Discrete truncation method for measuring the cardiac t2* values in patients with thalassemia

OBJECTIVE

In clinical work, it has been found that there are differences between the dark-blood (DB) and bright-blood (BB) cardiac magnetic resonance (CMR) T2* values (DB-T2* and BB-T2*) measured by the current automatic truncation method in patients with cardiac iron overload. The paper aims to develop a novel discrete truncation method to measure cardiac T2* value in patients with thalassemia.

METHODS

The cardiac T2* values of 349 thalassemia (TM) patients (mean age, 13.41 years ±8.761, 173 males) from three hospitals during January 2011 to June 2023 were measured by CMRtools software. Different truncation methods were used to remove signal values that deviated from the fitting curve and the corresponding T2* values were recorded. The difference, correlation and consistency of DB-T2* and BB-T2* measured by different methods were compared.

RESULTS

There was no significant difference between DB-T2* and BB-T2* measured by discrete truncation method (DB-T2* vs.BB-T2*, p = 0.249), respectively; and there was a high positive correlation (rs = 0.997, p < 0.0001). In the Bland-Altman analysis, the two methods had a very good agreement (p = 0.2489). There was a high positive correlation between DB-T2* and BB-T2* measured by the automatic truncation method (rs = 0.974, p < 0.0001), but there was a significant difference between them (DB-T2* vs.BB-T2*, p < 0.0001), respectively. In the Bland-Altman analysis, there was no good agreement between the two methods (p < 0.0001).

CONCLUSION

The discrete truncation method is more stable and reliable than the automatic truncation method in the measurement of cardiac T2* value in TM patients.

Systematic review of cost-effectiveness modelling studies for haemophilia

AIMS

Haemophilia is a rare genetic disease that hinders blood clotting. We aimed to review model-based cost-effectiveness analyses (CEAs) of haemophilia treatments, describe the sources of clinical evidence used by these CEAs, summarize the reported cost-effectiveness of different treatment strategies, and assess the quality and risk of bias.

METHODS

We conducted a systematic literature review of model-based CEAs of haemophilia treatments by searching databases, the Tufts Medical Center CEA registry, and grey literature. We summarized and qualitatively synthesized the approaches and results of the included CEAs, without a meta-analysis due the diversity of the studies.

RESULTS

32 eligible studies were performed in 12 countries and reported 53 pairwise comparisons. Most studies analysed patients with haemophilia A rather than haemophilia B. Comparisons of prophylactic versus on-demand treatment indicated that prophylaxis may not be cost-effective, but there was no clear consensus. Emicizumab was generally cost-effective compared with clotting factor treatments and was always dominant for patients with inhibitors. Immune tolerance induction following a Malmö protocol was found to be cost-effective compared to bypassing agents, while there was no consensus for the other protocols. Gene therapies as well as treatment with extended half-life coagulation factors were always cost-effective over their comparators. Studies were highly heterogenous regarding their time horizons, model structures, the inclusion of bleeding-related mortality and quality-of-life impacts. This heterogeneity limited the comparability of the studies. 19 of the 32 included studies received industry funding, which may have biased their results.

LIMITATIONS

It was not possible to perform a quantitative synthesis of the results due to the heterogeneity of the underlying studies.

CONCLUSION

Differences in results between previous CEAs may have been driven by heterogeneity in modelling approaches, clinical input data, and potential funding biases. A more consistent evidence base and modelling approach would enhance the comparability between CEAs.

Optimization of mtDNA-targeted platinum TALENs for bi-directionally modifying heteroplasmy levels in patient-derived m.3243A>G-iPSCs

Patient-derived induced pluripotent stem cells (iPSCs) are a useful pathological model for debilitating diseases caused by mitochondrial DNA (mtDNA) mutations. We established iPSCs derived from mitochondrial disease patients, heteroplasmic for the m.3243A>G mutation. The proportion of a selected mtDNA can be reduced by delivering a programmable nuclease into the mitochondria, and we developed various mtDNA-targeted Platinum TALENs (mpTALENs) to modify m.3243A>G-iPSC heteroplasmy levels in either wild-type or mutant direction. For TALEN optimization, the use of non-conventional repeat-variable di-residues (ncRVD)-LK/WK or NM-enhanced cleavage activity and specificity, and the replacement of conventional with obligate heterodimeric FokI nuclease domains increased target specificity and protected mtDNA from copy number depletion. In vitro, depending on whether wild-type or mutant mtDNA was targeted, we could obtain m.3243A>G-iPSCs with a higher or lower mutation load, while the cells retained their ability to differentiate into three germ layers. These results demonstrate that our mpTALEN optimization created a useful tool for altering heteroplasmy levels in m.3243A>G-iPSCs, improving the potential for studying mutation pathology. The enhanced efficiency also holds promise for using m.3243G(MUT)-mpTALEN as a therapeutic strategy for treating patients suffering from m.3243A>G mitochondrial diseases.

Embracing Controversy: A Second Look at CDC Reform Efforts in the Wake of COVID-19

The US Centers for Disease Control and Prevention (CDC) has responded to criticism claiming that the agency's COVID-19 response was lacking by proposing internal reforms intended to improve its performance during the next pandemic. The reforms are aimed at improving surveillance, analytic capacity, and agency communications. This article conducts a counterfactual analysis of the CDC's proposed reforms to ask how they might have changed outcomes in four cases of guidance controversy during the pandemic if they had been completed in advance of COVID-19. Although the CDC's planned reforms have merit, they are predicated on the ability to come to scientific closure in a highly charged political environment. To improve outcomes in a future pandemic, the agency should consider how it plans to communicate with the public when recovering from error and when addressing controversy spurred by criticism from credible experts. However, the ability of future presidents to limit CDC performance and communications in the next pandemic and the lack of political consensus around the value of independent public health expertise are likely to threaten any effort to improve pandemic response.

Sickle Cell Disease in Africa: SickleInAfrica Registry in Ghana, Nigeria and Tanzania

Introduction

Sickle cell disease (SCD) is most prevalent in Sub-Saharan Africa (SSA), where incomplete patient profiles and limited management strategies hinder research and healthcare standards.

Methods

We describe the first large-scale and multinational assessment of 13,403 SCD patients enrolled from 2017-2021 across 31 facilities in Ghana, Nigeria, and Tanzania into the SickleInAfrica consortium registry. We used hierarchical regression models to estimate and analyze the demographics, adoption levels of SCD diagnosis and therapies.

Results

The average age at diagnosis was 3 months, 19 months and 3 years in Ghana, Nigeria and Tanzania respectively, reflecting differences in country-specific newborn screening programs and policies. Hydroxyurea (HU) use was highest in Ghana (21%), followed by Nigeria (12%) and Tanzania (6%), with significant variability across facilities. Sex differences in SCD management were observed, with males more likely to receive HU and blood transfusions. At the consortium level, HU initiation correlated with enrolment age rather than age at diagnosis, highlighting the need for earlier intervention.

Conclusions

Our findings highlight the potential of the SickleInAfrica registry toward enhancing understanding of regional disparities in SCD care and potential gender inequalities, emphasizing the need for enabling policies toward strengthened SCD research and improved quality of life and care of patients in Africa.

Incidence and risk factors of venous thromboembolism in patients with acute Leukemia: A systematic review and meta-analysis

INTRODUCTION

Currently, no systematic review has been published regarding the incidence and risk factors of venous thromboembolism (VTE) in patients with acute leukemia. This study was implemented to identify the incidence and risk factors of VTE in patients with acute leukemia, aiming to offer guidance for corresponding clinical diagnosis and treatment.

MATERIALS AND METHODS

Studies in PubMed, Cochrane Library, Embase, and Web of Science were fully searched from database to January 2024. The risk of bias was assessed using NOS scale. Data analysis was performed with STATA 15.1.

RESULTS

Twenty-two studies covering 53,433 samples were included. The overall incidence of VTE in patients with acute leukemia was 9 % (95 % CI: 0.07-0.12; P < 0.01). Older age in children (OR=2.21; 95 % CI: 1.40-3.49; P < 0.001), older age in adults (OR=2.05; 95 % CI: 1.02-4.10; P = 0.044), non-B cell subtype in acute lymphoblastic leukemia (ALL) (OR=1.85; 95 % CI: 1.43-2.39; P < 0.001) were risk factors for VTE in patients with acute leukemia, while Hispanic ethnicity was associated with a lower risk of VTE (OR=0.81; 95 % CI: 0.67-0.99; P = 0.040). Subgroup analysis results revealed that, in patients with acute myeloid leukemia, male gender was associated with a lower risk of VTE (OR=0.83; 95 % CI: 0.70-0.99; P = 0.039); in patients with ALL, older age in adults (OR=4.41; 95 % CI: 2.25-8.66; P < 0.001) and T-cell subtype (OR=1.82; 95 % CI: 1.39-2.37; P < 0.001) was a risk factor, non-White was associated with a lower risk of VTE (OR=0.69; 95 % CI: 0.54-0.89; P = 0.004).

CONCLUSION

The overall incidence of VTE was high in patients with acute leukemia. Older age and T-cell phenotype were risk factors, while Hispanic ethnicity was associated with a lower risk of VTE. This suggests more attention should be paid to high-risk groups in clinical practice.

