New Perspectives on Polycythemia Vera: From Diagnosis to Therapy

Impact of Hydroxyurea to Treat Haematological Disorders on Male Fertility: Two Case Reports and a Systematic Review

PURPOSE

Hydroxyurea (HU) is a cytoreductive agent used as standard treatment option for sickle cell anaemia/disease (SCD), essential thrombocythemia (ET), and polycythaemia vera (PV). Despite its overall good safety profile, its use also in relatively young patients raises an interest on its potential impact on spermatogenesis. To perform a systematic review of all published articles investigating fertility in male patients affected by SCD, ET, and PV and treated with HU. Two paradigmatic case reports of patients affected by PV and ET, respectively, have been also reported.

MATERIALS AND METHODS

PubMed, EMBASE, and Cochrane databases were queried for all the published studies indexed up to November 15th, 2022. A combination of the following keywords was used: "hydroxyurea," "fertility," "male," "sperm," "sickle cell anaemia," "sickle cell disease," "essential thrombocythemia," "polycythaemia vera."

RESULTS

Of 48 articles identified, 8 studies, involving 161 patients, were eligible for inclusion. Overall, the number of spermatogonia per round cross section of seminiferous tubule were decreased in patients with SCD compared to healthy males. HU treatment was always associated with a worsening of semen parameters, even up to azoospermia. Notably, treatment discontinuation was associated with an improvement of semen parameters and a trend toward normalization in the case of PV and ET, with a less clear amelioration in men with SCD. In both our patients with either PV or ET, HU discontinuation was associated with a significant improvement of spermatogenesis with successful spontaneous pregnancies.

CONCLUSIONS

Published evidence do not consistently report normalization of spermatogenesis after HU discontinuation in SCD cases. Conversely, the literature almost consistently reported an improvement of semen parameters at the discontinuation of HU therapy in PV and ET cases. Our real-life two cases confirmed those findings. The willing of fatherhood and the need for effective fertility treatment warrant further research to improve work-up management in men with hematological disorders.

Clinical and Economic Implications of Hydroxyurea Intolerance in Polycythemia Vera in Routine Clinical Practice

Background/Objectives: Polycythemia vera (PV) is a chronic hematologic neoplasm commonly treated with hydroxyurea (HU). We utilized the advanced digitalized database of Maccabi Healthcare Services to retrospectively investigate the clinical and economic implications of HU intolerance in the routine clinical care of PV patients in Israel. Methods: We collected data on demographics, physician visits, hospitalizations, laboratory results, medication purchases, cardiovascular and thrombotic events, mental health, economic outcomes, and mortality. Outcomes included cardiovascular and other thrombotic events, disease progression, mental health events, economic outcomes, and overall mortality. Results: Of the 830 patients studied, 3 (0.4%) were resistant to HU treatment, 318 (38.3%) were intolerant to HU treatment, and 509 (61.3%) were stable on HU treatment. The venous thrombosis rate was significantly higher among HU-intolerant compared to HU-stable patients (1.58 vs. 0.47 per 100 person-years [PY], respectively; p < 0.001). The rate of progression to myelofibrosis was 6 vs. 0.9 per 100 PY in HU-intolerant patients vs. HU-stable patients, respectively (p < 0.001), and the rate of progression to acute myeloid leukemia (AML) was 1.16 vs. 0.2 per 100 PY in HU-intolerant patients vs. HU-stable patients, respectively (p < 0.001). The phlebotomy requirement, mortality rate, and total hospitalization days among HU-intolerant patients were significantly higher than in HU-stable patients (p = 0.049, p < 0.001, p < 0.001, respectively). More mental health-related events were noted in HU-intolerant patients vs. HU-stable patients (p = 0.007), and the total healthcare cost ratio was 2.65 for the HU-intolerant patients compared with HU-stable patients. Conclusions: This study suggests that HU-intolerant patients are more likely to have worse outcomes than HU-stable patients, highlighting the need for the close monitoring of these patients for disease-related complications or progression.

