesenchymal transition. Although the potential mechanisms of vascular injury have been widely described in diabetic kidney disease, hypertensive nephrosclerosis, and hemolytic uremic syndrome, they require further elucidation in other glomerulopathies. A better understanding of the pathogenesis of vascular injury in patients with glomerular diseases could contribute to the development of specific treatments for such injury.

BPDCN MYB fusions regulate cell cycle genes, impair differentiation, and induce myeloid-dendritic cell leukemia

MYB fusions are recurrently found in select cancers, including blastic plasmacytoid DC neoplasm (BPDCN), an acute leukemia with poor prognosis. They are markedly enriched in BPDCN compared with other blood cancers and, in some patients, are the only obvious somatic mutation detected. This suggests that they may alone be sufficient to drive DC transformation. MYB fusions are hypothesized to alter the normal transcription factor activity of MYB, but, mechanistically, how they promote leukemogenesis is poorly understood. Using CUT&RUN chromatin profiling, we found that, in BPDCN leukemogenesis, MYB switches from being a regulator of DC lineage genes to aberrantly regulating G2/M cell cycle control genes. MYB fusions found in patients with BPDCN increased the magnitude of DNA binding at these locations, and this was linked to BPDCN-associated gene expression changes. Furthermore, expression of MYB fusions in vivo impaired DC differentiation and induced transformation to generate a mouse model of myeloid-dendritic acute leukemia. Therapeutically, we present evidence that all-trans retinoic acid (ATRA) may cause loss of MYB protein and cell death in BPDCN.

Advances in biopharmaceutical products for hemophilia

Hemophilia is caused by the deficiency of clotting factors due to a single genetic abnormality. Replacement therapies have evolved from plasma-derived to recombinant coagulation factor concentrates but continue to have certain limitations. Monoclonal antibodies are clinical prophylactic treatment options unaffected by inhibitors and have better compliance than coagulation factor concentrates for patients with hemophilia. Gene therapy is a breakthrough in hemophilia treatment, as it drives the hepatic expression of factor VIII or factor IX and requires only a single administration to enable long-term replacement treatment in adult patients. Furthermore, biopharmaceutical products that target new pathways unaffected by inhibitors, including tissue factor pathway inhibitors, activated protein C, and antithrombin, as well as pharmaceutical technology advances to reduce dosing frequency, have demonstrated promising clinical results. This review provides a comprehensive overview of these biopharmaceutical products and explores the future of hemophilia treatment.

Primary uterine non-Hodgkin's lymphoma:a rare case report and review of the literature

Primary uterine non-Hodgkin lymphoma (NHL) is rarely reported, as its incidence is extremely low. We describe a 72 year old patient with primary uterine non-Hodgkin's lymphoma stage IV, diffuse B-cell large cells, who responded well to cytotoxic chemotherapy (R-CHOP). Radiological investigations exhibited certain characteristics, including magnetic resonance T2 weighted imaging, enhanced scanning, diffusion weighted imaging and apparent diffusion coefficient values. The lesion in the anterior wall of the uterine body was relatively large, with a size of about 34mm×47mm×43mm. The gold standard for diagnosis is still the pathological examination of a biopsy specimen, which revealed diffuse large cell of B lineage. This article reviews data collected from 141 patients in the literature.

A Narrative Review of Molecular, Immunohistochemical and In-Situ Techniques in Dermatopathology

Skin disorders pose a significant health burden globally, affecting millions of individuals across diverse demographics. Advancements in molecular techniques have revolutionised our understanding of the underlying mechanisms of skin disorders, offering insights into their pathogenesis, diagnosis, and potential targeted treatment. Furthermore, the integration of molecular diagnostics into clinical practice has enhanced the accuracy of skin disorder diagnoses. Polymerase chain reaction (PCR), next-generation sequencing (NGS), and other molecular assays have allowed for the detection of infectious agents, assessment of genetic mutations, and profile gene expression patterns with unequalled precision. These techniques have proven instrumental in distinguishing between subtypes of skin cancers, aiding treatment strategies and prognostic assessments. Moreover, molecular profiling is increasingly guiding the selection of therapeutic agents, ensuring a personalised and effective approach to managing skin disorders. The application of PCR has revolutionised the field by enabling the identification of microbial DNA (i.e., Mycobacterium tuberculosis and Epstein-Barr Virus) in skin infections and detecting specific genetic mutations associated with dermatological disorders (e.g., BRAF). DNA sequencing technologies, such as next-generation sequencing, have facilitated the elucidation of genetic variations and mutations in skin diseases (i.e., bullous disorders), paving the way for personalised treatment approaches. Gene expression profiling techniques, such as microarrays and RNA sequencing, have provided insights into dysregulated pathways and molecular signatures associated with conditions ranging from inflammatory skin disorders to cutaneous malignancies. Immunohistochemistry and fluorescence in situ hybridization have proven invaluable in determining protein expression patterns and detecting chromosomal abnormalities, respectively, aiding in the characterization of skin lesions in conjunction with the molecular data. Proteomic studies have contributed to understanding the intricate protein networks involved in dermatological conditions (i.e., psoriasis), while epigenetic analyses have shed light on the role of epigenetic modifications in gene regulation within skin cancer (i.e., Malignant Melanoma). Together, these molecular techniques have laid the groundwork for targeted therapies and precision medicine in dermatology, with implications for improved diagnostics and treatment outcomes. This review focuses on the routinely employed molecular techniques within dermatopathology, with a focus on cutaneous malignancies, autoimmune diseases, infectious diseases, and neonatal screening which can be implemented in the diagnosis and contribute to improved patient care.