Cellular and biochemical heterogeneity contributes to the phenotypic diversity of transfusion-dependent β-thalassemia

ABSTRACT

Transfusion-dependent thalassemia (TDT) is a type of protein aggregation disease. Its clinical heterogeneity imposes challenges in effective management. Red blood cell (RBC) variables may be clinically relevant as mechanistic parts or tellers of TDT pathophysiology. This is a cross-sectional study of RBC and plasma physiology in adult patients with TDT vs healthy control. TDT plasma was characterized by increased protein carbonylation, antioxidants, and larger than normal extracellular vesicles. RBCs were osmotically resistant but prone to oxidative hemolysis. They overexposed phosphatidylserine and exhibited pathologically low proteasome proteolytic activity (PPA), which correlated with metabolic markers of the disease. RBC ultrastructure was distorted, with splenectomy-related membrane pits of 300 to 800 nm. Plasma metabolomics revealed differences in heme metabolism, redox potential, short-chain fatty acids, and nitric oxide bioavailability, but also in catecholamine pathways. According to coefficient of variation assessment, hemolysis, iron homeostasis, PPA, and phosphatidylserine exposure were highly variable among patients, as opposed to RBC fragility and plasma antioxidants, amino acids, and catecholamines. Sex-based differences were detected in hemolysis, redox, and energy variables, whereas splenectomy-related differences referred to thrombotic risk, RBC morphology, and plasma metabolites with neuroendocrine activity. Hepcidin varied according to oxidative hemolysis and metabolic markers of bacterial activity. Patients with higher pretransfusion hemoglobin levels (>10 g/dL) presented mildly distorted profiles and lower membrane-associated PPA, whereas classification by severity of mutations revealed different levels of hemostasis, inflammation, plasma epinephrine, hexosamines, and methyltransferase activity markers. The currently reported heterogeneity of cellular and biochemical features probably contributes to the wide phenotypic diversity of TDT at clinical level.

Treatment Landscape in Pediatric Immune Thrombocytopenia: Addressing Unmet Needs

Pediatric immune thrombocytopenia (ITP) is associated with a multifaceted burden on children and their parents/caregivers due to bleeding, fatigue, activity restrictions, and psychological distress. Most children recover within 12 months, but up to 30% develop chronic ITP. While emergent therapies, such as steroids and intravenous immunoglobulin, are effective in many children and transiently raise platelet counts, 38-47% of children require subsequent therapies. The choice of subsequent therapy for individual children with ITP is often complex and the absence of head-to-head comparisons of available therapies and the use of nonstandardized outcomes in randomized clinical trials complicates treatment decisions. Furthermore, medication access varies globally and by age. Additional unmet needs in pediatric ITP include a lack of support and educational resources allowing children and parents/caregivers to effectively participate in treatment decisions, inadequate prediction of treatment response and disease chronicity, heterogeneous approaches to diagnostic evaluation of ITP, scarcity of novel treatments for children unresponsive to current therapies, and the need for a multispecialty approach to support the mental health of children and their families. This review summarizes the known impact of ITP on children and their families, current treatment strategies, and unmet needs in pediatric ITP.

ObMetrics: A Shiny app to assist in metabolic syndrome assessment in paediatric obesity

OBJECTIVE

To introduce ObMetrics, a free and user-friendly Shiny app that simplifies the calculation, data analysis, and interpretation of Metabolic Syndrome (MetS) outcomes according to multiple definitions in epidemiological studies of paediatric populations. We illustrate its usefulness using ethnically different populations in a comparative study of prevalence across cohorts and definitions.

METHODS

We conducted a case study using data from two ethnically diverse paediatric populations: a Hispanic-American cohort (N = 1759) and a Hispanic-European cohort (N = 2411). Using ObMetrics, we computed MetS classifications (Cook, Zimmet, Ahrens) and component-specific z-scores for each participant to compare prevalences.

RESULTS

The analysis revealed significant heterogeneity in MetS prevalence across different definitions and cohorts. According to Cook, Zimmet, and Ahrens's definitions, MetS prevalence in children with obesity was 25%, 12%, and 48%, respectively, in the Hispanic-European cohort, and 38%, 27%, and 66% in the Hispanic-American cohort. Calculating component-specific z-scores in each cohort also highlighted ethnic-specific differences in lipid metabolism and blood pressure. By automating these complex calculations, ObMetrics considerably reduced analysis time and minimised the potential for errors.

CONCLUSION

ObMetrics proved to be a powerful tool for paediatric research, generating detailed reports on the prevalence of MetS and its components based on various definitions and reference standards. Our case study further provides valuable insights into the challenges of characterising metabolic health in paediatric populations. Future efforts should focus on developing unified consensus guidelines for paediatric MetS. Meanwhile, ObMetrics enables earlier identification and targeted intervention for high-risk children and adolescents.

Evaluating the Cost-Effectiveness of Etranacogene Dezaparvovec Gene Therapy for Hemophilia B Treatment in the USA

BACKGROUND

Hemophilia B, a severe genetic disorder, involves substantial treatment costs and frequent interventions. Etranacogene dezaparvovec (EDZ) is a recently approved gene therapy for hemophilia B.

OBJECTIVE

This study evaluates the cost-effectiveness of EDZ compared with conventional factor IX (FIX) prophylaxis.

METHODS

A semi-Markov model simulated a cohort of adult males with severe hemophilia B to assess the economic impact of EDZ versus FIX prophylaxis over a lifetime horizon from a health system perspective in the USA. Inputs derived from clinical trials included therapy durability and transition probabilities based on Pettersson Scores. Scenario analyses incorporated frameworks suggested by the Institute for Clinical and Economic Review for single or short-term transformative therapies.

RESULTS

Base-case analysis showed that at a cost of US$3.5 million, EDZ led to lifetime cost savings of US$11 million and an additional 0.64 quality-adjusted life years (QALYs) compared with FIX. However, FIX has extremely high annual costs. When annual cost offsets attributed to EDZ were capped at US$150,000, EDZ was found to have a threshold price of US$3.1 million at a willingness-to-pay of US$150,000 per QALY.

CONCLUSION

EDZ proved to be a dominant strategy over FIX prophylaxis in the base-case scenario, providing large cost savings and slightly better outcomes. The substantial costs associated with FIX are a primary driver behind these results. The introduction of cost-offset caps significantly affects the value-based price of EDZ. Using caps on cost offsets in considering price can help to balance affordability and value in the health system.

SOHO State of the Art Updates and Next Questions | Updates on Myelofibrosis With Cytopenia

Myelofibrosis (MF) is a rare hematologic malignancy that is characterized by dysregulation of the JAK-STAT pathway resulting in fibrosis of the bone marrow, splenomegaly, and abnormalities in peripheral blood counts including anemia, leukocytosis, and thrombocytopenia. This disease has 2 phenotypic extremes - myeloproliferative and cytopenic. Cytopenic myelofibrosis presents with pronounced cytopenia and a different landscape of genetic mutations which results in worse clinical outcomes and a poor prognosis. Patients with cytopenic MF are at high risk of developing various complications like bleeding, infections, and transfusion dependency. Historically, the only Federal Drug Administration (FDA) approved therapy was ruxolitinib, a JAK1/2 inhibitor, which improved constitutional symptoms and splenomegaly, however, exacerbated anemia and thrombocytopenia.1,2 There were very few options for patients with anemia and thrombocytopenia, and supportive treatments for these problems lack efficacy. Fortunately, there are newer treatment options which may allow for treatment of the symptoms and splenomegaly in the setting of cytopenias and even improve cytopenias. This up-to-date review not only highlights the prevalent options in therapeutic marketplace, but also sheds light on the significant unmet need of addressing anemia and thrombocytopenia in cytopenic MF.

Incidence of venous thromboembolism in pediatric orthopedics: A systematic review

BACKGROUNDS

Children undergoing orthopedic procedures often present numerous risk factors for thromboembolism. A recent survey, conducted by the Pediatric Orthopaedic Society of North America (POSNA), indicates that pediatric orthopedic surgeons are unaware of venous thromboembolism (VTE) prevention protocols and feel that certain procedures should require thromboprophylaxis. The aim of this systematic review was to properly assess the incidence of VTE in pediatric orthopedics. By using a thorough and broad search of the literature, the incidence according to different subspecialties of pediatric orthopedics was evaluated.

METHODS

A systematic review on VTE in pediatric orthopedics was conducted. Four databases were searched for articles reporting these events. Three major search concepts: "pediatrics", "orthopedic surgery/trauma" and "VTE complications" were used and broken down in MeSH, EmTree and their free vocabulary synonyms for proper literature review. Two independent authors screened 8467 titles and abstracts. Seventy articles reporting VTE in children treated by orthopedic surgeons were selected for data extraction. We reported median incidences by orthopedic subtypes and by study characteristics with a semi-quantitative review model.

RESULTS

The 70 articles yielded a total of 845,010 participants. Spine articles (33/70) provided 25,2% of the children included in the review. Trauma studies (16/70) accounted for 47.5% of the participants. The overall VTE median incidence was 0.16% [95% CI: 0.0-1.01%]. Musculoskeletal infections had a noticeably higher median incidence of 3.5% [CI: 0.0-13.8%]. Small variations were seen for the other subtypes: trauma, spine and elective surgeries. Subgroups by article characteristics did not differ significantly either.

