Women and girls with haemophilia and bleeding tendencies: Outcomes related to menstruation, pregnancy, surgery and other bleeding episodes from a retrospective chart review

Introduction

Women or girls with haemophilia (WGH) represent a group of female symptomatic carriers who experience bleeding events more frequently than non‐carriers. Bleeding events include spontaneous/traumatic bleeds and prolonged bleeding related to surgery, menstruation and pregnancy. Challenges for the treatment of WGH include lack of screening, diagnosis and treatment guidelines.

Aim

Evaluate clinical characteristics, haemostasis management and clinical outcomes regarding menstruation, childbirth, dental procedures, surgeries and other bleeding events in WGH.

Methods

A retrospective, non‐interventional review of medical records from WGH among three haemophilia treatment centres (HTCs) was conducted in the United States (2012–2018). Patients with ≥2 visits to the HTC and who had undergone intervention for haemostasis management with the outcome documented were included. Descriptive statistics were used.

Results

Of 47 women and girls included in the chart review (37 with factor VIII deficiency, 10 with factor IX deficiency), median age at diagnosis was 22.6 years. Approximately 79% (n = 37) were diagnosed with mild haemophilia. Events of interest were primarily managed by factor concentrates or antifibrinolytics. Most treatment approaches were successful across clinical scenarios, except for heavy menstrual bleeding being insufficiently controlled in 8 (57%) of the 14 patients who experienced it.

Conclusions

Bleeding events in WGH, such as excessive and prolonged bleeding during menstruation, demonstrate a unique burden and require specific medical intervention. These results highlight the importance of assessing the need for haemostasis management in WGH and may contribute to future prospective study designs.

Real-world data demonstrate improved bleed control and extended dosing intervals for patients with haemophilia B after switching to recombinant factor IX Fc fusion protein (rFIXFc) for up to 5 years

Introduction

In clinical trials, recombinant factor IX fusion protein (rFIXFc) has demonstrated safety, efficacy and prolonged activity with extended dosing intervals for treatment of haemophilia B.

Aim

To assess the real‐world clinical utility of rFIXFc in a variable patient population and routine clinical practice.

Methods

A multicentre, retrospective chart review was conducted of patients with haemophilia B who had received rFIXFc prophylaxis or on‐demand treatment for ≥6 months across six sites in the United States.

Results

Sixty‐four eligible patients were identified who had a median (range) duration on rFIXFc of 2.7 (0.5‐5.0) years. Of 32 patients on rFIXFc prophylaxis who switched from prophylaxis with another factor treatment (ie pre‐rFIXFc) and had a known pre‐rFIXFc dosing interval, the initial dosing interval was lengthened for 26 (81%) patients and maintained for the remaining 6 (19%) patients. Most (n = 48 [91%]) patients who received rFIXFc prophylaxis from the beginning to the end of the chart review period (n = 53) maintained or lengthened the dosing interval from first through last dose of rFIXFc. For patients receiving rFIXFc prophylaxis, there was an approximate 50% reduction in weekly factor consumption compared with pre‐rFIXFc prophylaxis. Overall annualized bleed rates, annualized spontaneous bleed rates and annualized joint bleed rates decreased after switching to rFIXFc prophylaxis (n = 24 with bleed data). Compliance to recommended treatment improved or remained stable in most patients with available data (30/31).

Conclusion

Recombinant factor IX fusion protein prophylaxis improved bleed control, reduced overall consumption, reduced frequency of infusion and improved compliance for patients with haemophilia B in a real‐world setting.

Molecular characterization of Orientia tsutsugamushi serotypes causing scrub typhus outbreak in southern region of Andhra Pradesh, India

Background & objectives:

Scrub typhus is a vector-borne zoonotic infection caused by Orientia tsutsugamushi. Local epidemiology of the circulating serotypes of scrub typhus is not available from most parts of India. We conducted this study for the diagnosis of scrub typhus using IgM ELISA and to detect O. tsutsugamushi serotypes circulating in southern Andhra Pradesh, India.

Methods:

Samples were collected from patients clinically suspected to have scrub typhus and were subjected to IgM ELISA to measure IgM antibodies against O. tsutsugamushi. Nested polymerase chain reaction (PCR) was performed targeting strain-specific regions in ELISA-positive samples.