Assessing haematological parameters and probable toxicity analysis in two coastal fish species at harbouring areas of Digha coastal belt, West Bengal, India

Coastal ecosystems are vital for maintaining the biodiversity and human livelihoods, but they are increasingly subjected to anthropogenic pressures, including pollution from various sources. Present work intends to assess the possible threats in coastal ecosystem as well as coastal fish species, in particular, through haematological parameters caused due to exposure of environmental contaminants like polycyclic aromatic hydrocarbons (PAHs), potentially toxic metals (PTMs), etc. This study analysed the haematological parameters and probable toxicity levels in two important coastal fish species, viz., Mystus sp. and Mugil sp. widely available in Digha coastal belt. Different haematological parameters, such as WBCs (White Blood Cells), Lym (Lymphocytes), Gran (Granulocytes), Mid (Monocytes), RBCs (Red Blood Cells), HCT (Haematocrit) value, MCV (Mean Corpuscular Volume), MCH (Mean Corpuscular Haemoglobin), MCHC (Mean Corpuscular Haemoglobin Concentration), RDW- CV (Red Cells Distribution Width-Co-efficient of Variation), RDW- SD (Red Cells Distribution Width-Standard Deviation), PLT (Total Platelet Count), MPV (Mean Platelet Volume), PDW- SD (Platelet Distribution Width-Standard Deviation), PDW- CV (Platelet Distribution Width-Co-efficient of Variation), PCT (Plateletcrit), PLCR (Platelet Large Cell Ratio), PLCC (Platelet Large Cell Count) and many others were measured directly through Erba H360 Haematology Analyser, simultaneously air dried blood smear was stained by Haematoxylin-Eosin(H-E) and Giemsa stain for assessing morphometric alterations of RBCs, WBCs, platelets as well as to determine the differential counts of WBCs by observing through Leica DM2000 microscope. Evidence of several abnormalities in the erythrocyte's nucleus (ENAs) and the abundance of abnormal celled erythrocytes (ECAs), carcinoma (lymphoproliferative disorder, polycythaemia vera, Hodgkin lymphoma and non-Hodgkin lymphoma), elevation of WBCs content, Lym %(Lymphocyte percentage), Eo(Eosinophils), monocytes, HCT and gross depletion of Ne(Neutrophils), basophils, and PLCR levels indicated a sign of major impact of contamination to two intoxicated fishes which may also affect the human being through food chain and may result into leukaemia in mammalian species, finally. However, comprehensive evaluation of the long-term impacts of the contaminants like PAHs and/or PTMs, etc., on fish populations, human health risk and coastal ecosystem is required to be addressed.

Erythrocytosis: Diagnosis and investigation

An absolute erythrocytosis is present when the red cell mass is greater than 125% of the predicted. This is suspected when the hemoglobin or hematocrit is above the normal range. An erythrocytosis can be classified as primary or secondary and congenital or acquired. The commonest primary acquired disorder is polycythemia vera. The diagnostic criteria for PV have evolved over time and this is the main diagnosis managed in hematology clinics. There are a variety of rare congenital causes both primary and secondary. In particular in young patients and/or those with a family history a congenital cause is suspected. There remains a larger cohort with acquired erythrocytosis mainly with non-hematological pathology. In order to explore for a cause of erythrocytosis, measurement of the erythropoietin level is a first step. A low erythropoietin level indicates a primary cause and a normal or elevated level indicates a secondary etiology. Further investigation is then dictated by initial findings and includes mutational testing with PCR and NGS for those in whom a congenital cause is suspected. Following this possibly bone marrow biopsy, scans, and further investigation as indicated by history and initial findings. Investigation is directed toward the identification of those with a hematological disorder which would be best managed following guidelines in hematology clinics and referral elsewhere in those for whom there are non-hematological reasons for the elevated hemoglobin.

A case report and literature review of IgA nephropathy presenting as nephrotic syndrome in polycythemia vera

A 66-year-old non-smoker presented with a 2-week history of new-onset pedal oedema and gross haematuria. On evaluation, he was found to be hypertensive and oedematous with a haemoglobin of 19.1 g/dl, platelet count of 546,000/mm3, and creatinine of 2.6 mg/dl. Urine examination revealed abundant RBCs with 3+ albumin on three separate occasions. His 24-h urine protein level was 3830 mg/day, with a serum cholesterol level of 303 mg/dl. Secondary erythrocytosis and thrombocytosis tests were negative. Bone marrow examination revealed hypercellularity, erythroid hyperplasia, tight clusters of large megakaryocytes, and megakaryocytic hyperplasia suggestive of polycythemia vera. PCR analysis revealed a JAK2V617 F (exon 14) mutation. In view of nephrotic syndrome, azotemia, and microscopic haematuria, a renal biopsy was performed, which revealed features of IgA nephropathy with advanced interstitial fibrosis and tubular atrophy. He was started on angiotensin receptor blockers with hydroxy urea as a part of treatment. This case report highlights the association of glomerular disease with polycythaemia vera and the need of prompt renal biopsy for diagnosis and management.