CONCLUSION

Thrombotic complications are rare events in pediatric orthopedics, but knowledge epidemiologic is important because its potential severity. In this review, VTE median incidence for all orthopedic subtypes was around 0.16% [CI: 0.0-1.01%]. According to subspecialty assessment, musculoskeletal infections were associated with greater risk of VTE occurrence.

LEVEL OF EVIDENCE

III - Systematic review.

Biochemical and medical aspects of vitamin B1 research

Vitamin B1 is an indispensable food factor for the human and animal body. In animals, vitamin B1 is found in the form of thiamine and its phosphate esters - thiamine mono-, di- and triphosphate, as well as an adenylated derivative - adenosine thiamine triphosphate. At present, the only vitamin B1 form with biochemical functions being elucidated is thiamine diphosphate, which serves as a coenzyme for several important enzymes involved in carbohydrate, amino acid, fatty acid and energy metabolism. Here we review the latest developments in the field of vitamin B1 research in animals. Transport, metabolism and biological role of thiamine and its derivatives are considered as well as the involvement of vitamin B1-dependent processes in human diseases and its therapeutic issues, a field that has gained momentum with several important recent developments.

Epidemiology of metabolic syndrome

The global increase of overweight and obesity in children and adults is one of the most prominent public health threats, often accompanied by insulin resistance, hypertension, and dyslipidemia. The simultaneous occurrence of these health problems is referred to as metabolic syndrome. Various criteria have been proposed to define this syndrome, but no general consensus on the specific markers and the respective cut-offs has been achieved yet. As a consequence, it is difficult to assess regional variations and temporal trends and to obtain a comprehensive picture of the global burden of this major health threat. This limitation is most striking in childhood and adolescence, when metabolic parameters change with developmental stage. Obesity and related metabolic disorders develop early in life and then track into adulthood, i.e., the metabolic syndrome seems to originate in the early life course. Thus, it would be important to monitor the trajectories of cardio-metabolic parameters from early on. We will summarize selected key studies to provide a narrative overview of the global epidemiology of the metabolic syndrome while considering the limitations that hinder us to provide a comprehensive full picture of the problem. A particular focus will be given to the situation in children and adolescents and the risk factors impacting on their cardio-metabolic health. This summary will be complemented by key findings of a pan-European children cohort and first results of a large German adult cohort.

Nanozymes in biomedicine: Unraveling trends, research foci, and future trajectories via bibliometric insights (from 2007 to 2024)

Nanozymes, a new generation of artificial enzymes, have attracted significant attention in biomedical applications due to their multifunctional properties, multi-enzyme mimicking abilities, cost-effectiveness, and high stability. Leveraging these diverse catalytic activities, an increasing number of nanozyme-based therapeutic strategies have been developed for the treatment of various diseases. Despite substantial research efforts, a significant gap remains in comprehensive studies examining the progression, key areas, current trends, and future directions in this field. This study provides a comprehensive overview of nanozyme applications in biomedical research over the past 17 years, utilizing data from the Web of Science Core Collection, covering the period from January 1, 2007, to October 8, 2024. Advanced bibliometric and visualization tools were employed to facilitate a comprehensive analysis. The results highlight China's dominant role in this field, accounting for 76.83 % of total publications, significantly influencing the evolution of research in this area. Key contributions were made by institutions such as the Chinese Academy of Sciences, the University of Chinese Academy of Sciences, and the University of Science and Technology of China, with Qu Xiaogang as the leading author. The journal ACS Applied Materials & Interfaces has become the most prolific publisher in this field. Keyword analysis indicates that since 2022, research hotspots in this field have increasingly focused on areas such as photothermal therapy, chemodynamic therapy, and ferroptosis. Challenges such as obstacles to clinical translation, limitations in recyclability, and insufficient targeting ability were addressed. The potential applications of emerging interdisciplinary technologies, such as artificial intelligence, machine learning, and organoids, in advancing nanozyme development were explored. This study offers a data-driven roadmap for researchers to navigate the evolving landscape of nanozyme innovation, emphasizing interdisciplinary collaboration in impactful biomedical applications.

Successful dupilumab treatment in a patient with severe dermatitis following allogenic hematopoietic stem cell transplantation

BACKGROUND

Allogenic hematopoietic stem cell transplantation (HSCT) is the optimal treatment of hematologic diseases and various malignancies. Development of allergic disease in a transplant patient has been reported.

CASE PRESENTATIONS

A 49-year-old male with no history of atopy underwent two allogenic HSCTs for aplastic anemia from his brother with severe atopic dermatitis 11 years ago. The patient developed eczema on whole body and an elevated peripheral blood eosinophil count of 5775 cells/µL at 3 months after the second HSCT. Despite prolonged treatment with systemic corticosteroids and immunomodulators the skin rash and elevated blood eosinophil count persisted. However, after 4 months of dupilumab therapy, the patient showed near-complete clearance of symptoms. The sustained clinical improvement was observed during 36 months treatment without adverse drug reactions.

CONCLUSIONS

Although rare, atopic dermatitis can occur after HSCT, and dupilumab may be safe and effective for refractory conditions.

Elevated Fab glycosylation of autoantibodies maintained during B cell depletion therapy

Several chronic autoimmune diseases are characterized by elevated autoantibody Fab glycosylation. Whether Fab glycans link to disease state or development remains unclear, yet may serve as a marker thereof. Many autoimmune diseases are treated with B cell depletion therapies that particularly result in a decline of autoantibodies. The question arises whether B cell depletion therapy may have an impact on Fab glycosylation. Here, we investigated the longitudinal effects of B cell depletion therapy on Fab glycosylation of total IgG and IgG autoantibodies in rheumatoid arthritis (RA), pemphigus vulgaris (PV), ANCA-associated vasculitis (AAV), and multiple sclerosis (MS). Baseline Fab glycosylation was compared to 6-12 months into therapy by lectin affinity chromatography, determining Fab sialylation as an estimate of Fab glycosylation. We observed a modest decrease in Fab glycosylation of total IgG for RA (median 13.8%[IQR 11.7-16.3] - 9.1%[IQR8-11]) and PV (16.4%[IQR14.9-17.5] - 13.01%[IQR10.8-15.5]) after 6 months, whereas for AAV Fab glycosylation slightly increased (11.6%[IQR7.4-15] - 14.9%[IQR11.4-19.3]), and no changes were found for MS. Autoantibody titers (anti-CCP, anti-PR3, anti-Dsg3) had declined following B cell depletion therapy, yet their elevated Fab glycosylation levels were maintained. Taken together, Fab glycosylation levels of autoantibodies do not decrease upon B cell depletion therapy, thereby retaining their predictive potential as biomarker.

Hepatobiliary Manifestations in Thalassemia Patients: A Narrative Review

Thalassemia is one of the most common inherited blood disorders worldwide. This defect causes a disproportionate ratio of α- and β-globin chains resulting in ineffective erythropoiesis leading to increased iron absorption. In patients where the imbalance between α and β globin chains is great they are dependent on blood transfusions for survival. This results in transfusional iron overload but also comes with additional risks such as transfusion-transmissible viral infections like hepatitis B and C. This can lead to various complications like liver fibrosis, cirrhosis and hepatocellular carcinoma, which are important causes with morbidity and mortality in patients of thalassemia today. These hepatobiliary manifestations and their management are briefly discussed in this review. Understanding hepatobiliary complications in thalassemia is vital for optimizing patient care.

Arginine Therapy for Pain in Sickle Cell Disease: A Phase-2 Randomized, Placebo-Controlled Trial

We present a prospective randomized, placebo-controlled trial of intravenous arginine in patients 3-21 years hospitalized with sickle cell disease vaso-occlusive pain episodes (SCD-VOE) at two tertiary-care children's hospitals. Participants were randomized into 1 of 3 arms: Standard-dose (SD; 100 mg/kg/dose) every 8 h, Loading-dose (200 mg/kg followed by SD), or Placebo. The primary outcome was total parenteral opioid use (TPO). Secondary outcomes included time-to-crisis-resolution, pain scores, patient-reported outcomes (PROs), arginine bioavailability, and biomarkers of oxidative stress/mitochondrial function. Of 1548 patients screened, 108 were randomized (36 per study-arm; mean 12.6 ± 3.8 years, 52% female, and 65% hemoglobin-SS). This study did not meet its primary endpoint. TPO, time-to-crisis-resolution, pain scores, and PROs at discharge were similar across arms. Post hoc sensitivity analyses of children 5-16 years old demonstrated nearly double TPO utilization in those receiving placebo versus arginine (n = 87, p = 0.056), achieving significance in patients with plasma arginine < 60 μM. Arginine was low at presentation in 79% of patients (mean 50 ± 28 μM), and increased with arginine therapy (p < 0.001). Arginine bioavailability at VOE presentation inversely correlated with time-to-crisis-resolution (r = -0.39, p = 0.01) after placebo, an association eliminated by arginine supplementation (r = -0.04, p = 0.70). A dose-dependent increase in platelet-mitochondrial activity occurred after arginine versus no change after placebo (p < 0.001); plasma protein-carbonyl levels, a measure of oxidative stress, decreased after arginine therapy (p < 0.001) but increased in the placebo group (p = 0.02). SCD-VOE is associated with an acquired arginine deficiency that correlates with worse clinical outcomes. Arginine improved mitochondrial function and decreased oxidative stress compared to placebo, with clinically relevant opioid-sparing becoming significant in children with the lowest arginine concentration. TRIAL REGISTRATION: Registered with ClinicalTrials.gov (NCT02536170) in August 2015.