Results:

Of a total of 663 samples, 258 (38.91%) were found to be positive by IgM ELISA. Serotypes could be detected in 230 (34.69%) samples only. Only two serotypes, Karp and Kawasaki, were found in the serum samples, with the former being predominant. The dual infection of Karp and Kawasaki serotypes was found in seven patients. Other serotypes such as Gilliam, Kuroki and Kato were not detected in the samples.

Interpretation & conclusion:

The nested PCR products proved useful in presumptively identifying the endemic O. tsutsugamushi serotypes. The present study could be significant in understanding scrub typhus epidemiology in this region.

Effect of 4-methoxy 1-methyl 2-oxopyridine 3-carbamide on Staphylococcus aureus by inhibiting UDP-MurNAc-pentapeptide, peptidyl deformylase and uridine monophosphate kinase

AIMS

The present study aimed to investigate the anti-Staphylococcus aureus and anti-biofilm properties of 4-methoxy-1-methyl-2-oxopyridine-3-carbamide (MMOXC) on S. aureus UDP-MurNAc-pentapeptide (MurF), peptidyl deformylase (PDF) and uridine monophosphate kinase (UMPK).

METHODS AND RESULTS

The in vitro efficacy of MMOXC was evaluated using quantitative polymerase chain reaction, in vitro assays and broth microdilution methods. Further, the minimum inhibitory concentration (MIC), IC₅₀ and zone of inhibition were recorded in addition to the anti-biofilm property. MMOXC inhibited pure recombinant UMPK and PDF enzymes with a K_i of 0·37 and 0·49 μmol l^-1 . However K_i was altered for MurF with varying substrates. The MurF K_i for UMT, d-Ala-d-Ala and ATP as substrates was 0·3, 0·25 and 1·4 μmol l^-1 , respectively. Real-time PCR analysis showed a significant reduction in PDF and MurF expression which correlated with the MIC₉₀ at 100 μmol l^-1 and IC₅₀ in the range 42 ± 1·5 to 50 ± 1 μmol l^-1 against all strains tested. At 5 μmol l^-1 MMOXC was able completely to remove preformed biofilms of S. aureus and other drug resistant strains.

CONCLUSIONS

MMOXC was able to kill S. aureus and drug resistant strains tested by inhibiting MurF, UMPK and PDF enzymes and completely obliterated preformed biofilms.

SIGNIFICANCE AND IMPACT OF THE STUDY

Growth reduction and biofilm removal are prerequisites for controlling S. aureus infections. In this study MMOXC exhibited prominent anti-S. aureus and anti-biofilm properties by blocking cell wall formation, RNA biosynthesis and protein maturation.

Comparative evaluation of recombinant HSP70 (N & C-terminal) fragments in the detection of equine trypanosomosis

Trypanosomosis (Surra) is an economically important disease caused by Trypanosoma evansi which is an extracellular parasite present in the plasma, tissues and other body fluids of a wide range of hosts including domesticated animals. Currently, serological reports are based on detection of antibodies by ELISA using whole cell lysate (WCL) antigen, which has a limitation of persistence of anti-trypanosomal antibodies after successful treatment of the disease. Moreover, it has some ethical issues also like requirement of mice for in vivo maintenance of parasite for preparing the antigen. Therefore, in the present study, an attempt was made to evaluate the in vitro production of recombinant heat shock protein 70 (HSP70) for detection of antibodies in experimentally infected ponies. The amino acid sequence analysis of HSP70 revealed that N-terminal region of the protein was highly conserved while the C-terminal region was most divergent. The four different regions of HSP70 protein viz. HSP-1, HSP-2, HSP-3 and HSP-4 were cloned and expressed, among which HSP-1 (N-terminal region) & HSP-2 (C-terminal region) were truncated while HSP-3 & HSP-4 were complete C-terminal proteins. The recombinant fragments were probed with sequentially pooled experimental serum samples where antibodies were detected in these fragments from 10(th) day post infection till the termination of the experiment. Further, these recombinant fragments were also comparatively evaluated with WCL antigen in ELISA using experimental as well as field serum samples. It was observed that after successful treatment of infected ponies, there was a sharp fall in antibodies (within 90 days) when tested with recombinant HSP's fragments, while antibodies persisted even after 469 days when tested against WCL antigen. The sensitivity and specificity of all HSP70 fragments were also estimated from field serum samples with reference to WCL antigen ELISA. The HSP-1 showed minimum sensitivity (41.03%) among all the recombinant fragments. Among the C-terminal fragments, maximum sensitivity was observed with the HSP-2 (61.54%) while minimum was observed with HSP-4 (48.72%). The specificity increases for recombinant fragments from N-terminal to C-terminal region of protein and maximum specificity was observed with HSP-4 fragment (91.3%).