Updated threshold, renewed problems: should the diagnostic criteria of polycythemia vera be reconsidered? A retrospective cross-sectional cohort study

OBJECTIVE

This aim of this study was to evaluate hemoglobin and hematocrit values of polycythemia vera and secondary polycythemia patients with updated World Health Organization thresholds. In addition, by determining our own threshold values, we aimed to demonstrate the necessity of bone marrow biopsy and genetic analysis to be used for further diagnosis in patients with high-normal hematocrit and hemoglobin values.

METHODS

A cross-sectional and retrospective study was performed with the medical records of patients from Eskisehir City Hospital hematology clinics and outpatient clinics between July 1, 2019 and July 1, 2020. The study included patients with polycythemia, divided into two groups according to polycythemia vera and secondary polycythemia. A bone marrow biopsy was performed on patients with either Janus kinase mutation positivity and/or subnormal erythropoietin levels. Receiver operating characteristics analysis was used to find threshold values, and the diagnostic efficiency of these values in differentiating World Health Organization thresholds in 2008 and 2016 was evaluated.

RESULTS

A total of 73 patients were included. The median age was 43.5 years (min: 18; max: 84). The hematocrit value of 54.1 was predicted to diagnose polycythemia vera with a sensitivity of 45% and a specificity of 80%. Subsequent analysis revealed that an hemoglobin value of 17.7 was indicative of diagnosing polycythemia vera with a sensitivity of 60% and a specificity of 63%. The mean follow-up length was 6.4 months (2-12).

CONCLUSION

Our study demonstrated that modified World Health Organization criteria might lead to unnecessary additional tests for polycythemia vera patients with high-normal hemoglobin and hematocrit values.

The effect of polycythemia vera on choroidal thickness and retrobulbar blood flow

BACKGROUND

To evaluate the choroidal thickness and retrobulbar hemodynamic parameters in polycythemia vera (PV) patients in comparison with healthy individuals, and to investigate the relationship of these values with blood hematocrit levels.

METHODS

This prospective study included the 35 eyes of 35 PV patients and the 30 eyes of 30 healthy individuals. Choroidal thickness was measured at the subfoveal area and at 500 µm intervals nasal and temporal to the fovea up to a distance of 1500 µm. Color Doppler ultrasonography (CDU) was used to evaluate the retrobulbar vessels. Complete blood count values were recorded.

RESULTS

Choroidal thickness was found to be significantly lower in the PV group than in the control group at the subfoveal, nasal 500, and temporal 500 and 1000 µm measurement points (p = 0.01, p = 0.011, p = 0.04, p = 0.045, respectively). The central retinal artery (CRA) peak systolic velocity (PSV) and end diastolic velocity (EDV) values and the ophthalmic artery (OA) PSV value were significantly lower in the PV group than in the control group (p < 0.001, p < 0.001, p = 0.019, respectively). No significant difference was present between the groups in terms of CRA and OA resistive index (RI) and pulsatile index (PI) values (p = 0.388, p = 0.564, p = 0.897, p = 0.693, respectively). A negative correlation was found between the blood hematocrit levels and the subfoveal, nasal 500 µm, and temporal 500 µm choroidal thickness measurements and the CRA PSV and EDV and the OA PSV values.

CONCLUSIONS

PV may cause microvascular changes and lead to ocular vascular complications by affecting the choroidal and retrobulbar blood flow.

Polycythemia vera disease profile in an African population-experience from a tertiary facility in Ghana

Objectives

The study describes the clinical and laboratory profile of the patients with polycythemia vera at Komfo Anokye Teaching Hospital in Kumasi, Ghana.

Methods and design

This was a retrospective hospital-based cohort study conducted from September 2020 to August 2022. Hematology clinic entry book was used to identify the patient's unique hospital code. Using these unique codes, retrospective data were collected using an Excel spreadsheet from the Hospital Lightwave health information management system (LHIMS) database.