Prophylactic Weekly Efanesoctocog Alfa Versus Standard-Care Factor VIII in People Living With Severe Hemophilia A : A Cost-Effectiveness Analysis

BACKGROUND

Prophylaxis goals for patients with severe hemophilia A encompass advancement toward the hemophilia-free mind (freedom from bleeding, pain, arthropathy, and treatment burden). Efanesoctocog alfa, the first ultra-long half-life factor VIII agent that enables once-weekly prophylaxis, shows a 77% improvement in annualized bleeding rate compared with standard-care factor VIII prophylaxis.

OBJECTIVE

To evaluate the conventional and distributional cost-effectiveness of prophylaxis with efanesoctocog alfa versus standard-care factor VIII (standard half-life and extended half-life) in the United States.

DESIGN

Markov model.

DATA SOURCES

XTEND-1 study and other published sources.

TARGET POPULATION

Patients with severe hemophilia A.

TIME HORIZON

Lifetime.

PERSPECTIVE

U.S. health system and societal.

INTERVENTION

Prophylaxis with efanesoctocog alfa versus standard-care factor VIII.

OUTCOME MEASURES

Incremental cost-effectiveness ratio (ICER; cost per quality-adjusted life-year [QALY]) and threshold inequality aversion parameter (equity weight).

RESULTS OF BASE-CASE ANALYSIS

Efanesoctocog alfa and standard-care factor VIII accrued 19.7 and 14.6 discounted lifetime QALYs at costs of $22.1 million and $11.2 million, respectively, with an ICER of $2.13 million per QALY. The distributional cost-effectiveness analysis (DCEA)-derived threshold equity weight was 6.9, exceeding commonly used U.S. equity standards. Results were consistent across all scenario analyses.

RESULTS OF SENSITIVITY ANALYSIS

Only the price of efanesoctocog alfa could change the conclusion. Efanesoctocog alfa needs to be priced at less than 53% of its current price for conventional cost-effectiveness and less than 59% for distributional cost-effectiveness. Standard-care factor VIII was favored in 100% of 10 000 probabilistic iterations.

LIMITATION

Benchmark equity weights (as opposed to hemophilia-specific weights) to interpret DCEA results.

CONCLUSION

Prophylaxis with efanesoctocog alfa is not conventionally or distributionally cost-effective for severe hemophilia A in the United States at current pricing and equity weight thresholds.

PRIMARY FUNDING SOURCE

National Institutes of Health; National Heart, Lung, and Blood Institute.

Vasculopathy among children and adolescents with sickle cell disease: the crosstalk with annexin A1, vitamin D, and myocardial iron overload

BACKGROUND

Annexin A1 plays an important role in myocardial defense against ischemia-reperfusion injury. We aimed to evaluate the role of annexin A1 as a potential marker of vasculopathy in children and adolescents with sickle cell disease (SCD) and its relation to myocardial iron content (MIC) and vitamin D status.

RESEARCH DESIGN AND METHODS

Forty-one patients with SCD were compared with 40 age- and sex-matched healthy controls, and underwent assessment of serum annexin A1, vitamin D, Doppler echocardiography and cardiac magnetic resonance (CMR).

RESULTS

Six (14.6%) SCD patients had cardiac disease, five (12.2%) had abnormal MIC (≥1.16) and 10 (24.4%) had pulmonary hypertension risk. Annexin A1 levels were significantly lower among patients with SCD compared with healthy controls (p < 0.001). SCD patients with pulmonary hypertension risk, evidence of diastolic dysfunction, and nephropathy as well as those with serum ferritin ≥ 2500 µg/L and vitamin D deficiency had lower Annexin A1 levels than those without. Serum annexin A1 levels were negatively correlated to urinary albumin creatinine ratio (UACR) and Tei index while positively correlated to vitamin D among SCD patients.

CONCLUSIONS

Annexin A1 could be a promising marker of vasculopathy and may provide a biochemical explanation for vitamin D deficiency in SCD.

Psoriasis in Obese Adolescents with Diabetes-From Common Molecular Background to Vicious Circle of Metabolic Syndrome-Case Report and Review of Literature

Psoriasis and type 1 diabetes mellitus (T1DM) are chronic autoimmune diseases sharing common immunological pathways, particularly the involvement of interleukin 17 (IL-17), driving Th17-mediated inflammation. This review explores the overlap between psoriasis, obesity, T1DM, and necrobiosis lipoidica (NL), a skin condition associated with diabetes. Obesity exacerbates inflammation through immune cell activation in adipose tissue and the release of proinflammatory adipokines, such as leptin, resistin, and IL-18, which enhance autoimmune responses and insulin resistance. Leptin promotes the differentiation of Th1 and Th17 cells, which are central to autoimmune responses in both psoriasis and T1DM. The coexistence of psoriasis, T1DM, and insulin resistance further complicates metabolic control, increasing the risk of complications like diabetic nephropathy and cardiovascular disease. Biologic treatments targeting IL-17A and IL-17F offer promising therapeutic options for managing both skin and metabolic symptoms. The early identification and management of metabolic risk factors, along with personalized interventions, are essential to improve clinical outcomes in patients with psoriasis and T1DM, particularly in obese individuals. This case report and review highlight the complex interplay of these conditions and emphasize the need for integrated treatment strategies.

Soluble P-selectin, but not circulating cell-free DNA, is a potential diagnostic biomarker in heparin-induced thrombocytopenia

BACKGROUND

Heparin-induced thrombocytopenia (HIT) is characterized by the presence of anti-platelet factor 4 (PF4) antibodies, which bind to platelets via Fcγ receptor IIA (FcγRIIA), potentially leading to thrombosis.

OBJECTIVES

To identify novel immunothrombosis markers and assess their diagnostic utility in HIT.

METHODS

A single-center cross-sectional retrospective study was performed including 144 patients from a cohort that included 69 confirmed HIT patients (PF4+/serotonin release assay [SRA] +), 39 patients in whom HIT was excluded (PF4+/SRA-), and 11 patients negative by both screening and confirmatory tests (PF4-/SRA-). Additionally, 26 healthy volunteers were included as controls. We utilized multiplex arrays and ELISA to evaluate 41 biomarkers of immunothrombosis and digital PCR to quantify circulating cell-free DNA (ccf-DNA).

RESULTS

Compared with healthy controls, HIT patients showed increased levels of D-dimer and soluble thrombomodulin, but reduced ADAMTS-13, consistent with a procoagulant status. Soluble adhesion molecules (soluble intercellular adhesion molecule-1, soluble vascular cell adhesion molecule-1), cytokines (interleukin [IL]-6, IL-8), and markers of platelet (sP-selectin, thromboxane 2 [TXB2], sFcγRIIA) and endothelium activation (angiopoietin-2), along with mitochondrial and genomic ccf-DNA, were elevated, implying a prothrombotic phenotype. Notably, sP-selectin was the only marker that differentiated PF4+/SRA+ patients from PF4+/SRA- and PF4-/SRA- patients and controls (P < .001). TXB2 also distinguished PF4+/SRA+ from PF4+/SRA- but not from the other 2 groups. Receiver operating characteristic analysis yielded an area under curve (AUC) of 0.83 for P-selectin and 0.80 for PF4 ELISA. Combining P-selectin and PF4 ELISA improved AUC to 0.88 (82.6% sensitivity, 87.2% specificity). Multivariate analysis revealed that soluble P-selectin is independently associated with HIT.

CONCLUSION

HIT results in significant immunothrombotic responses, with sP-selectin as potential biomarker for the diagnosis of this condition.

Health-related quality of life and economic impacts in adults with transfusion-dependent β-thalassemia: findings from a prospective longitudinal real-world study

PURPOSE

To characterize the health-related quality of life (HRQoL) and economic impacts of transfusion-dependent β-thalassemia (TDT).

METHODS

A prospective longitudinal real-world study was conducted in adults with TDT in the US and Europe (France, Germany, Italy, UK) over 6 months. Eligibility criteria included receiving ≥ 8 blood transfusions/year in each of the 2 years before enrollment. Study outcomes assessed at months 0, 3, and 6, included demographics, clinical characteristics, patient-reported outcome measures (EQ-VAS, FACT-G, FACIT-F, 11-point Numerical Rating Scale (NRS) of pain, TranQoL, and WPAI), and responses to bespoke questions on financial burden/distress.