Cutaneous fungal infection in a renal transplantation patient due to a rare fungus belonging to order Pleosporales

Fungal infections are being increasingly reported from immuno-compromised as well as immuno-competent patients. Transplant patients are on long term immunosuppressive therapy which makes them highly vulnerable to opportunistic fungal infections .These infections can be cutaneous or systemic. Several fungi have been reported to be the culprits such as Candida spp., Aspergillus spp., C. neoformans, P. carinii, and zygomycetes group of fungi. Cutaneous infections are most commonly caused by Pityriasis (tinea) versicolor, dermatophytes, and candida sp but these days the demtiaceous fungi are becoming more frequently reported .Here we report a case of post renal transplant cutaneous infection caused by dematiaceous fungus belonging to the order Pleosporales.

Abstract P3-07-05: Frequent BRCA1 and BRCA2 mutations are found in Mexican and Mexican-American women with breast cancer

Background: The Arizona Cancer Registry has shown that in Pima County, AZ, breast cancer diagnosed in young Latinas increased 40% from 2004-2008, compared to 1999-2003, and Latinas more likely to die of their cancer. This study seeks to characterize genetic variation in women of Mexican ancestry with breast cancer using next generation sequencing, with the goal of providing prevalence information to help guide screening and cancer prevention efforts.

Methods: The ELLA Binational Breast Cancer Study enrolled women of Mexican ancestry living in either U.S. or Mexico within 24 months of breast cancer diagnosis. Mexican women from the state of Jalisco were collected through collaboration with the Universidad de Guadalajara and women of Mexican ancestry were recruited from Tucson and Phoenix, AZ. Genomic DNA from 92 ELLA study participants (49 from the U.S. and 43 from Mexico) was enriched for breast cancer influencing gene sequence using the BROCA panel with standard techniques. Samples were sequenced with next generation sequencing and variants identified.

Results: Sequencing of breast cancer risk genes in 92 Mexican and Mexican-American women with breast cancer revealed the presence of deleterious mutations in 15% of women (14/92). Five carry mutations in BRCA1, 5 in BRCA2, 2 in CHEK2, 1 in PALB2 and 1 in RAD51C. An additional 9% of participants (8/92) carry rare mutations of unknown functional consequence in the same genes. Four carry mutations in BRCA1 or BRCA2 at sites predicted to alter splice enhancers and four carry missense mutations in CHEK2 that are predicted to damage to kinase function. None of these variants appear in public databases or are characterized functionally in gene-specific databases. Dozens of women carry VUS or novel variants.

Women carrying BRCA1 mutations are significantly more likely to have had triple negative pathology. Women carrying other mutations known or thought to be deleterious are also more likely to have been younger at diagnosis, to have more aggressive breast cancer or to report a family history of breast cancer.

Table 1. Deleterious MutationsGeneEffectTotalBRCA1185delAG1BRCA12569delC2BRCA1Del Complete Gene1BRCA1Del Exons 9-121BRCA2c.658delGT1BRCA2c.3264insT2BRCA2c.5195delT1BRCA2c.6024insG1CHEK2R160G2PALB2S779 Stop1RAD51CDel Exons 4-91

Conclusion: Deleterious BRCA1 and BRCA2 gene mutations are common among women of Mexican ancestry diagnosed with breast cancer. Within this cohort, the prevalence of BRCA1/2 mutations is 11%, and 4% of women carry mutations in other genes increasing breast cancer risk. This is higher than the 10% mutation prevalence estimated for Ashkenazi Jewish women with breast cancer. An additional 9% of women carry variants likely to disrupt gene function and dozens of VUS and novel variants are found in these women. Further analysis of samples from the remaining 942 women using genetic sequencing will help further elucidate the role of genetic risk factors in women of Mexican ancestry with breast cancer.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-07-05.

