CyBorD-DARA in Newly Diagnosed Transplant-Eligible Multiple Myeloma: Results from the 16-BCNI-001/CTRIAL-IE 16-02 Study Show High Rates of MRD Negativity at End of Treatment

The phase 1b 16-BCNI-001/CTRIAL-IE 16-02 CyBorD-DARA trial investigated the combination of Daratumumab with cyclophosphamide, bortezomib and dexamethasone in patients with newly diagnosed multiple myeloma (NDMM), followed by autologous stem cell transplantation and Daratumumab maintenance. CR/sCR rates were 50% after transplant and 62.5% at end of treatment. The overall percentage of patients achieving complete response or better was 77.8%. Progression-free survival rate at end of maintenance was 81.3% and estimated 2-year overall survival was 88.9%. 37.5% of patients demonstrated sustained MRD negativity to a level of 10^-5 from transplant to analysis at EOT. In this phase 1b study, we have shown CyBorD-DARA to be an effective and well-tolerated immunomodulatory agent-free regiment in transplant-eligible NDMM.

General practitioner views on the determinants of test ordering: a theory-based qualitative approach to the development of an intervention to improve immunoglobulin requests in primary care

BACKGROUND

Research suggests that variation in laboratory requesting patterns may indicate unnecessary test use. Requesting patterns for serum immunoglobulins vary significantly between general practitioners (GPs). This study aims to explore GP's views on testing to identify the determinants of behaviour and recommend feasible intervention strategies for improving immunoglobulin test use in primary care.

METHODS

Qualitative semi-structured interviews were conducted with GPs requesting laboratory tests at Cork University Hospital or University Hospital Kerry in the South of Ireland. GPs were identified using a Health Service Executive laboratory list of GPs in the Cork-Kerry region. A random sample of GPs (stratified by GP requesting patterns) was generated from this list. GPs were purposively sampled based on the criteria of location (urban/rural); length of time qualified; and practice size (single-handed/group). Interviews were carried out between December 2014 and February 2015. Interviews were transcribed verbatim using NVivo 10 software and analysed using the framework analysis method. Emerging themes were mapped to the theoretical domains framework (TDF), which outlines 12 domains that can enable or inhibit behaviour change. The behaviour change wheel and behaviour change technique (BCT) taxonomy were then used to identify potential intervention strategies.

RESULTS

Sixteen GPs were interviewed (ten males and six females). Findings suggest that intervention strategies should specifically target the key barriers to effective test ordering, while considering the context of primary care practice. Seven domains from the TDF were perceived to influence immunoglobulin test ordering behaviours and were identified as 'mechanisms for change' (knowledge, environmental context and resources, social/professional role and identity, beliefs about capabilities, beliefs about consequences, memory, attention and decision-making processes and behavioural regulation). Using these TDF domains, seven BCTs emerged as feasible 'intervention content' for targeting GPs' ordering behaviour. These included instructions on how to effectively request the test (how to perform behaviour), information on GPs' use of the test (feedback on behaviour), information about patient consequences resulting from not doing the test (information about health consequences), laboratory/consultant-based advice/education (credible source), altering the test ordering form (restructuring the physical environment), providing guidelines (prompts/cues) and adding interpretive comments to the results (adding objects to the environment). These BCTs aligned to four intervention functions: education, persuasion, environmental restructuring and enablement.

CONCLUSIONS

This study has effectively applied behaviour change theory to identify feasible strategies for improving immunoglobulin test use in primary care using the TDF, 'behaviour change wheel' and BCT taxonomy. The identified BCTs will form the basis of a theory-based intervention to improve the use of immunoglobulin tests among GPs. Future research will involve the development and evaluation of this intervention.

The issue of anti-D: an integrated seamless approach from recognition of need to bedside administration

BACKGROUND

The appropriate and timely administration of Anti-D immunoglobulin to Rhesus (D) negative women who have delivered Rhesus (D) positive babies is a vital part of obstetric care. Anti-D has an especially high profile in Ireland because of the tragic inadvertent transmission of Hepatitis C to Irish women in past decades.