RESULTS

Overall, 155 adults with TDT participated (mean age [standard deviation (SD)]: 38.5 [10.8] years; 65.8% female). Most participants resided in the US (53.5%) or UK (22.6%). EQ-VAS, FACT-G, and FACIT-F mean (SD) scores at month 0 were lower among participants than the US general population (67.1 [20.4] versus 80.4 [15.6], 70.1 [19.0] versus 77.0 [16.1], and 27.9 [13.7] versus 43.6 [9.4], respectively; all p < 0.001). Mean (SD) TranQoL total score was 53.9 (18.5) and overall level of pain was "moderate" (NRS mean [SD]: 3.5 [2.8]). Part- or full-time employed participants missed a mean of 5.9 h of work in the preceding 7 days with out-of-pocket expenses being a moderate-to-major burden for 55% of participants. The findings were consistent over time.

CONCLUSIONS

Participants reported substantial humanistic and economic burdens associated with living with TDT. Our findings highlight the need for alternative treatment options that contribute to improvements in HRQoL and reduce economic burden in this patient population.

Immune Thrombocytopenia in Finnish Children and Adolescents: A Population-Based Cohort Study

AIM

Immune thrombocytopenia (ITP) is the most common cause of thrombocytopenia in children. This study aimed to describe the diagnostics, patient characteristics, and treatment strategies regarding children with ITP, as well as identify risk factors for chronic disease.

METHODS

This study included 403 Finnish children aged under 16 years at diagnosis, who were first diagnosed with ITP between 2006 and 2020.

RESULTS

Of the 367/403 patients with complete follow-up data, 242 (65.9%) recovered within three months. Chronic ITP developed in 25.9% of the children. Severe bleeding events occurred in 3.7% of them, with no intracranial bleeding events or deaths reported. Pharmacological treatment was administered to 40.2% of the patients. An elevated risk of chronic ITP was found in the children presenting with an insidious disease onset, female gender, higher age, higher platelet counts, and an absence of recent viral infections. As many as 83.3% of the patients with an insidious disease onset and no recent infections developed chronic ITP.

CONCLUSION

Most of the children with ITP experienced short and uncomplicated disease courses. Chronic illness was more likely when the disease onset was insidious, the platelet count was not extremely low, and there was no recent history of an infection.

Integrating QSAR modelling with reinforcement learning for Syk inhibitor discovery

Spleen tyrosine kinase (Syk) is a crucial mediator of inflammatory processes and a promising therapeutic target for the management of autoimmune disorders, such as immune thrombocytopenia. While several Syk inhibitors are known to date, their efficacy and safety profiles remain suboptimal, necessitating the exploration of novel compounds. The study introduces a novel deep reinforcement learning strategy for drug discovery, specifically designed to identify new Syk inhibitors. The approach integrates quantitative structure-activity relationship (QSAR) predictions with generative modelling, employing a stacking-ensemble model that achieves a correlation coefficient of 0.78. From over 78,000 molecules generated by this methodology, we identified 139 promising candidates with high predicted potency, binding affinity and optimal drug-likeness properties, demonstrating structural novelty while maintaining essential Syk inhibitor characteristics. Our approach establishes a versatile framework for accelerated drug discovery, which is particularly valuable for the development of rare disease therapeutics.Scientific contributionThe study presents the first application of QSAR-guided reinforcement learning for Syk inhibitor discovery, yielding structurally novel candidates with predicted high potency. The presented methodology can be adapted for other therapeutic targets, potentially accelerating the drug development process.

Serum ferritin can serve as a biomarker for the prognosis and increased the prognostic predictive value of ISS/RISS in multiple myeloma patients

PURPOSE

Multiple myeloma (MM) is a terminally differentiated plasma cell hematological malignancy. The revised international staging system (RISS) is commonly used in patients with de novo MM, but it has limitations in predicting prognosis. Better biomarkers need to added to the staging system.

RESULTS

This retrospective study included a total of 302 patients. Smooth curve fitting analysis showed that serum ferritin levels were associated with relapse and all-cause death. The K-M curve analysis indicated that MM patients with higher ferritin levels had shorter PFS (p < 0.0056) and OS (p = 0.0014). Multivariate Cox regression analysis also showed MM patients with high serum ferritin had poor PFS (p = 0.0012) and OS (p = 0.0258), with independent correlation. The prediction model of ROC analysis based on Cox regression validated ferritin had a predictive value for PFS and OS, and increased the predictive value of ISS and RISS for OS.

CONCLUSION

We revealed that baseline serum ferritin levels were associated with prognosis in patients with MM, and patients with higher serum ferritin have poorer PFS and OS. Serum ferritin could increase the prediction value. The study provided a new evidence for searching for prognostic biomarkers in MM patients.

Diagnosis of a patient with severe sensorineural hearing loss as the initial symptom caused by novel compound heterozygous variant in SLA19A2 gene

OBJECTIVE

Thiamine-Responsive Megaloblastic Anemia (TRMA) syndrome, caused by biallelic variants in the SLC19A2 gene, typically presents with a triad of megaloblastic anemia, diabetes mellitus, and sensorineural hearing loss. This study aims to determine the genetic etiology and clinical phenotype of a patient who presented with severe sensorineural hearing loss as the initial symptom, and to expand our understanding of the SLC19A2 variant spectrum.

METHODS

Proband-only whole-exome sequencing was performed to screen the candidate variants, which were subsequently validated by Sanger sequencing within the family. cDNA sequencing based on RT-PCR and TA cloning analysis was used to determine the effect of splicing variants on mRNA processing of SLC19A2 gene. Detailed clinical features were evaluated by a diagnostic hearing test, laboratory and imaging examination.

RESULTS

A 2-year-5-month-old Chinese girl was diagnosed with diabetes mellitus and severe sensorineural hearing loss, without abnormal hemoglobin. DNA sequencing revealed a novel compound heterozygous variant of c.808-1G > A and c.1228C > T (p.Gln410*) in the SLC19A2 gene. Both variants were previously unreported. The c.808-1G > A splicing variant is located in intron 2 of SLC19A2, and is predicted to cause exon 3 skipping. The cDNA experiment confirmed this biological event, further indicating that the splicing variant can cause amino acid frameshift alteration (p.Glu270Valfs*10) in SLC19A2.

CONCLUSION

We report a patient with TRMA syndrome (without anemia) caused by a novel compound heterozygous variant in SLA19A2 gene. This study suggests that the possibility of TRMA syndrome should be considered when encountering patients with early-onset severe sensorineural hearing loss in clinical practice.

LEVEL OF EVIDENCE

Level 4.

The effect of combined oral contraceptives on thrombin generation assessed on ST Genesia- a paired clinical study

BACKGROUND

Treatment with combined oral contraceptives (COC) is associated with an increased risk of venous thromboembolism. Several changes of coagulant and anticoagulant factors induced by ethinyloestradiol during treatment with COC, have been demonstrated. Thrombin generation is a global test measuring both coagulant and anticoagulant factors, but the effect of COC on individuals starting COC, has not been examined before on the new equipment, ST Genesia. The aim of this project was to examine the effect of COC on thrombin generation on ST Genesia, in individuals before and after starting COC.

METHODS

Twenty-four female participants between 15 and 34 years of age, who were about to start treatment with ethinylestradiol/levonorgestrel-containing COC, were included in the study. Two blood samples were drawn from each of the study subjects, a baseline sample immediately before first COC dose, and a follow-up blood sample approximately 3-4 months after COC start. Standard biochemical analyses as well as standard and special coagulation analyses including thrombin generation on ST Genesia, were performed in all samples.

RESULTS

Thrombin generation, i.e., endogenous thrombin generation (ETP) and peak increased considerably after COC start, whereas time-to-peak was shortened. Thrombin-antithrombin complexes (TAT), prothrombin fragments (F1 + 2) and sex hormone binding globulin (SHBG) increased, and the coagulation inhibitors tissue factor pathway inhibitor (TFPI), protein S activity and antithrombin decreased slightly after COC start.

CONCLUSION

Although the coagulation factors only changed modestly, the global test thrombin generation performed on ST Genesia showed a considerable change after start of COC.

Unraveling Metabolic Syndrome in Youth: The Obesity Epidemic's Hidden Complication

BACKGROUND/OBJECTIVES

One of the metabolic complications of obesity is known as Metabolic Syndrome (MetS). This narrative review aims to synthesize current research on MetS in young populations, identify knowledge gaps, and guide future studies and funding priorities. It provides evidence-based insights into screening, diagnosis, and treatment, offering practical guidance for healthcare professionals.

METHODS

A comprehensive search of the literature was conducted to identify relevant studies on obesity in MetS in PubMed and Google Academic electronic database. The search was performed using a combination of "obesity", "complications", "metabolic syndrome", "children", and "adolescents" keywords. Studies were selected based on predefined inclusion and exclusion criteria to ensure relevance and methodological rigor.

RESULTS

The lack of universally accepted diagnostic criteria for MetS in children has led to inconsistencies in its definition across medical literature. Irrespective of the chosen diagnostic approach, the prevalence of MetS in children and adolescents has exhibited a concurrent rise with the increasing rates of obesity in this age group. The pathophysiology of MetS remains incompletely understood, with ongoing discussions on the interplay of genetic, epigenetic, environmental, dietary, and lifestyle factors. Screening for MetS is recommended for overweight and obese children.