Abstract A018: Genomic evaluation of inherited predisposition to breast cancer in women from the University of Arizona Cancer Center High Risk Breast Cancer Genetics Clinic

Background: One in 8 women will develop breast cancer over the course of her lifetime, making it the most common cancer affecting women and the 2nd leading cause of cancer death. 20% of women with breast cancer have 1 or more family members who have also been diagnosed. In 25% of familial cases, cancer occurs in both the breast and ovaries and is attributable to deleterious mutations in BRCA1/BRCA2 DNA repair genes. A woman with a BRCA gene mutation has an 85% lifetime risk for developing breast cancer and 20-60% risk for ovarian cancer. The remaining 75% of susceptibility is polygenic in nature and a large number of low-penetrance genes are involved. This project builds on the discovery of new breast cancer influencing genes that interact with BRCA1 and BRCA2 to function in DNA repair. Here, we utilize next generation parallel sequencing techniques to determine if 89 genes of interest thought to play a role in breast cancer susceptibility are found in women with strong family histories of breast cancer enrolled in the University of Arizona Cancer Center High Risk Breast Cancer Genetics Clinic (UACC BCGC).

Methods: The UACC BCGC is a unique and well-developed resource that is vital to the success of this translational project. The purpose of the high risk breast cancer genetics clinic is to provide cancer risk assessment and to manage surveillance and risk-reduction strategies in a cohort of high-risk women. This University of Arizona IRB-approved registry for epidemiologic and medical record information has been accruing for the past five years, and 182 subjects are currently enrolled with additional women being regularly recruited. Fifty-one (28%) of current UACC BCGC registry participants have identified BRCA1 or BRCA2 mutations and this study seeks genetic risk factors for cancer in other registry participants. The 72% of participants in the UACC BCGC database without identified BRCA mutations fall into four categories: 1) untested for BRCA mutations, 2) affected relative tests negative for deleterious BRCA mutation, 3) unaffected participant tests negative for deleterious BRCA mutation, and 4) BRCA negative participant diagnosed with breast cancer or “pre cancer”. Participants in categories 1, 2, and 4 were recruited. Genomic DNA was captured from the initial cohort of BCGC samples using Agilent Technologies HaloPlex protocols to enable additional analysis of novel custom genes of interest in addition to the University of Washington developed BROCA panel. Captured library DNA was denatured and subjected to cluster amplification on a Paired End Flow Cell in paired-end libraries with ~200 bp insert size, and sequenced on an Illumina HiSeq2000 instrument with 100 bp read lengths.

Results: We expect that our preliminary analysis will show variation within these 89 genes may explain up to 50% of breast cancer risk in families with a strong pattern of breast cancer enrolled in the UACC BCGC. It is our hope that discovering the genetic risk factors at work in high risk families will help clarify individual risk and that this genetic information can be utilized to improve the management of at-risk women. Population frequency of variation is a major thrust of this project and future studies will probe penetrance. Long terms goals include expanding our recruitment of patients and their family members to allow prospective analysis to determine if these heritable mutations correlate with development of other types of cancer.

Discussion: Women with strong personal and family histories of breast cancer are routinely tested for mutations in the BRCA1 and BRCA2 genes, but other gene testing is not generally available or offered. Researchers continue to study the genetic basis of the remaining familial breast cancer cases, and mutations in more than a dozen additional breast cancer risk genes have been identified. Some of these genes are highly penetrant with effect sizes similar to BRCA1 and BRCA2 (>5x increased lifetime risk), while others confer more moderate breast cancer risk (2-5x). Testing for most of these gene mutations is not yet available clinically and information in mutation status is difficult to interpret because we lack knowledge of the degree of risk conferred and/or the prevalence of these mutations in the general population. Discovering genetic risk factors at work in high risk families using our expanded panel at the UACC BCGC will help clarify individual risk and this genetic information can be utilized to improve the management of at-risk women. Identifying these patients is important because we can suggest specific cancer prevention options based on genetics. We can increase the chance of identifying cancer early and at a more treatable non-invasive stage by using intensive screening, recommending preventive medication, and/or risk reducing surgery to decrease the chance of developing invasive breast cancer in high risk individuals.