Predicting Intensive Care Unit Admission in COVID-19-Infected Pregnant Women Using Machine Learning

Background: The rapid onset of COVID-19 placed immense strain on many already overstretched healthcare systems. The unique physiological changes in pregnancy, amplified by the complex effects of COVID-19 in pregnant women, rendered prioritization of infected expectant mothers more challenging. This work aims to use state-of-the-art machine learning techniques to predict whether a COVID-19-infected pregnant woman will be admitted to ICU (Intensive Care Unit). Methods: A retrospective study using data from COVID-19-infected women admitted to one hospital in Astana and one in Shymkent, Kazakhstan, from May to July 2021. The developed machine learning platform implements and compares the performance of eight binary classifiers, including Gaussian naïve Bayes, K-nearest neighbors, logistic regression with L2 regularization, random forest, AdaBoost, gradient boosting, eXtreme gradient boosting, and linear discriminant analysis. Results: Data from 1292 pregnant women with COVID-19 were analyzed. Of them, 10.4% were admitted to ICU. Logistic regression with L2 regularization achieved the highest F1-score during the model selection phase while achieving an AUC of 0.84 on the test set during the evaluation stage. Furthermore, the feature importance analysis conducted by calculating Shapley Additive Explanation values points to leucocyte counts, C-reactive protein, pregnancy week, and eGFR and hemoglobin as the most important features for predicting ICU admission. Conclusions: The predictive model obtained here may be an efficient support tool for prioritizing care of COVID-19-infected pregnant women in clinical practice.

Acute Promyelocytic Leukemia-like AML: Genetic Perspective and Clinical Implications

Acute promyelocytic leukemia (APL) is a rare type of AML, characterized by the t(15;17) translocation and accounting for 8-15% of cases. The introduction of target therapies, such as all-trans retinoic acid (ATRA) and arsenic trioxide (ATO), radically changed the management of APL, making it the most curable AML subtype. However, a small percentage (estimated to be 2%) of AML presenting with APL-like morphology and/or immunophenotype lacks t(15;17). This rare APL-like AML group, whose first case was described in the early 1990s, now includes over 40 entities. These diseases present great heterogeneity in terms of genetic lesions, clinical presentation, sensitivity to targeted agents and chemotherapy, and prognosis. Furthermore, the diagnosis is very challenging. Thus, in this paper, we aim to comprehensively review the literature reports and studies addressing APL-like entities, investigate the biological mechanisms of leukemogenesis, evaluate the clinical characteristics, and discuss future lines of research and possible clinical approaches.

Pancreatic Neuroendocrine Tumor: The Case Report of a Patient with Germline FANCD2 Mutation and Tumor Analysis Using Single-Cell RNA Sequencing

Background: Neuroendocrine neoplasms are a rare and heterogeneous group of neoplasms. Small-sized (≤2 cm) pancreatic neuroendocrine tumors (PanNETs) are of particular interest as they are often associated with aggressive behavior, with no specific prognostic or progression markers.

METHODS

This article describes a clinical case characterized by a progressive growth of nonfunctional PanNET requiring surgical treatment in a patient with a germline FANCD2 mutation, previously not reported in PanNETs. The patient underwent whole exome sequencing and single-cell RNA sequencing.

RESULTS

The patient underwent surgical treatment. We confirmed the presence of the germline mutation FANCD2 and also detected the germline mutation WNT10A. The cellular composition of the PanNET was analyzed using single-cell sequencing, and the main cell clusters were identified. We analyzed the tumor genomics, and used the data to define the effect the germline FANCD2 mutation had.

CONCLUSIONS

Analysis of the mutational status of patients with PanNET may provide additional data that may influence treatment tactics, refine the plan for monitoring such patients, and provide more information about the pathogenesis of PanNET. PanNET research using scRNA-seq data may help in predicting the effect of therapy on neuroendocrine cells with FANCD2 mutations.

Emergencies in Hematology: Why, When and How I Treat?

Hematological emergencies are critical medical conditions that require immediate attention due to their rapid progression and life-threatening nature. As various examples, hypercalcemia, often associated with cancers such as multiple myeloma, can lead to severe neurological and cardiac dysfunction. Hyperleukocytosis, common in acute myeloid leukemias, increases the risk of leukostasis and multiorgan failure. Sickle cell crisis, a common complication in sickle cell disease, results from vaso-occlusion, leading to acute pain and tissue ischemia. Tumor lysis syndrome, reported in cases of rapid destruction of cancer cells, causes electrolyte imbalances and acute kidney injury. Acute transfusion reactions, fundamental in hematological conditions, can range from mild allergic responses to severe hemolysis and shock, requiring prompt management. Disseminated intravascular coagulation, involving excessive coagulation and bleeding, is commonly triggered by hematological malignancies, common in the first phases of acute promyelocytic leukemia. Recently, in the era of bispecific antibodies and chimeric antigen receptor T cells, cytokine release syndrome is a manifestation that must be recognized and promptly treated. Understanding the pathophysiology, recognizing the clinical manifestations, and ensuring adequate diagnostic strategies and management approaches for each condition are central to early intervention in improving patient outcomes and reducing mortality.

Rescue of the endogenous FVIII expression in hemophilia A mice using CRISPR-Cas9 mRNA LNPs

Gene editing provides a promising alternative approach that may achieve long-term FVIII expression for hemophilia A (HemA) treatment. In this study, we investigated in vivo correction of a mutant factor VIII (FVIII) gene in HemA mice. We first developed MC3-based LNPs for efficient mRNA delivery into liver sinusoidal endothelial cells (LSECs), the major site of FVIII biosynthesis. To target a five base pair deletion in FVIII exon 1 in a specific HemA mouse strain, we injected LNPs encapsulating Cas9 mRNA and specifically designed sgRNAs intravenously for in vivo gene editing of the mutant FVIII. Indel variants generated at the mutant site contained mostly a single base-pair deletion, resulting in frameshift correction of FVIII gene. Sustained endogenous FVIII activity up to 6% was achieved over 26 weeks in treated HemA mice. Sequencing data indicated an average gene editing rate of 15.3% in LSECs. Our study suggests that optimized MC3 LNP formulations, combined with CRISPR-Cas9 technology, can effectively correct the mutant FVIII gene in LSECs and restore FVIII activity for therapeutic treatment of HemA.