Results

A total of 20 participants were recruited over the period of 2 years. The overall mean age was 51.53 ± 16.39 years. The hematological profile of the male participants revealed a mean hemoglobin of 18.25 ± 1.373 g/dl, mean hematocrit of 52 ± 3.47%, and a mean platelet of 345.5 ± 180.82. Comparatively, the mean hemoglobin, hematocrit, and platelet for the female participants were higher with figures of 19.26 ± 1.43 g/dl, 53 ± 3.61%, and 816 ± 935.32, respectively. Headache, tiredness, numbness, splenomegaly, and abnormal labs were the most common reasons why participants sought medical attention. Majority (60%) of the study participants had Janus Kinase 2 mutation. New-onset hypertension was identified in 45% of the study participants during follow-up. Thromboembolism was seen in 10% of the study population.

Conclusion

Polycythemia vera is an uncommon disease in Ghana mostly found in older males above 50 years. It is important to recognize it early to initiate therapy aimed at preventing common complications such as hypertension and thromboembolism. Polycythemia vera should be considered a differential diagnosis for patients with secondary hypertension.

Real-world patient characteristics and treatment patterns of polycythemia vera in Taiwan between 2016 and 2017: a nationwide cross-sectional study

Background

Polycythemia vera (PV) patients often experience constitutional symptoms and are at risk of thromboembolism as well as disease progression to myelofibrosis or acute myeloid leukemia. Not only is PV often overlooked but treatment options are also limited, however.

Objectives

To explore the patient characteristics and treatment pattern of PV patients in Taiwan, and compare with other countries reported in the literature.

Design

This is a nationwide cross-sectional study.

Methods

The National Health Insurance Research Database in Taiwan, which covers 99% of the population, was utilized. Patients were identified during the cross-sectional period between 2016 and 2017, and their retrospective data were retrieved from 2001 to 2017.

Results

A total of 2647 PV patients were identified between 1 January 2016 and 31 December 2017. This study described the demographic information of these patients, including number of patients by risk stratification and by sex, age at diagnosis, age at cross-sectional period, rate of bone marrow aspiration/biopsy at diagnosis, comorbidities, number of postdiagnosis thrombosis, number of disease progression, and death. The mortality rate of PV patients (4.1%) over 60 of age was higher than the general population of the same age group (2.8%). This study also compared the different treatment patterns between sexes and risk groups. Hydroxyurea was deferred to an older age, but conversely was prescribed at higher dose to younger patients. Alarmingly, a high proportion of patients did not receive phlebotomy or hydroxyurea for at least 2 years. Furthermore, discrepancies in prevalence, age at diagnosis, sex ratio, incidence of thrombosis and mortality were also found when compared with data reported in other countries.

Conclusion

The clinical landscape of PV in Taiwan between 2016 and 2017 was examined. Distinctive patterns of phlebotomy and hydroxyurea were identified. Overall, these findings highlight the importance of understanding the patient characteristics and treatment patterns of PV in different regions to better inform clinical practice and improve patient outcomes.

Diagnosis and Management of Cerebral Venous Thrombosis Due to Polycythemia Vera and Genetic Thrombophilia: Case Report and Literature Review

(1) Background: Cerebral venous and dural sinus thrombosis (CVT) rarely appears in the adult population. It is difficult to diagnosis because of its variable clinical presentation and the overlapping signal intensities of thrombosis and venous flow on conventional MR images and MR venograms. (2) Case presentation: A 41-year-old male patient presented with an acute isolated intracranial hypertension syndrome. The diagnosis of acute thrombosis of the left lateral sinus (both transverse and sigmoid portions), the torcular Herophili, and the bulb of the left internal jugular vein was established by neuroimaging data from head-computed tomography, magnetic resonance imaging (including Contrast-enhanced 3D T1-MPRAGE sequence), and magnetic resonance venography (2D-TOF MR venography). We detected different risk factors (polycythemia vera-PV with JAK2 V617F mutation and inherited low-risk thrombophilia). He was successfully treated with low-molecular-weight heparin, followed by oral anticoagulation. (3) Conclusions: In the case of our patient, polycythemia vera represented a predisposing risk factor for CVT, and the identification of JAK2 V617F mutation was mandatory for the etiology of the disease. Contrast-enhanced 3D T1-MPRAGE sequence proved superior to 2D-TOF MR venography and to conventional SE MR imaging in the diagnosis of acute intracranial dural sinus thrombosis.