Citation Format: Ateefa Chaudhury, Corina Mauss, Joanne Jeter, Christina Laukaitis. Genomic evaluation of inherited predisposition to breast cancer in women from the University of Arizona Cancer Center High Risk Breast Cancer Genetics Clinic. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Breast Cancer Research: Genetics, Biology, and Clinical Applications; Oct 3-6, 2013; San Diego, CA. Philadelphia (PA): AACR; Mol Cancer Res 2013;11(10 Suppl):Abstract nr A018.

Isolation, speciation, and antibiogram of clinically relevant non-diphtherial Corynebacteria (Diphtheroids)

PURPOSE

Coryneform or the non-diphtherial Corynebacterium species largely remains a neglected group with the traditional consideration of these organisms as contaminants. This concept, however, is slowly changing in the light of recent observations. This study has been done to find out the species distribution and antibiogram of various members of the clinically relevant Coryneform group, isolated from various clinical materials.

MATERIALS AND METHODS

One hundred and fourteen non-duplicate isolates of diphtheroids from various clinical isolates were selected for the study. The isolates were identified to the species level by using a battery of tests; and antimicrobial susceptibility was tested by using a combination of Clinical and Laboratory Standards Institute (CLSI) and the British Society for Antimicrobial Chemotherapy (BSAC) guidelines, in the absence of definitive CLSI guidelines.

RESULTS

Corynebacterium amycolatum was the predominant species (35.9%) in our series followed by the CDC Group G organisms (15.7%). Each of the remaining 19 species comprised of less than 10% of the isolates. More than half the total isolates were resistant to the penicillins, erythromycin, and clindamycin; while excellent activity (all the strains being susceptible) was shown by vancomycin, linezolid, and tigecycline. Chloramphenicol and tetracycline also had good activity in inhibiting more than 80% of the isolates. Multiply drug resistance was exhibited by all the species.

CONCLUSION

This study was an attempt to establish the clinical significance of coryneform organisms. The high level of resistance shown by this group to some of the common antibacterial agents highlights the importance of processing these isolates in select conditions to guide the clinicians towards an appropriate therapy.

Isolation of Legionella pneumophila from clinical & environmental sources in a tertiary care hospital

BACKGROUND & OBJECTIVES

Legionella pneumophila and other members of this genus are important respiratory pathogens but legionellosis often remains a neglected and under reported condition. Hence, this study was done to find out the presence of this organism in patients admitted to a tertiary care hospital with community-acquired pneumonia (CAP).

METHODS

A total of 470 lower respiratory tract samples and 24 water samples from hospital outlets were examined. Culture was done on buffered charcoal yeast extract agar with supplements and identification of the isolates was done by microscopy and biochemical tests.

RESULTS

L. pneumophila could be isolated from 12 (2.55%) patients suffering from community-acquired lower respiratory tract infection, unassociated with other aetiological agents of bacterial pneumonia. Of the 24 water samples tested, 8 (33.3%) grew the same organism.

INTERPRETATION & CONCLUSION

Our study has shown that Legionella is present in the hospital environment and was the aetiological agent of lower respiratory tract infection in 2.55 per cent of patients. A larger study and reports from other parts of the country may help in determining the true significance of legionellosis in India.