The Importance of Antibody Titer Determination to the Effective Use of Convalescent Plasma

Convalescent Plasma (CP) has been used prophylactically and therapeutically over the past century to address a variety of infectious threats. Two tenets of the use of CP were clear from prior experience in the setting of other infectious outbreaks: (1) best results are obtained when CP is given early in the course of the disease, and (2) plasma containing high-titer neutralizing capacity is necessary to achieve optimal results. The magnitude of the COVID-19 pandemic along with the initial lack of effective therapeutic alternatives, combined with the relative safety of the approach of administration of CP, led to the initiation of an expanded access program (EAP) that ultimately provided CP to tens of thousands of individuals. When the program was initiated, no high-throughput assay was available for the determination of antibody titers, so antibody positive units were administered without regard to titer. With foresight regarding the need to ultimately determine such titers, samples from the CP units administered were retained and titers were determined retrospectively. An automated live-virus neutralization assay was ultimately selected for this purpose based on an evaluation of its accuracy and precision. Ultimately, an analysis performed in 13,794 individuals from the EAP for which clinical outcomes were known following the administration of single units of COVID-19 CP between the period of April and August 2020 indicated that higher titer COVID-19 CP was associated with a modest reduction in absolute mortality. The benefit observed was confined to individuals who were not intubated, and there was a trend toward a greater reduction in mortality using the highest SARS-CoV-2 neutralizing antibody-containing CP units. This experience during the COVID-19 pandemic is instructive for the future. To facilitate the production of CP that is likely to be most effective, high-throughput assays to determine neutralizing antibody titers need to be developed and implemented early during an outbreak to facilitate the identification and early administration of high-titer units.

Pregnancy: MPN management before, during, and after pregnancy

The aging obstetric population, combined with more frequent myeloproliferative neoplasm (MPN) diagnoses in younger patients, will result in hematologic providers increasingly caring for MPN patients in pregnancy. There are special considerations that pertain to management of pregnancy in MPN patients. This includes increased risks of thrombosis and hemorrhage as well as pregnancy complications that are likely related to placental dysfunction associated with an MPN diagnosis, including preeclampsia, preterm delivery, and intrauterine growth restriction. Complicating these outcomes is the uncertainty of the safety of many commonly used drugs in MPNs in pregnancy and breastfeeding. Given the overall low incidence of pregnancy in MPNs, many guidelines are based on expert opinions and extrapolation from other high-risk pregnancy populations. In this case-based review, we summarize the literature on MPN pregnancy outcomes and synthesize recommendations to provide guidance on the antepartum and postpartum management of MPN patients. Special attention is also made to issues relevant to preconception, including fertility and the use of assisted reproductive technology.

Non-[18F]FDG PET-Radiopharmaceuticals in Oncology

Molecular imaging is a growing field, driven by technological advances, such as the improvement of PET-CT scanners through the introduction of digital detectors and scanners with an extended field of view, resulting in much higher sensitivity and a variety of new specific radiopharmaceuticals that allow the visualization of specific molecular pathways and even theragnostic approaches. In oncology, the development of dedicated tracers is crucial for personalized therapeutic approaches. Novel peptides allow the visualization of many different targets, such as PD-1 and PD-L1 expression, chemokine expression, HER expression, T-cell imaging, microenvironmental imaging, such as FAP imaging, and many more. In this article, we review recent advances in the development of non-[18F]FDG PET radiopharmaceuticals and their current clinical applications in oncology, as well as some future aspects.

Pathobiological Features and Therapeutic Opportunities Linked to TNF Family Member Expression in Classic Hodgkin Lymphoma

The tumor necrosis factor (TNF) family, which includes 19 ligands and 29 receptors, influences cellular proliferation, differentiation, and apoptosis. The TNF family plays a crucial role in the pathogenesis of Hodgkin lymphoma (HL), particularly through its influence on the tumor microenvironment (TME). Hodgkin Reed-Sternberg (HRS) cells, the hallmark of classic HL (cHL), exhibit overexpression of TNF receptor family members such as CD30 and CD40. Given the critical roles of CD30 and CD40 in the survival and proliferation of HRS cells within the TME, targeting these TNF receptors represents a promising therapeutic strategy; therapies that target CD30 have already shown efficacy in clinical settings. The programmed death-1 (PD-1)/programmed death-ligand 1 (PD-L1) axis plays a crucial role in immune evasion by HRS cells, which express PD-L1 that interacts with PD-1 on T cells, leading to T cell exhaustion and a diminished immune response against the tumor. By blocking this interaction, checkpoint inhibitors such as nivolumab and pembrolizumab have demonstrated high response rates in patients with cHL, particularly in those who have not responded to conventional therapies. The integration of immune checkpoint inhibitors (ICIs) with standard chemotherapy regimens has improved outcomes for patients with advanced-stage cHL. By understanding how TNF signaling interacts with immune checkpoints, researchers can design more effective treatment regimens that simultaneously target multiple pathways. Combining TNF inhibitors with checkpoint blockade therapies may enhance the overall anti-tumor response by addressing both direct tumor signaling and the immune evasion mechanisms employed by tumor cells.

Toxicological profiling of methanolic seed extract of Abutilon indicum (L.) Sweet: in-vitro and in-vivo analysis

ETHNOPHARMACOLOGICAL RELEVANCE

Abutilon indicum, a shrub of the Malvaceae family, is found abundantly in tropical countries like India. A. indicum is widely used for its high medicinal properties. Traditionally, A. indicum seed powder is consumed to treat piles, constipation, chronic cystitis, gonorrhea, gleet, and pregnancy-related problems. Despite having numerous medicinal properties and widespread traditional use of A. indicum seeds, scientific validation, and toxicity studies have yet to be documented.