Masked Polycythemia Vera and Iron Deficiency in a Fertile-Age Woman

Polycythemia vera (PV) is a myeloproliferative disorder that leads to increased red blood cell (RBC) mass. The V617F activating mutation for Janus kinase 2 (JAK2) is a classic finding in PV, but it is not exclusive to this condition. The radionuclide assay is an accurate method for accessing RBC, but hemoglobin (Hb) and hematocrit (Htc) values are frequently the first abnormal markers reported in a routine blood count and the basis for further investigation. Diagnostic criteria for PV were recently updated to include lower thresholds for Hb and Htc, increasing diagnostic sensitivity. However, it has been reported that a subset of patients does not meet these thresholds, besides having an active masked disease. We are presenting a case of a fertile-age woman with menometrorrhagia, whose blood loss and consequent iron depletion worked as a limiting factor for Hb and Htc increase, delaying the proper diagnosis. Splenomegaly, iron deficiency markers, and low erythropoietin supported PV investigation. The correction of iron depletion led to the unveiling of covert erythrocytosis. Concomitant hemoglobinopathies and secondary causes for erythrocytosis were excluded. The diagnosis was confirmed with polymerase chain reaction (PCR) for V617F-JAK2 mutation and bone marrow biopsy. As this case highlights, despite not meeting diagnostic criteria at presentation, masked PV exhibited clinical, laboratory, and imaging features of active symptomatic disease. For that, a higher level of suspicion must be held for fertile-age women who present with normal Hb and Htc levels and significant iron depletion, in the presence of low serum erythropoietin or splenomegaly.

Real-world treatments and thrombotic events in polycythemia vera patients in the USA

Polycythemia vera (PV) is a myeloproliferative neoplasm associated with increased risk of thrombotic events (TE) and death. Therapeutic interventions, phlebotomy and cytoreductive medications, are targeted to maintain hematocrit levels < 45% to prevent adverse outcomes. This retrospective observational study examined medical and pharmacy claims of 28,306 PV patients initiating treatment for PV in a data period inclusive of 2011 to 2019. Study inclusion required ≥ 2 PV diagnosis codes in the full data period, at least 1 year of PV treatment history, and ≥ 1 prescription claim and medical claim in both 2018 and 2019. Patients having ≥ 2 hematocrit (HCT) test results in linked outpatient laboratory data (2018-2019) were designated as the HCT subgroup (N = 4246). Patients were characterized as high- or low-risk at treatment initiation based on age and prior thrombotic history. The majority of patients in both risk groups (60% of high-risk and 83% of low-risk) initiated treatment with phlebotomy monotherapy, and during a median follow-up period of 808 days, the vast majority (81% low-risk, 74% high-risk) maintained their original therapy during the follow-up period. Hematocrit control was suboptimal in both risk groups; 54% of high-risk patients initiating with phlebotomy monotherapy sometimes/always had HCT levels > 50%; among low-risk patients, 64% sometimes/always had HCT levels above 50%. Overall, 16% of individuals experienced at least 1 TE subsequent to treatment initiation, 20% (n = 3920) among high-risk and 8% (n = 629) among low-risk patients. This real-world study suggests that currently available PV treatments may not be used to full advantage.

Subretinal fluid accumulation in a patient with polycythemia vera after receiving a prostaglandin I2 analogue treatment

Purpose

To report a case of polycythemia vera (PV) with subretinal fluid accumulation after the administration of prostaglandin I2 (PGI2) analogue.

Observations

A 57-year-old woman diagnosed as having PV was referred to our department for the evaluation of severe metamorphopsia in the left eye, which gradually progressed after the initiation of oral administration of PGI2 mimetics. At the first visit, the patient's best-corrected visual acuities (BCVAs) were 20/20 OD and 20/30 OS. Fundus examination and optical coherence tomography revealed the presence of subretinal fluid (SRF) in the left eye and multiple serous pigment epithelial detachments (PEDs) in both eyes. Fluorescein angiography revealed central serous chorioretinopathy (CSC)-like lesions, consisting of dye pooling corresponding to the PEDs in both eyes and dye leakage in the left eye. Indocyanine green angiography and laser speckle flowgraphy revealed dilated choroidal veins and reduced choroidal blood flow, respectively. The central choroidal thickness (CCT) measured at the first visit showed a relatively thickened choroid in the left eye. Laboratory data showed mild pancytosis. The patient was diagnosed as having CSC associated with a background of PV, presumably triggered by the PGI2 analogue. One month after cessation of drug administration, the patient's BCVA improved, the CCT slightly decreased, and serous retinal detachment and PED disappeared in the left eye.

