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Manganas K, Delicou S, Xydaki A, Kourakli A, Evliati L, Vlachaki E, Klironomos E, Diamantidis M, Lafiatis I, Kattamis A, Koskinas J. Predisposing factors for advanced liver fibrosis in patients with sickle cell disease. Br J Haematol 2023; 202:1192-1198. [PMID: 37438880 DOI: 10.1111/bjh.18970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/14/2023]
Abstract
Sickle cell disease (SCD) is one of the most common monogenic disorders worldwide and liver complications are common in this group of patients. Our study aims to highlight the prevalence of chronic liver complications and the main predisposing factors for advanced liver fibrosis in SCD patients. For this purpose, 219 patients from eight Thalassemia and Sickle Cell Units across Greece enrolled in our study and history of liver related disease complications was recorded, as well as a full laboratory and imaging analysis concerning their liver function. 13.6% of the patients had advanced liver fibrosis. The presence of liver fibrosis was significantly correlated with advanced age, male gender, cholelithiasis and higher LDH, γ-GT, INR, direct and indirect bilirubin levels. These patients had exhibited significantly more episodes of liver crises and acute intrahepatic cholestasis. No correlation was observed with right heart failure or previous viral hepatitis. Patients with advanced liver fibrosis were receiving a more intensive transfusion therapy for a longer period of time and had higher Liver Iron Concentration levels. Our study shows that liver complications and cirrhosis is a significant cause of morbidity in patients with SCD and it is primarily associated with intravascular hemolysis and vaso-occlusive phenomena and secondarily with iron overload.
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Affiliation(s)
| | - Sophia Delicou
- Thalassemia and Sickle Cell Unit, Hippokration General Hospital, Athens, Greece
| | - Aikaterini Xydaki
- Thalassemia and Sickle Cell Unit, Hippokration General Hospital, Athens, Greece
| | - Alexandra Kourakli
- Thalassemia & Hemoglobinopathies Unit, Hematology Division, Department of Internal Medicine, University of Patras Medical School, University Hospital, Patras, Greece
| | - Loukia Evliati
- Thalassemia and Sickle Cell Unit, General Hospital of Athens "Evaggelismos", Athens, Greece
| | - Efthymia Vlachaki
- Thalassemia and Sickle Cell Unit, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evangelos Klironomos
- Thalassemia and Sickle Cell Unit, "Venizelion" General Hospital, Heraklion, Greece
| | - Michail Diamantidis
- Thalassemia and Sickle Cell Unit, General Hospital of Larissa, Larissa, Greece
| | - Ioannis Lafiatis
- Thalassemia and Sickle Cell Unit, "Vostanio" General Hospital of Mytilene, Mytilene, Greece
| | - Antonios Kattamis
- "Agia Sophia" Children Hospital, First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - John Koskinas
- Department of Internal Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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Seremidi K, Kavvadia K, Kattamis A, Polychronopoulou A. Correction to: Dental caries and dental developmental defects as adverse effects of antineoplastic treatment in childhood cancer survivors. Eur Arch Paediatr Dent 2023:10.1007/s40368-023-00802-5. [PMID: 37178252 DOI: 10.1007/s40368-023-00802-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Affiliation(s)
- K Seremidi
- Department of Paediatric Dentistry, Athens School of Dentistry, National and Kapodistrian University of Athens, 2 Thivon Str., 11527, Goudi, Athens, Greece.
| | - K Kavvadia
- Department of Dentistry, School of Medicine, European University of Cyprus, Engomi, Cyprus
| | - A Kattamis
- Division of Paediatric Haematology-Oncology, First Department of Paediatrics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - A Polychronopoulou
- Department of Preventive and Community Dentistry, Athens School of Dentistry, National and Kapodistrian University of Athens, Athens, Greece
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Moutafidis D, Gavra M, Golfinopoulos S, Kattamis A, Chrousos G, Kanaka-Gantenbein C, Kaditis AG. Low- and High-Attenuation Lung Volume in Quantitative Chest CT in Children without Lung Disease. Children (Basel) 2021; 8:children8121172. [PMID: 34943369 PMCID: PMC8700567 DOI: 10.3390/children8121172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/21/2021] [Accepted: 12/07/2021] [Indexed: 06/14/2023]
Abstract
In contrast to studies of adults with emphysema, application of fixed thresholds to determine low- and high-attenuation areas (air-trapping and parenchymal lung disease) in pediatric quantitative chest CT is problematic. We aimed to assess age effects on: (i) mean lung attenuation (full inspiration); and (ii) low and high attenuation thresholds (LAT and HAT) defined as mean attenuation and 1 SD below and above mean, respectively. Chest CTs from children aged 6-17 years without abnormalities were retrieved, and histograms of attenuation coefficients were analyzed. Eighty examinations were included. Inverse functions described relationships between age and mean lung attenuation, LAT or HAT (p < 0.0001). Predicted value for LAT decreased from -846 HU in 6-year-old to -950 HU in 13- to 17-year-old subjects (cut-off value for assessing emphysema in adults). %TLCCT with low attenuation correlated with age (rs = -0.31; p = 0.005) and was <5% for 9-17-year-old subjects. Inverse associations were demonstrated between: (i) %TLCCT with high attenuation and age (r2 = 0.49; p < 0.0001); (ii) %TLCCT with low attenuation and TLCCT (r2 = 0.47; p < 0.0001); (iii) %TLCCT with high attenuation and TLCCT (r2 = 0.76; p < 0.0001). In conclusion, quantitative analysis of chest CTs from children without lung disease can be used to define age-specific LAT and HAT for evaluation of pediatric lung disease severity.
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Affiliation(s)
- Dimitrios Moutafidis
- Division of Pediatric Pulmonology, First Department of Pediatrics, National and Kapodistrian University of Athens School of Medicine & Agia Sofia Children’s Hospital, 115 27 Athens, Greece; (D.M.); (C.K.-G.)
| | - Maria Gavra
- CT, MRI & PET/CT Department, Agia Sofia Children’s Hospital, 115 27 Athens, Greece; (M.G.); (S.G.)
| | - Sotirios Golfinopoulos
- CT, MRI & PET/CT Department, Agia Sofia Children’s Hospital, 115 27 Athens, Greece; (M.G.); (S.G.)
| | - Antonios Kattamis
- Division of Pediatric Hematology-Oncology, First Department of Pediatrics, National and Kapodistrian University of Athens School of Medicine & Agia Sofia Children’s Hospital, 115 27 Athens, Greece;
| | - George Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, UNESCO, National and Kapodistrian University of Athens, 115 27 Athens, Greece;
| | - Christina Kanaka-Gantenbein
- Division of Pediatric Pulmonology, First Department of Pediatrics, National and Kapodistrian University of Athens School of Medicine & Agia Sofia Children’s Hospital, 115 27 Athens, Greece; (D.M.); (C.K.-G.)
| | - Athanasios G. Kaditis
- Division of Pediatric Pulmonology, First Department of Pediatrics, National and Kapodistrian University of Athens School of Medicine & Agia Sofia Children’s Hospital, 115 27 Athens, Greece; (D.M.); (C.K.-G.)