CONCLUSIONS

Establishing global, consensus-driven criteria that account for ethnicity, gender, and age would enhance diagnostic accuracy and treatment approaches. The prevention of excessive weight among children and adolescents stands as a paramount objective within modern society's healthcare system. Considering the complexity of the disease and the treatment, the team must be multidisciplinary.

Prediction of moderate to severe bleeding risk in pediatric immune thrombocytopenia using machine learning

This study aimed to develop and validate a risk prediction model for moderate to severe bleeding in children with immune thrombocytopenia (ITP). Data from 286 ITP patients were prospectively collected and randomly split into training (80%) and test (20%) sets. Least Absolute Shrinkage and Selection Operator (LASSO) regression was used for feature selection. Among seven machine learning algorithms, the eXtreme Gradient Boosting (XGBoost) model demonstrated the best performance (AUC = 0.886, 95% CI: 0.790-0.982) and was selected as the optimal model. Shapley Additive Explanations (SHAP) were used for model interpretation, identifying child age, age at diagnosis, and initial platelet count as key predictors of moderate to severe bleeding risk.

CONCLUSION

The XGBoost-based prediction model shows strong predictive performance and could assist healthcare providers in identifying high-risk ITP patients, supporting appropriate clinical decision-making.

TRIAL REGISTRATION NUMBER

ChiCTR2100054216, December 11, 2021 What is Known: • Current clinical practice relies solely on platelet counts to guide hospitalization and treatment in ITP children, often overlooking bleeding manifestations, leading to delayed or inappropriate treatment. Existing severe bleeding risk prediction models are primarily designed for adults and lack applicability to children.

WHAT IS NEW

 • This study prospectively collected data, enhancing accuracy. A novel machine learning-based prediction model was developed to assess moderate to severe bleeding risk in pediatric ITP patients.

The Role of the Intrauterine Environment in Shaping Childhood and Adolescence Metabolic Outcomes

Emerging research suggests that the intrauterine environment plays a critical role in predisposing individuals to metabolic syndrome (MetS), a constellation of conditions that heightens the risk for heart disease, stroke, and diabetes. Traditionally linked to lifestyle, the risk for MetS is now understood to be also influenced by fetal exposures. The environment in which a child lives offers abundant potential sources that can contribute to an increased risk of developing various diseases, and in some cases, these factors can be avoided. This review integrates findings from both epidemiological and experimental research to underscore the impact of prenatal factors, including maternal nutrition, obesity, gestational diabetes (GDM), and birth size, on the subsequent development of metabolic derangements in offspring, particularly during puberty. The progression of genetic and epigenetic studies has enlightened the pathophysiology of these conditions starting in the intrauterine period and continuing into early life. By examining data and studies, this article elucidates the prenatal influences and underlying mechanisms that contribute to the pathogenesis of MetS. The updated understanding of the link between the intrauterine environment and future health comorbidities will draw attention to intrauterine care and maternal health and contribute to the prevention of serious diseases in adulthood.

Bleeding Complications, Transfusion, and Acute Care Costs After Major Arthroplasty in Patients With Hereditary Bleeding Disorders: A National Healthcare Database Analysis

BACKGROUND

Advances in blood conservation have reduced the need for allogeneic transfusions in total knee and hip arthroplasty (TKA/THA). This study aimed to assess whether perioperative bleeding complications, including hemorrhage/hematoma, allogeneic transfusions, and postoperative anemia, occurred at similar rates between patients with hereditary bleeding disorders (BDs) and controls. Using a national health care database, we assessed the use of clotting factor concentrates (CFCs), perioperative outcomes, and resource utilization.

METHODS

A retrospective cohort study was conducted using the Premier Health Database (2017-2021) to analyze differences in outcomes and costs between 1528 patients with hereditary BDs and 20,509 non-BD controls undergoing elective TKA and THA. Summary statistics, bivariate analyses, and odds ratios (ORs) were used to evaluate perioperative outcomes and resource use.

RESULTS

Patients with hereditary BDs were slightly younger, predominantly female, and more often treated at larger, urban hospitals compared to controls. Bleeding complications, including hemorrhage and hematoma, were infrequent but higher in the BD group (1.1% vs 0.2%; P < .0001). Transfusion rates were higher in THA than TKA, with significantly increased odds for patients with hereditary BD: for THA, OR 2.7 (95% confidence interval [CI], 2.0-3.7; P < .0001); and for TKA, OR 2.6 (95% CI, 1.9-3.8; P < .0001). CFC exposures occurred in 16.4% of patients with hereditary BD compared to 0.03% in controls. Of 270 reported CFC exposures, factor VIII (FVIII) and von Willebrand factor (VWF) were most commonly used (49.6% and 23.0%, respectively), followed by FIX concentrate (12.6%) and bypassing agents, including FVIIa (8.5%) and anti-inhibitor coagulant complex (AICC; 3.7%). Antifibrinolytic therapy was administered in most cases. Pharmacy costs for patients with hereditary BD were significantly higher, with a mean of $23,792 (95% CI, $8722-$39,312), being over 30 times the mean cost in controls ($750; 95% CI, $739-$762). Other outcomes were not different, except for a higher incidence of venous thromboembolism in the BD group (OR 3.9, 95% CI, 2.4-6.1; P < .0001).

CONCLUSIONS

THA and TKA in patients with hereditary BDs are relatively safe, with most outcomes comparable to controls. However, higher rates of bleeding, transfusion, and VTE underscore the need for optimizing anemia management and targeted use of CFCs along with antifibrinolytic therapy.

X-linked sideroblastic anemia in females

ABSTRACT

X-linked sideroblastic anemia (XLSA) in female carriers of 5-aminolevulinic acid synthase 2 mutations is not uncommon. We describe unique features and genotype/phenotype correlations in females with XLSA and evaluate the contributions of X-chromosome skewing and clonal hematopoiesis, emphasizing the importance of distinguishing it from myelodysplastic syndromes with ring sideroblasts.

Epigenetic modifications of nuclear and mitochondrial DNA are associated with the disturbance of serum iron biomarkers among the metabolically unhealthy obesity school-age children

BACKGROUND

Serum iron biomarkers are disordered on the progression of obesity and its associated metabolic syndrome (MetS). However, limited evidence is explored the interactions between serum iron biomarkers and the incidence of MetS. Thus, the purpose of this study is to discuss whether epigenetic modifications of nuclear and mitochondrial DNA (mtDNA) are associated with the disturbance of serum iron biomarkers among the metabolically unhealthy obesity (MUO) school-age children.

METHODS

A representative cross-sectional study was performed using the data from 104 obesity school-age children, while the subjects without obesity were as controls (n = 65). Then, the 104 obesity subjects were defined as metabolically healthy obesity (MHO, n = 60) and MUO (n = 44) subgroups according to whether they were accompanied with MetS. Their serum metabolic indicators, transferrin receptor 1 (TFR1), transferrin (TF) and genome-wide methylation were determined by the Elisa method. Moreover, the methylation levels of TFR1 and TF were measured by the Bisulfite sequencing PCR (BSP-PCR). Furthermore, the copy number (mtDNA-CN) and methylation of mtDNA were detected by the RT-PCR, while the semi-long RT-PCR was then used to estimate the lesions of mtDNA.

RESULTS

Compared with the control and MHO groups, the levels of MetS related indicators, anthropological characteristics and 8-OHdG were higher, and the concentrations of CAT, GSH-Px, TF, TFR1 and genome-wide methylation were lower in the MUO group in a BMI-independent manner (P < 0.05). Then, the contents of serum iron were lower in both the MHO and MUO groups than those in the control group (P < 0.017). Moreover, they were positively related with the contents of serum CAT and GSH-Px, and negatively with 8-OHdG, TF and TFR1 (P < 0.05). Furthermore, the methylation patterns on the TF, TFR1 and mtDNA were higher in the MUO group than those in the MHO and control groups (P < 0.017), which were negatively correlated with their serum contents (P < 0.05). Meanwhile, the ratio of methylated/unmethylated mtDNA was significantly associated with their mtDNA-CN and lesions (P < 0.05).

CONCLUSIONS

Our findings suggested that the impairments on the epigenetic modifications of nuclear (genome-wide DNA, TF and TFR1) and mtDNA were associated with the disturbance of serum iron biomarkers to involve in the pathophysiology of MetS among the school-age MUO children.

TRIAL REGISTRATION

This study was approved by the Ethics Committee of Beijing Children's Hospital affiliated to Capital Medical University (No. IEC-C-006-A04-V.06), which was also registered at the website of http://www.chictr.org.cn/showproj.aspx?proj=4673 (No: ChiCTR-OCH-14004900).

Therapeutic potential of synthetic and natural iron chelators against ferroptosis

Ferroptosis, a regulated form of cell death, is characterized by iron accumulation that results in the production of reactive oxygen species. This further causes lipid peroxidation and damage to the cellular components, eventually culminating into oxidative stress. Recent studies have highlighted the pivotal role of ferroptosis in the pathophysiological development and progression of various diseases such as β-thalassemia, hemochromatosis, and neurodegenerative disorders like AD and PD. Extensive efforts are in progress to understand the molecular mechanisms governing the role of ferroptosis in these conditions, and chelation therapy stands out as a potential approach to mitigate ferroptosis and its related implications in their development. There are currently both synthetic and natural iron chelators that are being researched for their potential as ferroptosis inhibitors. While synthetic chelators are relatively well-established and studied, their short plasma half-life and toxic side effects necessitate the exploration and identification of natural products that can act as efficient and safe iron chelators. In this review, we comprehensively discuss both synthetic and natural iron chelators as potential therapeutic strategies against ferroptosis-induced pathologies.