Conclusions and importance

Our case of PV presenting with CSC-like lesions after PGI2 analogue administration indicates the possible risk of SRF accumulation by PGI2 analogues in patients with PV.

S, R. D. JAK2 Mutation and Its Assessment in Relation to Profile of Young Polycythemia Patients in India

Purpose The main aim of this study was to detect the presence of JAK2 mutation and its assessment in relation to the clinical, hematological, and mutational profile of young patients with established polycythemia.

Methods Cross-sectional observational study was undertaken over a period of 1 year in a tertiary care center. Sixty patients were included in our study between the age 18 and 50 years with confirmed diagnosis of polycythemia vera. Reports of all the investigations including bone marrow biopsy and JAK2 mutation testing were assessed.

Results Presence of JAK2 mutation V617F was found in 38% patients, while bone marrow panmyelosis was present in 67% patients. Higher mean hemoglobin levels were observed in JAK2 mutation-positive patients, compared with those who were negative. Thrombosis-related complications were observed in five patients, all of whom were JAK2 mutation positive, while out of the 18 patients requiring phlebotomy, 15 patients were JAK2 mutation positive.

Conclusion JAK2 mutation V617F in young Indian population is seen in significantly less cases as compared with Western data, while bone marrow panmyelosis is frequently observed and thus a significant finding for diagnosing polycythemia in our setting. Median hemoglobin was greater for JAK2 mutation-positive cases and so were the phlebotomy requirements and thrombotic events occurrences. Forty-two percent patients had history of some exposure to high-altitude areas adhering to the fact that high altitude is an established risk factor for developing polycythemia and the same is reinforced by our study.

Assessment of relation between JAK2 gene and thrombosis in myeloproliferative neoplasms

Background Thrombotic complications are the most considerable etiology causing morbidity and mortality in patients with philadelphia (Ph) negative myeloproliferative neoplasms (MPN). There are many studies evaluating the association of JAK2 mutation and risk of thrombosis in MPN with inconclusive results. We also investigated the relation between JAK2 mutation in all Ph negative MPN and thrombosis. Material and Methods Thrombotic events and demographic features of 177 patients with Ph negative MPN were evaluated retrospectively. Results JAK2 V617 F mutation was detected in 57% of patients with essential thrombocythemia (ET), %90.3 of pateints with polycythemia vera (PV), 100% of pateints with primary myelofibrosis (PMF). Thrombotic complications occured more frequently with JAK2 mutation in all MPN patients than without (p=0.014). In JAK 2 mutation positive groups, the median age, thrombosis risk scores and leucocyte values are higher, splenomegaly and arterial and/or venous thrombosis are detected more frequently (p

Hospital incidence and medical costs of polycythemia vera in Spain: a retrospective database analysis

BACKGROUND

Polycythemia vera (PV) is one of the most common chronic myeloproliferative neoplasms, yet, little data is available on the epidemiology of PV in Spain and the costs of its management. This study aimed to evaluate the hospital incidence and mortality rate of PV in Spain, and to estimate hospital medical costs.

METHODS

Hospital admission records of patients with PV registered between 2005 and 2019 were obtained from a Spanish hospital discharge database and analyzed in a retrospective multicenter study.

RESULTS

Admission files of 490 patients were reviewed. Median age was 74 years; patients presented numerous conditions associated to age, namely hypertension, diabetes or anemia. Hospital mortality rate was associated to pulmonary heart disease, respiratory conditions and kidney disease. Most of the files analyzed corresponded to inpatient admissions; hospital incidence decreased over the study period in patients over 60 years. Median admission cost was €5580, increasing in patients deceased during the hospitalization. Admission cost increased significantly between 2006 and 2011.

CONCLUSIONS

This study provides an evaluation of hospital management and costs of PV in Spain. Future studies should focus on the revision of disease management in the country and measuring total medical costs, which could be higher than global estimations.