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Tragiannidis A, Kattamis A, Vyzantiadis TA. Invasive Fungal Infections in Children with Haematological Malignancies: Diagnostic and Therapeutic Challenges. J Fungi (Basel) 2021; 7:jof7070516. [PMID: 34203146 PMCID: PMC8305930 DOI: 10.3390/jof7070516] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 02/07/2023] Open
Affiliation(s)
- Athanasios Tragiannidis
- Children & Adolescent Haematology-Oncology Unit, Second Department of Paediatrics, Aristotle University of Thessaloniki, AHEPA Hospital, 53646 Thessaloniki, Greece;
| | - Antonios Kattamis
- Paediatric Haematology-Oncology Unit, First Department of Paediatrics, National and Kapodistrian University of Athens, Aghia Sophia Children’s Hospital, 11527 Athens, Greece;
| | - Timoleon-Achilleas Vyzantiadis
- First Department of Microbiology, Medical School, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
- Correspondence: ; Tel.: +30-2310-999027
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Petrocheilou G, Doulgeraki A, Polyzois G, Schiza V, Delaporta P, Kattamis A, Fragodimitri C. Radiographic Skeletal Features of Beta-Thalassemia: Pictorial Essay and Background Etiology. Semin Musculoskelet Radiol 2021. [DOI: 10.1055/s-0041-1731553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ampatzidou M, Kattamis A, Baka M, Paterakis G, Anastasiou T, Tzanoudaki M, Kaisari A, Avgerinou G, Doganis D, Papadakis V, Kitra V, Polychronopoulou S. Insights from the Greek experience of the use of Blinatumomab in pediatric relapsed and refractory acute lymphoblastic leukemia patients. Neoplasma 2020; 67:1424-1430. [PMID: 32701357 DOI: 10.4149/neo_2020_200128n93] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/29/2020] [Indexed: 11/08/2022]
Abstract
Pediatric refractory or relapsed acute lymphoblastic leukemia (ALL) poses unique therapeutic challenges, with novel immunotherapy approaches offering potential cure opportunities. In this frame, the use of Blinatumomab may induce durable remissions, serving as a successful bridge to allogeneic hematopoietic stem cell transplantation (allo-HSCT). Herein, we retrospectively summarize the Greek experience on pediatric relapsed/refractory B-cell precursor ALL patients that were treated with Blinatumomab in a compassionate, off-label setting as an effort to achieve disease clearance and proceed to allo-HSCT. In our cohort of 9 patients, 6/9 (66.7%) responded to Blinatumomab, achieving complete morphological remission (CR) after the 1st cycle, while minimal/measurable residual disease (MRD)-negativity (<10-4) after the 1st cycle was achieved in 2/2 patients (100.0%) with prior CR. A successful bridge to HSCT was feasible in 5/9 patients (55.6%). Median relapse-free survival (RFS) was 3.0 months (range 0.5-21.4 months) and median overall survival (OS) was 8.7 months (range 1.4-47.1 months) for the whole pediatric cohort. There was a trend of prolonged survival among patients who achieved MRD response after the 1st Blinatumomab administration. MRD response (defined as the >=2-log reduction of MRD value before and after Blinatumomab administration), was associated with a median RFS/OS of 7.4/7.6 months, while lack of MRD response was associated with a median RFS/OS of 0.5/3.0 months, respectively. Novel therapeutic maneuvers, in order to overcome disease resistance, i.e. increased usage of Blinatumomab dose (45 μg/m2/day), combination with donor lymphocyte infusions (DLIs), use of other immunotherapy salvage approaches (inotuzumabozogamicin), are herein discussed. Additionally, the optimal number of Blinatumomab cycles, the CD19-negative relapses and lineage switch, are also addressed. Our data although referred to a limited, however refractory or relapsed and heavily pretreated number of patients, strongly suggest that Blinatumomab may well induce sustained remissions and serve as an effective bridge to HSCT. Whether immunotherapy combined with chemotherapy can outweigh the need for subsequent allo-HSCT, if incorporated into frontline high-risk ALL therapy, remains an optimistic issue to be verified in future randomized clinical trials.
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Affiliation(s)
- M Ampatzidou
- Department of Pediatric Hematology-Oncology, Aghia Sophia Children's Hospital, Athens, Greece
| | - A Kattamis
- First Department of Pediatrics, Aghia Sophia Children's Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - M Baka
- Oncology Department, P. and A. Kyriakou Children's Hospital, Athens, Greece
| | - G Paterakis
- Immunology Laboratory, Department of Flow Cytometry , G. Gennimatas General Hospital, Athens, Greece
| | - T Anastasiou
- Hematology Laboratory, P. and A. Kyriakou Children's Hospital, Athens, Greece
| | - M Tzanoudaki
- Immunology Laboratory, Aghia Sophia Children's Hospital, Athens, Greece
| | - A Kaisari
- Bone Marrow Transplantation Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - G Avgerinou
- First Department of Pediatrics, Aghia Sophia Children's Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - D Doganis
- Oncology Department, P. and A. Kyriakou Children's Hospital, Athens, Greece
| | - V Papadakis
- Department of Pediatric Hematology-Oncology, Aghia Sophia Children's Hospital, Athens, Greece
| | - V Kitra
- Bone Marrow Transplantation Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - S Polychronopoulou
- Department of Pediatric Hematology-Oncology, Aghia Sophia Children's Hospital, Athens, Greece
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Karimi M, Zarei T, Haghpanah S, Azarkeivan A, Kattamis C, Ladis V, Kattamis A, Kilinc Y, Daar S, Alyaarubi S, Khater D, Wali Y, Elshinawy M, Almadhani A, Yassin M, Soliman AT, Canatan D, Obiedat M, Al-Rimawi H, Mariannis D, Christodoulides C, Christou S, Tzoulis P, Campisi S, Di Maio S, De Sanctis V. Evaluation of endocrine complications in beta-thalassemia intermedia (β-TI): a cross-sectional multicenter study. Endocrine 2020; 69:220-227. [PMID: 31853840 DOI: 10.1007/s12020-019-02159-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 12/09/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Data on the prevalence and type of endocrine disorders in β-thalassemia intermedia (β-TI) patients are scarce. This multicenter study was designed to determine the prevalence of endocrine complications and the associated risk factors in a large group of β-TI patients. METHODS In this cross-sectional multicenter study, 726 β-TI patients, aged 2.5-80 years, registered at 12 thalassemic centers, from nine countries, were enrolled during 2017. In a subgroup of 522 patients (mean age 30.8 ± 12.1; range: 2.5-80 years) from Qatar, Iran, Oman, Cyprus, and Jordan detailed data were available. RESULTS Overall, the most prevalent complications were osteopenia/osteoporosis (22.3%), hypogonadism (10.1%), and primary hypothyroidism (5.3%). In the subgroup multivariate analysis, older age was a risk factor for osteoporosis (Odds ratio: 7.870, 95% CI: 4.729-13.099, P < 0.001), hypogonadism (Odds ratio: 6.310, 95% CI: 2.944-13.521, P < 0.001), and non-insulin-dependent diabetes mellitus (NIDDM; Odds ratio: 17.67, 95% CI: 2.217-140.968, P = 0.007). Splenectomy was a risk factor for osteoporosis (Odds ratio: 1.736, 95% CI: 1.012-2.977, P = 0.045). Hydroxyurea was identified as a "protective factor" for NIDDM (Odds ratio: 0.259, 95% CI: 0.074-0.902, P = 0.034). CONCLUSIONS To the best of our knowledge, this is the largest cohort of β-TI patients with endocrine disorders evaluated in extremely heterogenic thalassemic populations for age, clinical, hematological, and molecular composition. The study demonstrates that endocrine complications are less common in patients with β-TI compared with β-TM patients. However, regular monitoring with timely diagnosis and proper management is crucial to prevent endocrine complications in β-TI patients.