AIMS OF THE STUDY

The primary objective of this study is to conduct a comprehensive study on phytochemical profiling, in-vitro cytotoxicity, mutagenicity, and in-vivo acute and sub-acute toxicity, and genotoxicity on animal models of methanolic extract of A. indicum seed (MAS).

MATERIALS AND METHODS

The qualitative analysis of MAS was explored through FTIR and HR LC-MS. For in-vitro cytotoxicity, the HEK-293 cell line was used, and the TA100 (Staphylococcus typhimurium) bacterial strain was used for the Ames mutagenicity test. A single oral dose of 250, 500, 1000, or 2000 mg/kg body weight of MAS was given to each male and female rat for acute toxicity study and observed for 14 days for any toxicity signs. In the sub-acute toxicity study, 250, 500, or 1000 mg/kg body weight of MAS was administered orally to each rat for 28 days. The experimental animals were weighed weekly, and general behavior was monitored regularly. After 28 days of the experiment, the rats were sacrificed, and different serum biochemical, hematological, and histological analyses were performed. The blood samples of different doses of MAS were used for genotoxicity study through comet assay.

RESULTS

FTIR analysis found different functional groups, which indicated the presence of phenolics, flavonoids, and alkaloids. HR LC-MS analysis depicts several components with different biological functions. The cell cytotoxicity and Ames mutagenicity results showed minimal toxicity and mutagenicity up to a certain dose. The acute toxicity study conducted in Wistar albino rats demonstrated zero mortality among the animals, and the LD50 value for seed extract was determined to be 2000 mg/kg body weight. Sub-acute toxicity assessments indicated that the administration of seed extract resulted in no adverse effects at dosages of 250 and 500 mg/kg body weight. However, at higher doses, specifically 1000 mg/kg body weight, the liver of the experimental rats exhibited some toxic effects. In the genotoxicity study, minimal DNA damage was found in 250 and 500 mg/kg doses, respectively, but slightly greater DNA damage was found in 1000 mg/kg doses in both male and female rats.

CONCLUSIONS

The consumption of A. indicum seed powder is deemed safe; however, doses exceeding 500 mg/kg body weight may raise concerns regarding use. These findings pave the path for the creation of innovative medicines with improved efficacy and safety profiles.

Real-world characteristics and outcomes of patients with high-risk and non-high-risk smoldering multiple myeloma using the Flatiron Health database

This study aimed to provide real-world evidence on progression risk in patients with high-risk smoldering multiple myeloma (SMM). This retrospective, observational study leveraged data from the Flatiron Health database. Eligible patients had SMM and relevant measures to apply Mayo 2018, International Myeloma Working Group (IMWG) 2020, and AQUILA trial risk criteria. Time to progression to active MM (TTP), progression or death (PFS), and death or progression on first-line MM therapy (PFS2) were evaluated using Kaplan-Meier methods and multivariate Cox regression models adjusted for age, Charlson Comorbidity Index, and time from SMM diagnosis to risk classification date. Across the three risk models (Mayo 2018, IMWG 2020, and AQUILA trial), high-risk patients with SMM had 3.0-4.0 times the risk of TTP, 2.1-3.5 times the risk of PFS, and 1.7-3.2 times the risk of PFS2 versus non-high-risk patients (p < 0.001 for all comparisons). Similar results were observed when patients with early treatment, early progression, and/or bone disease were excluded. This study demonstrates that high-risk patients with SMM have worse prognoses than non-high-risk patients, regardless of the criteria used, and highlights a need for early intervention testing.

Introducing a hemoglobin G-Makassar variant in HSCs by in vivo base editing treats sickle cell disease in mice

Precise repair of the pathogenic mutation in hematopoietic stem cells (HSCs) represents an ideal cure for patients with sickle cell disease (SCD). Here, we demonstrate correction of the SCD phenotype by converting the sickle mutation codon (GTG) into a benign G-Makassar variant (GCG) using in vivo base editing in HSCs. We show successful production of helper-dependent adenoviral vectors expressing an all-in-one base editor mapping to the sickle mutation site. In HSC-enriched cells from SCD patients, transduction with the base editing vector in vitro resulted in 35% GTG > GCG conversion and phenotypic improvements in the derived red blood cells. After ex vivo transduction of HSCs from an SCD mouse model and subsequent transplantation, we achieved an average of 88% editing at the target site in transplanted mice. Importantly, in vivo HSC base editing followed by selection generated 24.5% Makassar variant in long-term repopulating HSCs of SCD mice. The treated animals demonstrated correction of disease hallmarks without any noticeable side effects. Off-target analyses at top-scored genomic sites revealed no off-target editing. This in vivo approach requires a single non-integrating vector, only intravenous/subcutaneous injections, and minimal in vivo selection. This technically simple approach holds potential for scalable applications in resource-limiting regions where SCD is prevalent.

Fusion Genes in Myeloid Malignancies

Fusion genes arise from gross chromosomal rearrangements and have been closely linked to oncogenesis. In myeloid malignancies, fusion genes play an integral role in the establishment of diagnosis and prognostication. In the clinical management of patients with acute myeloid leukemia, fusion genes are deeply incorporated in risk stratification criteria to guide the choice of therapy. As a result of their intrinsic ability to define specific disease entities, oncogenic fusion genes also have immense potential to be developed as therapeutic targets and disease biomarkers. In the current era of genomic medicine, breakthroughs in innovation of sequencing techniques have led to a rise in the detection of novel fusion genes, and the concept of standard-of-care diagnostics continues to evolve in this field. In this review, we outline the molecular basis, mechanisms of action and clinical impact of fusion genes. We also discuss the pros and cons of available methodologies that can be used to detect fusion genes. To contextualize the challenges encountered in clinical practice pertaining to the diagnostic workup and management of myeloid malignancies with fusion genes, we share our experience and insights in the form of three clinical case studies.