Immune Dysregulation and Infectious Complications in MPN Patients Treated With JAK Inhibitors

BCR-ABL1-negative myeloproliferative neoplasms are burdened by a reduced life expectancy mostly due to an increased risk of thrombo-hemorrhagic events, fibrotic progression/leukemic evolution, and infectious complications. In these clonal myeloid malignancies, JAK2V617F is the main driver mutation, leading to an aberrant activation of the Janus kinase-signal transducer and activator of transcription (JAK-STAT) signaling pathway. Therefore, its inhibition represents an attractive therapeutic strategy for these disorders. Several JAK inhibitors have entered clinical trials, including ruxolitinib, the first JAK1/2 inhibitor to become commercially available for the treatment of myelofibrosis and polycythemia vera. Due to interference with the JAK-STAT pathway, JAK inhibitors affect several components of the innate and adaptive immune systems such as dendritic cells, natural killer cells, T helper cells, and regulatory T cells. Therefore, even though the clinical use of these drugs in MPN patients has led to a dramatic improvement of symptoms control, organ involvement, and quality of life, JAK inhibitors–related loss of function in JAK-STAT signaling pathway can be a cause of different adverse events, including those related to a condition of immune suppression or deficiency. This review article will provide a comprehensive overview of the current knowledge on JAK inhibitors’ effects on immune cells as well as their clinical consequences, particularly with regards to infectious complications.

Impact of Increased Hemoglobin on Spontaneous Intracerebral Hemorrhage

Background

Studies of the impact of increased hemoglobin on spontaneous intracerebral hemorrhage (ICH) are limited. The present study aimed to explore the effect of increased hemoglobin on ICH.

Methods

A retrospective single-center study using medical records from a database processed by univariate and multivariate analyses was performed in the People’s Hospital of Tibet Autonomous Region in Lhasa, Tibet, China.

Results

The mean hemoglobin level in 211 patients with ICH was 165.03 ± 34.12 g/l, and a median hematoma volume was 18.5 ml. Eighty-eight (41.7%) patients had large hematomas (supratentorial hematoma ≥ 30 ml; infratentorial hematoma ≥ 10 ml). No differences in ICH risk factors between the groups with different hemoglobin levels were detected. Increased hemoglobin was independently associated with large hematomas [odds ratio (OR) 1.013, P = 0.023]. Increased hemoglobin was independently associated with ICH with subarachnoid hemorrhage (OR 1.014, P = 0.016), which was more pronounced in men (OR 1.027, P = 0.002). Increased hemoglobin was independently associated with basal ganglia hemorrhage and lobar hemorrhage in men (OR 0.986, P = 0.022; OR 1.013, P = 0.044, respectively) but not in women (P > 0.1).

Conclusions

Increased hemoglobin was independently associated with large hemorrhage volume. Increased hemoglobin was independently associated with lobar hemorrhage in men and ICH with subarachnoid hemorrhage, which was more pronounced in men. Additional studies are needed to confirm our findings and explore potential mechanisms.

Clinical and Laboratory Features of JAK2 V617F, CALR, and MPL Mutations in Malaysian Patients with Classical Myeloproliferative Neoplasm (MPN)

Mutations of JAK2V617F, CALR, and MPL genes confirm the diagnosis of myeloproliferative neoplasm (MPN). This study aims to determine the genetic profile of JAK2V617F, CALR exon 9 Type 1 (52 bp deletion) and Type 2 (5 bp insertion), and MPL W515 L/K genes among Malaysian patients and correlate these mutations with clinical and hematologic parameters in MPN. Mutations of JAK2V617F, CALR, and MPL were analyzed in 159 Malaysian patients using allele-specific polymerase chain reaction, including 76 polycythemia vera (PV), 41 essential thrombocythemia (ET), and 42 primary myelofibrosis (PMF) mutations, and the demographics of the patients were retrieved. The result showed that 73.6% JAK2V617F, 5.66% CALR, and 27.7% were triple-negative mutations. No MPL W515L/K mutation was detected. In ET and PMF, the predominance type was the CALR Type 1 mutation. In JAK2V617F mutant patients, serum LDH was significantly higher in PMF compared to PV and ET. PV has a higher risk of evolving to post PV myelofibrosis compared to ET. A thrombotic event at initial diagnosis of 40.9% was high compared to global incidence. Only one PMF patient had a CALR mutation that transformed to acute myeloid leukemia. JAK2V617F and CALR mutations play an important role in diagnostics. Hence, every patient suspected of having a myeloproliferative neoplasm should be screened for these mutations.