AUDIT

We have reviewed our policy and procedures pertaining to the administration of Anti-D for sensitising events during pregnancy and postnatally, in the Mid-Western Health Board in 1999/2000. As a result, major changes were made in the storage, issue, recording and administration of Anti-D. New procedures in the transfusion laboratory and in the maternity hospital have been accepted by scientists and midwives and supported by haematology and obstetric medical staff. The pharmacy and haematology laboratory no longer have a role in this programme. IMPLEMENTATION OF MULTI-DISCIPLINARY CHANGE MANAGEMENT: As a result of these changes, the storage, issuing and tracking of Anti-D has become the responsibility of the hospital blood bank. Measurement offoeto-maternal haemorrhage (FMH) is now the responsibility of bio medical scientists in blood bank, utilising both flow cytometry (increasingly recognised as the gold standard method) and the Kleihauer method (Kleihauer-Betke). The programme has moved from a doctor-administered IV Anti-D Ig, to a midwife-administered IM preparation. Prescription remains the responsibility of the doctor. These changes are facilitated by the protocol guided issue of the appropriate dose of Anti-D Ig by bio medical scientists to midwives. The issue of the Anti-D Ig occurs simultaneously with issue of results of mother and baby's serology testing and estimation of volume of FMH. These major changes have been guided by audit and needs assessment and require close liaison between medical, nursing and laboratory scientific staff in haematology, transfusion and obstetrics. CRITICAL INCIDENT AUDIT-CASE REPORT: Before new procedures became official policy, a critical incident audit allowed us to pilot our protocol and to revise it using draft new procedures. In this critical incident we describe successful management of a patient with a large foeto-maternal haemorrhage. This incident supported the need for the procedural enhancements already underway. This critical incident re-emphasised the need for the planned systems improvements to be introduced quickly.

The rational use of platelet transfusions in children

Platelet transfusions are undoubtedly effective in securing hemostasis in bleeding children with absent or nonfunctioning platelets. They are, however, abused in some circumstances and are not without risk. The use of platelet transfusions to prevent rather than to treat bleeding in children with malignant disease has increased several times over the last two decades. When joining in this widespread practice, physicians should be aware that there is a relatively unimpressive evidence base supporting it and also that for patients with uncomplicated myelo-suppression the most persuasive studies suggest that a threshold platelet count of 10 x 10(9)/L is no less effective than the more customary 20 x 10(9)/L is. Still lower thresholds await evaluation. For children with nonmalignant conditions the use of platelet transfusions should be carefully evaluated on a case-by-case basis, but they should normally be avoided in the absence of clinically important bleeding. Neonates with thrombocytopenia, particularly those with immune disease due to a maternal alloantibody, are considered an exception to this generalization. The serious hazards of platelet transfusions include alloimmunization and the induction of refractoriness, graft-versus-host (GVH) disease, and the transmission of infection, all of which can be life threatening. Less risky alternative therapeutic approaches may become more widely available in the future, including recombinant thrombopoietin and lyophilized heat-treated platelet membrane preparations.

Adhesion molecules in clinical medicine

Cellular adhesion molecules (CAMs) are critical components in the processes of embryogenesis, tissue repair and organization, lymphocyte function, lymphocyte homing and tumor metastasis, as well as being central to the interactions between hemopoietic progenitors and bone marrow microenvironment, and between leukocytes and platelets with vascular endothelium. Expression of CAMs regulates normal hemopoiesis and migration and function of mature hemopoietic cells. CAMs are an important part of the inflammatory response and may regulate cytokine synthesis. In addition, CAM expression may be critical for tumorigenesis. Monoclonal antibodies to CAMs have been developed for clinical use; initial results suggest that these agents have great potential in the prevention and treatment of inflammation, thrombosis, reperfusion injury, and graft rejection.