Description and Modeling of Relevant Demographic and Laboratory Variables in a Large Oncology Cohort to Generate Virtual Populations

Background/Objectives: Pathophysiological variability in patients with cancer is associated with differences in responses to pharmacotherapy. In this work, we aimed to describe the demographic characteristics and hematological, biochemical, and coagulation variables in a large oncology cohort and to develop, optimize, and provide open access to modeling equations for the estimation of variables potentially relevant in pharmacokinetic modeling. Methods: Using data from 1793 patients with cancer, divided into training (n = 1259) and validation (n = 534) datasets, a modeling network was developed and used to simulate virtual oncology populations. All analyses were conducted in RStudio 4.3.2 Build 494. Results: The simulation network based on sex, age, biogeographic origin/ethnicity, and tumor type (fixed or primary factors) was successfully validated, able to predict age, height, weight, alpha-1-acid glycoprotein, albumin, hemoglobin, C-reactive protein and lactate dehydrogenase serum levels, platelet-lymphocyte and neutrophil-lymphocyte ratios, and hematocrit. This network was then successfully extrapolated to simulate the laboratory variables of eight oncology populations (n = 1200); only East Asians, Sub-Saharan Africans, Europeans, only males, females, patients with an ECOG performance status equal to 2, and only patients with pancreas cancer or ovarian cancer. Conclusions: this network constitutes a valuable tool to predict relevant characteristics/variables of patients with cancer, which may be useful in the evaluation and prediction of pharmacokinetics in virtual oncology populations, as well as for model-based optimization of oncology treatments.

Reduced Platelet Activation in Triple-Negative Essential Thrombocythemia Compared with JAK2V617F-Mutated Essential Thrombocythemia

PURPOSE

Triple-negative (TN) essential thrombocytopenia (ET) is characterized by the absence of driver mutations while retaining histologic and phenotypic characteristics sufficient for an ET diagnosis. Our understanding of TN-ET and its platelet activation remains incomplete. We carried out a large-scale multicenter clinical analysis to analyze the clinical and molecular characteristics and thrombotic complications of TN-ET. We also related the above characteristics to platelet activation to further explore the thrombosis mechanism of TN-ET.

EXPERIMENTAL DESIGN

A retrospective multicenter study was conducted on 138 patients with TN-ET and 759 patients with ET with driver mutations from March 1, 2012 to December 1, 2021. The clinical and molecular characteristics of the patients with TN-ET were summarized. Additionally, platelet activation, apoptosis, and reactive oxygen species (ROS) levels were analyzed in 73 patients with TN-ET from this cohort and compared with 41 age- and sex-matched healthy donors.

RESULTS

Compared with patients with the JAK2V617F mutation, those with TN mutation were younger (P < 0.001) and exhibited fewer thrombotic events before diagnosis (P < 0.001) and during follow-up (P = 0.039). Patients with TN mutation also presented with significantly reduced CD62P expression in platelets (P = 0.031), slightly reduced calcium concentration in platelets (P = 0.063), increased mitochondrial membrane potential (P = 0.011), reduced phosphatidylserine exposure (P = 0.015), reduced levels of ROS (P = 0.043) and MitoSOX in platelets (P = 0.047).

CONCLUSIONS

In comparison with JAK2V617F-mutated ET, TN-ET is associated with lower platelet ROS levels, which leads to reduced platelet activation and consequently a lower risk of thrombosis.

Relationship between mutations in severe hemophilia A and risk of inhibitor development: A large single-center study

BACKGROUND

One of the major problems for patients with severe hemophilia A (HA) is the development of neutralizing antibodies against factor VIII. This study aimed to analyze the molecular and clinical profiles of patients with severe HA and to determine if certain genetic variants predispose to inhibitor development in these patients.

METHODS

A single-center study was conducted among patients with severe HA between March 20, 2000, and June 31, 2023. Demographic data and laboratory results of patients were collected. The inverse-shifting PCR (IS-PCR) technique was initially used to screen patients for intron 22 and 1 inversions (Inv-22 and Inv-1).

RESULTS

A total of 480 patients with severe HA (408 without inhibitors and 72 with inhibitors) were enrolled in this study. The median age of the patients at the time of diagnosis was 6 months (IQR: 3 months to 18 months). Inv-22 was observed in 199 (41.5 %) of the cases. Among those patients who developed inhibitors, 53 (73.6 %) were classified as high-titer and 19 (26.4 %) as low-titer. Inv-22, positive family history of inhibitor formation, and history of intense injections revealed a statistically significant association with the risk of inhibitor development.

CONCLUSION

The results of this study confirm the important role of different genetic variants, family history of inhibitor formation, and history of intense injections for the formation of inhibitors in patients with severe HA. This would allow us to stratify the patients which can have important clinical implications, especially in terms of their management and outcome.

The Dual PIM/FLT3 Inhibitor MEN1703 Combines Synergistically With Gilteritinib in FLT3-ITD-Mutant Acute Myeloid Leukaemia

MEN1703 is a first-in-class, oral, Type I dual PIM/FMS-like tyrosine kinase 3 inhibitor (FLT3i) investigated in a Phase I/II DIAMOND-01 trial in patients with acute myeloid leukaemia (AML). Gilteritinib is a highly potent and selective oral FLT3i approved for the treatment of relapsed/refractory AML with FLT3 mutations. Although gilteritinib showed strong single-agent activity in FLT3-mutated AML, the development of gilteritinib resistance limits response durability, indicating the importance of novel combination strategies to improve disease outcome. PIM kinases govern FLT3-ITD signalling and increased PIM kinase expression is found in samples from AML patients relapsing on FLT3i. Here, we report that the simultaneous inhibition of PIM and FLT3, through the combination of MEN1703 and gilteritinib, can consistently improve the in vitro/in vivo antitumor activity over the single agents, demonstrating the benefit of this combination. Moreover, we demonstrate that resistance to gilteritinib can be circumvented by combining MEN1703 with gilteritinib. MEN1703 interferes with FLT3 upregulation, Mcl-1 overexpression and PIM kinase signalling, which are all involved in FLT3i resistance. We also show that MEN1703 downregulates stromal cytokines that promote cytokine-mediated resistance of AML blast cells to FLT3 inhibition. These results demonstrate the importance of the combination approach to overcome microenvironment-mediated resistance to FLT3 inhibitors.