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Affiliation(s)
- Mehran Karimi
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Tahereh Zarei
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sezaneh Haghpanah
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Azita Azarkeivan
- Pediatric Hematology-Oncology, Adult Thalassemia Clinic, Tehran, Iran
| | - Christos Kattamis
- Thalassemia Unit, Division of Pediatric Hematology-Oncology, First Department of Pediatrics, University of Athens "Agia Sofia" Children's Hospital, Athens, Greece
| | - Vassilis Ladis
- Thalassemia Unit, Division of Pediatric Hematology-Oncology, First Department of Pediatrics, University of Athens "Agia Sofia" Children's Hospital, Athens, Greece
| | - Antonios Kattamis
- Thalassemia Unit, Division of Pediatric Hematology-Oncology, First Department of Pediatrics, University of Athens "Agia Sofia" Children's Hospital, Athens, Greece
| | - Yurdanur Kilinc
- Department of Pediatric Hematology, Medical Faculty, Çukurova University, Adana, Turkey
| | - Shahina Daar
- Department of Hematology, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Saif Alyaarubi
- Department of Hematology, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Doaa Khater
- Department of Hematology, College of Medicine & Health Sciences, Sultan Qaboos University and Muscat, Sultanate of Oman Pediatric Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Yasser Wali
- Department of Hematology, College of Medicine & Health Sciences, Sultan Qaboos University and Muscat, Sultanate of Oman Pediatric Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mohamed Elshinawy
- Department of Hematology, College of Medicine & Health Sciences, Sultan Qaboos University and Muscat, Sultanate of Oman Pediatric Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ali Almadhani
- Department of General Medicine, Sohar Hospital, Sohar, Oman
| | - Mohamed Yassin
- Department of Pediatrics, Division of Endocrinology, Hamad General Hospital Doha, Qatar and Department of Pediatrics, Division of Endocrinology, Alexandria University Children's Hospital, Alexandria, Egypt
| | - Ashraf T Soliman
- Department of Pediatrics, Division of Endocrinology, Hamad General Hospital Doha, Qatar and Department of Pediatrics, Division of Endocrinology, Alexandria University Children's Hospital, Alexandria, Egypt
| | - Duran Canatan
- Thalassemia Diagnosis Center of Mediterranean Blood Diseases Foundation, Antalya, Turkey
| | - Maha Obiedat
- King Abdullah University Hospital, Princess Rahma Teaching hospital, Irbid, Jordan
| | - Hala Al-Rimawi
- King Abdullah University Hospital, Princess Rahma Teaching hospital, Irbid, Jordan
| | | | | | | | - Ploutarchos Tzoulis
- Department of Endocrinology, Whittington Hospital, University College London, London, UK
| | | | | | - Vincenzo De Sanctis
- Pediatric and Adolescent Outpatient Clinic, Quisisana Hospital, Ferrara, Italy.
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Athanasiadis DI, Athanasiadou KI, Voulgaridou A, Zafeiriou DI, Kattamis A, Christodoulou DK, Papakonstantinou E. Coexistence of Constitutional Mismatch Repair Deficiency syndrome and Lynch syndrome in a family of seven : MSH6 mutation and childhood colorectal cancer - a case series. Acta Gastroenterol Belg 2020; 83:479-481. [PMID: 33094597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE To present a case series of two fraternal twin girls who passed away from brain and colorectal cancers attributed to Constitutional Mismatch Repair Deficiency syndrome (CMMRD). A review of literature for CMMRD-related pediatric malignancies is also presented. METHODS The two girls were diagnosed with cancer at the age of 11 and 13 respectively. The early onset of multiple malignancies in the family raised clinical suspicion for a potential genetic mutation. The presence of café-au-lait spots at clinical examination led to further investigations for neurofibromatosis. RESULTS Neurofibromatosis type 1 testing was negative in both children. Genetic analysis turned out positive for biallelic MSH6 mutations in the two girls, leading to CMMRD syndrome diagnosis. Both parents and two out of three alive siblings were diagnosed with Lynch syndrome. CONCLUSIONS Colorectal cancer is a very rare finding in childhood and should raise suspicion for CMMRD syndrome and should be followed by regular screening.
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Affiliation(s)
| | | | | | - Dimitrios I Zafeiriou
- 1st Department of Pediatrics, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Antonios Kattamis
- Hematology/Oncology Unit, 1st Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios K Christodoulou
- Department of Gastroenterology, University Hospital and Medical School of Ioannina, Ioannina, Greece
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Kyriazoglou A, Konteles V, Liontos M, Sofianidis G, Zagouri F, Koutsoukos K, Tsironis G, Tsiara A, Kaparelou M, Zakopoulou R, Cohen A, Dimitriadis E, Mahaira L, Michali D, Arnogiannaki N, Stefanaki K, Dimopoulos M, Kattamis A. Expression analysis of NHEJ and HR genes in Ewing sarcomas: Indications of DSB repair dysfunction. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz283.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Avgerinou G, Oikonomopoulou C, Kaisari A, Ioannidou E, Komitopoulou A, Paisou A, Tourkantoni N, Filippidou M, Kattamis A, Vessalas G, Peristeri I, Goussetis E, Kitra V. Successful long-term hematological and immunological reconstitution by autologous cord blood transplantation combined with post-transplant immunosuppression in two children with severe aplastic anemia. Pediatr Transplant 2019; 23:e13320. [PMID: 30407702 DOI: 10.1111/petr.13320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 08/17/2018] [Accepted: 10/12/2018] [Indexed: 12/17/2022]
Abstract
aUCBT is a valuable curative option in pediatric patients with refractory idiopathic SAA and no available matched sibling or unrelated donors. Experience in the use of autologous cord blood units in patients with SAA is limited and private for-profit cord blood-banking programs are controversial. We report the successful treatment of two patients with SAA, aged 15 and 24 months, with autologous cord blood combined with immunosuppression. After conditioning with 200 mg/kg cyclophosphamide and ATG, 7.5 mg/kg, 32.2 × 107 /kg, and 3.8 × 107 /kg autologous cord blood nucleated cells were infused, respectively. One of our patients underwent transplantation after failure of IST. Both patients received post-transplant immunosuppression with cyclosporine for 12 months. They remain disease-free 6 years post-transplantation.
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Affiliation(s)
- Georgia Avgerinou
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Aikaterini Kaisari
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - Elda Ioannidou
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - Anna Komitopoulou
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - Anna Paisou
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - Natalia Tourkantoni
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Filippidou
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios Kattamis
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - George Vessalas
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - Ioulia Peristeri
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - Evgenios Goussetis
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - Vasiliki Kitra
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
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De Sanctis V, Soliman AT, Daar S, Di Maio S, Yassin MA, Canatan D, Vives Corrons JL, Elsedfy H, Kattamis A, Kattamis C. The experience of a tertiary unit on the clinical phenotype and management of hypogonadism in female adolescents and young adults with transfusion dependent thalassemia. Acta Biomed 2019; 90:158-167. [PMID: 30889170 PMCID: PMC6502154 DOI: 10.23750/abm.v90i1.8143] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Transfusion-dependent β-thalassemia (TDT) is associated with several complications necessitating a multidisciplinary approach for diagnosis, treatment and follow-up. Hypogonadism in female TDT patients is one of the most common endocrine complications, requiring hormone replacement therapy (HRT) throughout reproductive life. Little is known about the balance of benefits versus risks of treatment with sex steroids. AIM The aim of this manuscript is to review the action and the associated adverse effects of HRT in hypogonadal TDT females. DESIGN Retrospective medical database records from a single centre, over a period of 38 years (January 1980 to June 2018), were reviewed. STUDY POPULATION Forty-two cases of hypogonadism in TDT females followed in a pediatric and adolescent outpatient clinics, were in included in the study. METHODS Auxological, clinical, laboratory, hormonal and imaging investigations were reviewed, as well as all adverse events registered during HRT. MAIN RESULTS In general, HRT was safe for most patients. There were few minor side effects and a couple of rare but serious adverse events. CONCLUSIONS The study provides a representative clinical profile of long-term effects of HRT in hypogonadal adolescents and young adult TDT women. Our results highlight also the need for further research in other areas for which HRT may have a role. We hope this will contribute to a wider understanding, and potential improvement, of patient safety and quality of life.
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Affiliation(s)
- Vincenzo De Sanctis
- Pediatric and Adolescent Outpatient Clinic, Quisisana Hospital, Ferrara, Italy.