Protein A immunoadsorption in chronic refractory ITP reverses increased platelet activation but fails to achieve sustained clinical benefit

Adults with chronic relapsing ITP present a difficult therapeutic challenge. The ongoing antibody-mediated platelet destruction in this group might be expected to be associated with increased expression of platelet surface membrane activation antigens. We have studied a group of 10 patients with refractory ITP and 35 healthy controls. Using an immediate, sensitive, unfixed, whole blood, flow cytometric method to detect platelet surface P-selectin and GP53, we have detected markedly increased platelet activation in the ITP group compared with the controls (P-selectin; patient median 24.5% v control median 2.0%. GP53 median 6.5% v 2.1%, P < 0.01 for both). Five patients underwent protein A immunoadsorption therapy. The effect of protein A immunoadsorption on platelet activation before, during and after 18 treatments in these patients was studied and patients were followed-up to assess clinical outcome. Platelet-associated immunoglobulin measurements were made before and at the end of six treatments. Platelet activation decreased after immunoadsorption. P-selectin expression fell significantly; pre- and post-treatment median values differed by 15.5%, P < 0.01, for GP53 the difference was 2.5%, P = NS. A reduction in both platelet-associated IgG (median reduction of 11.8 ng/10(6) platelets, P = 0.08) and IgM (7.6 ng/10(6) platelets, P = 0.06) was recorded.

Haemophilia

Although the nature of haemophilia has been understood for thousands of years, knowledge of its molecular genetics is recent. These X-linked bleeding disorders have diverse underlying DNA defects and, in 1992, DNA inversion within the X chromosome was found to explain half of the most serious cases of haemophilia A. The life-span and quality-of-life for patients with haemophilia had improved steadily throughout the early 1980s but the principal cause of death remained intracranial haemorrhage until the epidemic of HIV infection due to contaminated factor concentrates. Infection with hepatitis C virus is almost universal for patients treated with clotting factors before 1985. No curative treatment is available for hepatitis C at present. Knowledge of the transmission of viruses in concentrates has led to important developments in processing techniques to eliminate them. Recombinant technology has produced factor VIII and, more recently, factor IX concentrate which is likely to be very safe. Development of inhibitors to factor concentrates (especially factor VIII) remains one of the most serious complications of haemophilia. The variety of treatments available testifies to the lack of a single universally efficacious one. The use of prophylactic treatment has been conclusively demonstrated to result in a preservation of joint function in severely affected patients who might otherwise develop significant joint problems. The many facets of the care of patients with severe haemophilia, ranging from dental care to genetic counselling, can be advantageously co-ordinated in a haemophilia comprehensive care centre.

Current Practice in the Treatment of Haemophilia

Haematologists are long standing proponents of evidence based practice-well exemplified among professionals who care for patients with haemophilia. The rapidly expanding range of therapeutic products and the numerous accompanying clinical trials are swiftly interpreted and translated into clinical practice. This translation is formalised by frequently updated quidelines issued by the United Kingdom Haemophilia Centre Directors' Organisation (UKHCDO) and relevant to all doctors involved in the care of patients with haemophilia. In the last five years eight sets of guidelines have been issued in the UK alone relating to the treatment of haemophilia and its complications [1-8]. Against this background we aim to review current practice in the treatment of haemophilia.

Correlation of GP53 and P-selectin expression in myeloproliferative disorders and normal controls