[Extramedullary hematopoiesis, a rare complication of sickle cell disease: A six-case series and literature review]

INTRODUCTION

Extramedullary hematopoiesis (EMH) is very rarely described during sickle cell disease (SCD). Our aim was to describe six cases of EMH occurring in adult SCD patients and to conduct a literature review.

METHODS

Retrospective, descriptive, and monocentric study, identifying all cases of EMH recorded in our cohort of adult SCD patients, up to April 2024. A literature review via PubMed included thirty-five articles (44 patients).

RESULTS

Six patients (4 men, 83.3% with SS genotype [n=5], 1 SC), with a median age of 22 (range 12-64) years at the time of EMH diagnosis were included. Four patients (66.7%) had an aseptic osteonecrosis of the hip. The localization of EMH varied: paravertebral (n=3), peri-articular in the hip (n=1), adrenal (n=1), hepatic (n=1), splenic (n=1) and was similar to the localizations reported in the literature. EMH was symptomatic at diagnosis in half of the cases. The diagnosis was established by histology (n=3/3) and/or typic magnetic resonance imaging (MRI) (n=4/4). The median baseline hemoglobin was 9.1 (extremes 5.8-10.9) g/dL. A watch-and-wait approach was primarily observed.

CONCLUSION

EMH in SCD patients appears to be rare, with varied localizations. Its diagnosis is made with MRI and/or biopsy, and its treatment is not consensual.

Aetiology, diagnosis and treatment of thalassemia-associated osteoporosis of the adult

AIM

This review aims to overview factors contributing to TAO development and addresses the targeted diagnostic work-up and treatment management in adult thalassemic patients.

RESULTS

Osteoporosis management in Thalassemia is challenging because several factors contributing to its pathogenesis should be considered and controlled starting from child- hood. A multidisciplinary approach is crucial. Evidence concerning the efficacy of available anti-osteoporosis drugs in thalassemic patients is scarce. In this scenario, clinical experience and center resources often guide the treatment choice. More efforts should be made to share knowledge in this field in order to indicate specific treatment strategies for TAO management.

METHODS

We performed a literature search in Pubmed from 1992 to March 2024 using the words Thalassemia and: osteoporosis, Bisphosphonates, Denosumab, Teriparatide, Romosozumab, hormone replacement therapy, growth hormone, hypogonadism, calcium, vitamin D, bone disease, sarcopenia. The search was limited to English literature including original studies, reviews, meta-analyses, case reports.

Tolerance to factor VIII in the era of nonfactor therapies: immunologic perspectives and a systematic review of the literature

Persons with hemophilia A lack clotting factor (F)VIII (FVIII) due to a genetic mutation in the F8 gene. The administration of FVIII concentrate leads to the development of neutralizing anti-FVIII antibodies (inhibitors) in about 30% of children with severe hemophilia A. The other 70% of children do not mount a detectable antibody response, suggesting that they may have developed tolerance toward FVIII. Our knowledge on the underlying immunologic mechanisms that determine formation of inhibitors or apparent tolerance to FVIII is limited. Up to recently, FVIII concentrates were regularly used as prophylaxis. In the last years, nonfactor therapy for prophylaxis is increasingly used, in which case FVIII concentrate administration is limited to treatment for bleeding or perioperative hemostasis. As nonfactor therapy is very effective in the prevention of bleeds, patients may not be exposed to the deficient FVIII protein for periods up to a year or longer. Thus, while in the past persons with severe hemophilia were frequently exposed to the deficient antigen, exposure is now reduced to incidental treatment moments. It is currently not known how this will affect the tolerance for FVIII. In this review, we will discuss tolerance to FVIII from a clinical, immunologic, and epidemiologic perspective. We aimed to provide an outlook on the effect of reduced FVIII exposure on tolerance for FVIII in persons with hemophilia A.

Unravelling the Causal Relationship between Endometriosis and the Risk for Developing Venous Thromboembolism: A Pooled Analysis

To investigate the effect of endometriosis on venous thromboembolism (VTE) in oral contraceptive (OC) users. Pooled analysis on a harmonized dataset compromising international patient-centric cohort studies: INAS-VIPOS, INAS-SCORE, and INAS-FOCUS. Eleven European countries, the United States, and Canada. Individuals being newly prescribed an OC with or without an endometriosis and no VTE history.Detailed information was captured using self-administered questionnaires at baseline and every 6 to 12 months thereafter. Self-reported VTEs were medically validated and reviewed by an independent adjudication committee. Incidence rates (IRs) were calculated per 10,000 woman-years. The association of endometriosis on VTE was determined in a time-to-event analysis, calculating crude and adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) using stabilized inverse probability of treatment weighting (IPTW).A total of 22,072 women had an endometriosis diagnosis, and 91,056 women did not. Women with endometriosis contributed 78,751 woman-years during which 41 VTE events occurred (IR: 5.2/10,000, 95% CI: 3.7-7.1) compared to 127 VTEs during 310,501 woman-years in women without endometriosis (IR: 4.1/10,000, 95% CI: 3.4-4.9). The hazard ratio of VTE in women with endometriosis was 1.79 (95% CI: 1.24-2.57) using stabilized IPTW controlling for age, body mass index, smoking, education, age at menarche, and family history of VTE. Subgroup and sensitivity analyses showed similar results.These results highlight the importance of considering endometriosis as a potential factor contributing to VTE in women using OC; however, further research on the relationship between endometriosis and VTE is warranted.

Sideroblastic anemia in children: challenges in diagnosis and management in three cases

Sideroblastic anemias (SAs) represent a heterogeneous group of rare hematological disorders characterized by iron accumulation in mitochondria of erythroblasts with ineffective erythropoiesis. SAs are categorized into acquired and congenital forms. Acquired, secondary, and clonal, SA is rare in pediatric populations. Congenital SA (CSA) is classified into syndromic and non-syndromic forms. Herein, we describe three cases of pediatric patients with SA. The diagnosis of SA was based on the presence of type 3 sideroblasts on BM aspirate smear (greater than 15%) and genetic tests. In the first case, the diagnosis of myelodysplastic syndrome with ring sideroblasts (MDS-RS) with somatic SF3B1 mutation was made at the age of 11 years. A whole exome sequencing did not reveal any germinal predisposition for MDS. A wait-and-see strategy was adopted. After one year- of follow-up, no blood transfusion was needed and no further cytopenia occurred. The two other children had presented anemia at an early age and were diagnosed with CSA. The first case was a girl with SCL25A38 gene mutation. For the second one, the diagnosis of aminolevulinic acid synthase 2 deficiency was considered the most plausible given the family history and the favourable response to pyridoxine. Iron overload occurred in both patients with CSA, requiring chelation therapy. In conclusion, Perls' stain remains a valuable tool for guiding the diagnosis of unexplained anemia in pediatric patients. Genetic testing is crucial for the characterization of congenital sideroblastic anemias. The incidence of myeloid neoplasms with ring sideroblasts is exceptional in children, and the long-term prognosis remains undefined.

Systemic Inflammatory Diseases in Children With Sickle Cell Disease: A French Multicenter Observational Study on Diagnostic and Therapeutic Issues

BACKGROUND

Systemic inflammatory diseases (SIDs) have been reported in patients with sickle cell disease (SCD), but clinical data in children are scarce.

OBJECTIVES

To identify clinical and laboratory features at diagnosis of SID in children with SCD and to describe their evolution.

METHODS

Data from children with SCD and SIDs were retrospectively collected in a French multicenter study from 1991 to 2018. Information included clinical characteristics, inflammatory markers, autoantibodies patterns, treatments, and complications. Inflammatory marker levels were compared at SID diagnosis and at the last follow-up. Statistical analyses were performed using Cran R software.

RESULTS

Among a cohort of 3800 children with SCD, 43 SIDs were identified in 35 study participants: autoimmune liver disease (AILD, n = 13), inflammatory bowel disease (IBD, n = 7), juvenile idiopathic arthritis (JIA, n = 6), systemic lupus erythematosus (n = 4), autoimmune hemolytic anemia (n = 3), Sjögren syndrome (n = 1), histiocytic necrotizing lymphadenitis (n = 2), vasculitis (n = 2), myasthenia gravis (n = 1), sarcoidosis (n = 1), idiopathic inflammatory granulomatous uveitis (n = 1), mixed connective tissue disease (n = 2). Prevalence of SID was 0.9% in our cohort of children with SCD. The median time between initial symptoms and SID diagnosis was 10 (3-20) months, notably longer in children with JIA, IBD, and Sjögren syndrome. Sixteen patients (46%) exhibited hypergammaglobulinemia (>20 g/L) at diagnosis. No significant differences were observed for other inflammatory parameters. Twenty-one children (60%) received systemic steroids and 13 (37%) biological therapies. Three patients (9%) underwent hematopoietic stem cell transplantation. Nine patients (26%) had severe infections; one died.