Advancements in leukemia management: Bridging diagnosis, prognosis and nanotechnology (Review)

Leukemia is a cancer that starts in blood stem cells in the bone marrow. Today, the proper diagnosis and prognosis of leukemia are essential in mitigating the morbidity and mortality associated with this malignancy. The advent of novel biomarkers, particularly those related to minimal residual disease, has paved the way for personalized therapeutic strategies and enables the quantitative assessment of patient responses to treatment regimens. Novel diagnostic and targeted drug delivery may be helpful for the improved management of leukemia. Genetic clinical parameters, such as chromosomal abnormalities, are crucial in diagnosing and guiding treatment decisions. These genetic markers also provide valuable prognostic information, helping to predict patient outcomes and tailor personalized treatment plans. In the present review, the studies on the diagnostic and prognostic parameters of leukemia were analyzed. The prognosis of leukemia was investigated in most of the studies, and the remaining were performed on diagnosis. The clinical and laboratory prognostic parameters were the most common, followed by diagnostic hematological parameters, diagnostic blood parameter studies, and diagnostic immunological parameters. Clinical and laboratory prognostic and hematologic parameters were the most extensively studied. The methods used to diagnose and prognose the leukemia cases in these studies were predominantly clinical hematology. Numerous surface proteins and receptors, including CD45, CD27, CD29, CD38, CD27, CD123, CD56 and CD25, react similarly in various kinds of leukemia, which are ideal for targeted drug delivery. Drug delivery to leukemia cells encounters several significant obstacles, including heterogeneity, that hinder the effectiveness of treatment. Nanocarriers play a critical role in targeted drug delivery for leukemia by enhancing the precision of treatments directed at surface proteins and receptors. Additionally, they can be functionalized with targeting drugs and antibodies to target specific tissues and cells.

Comparison of plasma cell bone marrow counts by different methods in patients diagnosed with plasma cell disorders

INTRODUCTION

Plasma cell quantification in bone marrow is important for diagnosis, prognosis, and treatment of plasma cell diseases. It can be performed by several methods such as aspiration, imprint and flow cytometry, and biopsy.

OBJECTIVES

To compare plasma cell counts at diagnosis of plasma cell diseases using different methods.

METHODS

An observational study was carried out of laboratory results of adult patients with plasma cell diseases, who underwent aspiration, imprint cytology, flow cytometry (CD38, C138) and biopsy in a single institution between January 2015 and May 2021. The intraclass correlation coefficient was used to assess agreement between different methods with results stratified into three groups: <10%; 10-59% and ≥60% of infiltration.

RESULTS

Sixty-seven cases were studied: 59.7% were men with a median age of 70 (range: 32-85) years. The diagnoses were multiple myeloma in 61%, gammopathy of undetermined significance in 25.4%, smoldering myeloma in 6% and other plasma cell dyscrasias in 7.6%. Less than 10% infiltration was found in 32 (47.7%), 35 (52.2%), 44 (65.7%) and 25 (37.3%) of patients, respectively by aspiration, imprint cytology, flow cytometry and biopsy. Infiltration ≥60% was detected in 7 (10.4%), 4 (6.0%), 2 (3.0%) and 21 (31.3%) cases, respectively. There was disagreement between the results in 37 (55.2%) of patients. Of these, 28 had greater infiltration in biopsies. The concordance (Kappa index) of biopsy with aspiration, imprint and flow cytometry was 0.501, 0.408 and 0.17; of aspiration with imprint and flow cytometry, it was 0.738 and 0.541 and between imprint and flow cytometry, it was 0.573%.

CONCLUSIONS

Only aspiration and imprint cytology results agreed. Biopsy showed greater infiltrations than the other methods, but aspiration, and imprint and flow cytometry provided additional data in the diagnosis and thus should also be performed.

S. ABO Blood Group and Auditory Function in Young Adults

Introduction

In recent years, research on the effect of blood group on hearing function has gained more attention. Some blood groups show susceptibility to certain general health and auditory disorders like noise induced hearing loss, infections, coronary artery disease, gastric carcinoma and duodenal ulcer.

Aims

The present study aimed to determine the differences in middle ear and cochlear function among persons with different blood groups (AB, A, B, O).

Materials and methods

Sixty adults (18-24 years) with normal hearing sensitivity were included in the study. They were divided into four groups based on blood groups (A, B, AB, O) with 15 participants each. High-frequency thresholds, distortion product otoacoustic emissions (DPOAE) and resonance frequency were measured. High-frequency thresholds for both ears were measured at octave frequencies from 9 kHz to 16 kHz. Resonant frequency was determined using sweep frequency method.

Results

The findings demonstrated that individuals with blood group AB and O had considerably lower DPOAE amplitudes. Resonance frequency and extended high frequency thresholds did not, however, differ significantly between the blood groups.

Conclusion

The decrease in the amplitude of otoacoustic emissions (OAE) can be explained by a reduction in the quantity of robust outer hair cells and elevated protein levels, which in turn lead to a reduction in the cochlear blood flow in persons with blood type O and AB, respectively. More research with greater numbers of participants is necessary to improve the generalization of the findings.

A retrospective study of the aetiology of increased mean platelet volume in dogs presented to a small animal teaching hospital in Greece

Background

The aetiology of increased mean platelet volume in dogs is currently uncertain. Our aim was to investigate the aetiology of increased mean platelet volume in dogs with and without thrombocytopenia.