Platelet degranulation occurs when platelets are activated. Alpha degranulation releases P-selectin whereas lysosomal degranulation releases GP53. A correlation between these two markers might therefore be expected. We studied the correlation between P-selectin and GP53 in 50 patients with myeloproliferative disorders (MPD), 35 normal controls and 105 disease controls (patients with inflammatory bowel disease [IBD, n = 52], rheumatoid arthritis [RA, n = 26] and coronary artery disease [CAD, n = 27]) by flow cytometry before and after stimulation with thrombin ex vivo. There was no significant correlation between percentage expression of P-selectin and GP53 in unstimulated samples in normal individuals; r = 0.13, P = 0.3, n = 34. Mild thrombin stimulation (10 mU/ml) led to both alpha and lysosomal degranulation with a strong correlation (r = 0.62, P < 0.001, n = 35). Disease controls (IBD, RA and CAD) showed similar trends. In patients with MPD, in contrast, a strong correlation between the expression of these platelet activation markers was demonstrable in unstimulated samples (r = 0.37, P = 0.007, n = 50). P-selection and GP53 expression in stimulated samples also correlated well. The data support the existence of different control pathways for the steady state expression of P-selection and GP53. Heterogeneous steady state responses of P-selectin and GP53 may be physiological and loss of this heterogeneity may be a hitherto unreported and pathologically important feature of MPD. This lack of correlation appears to be specific to MPD and is not simply a function of increased in vivo platelet activation.

Platelet surface activation antigen expression at baseline and during elective angioplasty in patients with mild to moderate coronary artery disease

Platelet activation is an important pre-thrombotic event. The elucidation of its pathophysiology could contribute to a reduction in the mortality associated with coronary artery disease-the foremost cause of death in the UK. We examined the platelets of 27 patients with angiographically documented coronary artery disease. All patients had stable angina and were taking their regular medication-including aspirin. We demonstrated significantly increased expression of GP53 and activated GPIIb/IIIa on the platelet surface using a sensitive flow cytometric method of detection. Comparison was made with a control group of 35 patients. Seventeen of the patients had coronary angioplasty carried out. Serial studies of these patients demonstrate an immediate and sustained increase in platelet activation and this has important implications for prevention of restenosis after angioplasty.

Effect of fixation on quantification of the expression of leucocyte function-associated surface antigens

The surface expression of adhesion molecules and other function-associated antigens on peripheral blood leucocytes may be measured by flow cytometry. However, quantification of these antigens is difficult, because their expression can be rapidly and artefactually modulated if the cells are activated in vitro. Consequently, it is common, when analyzing these antigens either: (1) to label leucocytes in whole blood at 4 degrees C, to lyse erythrocytes and then fix the leucocytes, or (2) to fix the leucocytes in whole blood, to lyse the erythrocytes, and then label the leucocytes. We have compared the mean fluorescence intensity (MFI) values for CD11b, CD18, and L-selectin (Leu-8 and TQ1 epitopes) on human peripheral blood leucocytes, using these two approaches. In addition, we have simultaneously evaluated how anticoagulants (acid citrate, K3EDTA, and heparin) and the presence or absence of divalent metal ions (Ca2+ and Mg2+) affect the expression levels of these antigens. The results for all four epitopes varied markedly depending on the preparation procedure used but were less affected by the choice of anticoagulant and whether divalent cations were or were not present in the media used for cell preparation and labelling. Comparison of the results obtained using these procedures, which involve fixation with formaldehyde, with those obtained by a recently developed procedure in which unfixed leucocytes were labelled with the vital nuclear dye LDS-751 and antibodies together, then analysed in unlysed whole blood at 4 degrees C, showed that formaldehyde-based preparation techniques underestimated the expression (MFI) of CD18, Leu-8, and TQ1. It is recommended that, whenever practicable, measurements are made on unfixed cells stained using the newer procedure.

Platelets circulate in an activated state in inflammatory bowel disease

BACKGROUND/AIMS

Platelets show proinflammatory as well as prothrombotic properties. Patients with inflammatory bowel disease are at increased risk of systemic thromboembolism, and multifocal microvascular infarction has been proposed as a pathogenetic mechanism in Crohn's disease. The aim of this study was to determine if inflammatory bowel disease is associated with abnormal platelet behavior.

METHODS

Platelet activation and aggregability were assessed using flow cytometry, Born aggregometry, and the modified method of Wu and Hoak. Serum beta-thromboglobulin was measured in patients with Crohn's disease and ulcerative colitis and, as controls, in healthy volunteers and patients with active rheumatoid arthritis.