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Geitona M, Karagianni V, Kattamis A, Voskaridou E, Drosou M, Vini D, Kalogeropoulou M. The Economic Burden of Treating Thalassemia In Greece. Value Health 2014; 17:A526. [PMID: 27201661 DOI: 10.1016/j.jval.2014.08.1661] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- M Geitona
- University of Peloponnese, Corinth, Greece
| | - V Karagianni
- Technological educational institute of Athens, Egaleo, Greece
| | - A Kattamis
- Ag. Sofia Children Hospital, Goudi, Greece
| | - E Voskaridou
- Laiko General Hospital of Athens, Ambelokipi, Greece
| | - M Drosou
- Agios Panteleimon General Hospital, Nikaia, Greece
| | - D Vini
- Agios Panteleimon General Hospital, Nikaia, Greece
| | - M Kalogeropoulou
- Center for Health Services Management and Evaluation, National and Kapodistrian University of Athens, Athens, Greece
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Geller T, Prakash V, Batanian J, Guzman M, Duncavage E, Gershon T, Crowther A, Wu J, Liu H, Fang F, Davis I, Tripolitsioti D, Ma M, Kumar K, Grahlert J, Egli K, Fiaschetti G, Shalaby T, Grotzer M, Baumgartner M, Braoudaki M, Lambrou GI, Giannikou K, Millionis V, Papadodima SA, Settas N, Sfakianos G, Stefanaki K, Kattamis A, Spiliopoulou CA, Tzortzatou-Stathopoulou F, Kanavakis E, Gholamin S, Mitra S, Feroze A, Zhang M, Esparza R, Kahn S, Richard C, Achrol A, Volkmer A, Liu J, Volkmer J, Majeti R, Weissman I, Cheshier S, Bhatia K, Brown N, Teague J, Lo P, Challis J, Beshay V, Sullivan M, Mechinaud F, Hansford J, Arifin MZ, Dahlan RH, Sobana M, Saputra P, Tisell MT, Danielsson A, Caren H, Bhardwaj R, Chakravadhanula M, Hampton C, Ozals V, Georges J, Decker W, Kodibagkar V, Nguyen A, Legrain M, Gaub MP, Pencreach E, Chenard MP, Guenot D, Entz-Werle N, Kanemura Y, Ichimura K, Shofuda T, Nishikawa R, Yamasaki M, Shibui S, Arai H, Xia J, Brian A, Prins R, Pennell C, Moertel C, Olin M, Bie L, Zhang X, Liu H, Olsson M, Kling T, Nelander S, Biassoni V, Bongarzone I, Verderio P, Massimino M, Magni R, Pizzamiglio S, Ciniselli C, Taverna E, De Bortoli M, Luchini A, Liotta L, Barzano E, Spreafico F, Visse E, Sanden E, Darabi A, Siesjo P, Jackson S, Cohen K, Lin D, Burger P, Rodriguez F, Yao X, Liucheng R, Qin L, Na T, Meilin W, Zhengdong Z, Yongjun F, Pfeifer S, Nister M, de Stahl TD, Basmaci E, Orphanidou-Vlachou E, Brundler MA, Sun Y, Davies N, Wilson M, Pan X, Arvanitis T, Grundy R, Peet A, Eden C, Ju B, Phoenix T, Nimmervoll B, Tong Y, Ellison D, Lessman C, Taylor M, Gilbertson R, Folgiero V, del Bufalo F, Carai A, Cefalo MG, Citti A, Rutella S, Locatelli F, Mastronuzzi A, Maher O, Khatua S, Zaky W, Lourdusamy A, Meijer L, Layfield R, Grundy R, Jones DTW, Capper D, Sill M, Hovestadt V, Schweizer L, Lichter P, Zagzag D, Karajannis MA, Aldape KD, Korshunov A, von Deimling A, Pfister S, Chakrabarty A, Feltbower R, Sheridon E, Hassan H, Shires M, Picton S, Hatziagapiou K, Braoudaki M, Lambrou GI, Tsorteki F, Tzortzatou-Stathopoulou F, Bethanis K, Gemou-Engesaeth V, Chi SN, Bandopadhayay P, Janeway K, Pinches N, Malkin H, Kieran MW, Manley PE, Green A, Goumnerova L, Ramkissoon S, Harris MH, Ligon KL, Kahlert U, Suarez M, Maciaczyk J, Bar E, Eberhart C, Kenchappa R, Krishnan N, Forsyth P, McKenzie B, Pisklakova A, McFadden G, Kenchappa R, Forsyth P, Pan W, Rodriguez L, Glod J, Levy JM, Thompson J, Griesinger A, Amani V, Donson A, Birks D, Morgan M, Handler M, Foreman N, Thorburn A, Lulla RR, Laskowski J, Fangusaro J, DiPatri AJ, Alden T, Tomita T, Vanin EF, Goldman S, Soares MB, Remke M, Ramaswamy V, Wang X, Jorgensen F, Morrissy AS, Marra M, Packer R, Bouffet E, Pfister S, Jabado N, Taylor M, Cole B, Rudzinski E, Anderson M, Bloom K, Lee A, Leary S, Leprivier G, Remke M, Rotblat B, Agnihotri S, Kool M, Derry B, Pfister S, Taylor MD, Sorensen PH, Dobson T, Busschers E, Taylor H, Hatcher R, Fangusaro J, Lulla R, Goldman S, Rajaram V, Das C, Gopalakrishnan V. TUMOUR BIOLOGY. Neuro Oncol 2014; 16:i137-i145. [PMCID: PMC4046298 DOI: 10.1093/neuonc/nou082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023] Open
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Patsaoura A, Tatsi E, Margeli A, Kanavaki I, Delaporta P, Kyriakopoulou D, Kouraklis-Symeonidis A, Kattamis A, Papassotiriou I. Plasma neutrophil gelatinase-associated lipocalin levels are markedly increased in patients with non-transfusion-dependent thalassemia: Lack of association with markers of erythropoiesis, iron metabolism and renal function. Clin Biochem 2014; 47:1060-4. [PMID: 24721683 DOI: 10.1016/j.clinbiochem.2014.03.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 03/17/2014] [Accepted: 03/28/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Neutrophil Gelatinase-Associated Lipocalin (NGAL) (known as NGAL, Lipocalin 2, Siderocalin, Uterocalin, proteinase-3 and 24p3) is a mammalian small 25-kD peptide that belongs to the lipocalin superfamily, which consists of about 20 small lipoproteins. NGAL was initially discovered as an antibacterial factor of natural immunity and an acute-phase protein. NGAL is also an iron trafficking protein, a member of the non-transferrin-bound iron (NTBI) pool and an alternative to the transferrin-mediated iron-delivery pathway. Of note, NTBI, which is elevated in thalassemic patients, induces cellular toxicity. In this study we investigated the possible association of NGAL with parameters of erythropoiesis, iron metabolism and renal injury in patients with non-transfusion-dependent thalassemia (thalassemia intermedia or TI). PATIENTS AND METHODS Thirty-five patients with TI, 13 men and 22 women, aged 8-63 years, were included in the study, while, 20 healthy individuals served as controls. Plasma NGAL levels were determined using an immunoenzymatic technique. Erythroid marrow activity was estimated by measuring soluble transferrin receptors (sTfR) levels with a turbidimetric technique. NTBI levels were determined using electrothermal atomic absorption spectrometry. Cystatin C, β2-microglobulin and hs-CRP concentrations were measured by means of immunonephelometric techniques. RESULTS The main results of the study showed: a) NGAL levels were significantly higher in patients with TI compared to controls (139.1 ± 86.1 vs 51.2 ± 11.8 μg/L, p<0.0001), without significant effect of splenectomy or hydroxyurea on NGAL levels. Only 4 patients had NGAL levels within the control group range, b) no correlation was found between NGAL levels and either the parameters of erythropoiesis Hb, Hb F, reticulocytes and sTfR (p>0.66, p>0.67, p>0.63 and p>0.81 respectively), or with those of iron metabolism ferritin and NTBI (p>0.90 and p>0.95 respectively). CONCLUSIONS The increased NGAL levels reported for the first time in TI patients in this study are in agreement with the elevated expression of NGAL observed in TI mouse models. We postulate that the induction of NGAL in these patients may represent either a survival response, facilitating the survival of the less damaged thalassemic erythroid precursors, or a consequence of the abnormal iron regulation in TI.