Methods

The database of a teaching hospital was retrospectively searched for dogs with increased mean platelet volume (>14.4 fL) over a 3-year period. Complete blood counts were performed with an Advia 120 analyser. Cases with incomplete medical records or belonging to breeds known to be associated with macrothrombocytopenia were excluded.

Results

Sixty-six dogs were included, with Group 1 consisting of non-thrombocytopenic dogs (49/66, 74.2%) and Group 2 consisting of thrombocytopenic dogs (17/66, 25.8%). Diagnoses significantly differed between the two groups (p = 0.003). In Group 1, inflammatory/infectious diseases (69.4%) were the most common cause, followed by neoplastic diseases (8.2%) and diabetes mellitus (6.1%). Dogs in Group 2 were diagnosed with either inflammatory/infectious diseases (50.0%) or neoplastic diseases (50.0%). The small sample size- and a potential delayed haematological analysis of some of the blood samples, could have artifactually affected the mean platelet volume.

Conclusions

In dogs with thrombocytopenia and increased mean platelet volume, inflammatory/infectious or neoplastic diseases should be considered. In non-thrombocytopenic dogs, increased mean platelet volume is primarily associated with inflammatory/infectious diseases, with neoplasia and diabetes mellitus being infrequent causes.

Clinical validation and application of targeted long-range polymerase chain reaction and long-read sequencing-based analysis for hemophilia: experience from a hemophilia treatment center in China

BACKGROUND

Targeted long-read sequencing (LRS) is expected to comprehensively analyze diverse complex variants in hemophilia A (HA) and hemophilia B (HB) caused by the F8 and F9 genes, respectively. However, its clinical applicability still requires extensive validation.

OBJECTIVES

To evaluate the clinical applicability of targeted LRS-based analysis compared with routine polymerase chain reaction (PCR)-based methods.

METHODS

Gene variants of retrieved subjects were retrospectively and prospectively analyzed. Whole-genome sequencing was performed to further analyze undiagnosed cases. Breakpoints of novel genomic rearrangements were mapped and validated using long-distance PCR and long-range PCR combined with sequencing.

RESULTS

In total, 122 subjects were retrieved. In retrospective analysis of the 90 HA cases, HA-LRS assay showed consistent results in 84 cases compared with routine methods and characterized 6 large deletions with their exact breakpoints confirmed by further validation in 6 cases (routine methods only presented failure in amplifying the involved exons). In prospective analysis of the 21 HA subjects, 20 variants of F8 were identified in 20 cases. For the remaining HA patient, no duplication/deletion or single-nucleotide variant (SNV)/insertion and deletion (InDel) was found, but a potential recombination involving exons 14 and 21 of F8 was observed by LRS. Whole-genome sequencing analysis and further verification defined a 30 478 base pairs (bp) tandem repeat involving exons 14 to 21 of F8. Among the 11 HB patients, HB-LRS analysis detected 11 SNVs/InDels in F9, consistent with routine methods.

CONCLUSION

Targeted LRS-based analysis was efficient and comprehensive in identifying SNVs/InDels and genomic rearrangements of hemophilia genes, especially when we first expanded the panel to include F9. However, further investigation for complex gross rearrangement is still essential.

Gastrointestinal Bleeding/Angiodysplasia in Patients With Glanzmann Thrombasthenia

Glanzmann thrombasthenia (GT) is a common type of bleeding disorder, with a prevalence of 1/10,000 in Al Madinah, Saudi Arabia. GT causes bleeding owing to the lack of platelet aggregation associated with glycoprotein IIb/IIIa deficiency, which is characterized by mucocutaneous bleeding symptoms, such as epistaxis, gingival bleeding, and menorrhagia. Gastrointestinal angiodysplasia (GIAD) is a rare presentation of GT, where eight cases have been reported. GIAD is a vascular malformation of the digestive system caused by abnormal angiogenesis. Treatment of GIAD include surgical resection, electrocoagulation, embolization, and medical therapy with octreotide, thalidomide, and bevacizumab. GIAD has a high tendency to recur. We report the cases of eight patients of different ages who were diagnosed with GT and presented with gastrointestinal bleeding.

Point of care CD19 chimeric antigen receptor (CAR) T-cells for relapsed/refractory acute myeloid leukemia (AML) with aberrant CD19 antigen expression

Relapsed/refractory (r/r) acute myeloid leukemia (AML) is associated with poor prognosis. CD19 is a B-cell marker, is aberrantly expressed in AML, mostly with t(8; 21)(q22; q22.1). Here we report the results of a phase 2 study giving point of care produced CD19 CAR T- cells for r/r AML with aberrant expression of CD19 (NCT04257175). Lymphodepletion included fludarabine and cyclophosphamide The response was evaluated by bone marrow (BM) aspiration on day 28. Six patients (5 adults and 1 child) were included. Median number of previous chemotherapy lines was 4 (range, 3-8) and four patients received CAR T-cells 8-18 months post allogeneic hematopoietic stem cell transplantation (allo-HSCT). Cytokine release syndrome (CRS) of any grade occurred in all patients, and 1 patient had grade 3 CRS. Immune effector cell-associated neurotoxicity syndrome (ICANS) occurred in 2 patients at low grades. Tocilizumab was administered to 2 patients and corticosteroids to 3 patients. Four patients achieved a complete remission (CR), while 2/6 progressed (PD). Three patients (2 with CR and 1 with PD) underwent allo-HSCT (it was the second transplant in 2) 2-5 months post CAR T-cells infusion. The median duration of response in patients achieving CR was 8.5 (range; 3-14) months. However, all patients eventually died within 5 (1-18) months. In conclusion, CD19 CAR T- cell treatment for AML is feasible and safe. However, the response is short and should be followed by allo-HSCT. Hopefully, future long term results will be improved by combining the CAR T- cell therapy with the emerging novel effective anti-leukemic compounds.