RESULTS

Platelet surface expression of P-selectin and GP53 (markers of activation) were increased in Crohn's disease (13 of 30 patients abnormal for P-selectin; 9 of 28 abnormal for GP53) (P < 0.01) and ulcerative colitis (9 of 21 for P-selectin; 10 of 21 for GP53) (P < 0.01) compared with healthy controls. Increased circulating platelet aggregates (15 of 24 patients with Crohn's disease and 8 of 16 with ulcerative colitis) (P < 0.01), platelet aggregability in vitro, and serum beta-thromboglobulin were detected in active inflammatory bowel disease compared with healthy controls. Platelet behavior in active rheumatoid arthritis resembled that in healthy controls.

CONCLUSIONS

Increased platelet activation and aggregation are features of inflammatory bowel disease and may contribute to the risk of systemic thromboembolism and the pathogenesis of mucosal inflammation. Therefore, antiplatelet agents may be valuable in the management of inflammatory bowel disease.

Platelet activation in coronary artery disease

The role of platelets in coronary artery disease has become increasingly apparent in the last decade. Platelets are the main components of arterial thrombi, and they also contribute to the development of atheroma and smooth muscle hypertrophy in arterial walls. Platelets are known to circulate as round, inactive spheres which undergo a succession of changes before they become functional. These changes result in activated platelets. Platelet activation has been demonstrated during acute coronary events. There is increasing evidence that an increased proportion of platelets circulate in an activated form in patients with coronary artery disease and also in other disease states in which thrombosis is a feature. In this review we examine some of the evidence for these statements.

von Willebrand factor release and P-selectin expression is stimulated by thrombin and trypsin but not IL-1 in cultured human endothelial cells

The stimulated release of von Willebrand factor (vWF) from endothelial cells by secretagogues such as thrombin is associated with the translocation of Weibel-Palade bodies to the cell membrane and the surface expression of P-selectin (also known as GMP 140, PADGEM and CD 62). P-selectin, which is stored in Weibel-Palade bodies, is a neutrophil and monocyte adhesion molecule important in the initiation of inflammation. We have developed a simple assay for the detection of P-selectin on endothelial cells using indirect immunofluorescence and flow cytometry and have confirmed that this is temporally related to vWF release. The assay has been used to demonstrate that IL-1 does not cause Weibel-Palade body degranulation but that trypsin does. This has implications for the use of passaged endothelial cells in the study of vWF release and the assay has numerous possible applications in study of mechanisms of stimulated vWF release.

Fixation with formaldehyde induces expression of activation dependent platelet membrane glycoproteins, P selectin (CD62) and GP53 (CD63)

Platelet activation in vivo is important in the pathogenesis of thrombosis. Accurate measurement is difficult due to artefactual in vitro preparation related activation. This can be overcome by using whole blood techniques, such as flow cytometry. However, there is little consensus on methods of platelet preparation, procedures for use of fixation, or the optimal types/amounts of fixative. The use of unfixed platelets has received little attention. We describe a series of experiments comparing platelet activation antigen expression detected by flow cytometry in fixed and unfixed samples. Formaldehyde increased the expression of both CD62 and CD63. We recommend that fixation with formaldehyde should not be used when studying platelet activation.

Aplastic anaemia in systemic lupus erythematosus: a cellular immune mechanism?

Aplastic anaemia is a rare complication of systemic lupus erythematosus (SLE). The mechanism is unclear but is thought to be related to an autoantibody to bone marrow precursors of haematopoiesis. We report a case of SLE related aplastic anaemia in which therapy with methylprednisolone and high dose cyclophosphamide followed by prednisolone and azathioprine resulted in complete clinical and haematological remission. Bone marrow cultures showed inhibition of erythropoiesis when incubated with acute and remission serum. Myeloid colony growth was not affected by either serum. The serum inhibitor we demonstrated was only active in vitro, and we postulate that the mechanism for marrow aplasia may have been an autoimmune cellular process.