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Affiliation(s)
- Aikaterini Patsaoura
- Department of Clinical Biochemistry, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Elizabeth Tatsi
- Department of Clinical Biochemistry, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Alexandra Margeli
- Department of Clinical Biochemistry, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Ino Kanavaki
- Department of Clinical Biochemistry, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Polyxeni Delaporta
- First Department of Pediatrics, Athens University Medical School, Athens, Greece
| | | | | | - Antonios Kattamis
- First Department of Pediatrics, Athens University Medical School, Athens, Greece
| | - Ioannis Papassotiriou
- Department of Clinical Biochemistry, "Aghia Sophia" Children's Hospital, Athens, Greece.
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Mavrogeni S, Bratis K, van Wijk K, Kyrou L, Kattamis A, Reiber JHC. The reproducibility of cardiac and liver T2* measurement in thalassemia major using two different software packages. Int J Cardiovasc Imaging 2013; 29:1511-1516. [PMID: 23959438 DOI: 10.1007/s10554-013-0242-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 05/16/2013] [Indexed: 10/26/2022]
Abstract
In b-thalassemia major (TM) multiple blood transfusions are needed for survival. As a consequence these patients present iron overload in different organs, including heart and liver. Magnetic resonance imaging using a bright blood gradient echo sequence has been successfully used for the quantification of tissue iron. The aim is to evaluate of the accuracy and precision in the evaluation of liver and myocardial T2* values in TM using two different analytical software solutions. Thirty TM patients aged 20-56 years (mean age 37, 11M/19F) were scanned in a GE 1.5 T CVI system. Each scan included the measurement of heart and liver T2* and the left ventricular ejection fraction using standard techniques. The analysis of T2* of heart and liver was done using the two different analytical software solutions: the "Functool" protocol by GE and the T2* module of QMassMR v7.4 by Medis medical imaging systems bv, Leiden, The Netherlands. The cardiac and liver T2* measurements showed that both software solutions allow reproducible measurements with low intra-observer variations (accuracy < 0.3 ms, precision < 2 ms). There is a small but significant difference between the two solutions of 2.4 ms in cardiac and of 1.5 ms in liver measurements. However, from the clinical point of view these differences (<2 ms) are small with negligible impact on the patient's treatment management. The comparison of the T2* measurements using the two analytical software solutions proved that both techniques enable reproducible measurements for the evaluation of iron overload in heart and liver.
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Affiliation(s)
| | | | - Kees van Wijk
- Medis Medical Imaging Systems BV, P.O. Box 384, 2300 AJ, Leiden, The Netherlands.
| | | | | | - Johan H C Reiber
- Division of Image Processing, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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16
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Mavrogeni S, Bratis K, Papadopoulos G, Terrovitis J, Kitsiou A, Kattamis A, Papavassiliou A, Ageli K, Kolovou G. The Greek cardiac magnetic resonance experience: a comparison with the EuroCMR Registry. Hellenic J Cardiol 2013; 54:355-361. [PMID: 24100178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
INTRODUCTION We carried out an evaluation of Greek cardiovascular magnetic resonance (CMR) data in order to analyse the indications, safety, quality, and impact on management, in comparison with the EuroCMR registry. METHODS A retrospective analysis was performed of Greek CMR data from patients referred from 6 Greek cardiac clinics to 6 different MRI units in Athens that offer CMR services. A total of 10,000 CMR examinations carried out from 1995 to 2010 were evaluated retrospectively and included in the study. RESULTS Fifty percent of patients underwent evaluation for thalassaemic syndromes. In the remaining 50%, the most important indications were: a) workup of myocarditis/cardiomyopathies (40%), b) assessment of viability (5%), and c) congenital heart disease (5%). Image quality was good in 75%, moderate in 15%, and inadequate in 10% of cases. Complications occurred in 0.02%, including allergic reactions, dyspnoea, and panic attack. No death or cardiac complication was observed during or due to CMR; however, stress testing was not used in any of the cases. In 65% of all CMR studies, the initial diagnosis made by a non SCMR-trained person had no impact on the patients' management and did not offer any diagnostic contribution to referral clinicians, discouraging them from referring for CMR again. However, after the re-evaluation performed by an SCMR-trained person, the results of the Greek CMR were capable of satisfying all imaging needs in a percentage of patients equivalent to that presented in the EuroCMR registry (83% vs. 86%, p=NS), so that no further non-invasive imaging procedures would be required after CMR. CONCLUSIONS Thalassaemia and myocarditis were the most frequent CMR indications in Greece. However, the lack of training according to SCMR guidelines lowers the diagnostic efficacy significantly and leads to under-use of the technique.
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Kattamis C, Sofocleous C, Ladis V, Kattamis A. Athens University thalassemia expertise unit: evolution, structure, perspectives and patients' expectations. Georgian Med News 2013:94-98. [PMID: 24099821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Thalassemia Expertise Centres (TECs), were first organized in developed countries with high thalassemia prevalence in the 70's to meet the increasing demands of the implementation of frequent transfusions in the treatment of thalassemia, and to consequently adopt, the rapid advances in the management of the disease. Recent evaluation of longitudinal implementation of the national programs for prevention and treatment, demonstrated their efficacy for patients and public health. The beneficial effects focused on clinical symptoms amelioration, reduction of incidence and severity of complications and considerable improvement in survival, quality of life and social adaptation.National programs leaded to the modification of the most common genetic, fatal pediatric disease with short survival, to a chronic long-lived disease for adults and a very rare disease for children. In the few developed countries new perspectives for pediatric TECs need to be considered.
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Affiliation(s)
- C Kattamis
- Thalassemia Unit, First Department of Pediatrics, Athens University, "Aghia Sofia" Childrens' Hospital, Athens, Greece
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Delaporta P, Kattamis A, Apostolakou F, Boiu S, Bartzeliotou A, Tsoukas E, Papassotiriou I. Correlation of NT-proBNP levels and cardiac iron concentration in patients with transfusion-dependent thalassemia major. Blood Cells Mol Dis 2013; 50:20-4. [DOI: 10.1016/j.bcmd.2012.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 08/30/2012] [Accepted: 08/31/2012] [Indexed: 01/12/2023]
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Abstract
Osteoporosis is a major health problem affecting both men and women. Statins, besides their action as lipid-lowering agents, seem to have additional pleiotropic properties, among them a beneficial effect on bone mineral density. The entirety of experimental and the majority of clinical studies as well as the only relevant meta-analysis suggest that statins have an anabolic effect on bone metabolism. Statins, osteoporosis and adipogenesis share the same pathway, RANKL/OPG. It would appear that an imbalance in this pathway could be responsible for the manifestation of some metabolic disorders such as diabetes mellitus, atherogenesis, multiple myeloma, osteoporosis. Possibly in the future, drugs which can intervene in this biochemical and pathophysiological cascade, like statins, in a variety of doses, could be used for the management of ectopic ossification syndromes and other bone disorders, even as an additive treatment. Until then, further large longitudinal randomized controlled studies for each statin separately are required to confirm this hypothesis.