Recent Advances in the Use of Molecular Analyses to Inform the Diagnosis and Prognosis of Patients with Polycythaemia Vera

Genetic studies in the past decade have improved our understanding of the molecular basis of the BCR-ABL1-negative myeloproliferative neoplasm (MPN) polycythaemia vera (PV). Such breakthroughs include the discovery of the JAK2V617F driver mutation in approximately 95% of patients with PV, as well as some very rare cases of familial hereditary MPN caused by inherited germline mutations. Patients with PV often progress to fibrosis or acute myeloid leukaemia, both associated with very poor clinical outcome. Moreover, thrombosis and major bleeding are the principal causes of morbidity and mortality. As a result of increasingly available and economical next-generation sequencing technologies, mutational studies have revealed the prognostic relevance of a few somatic mutations in terms of thrombotic risk and risk of transformation, helping to improve the risk stratification of patients with PV. Finally, knowledge of the molecular basis of PV has helped identify targets for directed therapy. The constitutive activation of the tyrosine kinase JAK2 is targeted by ruxolitinib, a JAK1/JAK2 tyrosine kinase inhibitor for PV patients who are resistant or intolerant to cytoreductive treatment with hydroxyurea. Other molecular mechanisms have also been revealed, and numerous agents are in various stages of development. Here, we will provide an update of the recent published literature on how molecular testing can improve the diagnosis and prognosis of patients with PV and present recent advances that may have prognostic value in the near future.

Advances in the Treatment of Polycythemia Vera: Trends in Disease Management

Treatment modalities for polycythemia vera (PV) have evolved over time. Phlebotomy and low-dose aspirin suffice in low-risk patients, but cytoreductive therapies are indicated in all high-risk patients (age ≥ 65 years or those with a history of PV-related thrombotic event) and may be considered for low-risk patients with progressively increasing splenomegaly, progressively increasing leucocyte and platelet counts, and for those who do not tolerate phlebotomy. Hydroxyurea/hydroxycarbamide or interferons can be used as first-line drugs. Hydroxyurea may not be tolerated by some patients, and it also carries risk of myelosuppression. Interferon alfa is especially useful for PV symptoms, and the newer preparation, ropeginterferon alfa-2b, has lesser incidence of flu-like reactions. Ruxolitinib reduces the JAK2V617F mutation burden and is used as a second-line drug. Anagrelide reduces platelet production and can be used in conjunction with hydroxyurea in patients with excessive thrombocytosis. The alkylating agent, busulfan, can also be used as a last resort in patients with a limited life expectancy. Prospective future treatments include givinostat, a histone deacetylase inhibitor, and idasanutlin, a murine double minute 2 antagonist.

Polycythemia Vera (PV): Update on Emerging Treatment Options

Polycythemia Vera (PV) is a chronic myeloproliferative neoplasm characterized by exuberant red cell production leading to a broad range of symptoms that compromise quality of life and productivity of patients. PV reduces survival expectation, primarily due to thrombotic events, transformation to blast phase and post-PV myelofibrosis or to development of second cancers, which are associates with poor prognosis. Current therapeutic first line recommendations based on risk adapted classification divided patients into two groups, according to age (< or >60 years) and presence of prior thrombotic events. Low-risk patients (age <60 years and no prior history of thrombosis) should be treated with aspirin (81-100 mg/d) and phlebotomy, to maintain hematocrit <45%. High-risk patients (age >60 years and/or prior history of thrombosis), in addition to aspirin and phlebotomies, should receive cytoreductive therapy in order to reduce thrombotic risk. Nowadays hydroxyurea still remains the cytoreductive agent of first choice, reserving Interferon to young patients or childbearing women. During the last years, ruxolitinib emerged as a new treatment in PV patients, as second line therapy: it appeared especially effective in patients with severe pruritus, symptomatic splenomegaly, or post-PV myelofibrosis symptoms. Currently, in PV treatment, several molecules have been tested or are under investigation. At present, the drug that has shown the most encouraging results is givinostat.