CONCLUSION

Delayed diagnosis was frequent due to overlapping clinical presentations between SCD and SID. Clinicians must be aware of warning signs associated with elevated inflammatory markers, hypergammaglobulinemia, or specific antibodies. Therapeutic strategies remain challenging.

What is the importance of monitoring iron levels in different organs over time with magnetic resonance imaging in transfusion-dependent thalassemia patients?

INTRODUCTION

Iron overload is the main pathophysiological driver of organ damage in transfusion-dependent thalassemia (TDT). Magnetic resonance imaging (MRI) provides detailed insights into the distribution and severity of iron accumulation in the different organs.

AREAS COVERED

This special report describes the impact of MRI on clinical and therapeutic management and short- and long-term outcomes in TDT patients. PubMed, Scopus, and Google Scholar databases were searched to identify the relevant studies published before November 2024.

EXPERT OPINION

Cardiac and hepatic MRI are now well-established modalities, integrated into the clinical practice. They have become essential for tailoring iron chelation therapies to the specific patient's needs and for monitoring treatment efficacy. The improved control of cardiac iron burden has translated into reduced morbidity and mortality. The MRI accessibility remains limited in resource-limited settings and progress in this field relies on educating and training centers to ensure accurate execution and interpretation. The clinicopathological significance, prognostic value, and reproducibility of pancreatic iron levels assessment have been established, charting a path toward its clinical use. There are limited data about renal, adrenal, and pituitary iron deposition, and more research is needed to fully establish the functional significance and to standardize and validate the MRI protocols.

Relationship Between Sleep Apnea Symptoms and Metabolic Syndrome Among Racially and Ethnically Diverse Adolescents and Young Adults in the United States

Background

Metabolic Syndrome (MetSyn) and Sleep Apnea (SA) contribute to long-term cardiometabolic risks among adolescents and young adults (AYAs). Emerging research suggests that certain race and ethnic groups experience disproportionate burdens of MetSyn and SA. Therefore, this study investigated the association of SA symptoms and MetSyn among AYAs in the United States and reported on associated racial and ethnic disparities.

Methods

National Health and Nutrition Examination Survey data from 2015 to 2020 (N = 2539) were analyzed. Sleep disorders, medical conditions, and anthropometric data were collected via interviews and physical examinations. MetSyn was defined based on the International Diabetes Federation criteria. Bivariate associations were assessed by univariate logistic regression models and age-adjusted associations by multivariable logistic regression models. Stratified analyses examined race/ethnic group differences in the associations.

Results

Nearly 50% of the sample (mean age 20.6 years, 48.9% female, 55.3% non-Hispanic White) reported SA symptoms and 4.6% had MetSyn. After adjustment, central obesity was a consistent predictor of overall sleep apnea symptoms [aOR = 1.58; 95% CI: 1.29, 1.94], snoring [aOR = 2.10; 95% CI:1.70, 2.60], breath cessation [aOR = 2.59; 95% CI: 1.42, 4.73] and daytime sleepiness [aOR = 1.34; 95% CI: 1.06, 1.68]. Non-Hispanic Black individuals with MetSyn had significantly higher odds of sleep apnea symptoms [aOR = 4.19; 95% CI: 1.40, 12.51], snoring [aOR = 6.64; 95% CI: 2.10, 21.0], and breath cessation [aOR = 8.64; 95% CI: 3.12, 23.93] versus participants of other races and ethnicities without MetSyn.

Conclusion

This study highlights the significant relationships between parameters of MetSyn and SA symptoms, and the disproportionately higher odds of SA symptoms among certain race/ethnic groups with a heavy burden of metabolic disorders.

Melatonin Supplementation Alleviates Bone Mineral Density Decline and Circulating Oxidative Stress in Iron-Overloaded Thalassemia Patients

Thalassemia patients often exhibit low bone mineral density (BMD). The iron overload associated with thalassemia elevates oxidative stress levels, leading to reduced BMD. Melatonin improves BMD in postmenopausal osteopenia, however, its effect on BMD in thalassemia patients with iron overload has not been investigated. A randomized controlled study was conducted at Hematology Clinic, Faculty of Medicine, Chiang Mai University. Thalassemia patients with osteopenia and iron overloaded condition, as indicated by BMD Z-score <-2 at l-spine, femoral neck, or total hip, and serum ferritin level > 500 μg/L were recruited in this study. Patients were randomized to receive either melatonin 20 mg/day or placebo at bedtime for 12 months. BMD was re-evaluated 12 months after interventions. Bone turnover markers (BTM), malondialdehyde (MDA as an oxidative stress marker), and pain scores were assessed at baseline, 6, and 12 months. The outcomes, including BMD, BTM, MDA, and pain scores, were evaluated in all patients. Forty-one thalassemia patients (18 males) were enrolled in the study and randomly assigned to either the melatonin group (n = 21) or the placebo group (n = 20). Characteristics of patients were not differences between groups. Mean age was 30.8 ± 6.2 years old. Thirty-three patients (80.4%) were transfusion-dependent patients. At 12 months, mean BMD at l-spine in melatonin group was not significantly different from placebo group (p = 0.069). However, l-spine BMD at 12 months in the melatonin group was significantly greater than baseline (p = 0.029). Serum levels of P1NP and MDA were significantly reduced at 6 months compared to baseline following melatonin treatment. The melatonin group experienced a notable decrease in back pain scores after 12 months compared to the initial measurements. 20 mg daily melatonin supplementation for 12 months alleviated l-spine BMD loss in iron-overloaded thalassemia with low BMD. Melatonin also significantly reduced circulating oxidative stress and mitigated back pain in these patients.

Long-Term Experience with Luspatercept in Relapsed/Refractory Myelodysplastic Neoplasms: A Chinese Real-World Study

INTRODUCTION

Luspatercept has been shown to be efficacious for patients with relapsed or refractory lower-risk myelodysplastic neoplasms (LR-MDS) in both clinical trials and real-world studies. Nevertheless, long-term follow-up data in real-world settings remain scarce, particularly in Asia.

METHODS

Data from patients diagnosed with relapsed or refractory LR-MDS who had been treated with luspatercept at our center between June 2022 and May 2024 were retrospectively collected.

RESULTS

In total, 60 patients were included in this study (63.4% males). The median duration of luspatercept exposure was 9 (range 3-25) months, and the median follow-up time was 15 (range 3-26) months. The hematologic improvement-erythroid (HI-E) rate was 46.7%, 51.0%, 48.6%, and 43.3% at the 3rd, 6th, and 12th months, and at the end of follow-up, respectively. Among patients who were transfusion-dependent prior to luspatercept, 48.3%, 38.7%, and 25.8% achieved transfusion independence for 8, 12, and 16 weeks or longer at the 6th month. Over time, patients treated with luspatercept had a significant increase in hemoglobin level compared with that of the baseline from the 1st month to the end of follow-up (all P < 0.05). At the end of follow-up, 5 of 32 (15.6%) patients who had response had experienced a relapse, 1 patient (1.7%) had progressed to higher-risk myelodysplastic neoplasms (MDS), and 2 patients (3.3%) had progressed to acute myeloid leukemia. Three patients (5.0%) died of pulmonary infection. Serum erythropoietin (EPO) ≤ 500 IU/l at baseline was the only independent predictive factor for HI-E at the 3rd month (P = 0.007).

CONCLUSION

Luspatercept is proved efficacious and well tolerated in relapsed/refractory LR-MDS and appears to be beneficial in reducing disease progression and prolonging survival.

Thrombotic Complications Associated With Right Atrial Lines in Neonates and Infants Undergoing Cardiac Surgery. Is Calcium Chloride a Culprit?

OBJECTIVES

To determine if a change from calcium chloride to calcium gluconate infusion resulted in a decreased incidence of atrial thrombi and thrombotic events in neonates undergoing cardiac surgery.

DESIGN

A single-center, retrospective cohort analysis.

SETTING

A single center in Houston, TX.

PARTICIPANTS

135 neonates undergoing cardiac surgery who had either a central venous catheter or tunneled atrial catheter placed and received infusions of either calcium chloride or calcium gluconate in the perioperative period.

INTERVENTIONS

Patients either received a calcium chloride or calcium gluconate infusion in the perioperative period.

MEASUREMENTS AND MAIN RESULTS

The study cohort consisted of 93 procedures using calcium chloride and 88 procedures using calcium gluconate infusions. The 181 procedures were recorded on a total of 135 patients. The overall incidence of thrombosis was 9.9%. The association between calcium chloride or calcium gluconate infusion and thrombotic events was assessed using a generalized linear mixed model for binary data (proc Glimmix, SAS v.9.4, SAS Institute, Cary, NC), to account for within-subjects correlation in patients requiring more than one procedure. The odds of thrombotic events when receiving calcium chloride infusion was 3.45 times that with calcium gluconate infusion in the setting of neonatal cardiac surgery (15% v 4.6%, odds ratio = 3.46, 95% confidence interval = 1.02, 11.7, p = 0.047).

CONCLUSIONS

In this single-center study, a significant decrease in the odds of an atrial catheter-related thrombus when a calcium gluconate infusion is used instead of calcium chloride was shown.