Microangiopathic Hemolytic Anemia as the Initial Presentation of Metastatic Signet-Ring Cell Carcinoma of the Colon: A Case Report

Microangiopathic hemolytic anemia (MAHA) is a condition characterized by intravascular fragmentation of red blood cells, leading to the characteristic finding of schistocytes on a peripheral blood smear. The differential diagnoses of MAHA include thrombotic thrombocytopenic purpura (TTP), hemolytic-uremic syndrome (HUS), disseminated intravascular coagulation (DIC), idiopathic thrombocytopenic purpura (ITP), infections, malignancies, and solid organ transplantation. The commonly associated malignancies with MAHA are gastric, breast, prostate, lung, and lymphoma. Signet-ring cell carcinoma (SRCC) of the colon is a rare form of cancer and is associated with a very poor prognosis. SRCC often presents at an advanced stage, with symptoms such as altered bowel habits, abdominal pain, distension, and potential bowel obstruction or perforation. We report a case of a 51-year-old female who presented with hemolytic anemia, thrombocytopenia, and schistocytes on her peripheral blood smear. In the setting of a high PLASMIC score, she was initially treated for TTP without improvement, warranting further evaluation, and was ultimately diagnosed with SRCC of the colon.

A scoping review study of patients with a primary immune deficiency who have presented to the paediatric emergency department with a fever

AIM

To identify, analyse, and synthesise existing research on the characteristics and risk factors associated with primary immune deficiencies (PIDs), with focus on understanding how factors impede patient outcomes.

BACKGROUND

There is currently limited research regarding the management of this cohort when they present to an emergency department with the presentation urgency often being overlooked.

METHOD

Three databases, google scholar, and citations were searched for relevant studies under the criteria. Included papers were analysed and reported following the PRISMA guideline, and then critically appraised using the Mixed Method Appraisal Tool.

RESULTS

After a review of 625 titles and abstracts, 20 studies met the inclusion criteria. The majority being mixed method (n = 8) and case studies (n = 8). All chosen studies reported some form of management of a child with a PID, and most made recommendations for improvement.

CONCLUSIONS

Further research is needed to facilitate an understanding of how to enhance emergency management, to increase positive outcomes.

RELEVANCE TO PRACTICE

There is a critical need for improved management strategies for children with a PID presenting to ED with fever. Creating protocols, increasing staff knowledge, and implementing patient specific interventions are essential in improving outcomes and reducing serious complications in this high-risk paediatric population.

Hemophagocytic Lymphohistiocytosis in a Critically Ill Patient: A Case Report of a Potentially Fatal Entity

Background

Hemophagocytic lymphohistiocytosis (HLH) is a non-neoplastic proliferation and macrophage activation that induces cytokine-mediated bone marrow suppression and features of intense phagocytosis in the bone marrow and liver, leading to multi-organ dysfunction and ultimate failure. The diagnosis of HLH in an intensive care setting is challenging, and it is associated with high morbidity and mortality. HLH-94 is the standard protocol for treatment, consisting of dexamethasone and chemotherapy like etoposide.

Case Presentation

We present the case of a 73-year-old woman who had a prolonged hospitalization for vomiting, diarrhea, and dehydration. Her conditions were complicated by acute refractory pancytopenia on the 12th day of admission, leading to multi-organ failure, including anuric renal failure requiring renal replacement therapy and respiratory failure requiring intubation. After a thorough workup, she was diagnosed with HLH using HLH-2004 diagnostic criteria and confirmed by a bone marrow biopsy. She was started on supportive therapy and high-dose intravenous dexamethasone with an appropriate clinical response. Her pancytopenia improved, and she no longer required ventilator support for respiratory failure or dialysis for renal failure. Unfortunately, her hospital course was complicated by a sentinel event leading to her death.

Conclusion

This case emphasizes that early recognition and treatment initiation of HLH are crucial to prevent adverse outcomes and mortality. Treatment should be tailored based on the underlying HLH trigger, as chemotherapy-based treatment regimens may result in overtreatment and unnecessary toxicities. Further studies are needed to increase clinicians' awareness and management of secondary cases of HLH.

Effects of bone metabolism on hematopoiesis: A Mendelian randomization study

Objectives

Osteoblast is known to regulate hematopoiesis according to preclinical studies but the causal relationship in human remains uncertain. We aimed to evaluate causal relationships of bone mineral density (BMD) with blood cell traits using genetic data.

Methods

Summary statistics from the largest available genome-wide association study were retrieved for total body BMD (TBBMD), lumbar spine BMD (LSBMD), femoral neck BMD (FNBMD) and 29 blood cell traits including red blood cell, white blood cell and platelet-related traits. Using two-sample Mendelian randomization (MR) approach, inverse-variance weighted method was adopted as main univariable MR analysis. Multivariable MR (MVMR) analysis was conducted to evaluate whether the casual effect is independent of confounders.

Results

BMD was positively associated with reticulocyte-related traits, including high light scatter reticulocyte count and percentage, immature reticulocyte fraction, reticulocyte count and percentage, with causal effect estimate (beta) ranging from 0.023 to 0.064. Conversely, inverse association of BMD with hematocrit, hemoglobin, and red blood cell count was observed, with beta ranging from -0.038 to -0.019. The association remained significant in MVMR analysis after adjustment for confounders. For white blood cells, BMD was inversely associated with neutrophil count (beta: 0.029 to -0.019) and white blood cell count (beta: 0.024 to -0.02). Results across TBBMD, LSBMD, and FNBMD were consistent.

Conclusions

This study suggested bone metabolism had a causal effect on hematopoietic system in humans. Its causal effect on red blood cell traits was independent of confounders. Further studies on how improving bone health can reduce risk of hematological disorders are warranted.