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Fryssira H, Makrythanasis P, Kattamis A, Stokidis K, Menten B, Kosaki K, Willems P, Kanavakis E. Severe Developmental Delay in a Patient with 7p21.1-p14.3 Microdeletion Spanning the TWIST Gene and the HOXA Gene Cluster. Mol Syndromol 2011; 2:45-49. [PMID: 22570644 DOI: 10.1159/000334313] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2011] [Indexed: 11/19/2022] Open
Abstract
We describe a patient with a rare interstitial deletion of chromosome 7p21.1-p14.3 detected by array-CGH. The deletion encompassed 74 genes and caused haploinsufficiency (or loss of allele) of 6 genes known to be implicated in different autosomal dominant genetic disorders: TWIST, DFNA5, CYCS, HOXA11, HOXA13, and GARS. The patient had several morphological abnormalities similar to Saethre-Chotzen syndrome (caused by TWIST mutations) including craniosynostosis of the coronal suture and anomalies similar to those seen in hand-foot-uterus syndrome (caused by HOXA13 mutations) including hypospadias. The combined phenotype of Saethre-Chotzen syndrome and hand-foot-uterus syndrome of our patient closely resembles a previously reported case with a cytogenetically visible small deletion spanning 7p21-p14.3. We therefore conclude that microdeletions of 7p spanning the TWIST gene and HOXA gene cluster lead to a clinically recognizable 'haploinsufficiency syndrome'.
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Affiliation(s)
- H Fryssira
- Department of Medical Genetics, University of Athens Medical School, Choremio Research Laboratory, 'Aghia Sophia' Children's Hospital, Athens, Greece
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Kattamis C, Lazaropoulou C, Delaporta P, Apostolakou F, Kattamis A, Papassotiriou I. Disturbances of biomarkers of iron and oxidant-antioxidant homeostasis in patients with beta-thalassemia intermedia. Pediatr Endocrinol Rev 2011; 8 Suppl 2:256-262. [PMID: 21705975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Disturbances of oxidative stress and antioxidant status have been reported in patients with Β-ThM and in a limited number of patients with ThI. OBJECTIVES To I) study relevant biomarkers of iron metabolism, oxidative stress and antioxidant status, in untransfused patients with ThI and II) evaluate the relation of changes in biomarkers to the clinicalhematological phenotype and genotype. DESIGN Biomarkers of iron metabolism (ferritin, NTBI, sTfR), of oxidant activity (MDA, GSSG, GSSC/GSHT, NO) and of antioxidant enzymes (GR, GPx, SOD) and Vitamins (E, C, A) were estimated and analyzed in 20 controls and 33 patients with ThI, sub-classified into mild (17) and severe (16) types. All but five were untransfused. RESULTS Clinical phenotypes of mild and severe ThI were related to distinct genotypes, 11 for mild and 14 for severe. The three iron biomarkers were significantly increased in both ThI types compared to controls and in severe compared to mild types. The ferritin levels (total iron load) had a highly significant positive correlation with age (p〈0.001) and sTfR. Biomarkers with oxidant activity were also significantly increased in ThI patients compared to controls; significantly higher levels for MDA, NTBI, and GSSG/GSHT were found in severe ThI. The activity of antioxidant enzymes GR, GP and SOD, was significantly significantly reduced in patients, especially in the severe type. Vitamin C was mildly reduced in both types of ThI. CONCLUSIONS Activity of relevant biomarkers of iron and oxidant-antioxidant homeostasis was significantly increased in untransfused patients with ThI. These changes coincide with the severity of clinical phenotype, genotype and bone marrow erythroid activity evaluated by sTfR levels.
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Affiliation(s)
- Christos Kattamis
- First Department of Pediatrics, Athens University Medical School, Athens Greece.
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Gizi A, Papassotiriou I, Apostolakou F, Lazaropoulou C, Papastamataki M, Kanavaki I, Kalotychou V, Goussetis E, Kattamis A, Rombos I, Kanavakis E. Assessment of oxidative stress in patients with sickle cell disease: The glutathione system and the oxidant–antioxidant status. Blood Cells Mol Dis 2011; 46:220-5. [DOI: 10.1016/j.bcmd.2011.01.002] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 12/23/2010] [Accepted: 12/24/2010] [Indexed: 01/29/2023]
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Komitopoulou A, Platokouki H, Kapsimali Z, Moschovi M, Kattamis A, Pergantou H, Aronis S. Mutations and Polymorphisms in Genes Affecting Haemostasis Components in Children with Thromboembolic Events. Pathophysiol Haemos Thromb 2007; 35:392-7. [PMID: 17230042 DOI: 10.1159/000097695] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Accepted: 09/18/2006] [Indexed: 11/19/2022]
Abstract
The distribution of mutations/polymorphisms in genes affecting haemostasis [factor V Leiden (FVL), FV H1298R (FVR(2)), FII 20210A, b-Fib 455G-->A, FXIII V34L, PAI-1 4G, HPA-1b] among 141 children with thrombosis at various sites and 103 controls was compared. Additionally, the carriage of these mutations/polymorphisms was associated with the levels of their corresponding proteins in thrombosed children. Thrombosis was more frequent in boys (p = 0.021). No studied mutation/polymorphism was found to be a risk factor for thrombosis, except for FVL (odds ratio 3.8, 95% CI 1.4-10.6). The risk of thrombosis for FVL carriers was twice as high in children with an idiopathic thrombosis (odds ratio 5.4) than in thrombosed children with an underlying disease or a triggering event (odds ratio 2.7). FVL carriers had an odds ratio of 5.9 (95% CI 1.8-19.6) when FVR(2) was absent. In thrombosed children, the activated protein C resistance ratio was significantly lower in the presence of FVL (p < 0.001). Prothrombin and fibrinogen levels, although higher in FII 20210A and b-Fib 455G-->A carriers, did not reach statistical significance.
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Affiliation(s)
- A Komitopoulou
- Haemostasis/Haemophilia Unit, University of Athens, Aghia Sophia Children's Hospital, Athens, Greece.
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Papassotiriou I, Stamoulakatou A, Wajcman H, Kister J, Dimisianos G, Lazaropoulou C, Kanavaki I, Vavourakis E, Kattamis A, Kanavakis E, Traeger-Synodinos J. Observation of a rare hemoglobin variant [Hb Lulu island, beta107(G9)Gly-->Asp, GGC-->GAC] co-inherited with a beta+-thalassemia mutation [IVS-I-110 (G-->A)] or in the heterozygous state in a Greek-Albanian family. Hemoglobin 2006; 30:409-18. [PMID: 16987796 DOI: 10.1080/03630260600867842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We report clinical, hematological, biochemical, functional and molecular studies carried out on two first cousins from a Greek-Albanian family who have clinical and hematological findings consistent with the diagnosis of thalassemia intermedia. DNA studies determined that they had co-inherited a common Mediterranean beta-thalassemia (thal) mutation, IVS-I-110 (G-->A), in trans to a beta-globin gene mutation at codon 107 (GGC-->GAC), predicted to give rise to a rare unstable beta chain variant Hb Lulu Island or beta107(G9)Gly-->Asp.
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Affiliation(s)
- Ioannis Papassotiriou
- Department of Clinical Biochemistry, Aghia Sophia Children's Hospital, Athens, Greece.
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Chakalova L, Osborne CS, Dai YF, Goyenechea B, Metaxotou-Mavromati A, Kattamis A, Kattamis C, Fraser P. The Corfu deltabeta thalassemia deletion disrupts gamma-globin gene silencing and reveals post-transcriptional regulation of HbF expression. Blood 2004; 105:2154-60. [PMID: 15536151 DOI: 10.1182/blood-2003-11-4069] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The 7.2 kilobase (kb) Corfu deltabeta thalassemia mutation is the smallest known deletion encompassing a region upstream of the human delta gene that has been suggested to account for the vastly different phenotypes in hereditary persistence of fetal hemoglobin (HPFH) versus beta thalassemia. Fetal hemoglobin (HbF) expression in Corfu heterozygotes and homozygotes is paradoxically dissimilar, suggesting conflicting theories as to the function of the region on globin gene regulation. Here, we measure gamma- and beta-globin gene transcription, steady-state mRNA, and hemoglobin expression levels in primary erythroid cells cultured from several patients with Corfu deltabeta thalassemia. We show through RNA fluorescence in situ hybridization that the Corfu deletion results in high-level transcription of the fetal gamma genes in cis with a concomitant reduction in transcription of the downstream beta gene. Surprisingly, we find that elevated gamma gene transcription does not always result in a corresponding accumulation of gamma mRNA or fetal hemoglobin, indicating a post-transcriptional regulation of gamma gene expression. The data suggest that efficient gamma mRNA accumulation and HbF expression are blocked until beta mRNA levels fall below a critical threshold. These results explain the Corfu paradox and show that the deleted region harbors a critical element that functions in the developmentally regulated transcription of the beta-globin genes.