Cell shape is a key determinant of estrogen biosynhesis in adipose stromal cells

Abstract #5061

BACKGROUND: Accumulating evidence suggests that obesity is a high risk factor for breast cancer among post-menopausal women, which can at least partially be explained by the contribution of adipose tissue to local and circulating estrogen. In response to tumor cell-secreted cytokines, adipose stromal cells (ASCs) express a large amount of aromatase, a key enzyme in estrogen biosynthesis and a clinically proven target for breast cancer therapy. Increased estrogen production from ASCs in turn stimulates hormone-dependent tumor growth, creating a “vicious cycle” between estrogen-dependent tumor cells and estrogen-producing ASCs that is conducive to mammary tumorigenesis. In contrast to our knowledge of aromatase expression in tumor-associated ASCs, relatively little is known about its regulation in ASCs under disease-free conditions. Could aromatase expression in ASCs be induced without the presence of tumor cells? Is there any genetic or epigenetic difference in the inducibility of aromatase expression in cancer-free individuals? If so, might the difference be related to breast cancer risk?
 Material and Methods: ASCs were isolated from cancer-free individuals by using blendzyme. ACSs were plated in confluent and subconfluent states for several days and then were harvested for RNA isolation, enzymatic activity and protein study. Specific genes were expressed in ASCs using lentiviral expression system and were depleted by siRNA method. Co-culture system was established using ASC and ZR-75 cell line. In a xenograft model, ASCs were injected with the ZR-75 cells in mammary fat pad.
 Results: Aromatase expression in ASCs can be stimulated up to several hundred folds by cell shape changes induced by various physical or chemical stimuli. Our work uncovered several key signal-transducing molecules including Inhibitory kB Kinases (IKKs) in mediating the cell shape-triggered aromatase expression. Unexpectedly, activation of aromatase gene expression following cell shape change does not involve activation of NFkB, a downstream effector of IKKs. Rather, aromatase induction following cell shape change positively correlated with the expression level of CEBPβ; and CEBPβ knockdown severely impaired aromatase expression. Significant increase in aromatase expression was due to activation of the same breast cancer-associated promoters that are robustly stimulated in intratumoral adipose tissue. In a coculture and invivo xenograft model, ACSs were able to trigger E2 responsive genes as well as stimulate early tumor occurence in ZR-75 cells, respectively.
 Discussion: Our study suggests that genetic and epigenetic alterations in aromatase-inducing signaling pathway may result in excessive estrogen production and thus breast cancer development. Excess aromatase produced by the stromal cells are capable of initiating tumor in surrounding breast epithelial cells. Study further uncovers a previously unappreciated paradigm for regulation of aromatase expression in adipose tissue, which should have a far-reaching impact on risk assessment and prevention of breast cancer.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5061.

In vitro activity of antimicrobial agents against oxacillin resistant staphylococci with special reference to Staphylococcus haemolyticus

One hundred and sixty seven isolates of staphylococci isolated from the inpatients of a tertiary care referral hospital in South India were speciated and activity of oxacillin, glycopeptides, linezolid and quinupristin/dalfopristin against these isolates was tested by broth microdilution method. Of the 114 coagulase negative staphylococci (CoNS), 49.1 % were S. haemolyticus, isolated predominantly from urine (64.6%), while the rest belonged to 11 other species. More than half the isolates of S. aureus (52.8%) and 68.4% of the CoNS were oxacillin resistant. All the strains were uniformly susceptible to vancomycin, linezolid and quinupristin/dalfopristin; but 25.6% isolates of S. haemolyticus showed reduced susceptibility to teicoplanin (MIC: 8-16 mg/L). Our study demonstrates the high prevalence of oxacillin resistance among hospital isolates of S. aureus and CoNS in India. Vancomycin, along with the newer agents like linezolid and quinupristin/dalfopristin remains the drug of choice for treating multi drug resistant staphylococcal infections.

Lateral vibration of a water drop and its motion on a vibrating surface

The resonant modes of sessile water drops on a hydrophobic substrate subjected to a small-amplitude lateral vibration are investigated using computational fluid dynamic (CFD) modeling. As the substrate is vibrated laterally, its momentum diffuses within the Stokes layer of the drop. Above the Stokes layer, the competition between the inertial and Laplace forces causes the formation of capillary waves on the surface of the drop. In the first part of this paper, the resonant states of water drops are illustrated by investigating the velocity profile and the hydrostatic force using a 3d simulation of the Navier-Stokes equation. The simulation also allows an estimation of the contact angle variation on both sides of the drop. In the second part of the paper, we investigate the effect of vibration on a water drop in contact with a vertical plate. Here, as the plate vibrates parallel to gravity, the contact line oscillates. Each oscillation is, however, rectified by hysteresis, thus inducing a ratcheting motion to the water droplet vertically downward. Maximum rectification occurs at the resonant states of the drop. A comparison between the frequency-dependent motion of these drops and the variation of contact angles on their both sides is made. The paper ends with a discussion on the movements of the drops on a horizontal hydrophobic surface subjected to an asymmetric vibration.