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Affiliation(s)
- Lyubomira Chakalova
- Laboratory of Chromatin and Gene Expression, The Babraham Institute, Babraham Research Campus, Cambridge, CB2 4AT, United Kingdom
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Kattamis A, Dinopoulos A, Ladis V, Berdousi H, Kattamis C. Variations of ferritin levels over a period of 15 years as a compliance chelation index in thalassemic patients. Am J Hematol 2001; 68:221-4. [PMID: 11754409 DOI: 10.1002/ajh.1185] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We studied the changing pattern of the distribution of ferritin levels in 430 regularly-transfused patients with thalassemia in an attempt to evaluate compliance of chelation with deferoxamine. The study covered 15 years and was divided in three periods: 1981-1985, 1986-1990, and 1991-1995. The patients were stratified in age-groups. The mean ferritin levels of each period were calculated for each patient individually. The study showed that: (i) When all the patients were compared as a group, there was a significant decrease in mean ferritin between 1981-1985 and 1991-1995, despite a significant change in the patients' mean age; (ii) When patients of same age were compared between periods, there was a decrease in mean ferritin between 1981-1985 and 1991-1995, as well as a decrease in the proportion of patients with ferritin >4000 microg/L, with a parallel increase in the proportion of patients who had ferritin <2000 microg/L; (iii) When the same patients were followed longitudinally, they showed a decrease in their ferritin levels in all age groups with the exception of the late adolescence period. The decrease in iron overload observed in patients on close follow up implies that compliance with chelation therapy has improved with time and therefore, a favourable influence in survival could be expected.
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Affiliation(s)
- A Kattamis
- First Department of Pediatrics, University of Athens, Aghia Sophia Children's Hospital, Athens, Greece.
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Nicolatou-Galitis O, Papadaki T, Moschovi M, Moshovi M, Kamma JJ, van Vliet-Constantinidou C, Tsoumakas C, Kattamis A, Tzortzatou-Stathopoulou F. Gingival overgrowth as the initial paraneoplastic manifestation of Hodgkin's lymphoma in a child. A case report. J Periodontol 2001; 72:107-12. [PMID: 11210066 DOI: 10.1902/jop.2001.72.1.107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The purpose of this paper is to present the first case of gingival overgrowth, premature root resorption, and alveolar bone loss, which preceded the diagnosis of a stage IVB Hodgkin's lymphoma (HL) in a 9-year-old boy. METHODS The child presented complaining of gingival pain which first appeared 3 months prior. Clinical examination revealed inflamed, hyperplastic gingivae, while x-ray showed premature root resorption and alveolar bone loss. Medical work-up was significant for cervical lymphadenopathy. Gingival biopsy, followed by lymph node resection, was performed twice. RESULTS Histological examination of both gingival biopsies disclosed a mixed inflammatory infiltrate, while classical Hodgkin's lymphoma of the nodular sclerosis type was diagnosed from the second lymph node biopsy. Chemotherapy was instituted with mustard-vincristine-procarbazine-prednizone and adriamycine-bleomycine-vinblastine-dacarbazine. Remission of the lymphoma was observed with concomitant regression of the gingival overgrowth. CONCLUSIONS The inflammatory gingival overgrowth, premature root resorption of deciduous teeth, and alveolar bone loss in this case, in conjunction with the regression of gingival overgrowth which followed the completion of chemotherapy, are strongly indicative of a paraneoplastic manifestation of HL. The postulated mechanism for the development of the manifestation is the constitutive activation of the transcription factor NF-kB. The gingival inflammatory reaction was probably further aggravated by the bacterial-stimulated cytokine secretion released by monocytes.
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Affiliation(s)
- O Nicolatou-Galitis
- Department of Oral Pathology and Surgery, School of Dentistry, University of Athens, Greece.
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Peristeri J, Kitra V, Goussetis E, Petropoulos D, Theodosaki M, Kattamis A, Graphakos S. Haematopoietic stem cell transplantation for the management of haemoglobinopathies in Greek patients. Transfus Sci 2000; 23:263-4. [PMID: 11099911 DOI: 10.1016/s0955-3886(00)00103-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- J Peristeri
- Bone Marrow Transplantation Unit, St. Sophia Children's Hospital, 115 27 Athens, Greece.
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Papanikolaou N, Ghiatas A, Kattamis A, Ladis C, Kritikos N, Kattamis C. NON-INVASIVE MYOCARDIAL IRON ASSESSMENT IN THALASSAEMIC PATIENTS. T2 relaxometry and magnetization transfer ratio measurements. Acta Radiol 2000. [DOI: 10.1034/j.1600-0455.2000.041004348.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Papanikolaou N, Ghiatas A, Kattamis A, Ladis C, Kritikos N, Kattamis C. Non-invasive myocardial iron assessment in thalassaemic patients. T2 relaxometry and magnetization transfer ratio measurements. Acta Radiol 2000; 41:348-51. [PMID: 10937756 DOI: 10.1080/028418500127345442] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To compare T2 relaxometry and magnetization transfer ratio (MTR) measurements of myocardial tissue in normal volunteers and thalassaemic patients for assessment of the myocardial iron levels. MATERIAL AND METHODS All examinations were done on a 1 T MR system using a multi-echo spin-echo sequence with 8 echoes for T2 measurements and a gradient echo sequence for MTR measurements. Diastolic cardiac triggering was used in both sequences. Ten patients and 10 normal subjects were included in the study. T2 and MTR measurements were correlated with serum ferritin levels. RESULTS Regression analysis between T2 and MTR measurements and ferritin demonstrated a reversed linear relationship, (r=-0.932, p<0.05) and (r= -0.824, p<0.05), respectively. Mean T2 relaxation time and mean MTR of the normal subjects (57.95+/-4.9 ms and 43.70+/-3.3%) was significantly higher than that of the thalassaemic patients (38.8+/-6.2 ms and 26.40+/-6.1%) (p<0.01), respectively. CONCLUSION MTR measurements can be used to complement T2 measurements for non-invasive myocardial iron assessment.
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Affiliation(s)
- N Papanikolaou
- Philips Greece Medical Systems, Department of MR Clinical Science, Agia Sophia Childrens Hospital, Athens
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Goussetis E, Peristeri J, Kitra V, Kattamis A, Petropoulos D, Papassotiriou I, Graphakos S. Combined umbilical cord blood and bone marrow transplantation in the treatment of beta-thalassemia major. Pediatr Hematol Oncol 2000; 17:307-14. [PMID: 10845229 DOI: 10.1080/088800100276299] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
The authors report on three children with beta-thalassemia major, class II, III, and III according to the Pesaro classification, with a body weight of 16, 62, and 50 kg, respectively, who received grafts using both umbilical cord blood (UCB) and bone marrow (BM) stem cells from their HLA-matched siblings. The number of UCB nucleated cells collected was 2 x 10(7)/kg, 1.2 x 10(7)/kg, and 2.5 x 10(7)/kg, respectively, and was considered insufficient to secure engraftment. The authors increased the number of hematopoetic progenitors by harvesting BM from the same donors. All 3 patients showed prompt engraftment with neutrophil recovery on days 17, 18, and 17 post-transplant, respectively, and platelet recovery on days 19, 25, and 22 post-transplant, respectively. One patient had remarkably increased HbF of values 31, 19, and 12% at 3, 6, and 12 months post-transplant, respectively, which were accompanied by an increase in the G gamma/A gamma ratio, suggesting UCB-derived hematopoetic reconstitution. All patients are alive and transfusion independent 23, 18, and 16 months post-transplant, respectively. For patients with homozygous beta-thalassemia who are at high risk of graft failure, either because of major prior alloimmunization or an insufficient amount of UCB stem cells, combined transplantation with UCB and BM could offer a quick and safe alternative therapy.
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Affiliation(s)
- E Goussetis
- Bone Marrow Transplantation Unit, Aghia Sophia Children's Hospital, Athens, Greece.
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Abstract
PURPOSE Immune reconstitution was studied in 30 children who had received purged autologous bone marrow transplantation for neuroblastoma or acute myeloid leukemia (AML). METHODS Patients with neuroblastoma received high-dose chemotherapy and total body irradiation, and patients with AML received chemotherapy alone. Marrows were purged ex vivo with either antineuroblastoma monoclonal antibodies (neuroblastoma) or 4-hydroperoxycyclophosphamide (AML). Lymphocyte subsets, mitogen stimulation studies, and immunoglobulin levels were studied every 4 months. RESULTS There were no significant differences between the two groups of patients in lymphocyte number or subsets over time. In both groups, CD2+ and CD4+ cells were below normal in 33% of patients at 12 months. CD4+/CD8+ ratios were below normal for up to 8 months after transplantation and natural killer cells were elevated for up to 2 years in most patients. Median IgG and IgA levels were below the age mean even at 2 years after transplantation, although patients with AML had significantly higher IgG levels at 12 months compared with those with neuroblastoma. Lymphocyte proliferative responses to mitogens were markedly reduced at 4 months but returned to normal at 8 months. Despite the delay in immune reconstitution, there were no life-threatening infections. CONCLUSIONS There appeared to be little difference in the overall kinetics of immune reconstitution between the children with neuroblastoma, who received total body irradiation and high-dose chemotherapy, and those with AML, who received high-dose chemotherapy alone as their pretransplant preparative regimen.
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Affiliation(s)
- N Kamani
- Division of Oncology, The Children's Hospital of Philadelphia, PA, USA
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Kostaridou S, Ladis V, Kattamis A, Laras A, Hadziyannis SJ. HBeAg-negative hepatitis B in a previously thalassemic patient during immunosuppressive therapy for chronic GVHD. Bone Marrow Transplant 1998; 22:919-21. [PMID: 9827822 DOI: 10.1038/sj.bmt.1701433] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We report the case of a 15-year-old previously thalassemic girl who, 15 months after allogeneic BMT, developed HBeAg-negative hepatitis B (variant with mu-1896). In the absence of another route of transmission, HBV reactivation is postulated. The time of emergence of the HBV variant (with mu-1896) is probably related to the development of anti-HBe immunity. This mutant strain is associated with fulminant hepatitis. The patient achieved complete remission and HBV eradication despite having moderate GVHD and receiving immunosuppressive therapy.
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Affiliation(s)
- S Kostaridou
- First Department of Pediatrics, Aghia Sophia Children's Hospital, University of Athens, Greece
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Abstract
PURPOSE We assessed the value of marrow cultures for defining the pathophysiology, diagnosis, and therapeutic response to immunosuppressive therapy in childhood pure red cell aplasia (PRCA). PATIENTS AND METHODS Patients were evaluated either at diagnosis (n = 23) or at the time of treatment failure (n = 2). Twelve patients had transient erythroblastopenia of childhood (TEC), 4 had Diamont-Blackfan anemia (DBA), and 9 had acquired sustained PRCA (A-Su-PRCA). Bone marrow mononuclear cells were cultured with combination of human recombinant (rhu) erythropoietin (EPO), granulocyte monocyte colony stimulating factor (GM-CSF), granulocyte colony stimulating factor (G-CSF), Interleukin 3 (IL-3), either with or without stem cell factor (SCF), and burst forming unit of erythroid (BFU-E) growth was assessed. RESULTS The combination of growth factors without SCF failed to induce any erythropoiesis (BFU-E < 10/10(5) mononuclear cells) in 10 patients (2 with TEC, 2 with DBA, and 6 with A-Su-PRCA), although the growth of erythroid colonies was substantially lower in the remaining patients than in controls (45.5 +/- 15.4 versus 91.7 +/- 12.7, p < 0.05). Addition of SCF restored erythropoiesis in all but 6 patients (5 with A-Su-PRCA and 1 with DBA). Five of 6 nonresponders did not respond to any immunomodulating therapy; of the 5, 3 had or developed some evidence of myelodysplasia. CONCLUSION Our data indicate that in vitro colony studies might prove to be a useful diagnostic tool, because erythropoiesis' poor response to growth factors, including SCF, may suggest the diagnosis of myelodysplasia. Moreover, it may have predictive value; in cases of PRCA, regardless of etiology, poor growth of erythropoietic colonies may predict refractoriness to immunomodulating therapy.
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Affiliation(s)
- E S Gussetis
- Bone Marrow Transplantation Unit, University of Athens, Aghia Sophia Children's Hospital Thivon and Levadias, Athens, Greece
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Affiliation(s)
- D K Shah
- Department of Radiation Oncology, The University of Pennsylvania School of Medicine, Philadelphia, USA
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Gomez J, Kattamis A, Schenck RC. Pseudothrombophlebitis in an adolescent without rheumatic disease. A case report. Clin Orthop Relat Res 1994:250-3. [PMID: 7955690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Pseudothrombophlebitis syndrome is the occurrence of calf pain and swelling caused by extrinsic compression of the popliteal vessels by an enlarging Baker's cyst or by calf inflammation that occurs as the result of a ruptured Baker's cyst. Few cases of pseudothrombophlebitis syndrome have been reported in patients less than 18 years of age, and nearly all these young patients had juvenile rheumatoid arthritis. Reported here is the case of a 17-year-old male patient without rheumatic disease who presented to the outpatient clinic with a 1-week history of an increasingly painful swelling of the right calf without any history of precipitating factors for a deep vein thrombosis.
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Affiliation(s)
- J Gomez
- Department of Pediatrics, University of Texas Health Science Center, San Antonio 78284-7774
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Traeger-Synodinos J, Kanavakis E, Tzetis M, Kattamis A, Kattamis C. Characterization of nondeletion alpha-thalassemia mutations in the Greek population. Am J Hematol 1993; 44:162-7. [PMID: 8213764 DOI: 10.1002/ajh.2830440305] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
alpha-Thalassemia is usually due to deletions within the alpha-globin gene cluster, leading to loss of function of one (-alpha) or both [-(alpha) or --] alpha-globin genes. Nondeletion mutations (denoted alpha alpha T or alpha T alpha) are less frequent and in Greece are not well defined. We report the analysis of 16 nondeletion alpha-thalassemia chromosomes using a polymerase chain reaction method to amplify specifically the alpha 2-globin gene, which was subsequently screened using ASO hybridization or restriction enzyme analysis for four mutations already characterized in other Mediterranean and Middle Eastern populations. Of the 16 nondeletion chromosomes, nine had the polyadenylation signal mutation (alpha PolyA alpha), two the IVSI 5' pentanucleotide deletion (alpha Hph alpha), two the Hb Icaria mutation (alpha Ic alpha), and one the initiation codon mutation (alpha Nco alpha). In two, the defects are still undefined. These findings show that nondeletion alpha-thalassemia in Greece is heterogeneous and that the most frequent mutation (accounting for > 50%) is the polyadenylation signal mutation, which to date was most commonly found in the Saudi Arabian population.
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Affiliation(s)
- J Traeger-Synodinos
- First Department of Pediatrics, Athens University, St. Sophie's Children's Hospital, Greece
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Affiliation(s)
- C Kattamis
- First Department of Pediatrics, St Sophie's Children's Hospital, Athens University, Greece
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