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.

Joint and individual associations between multiple vitamins and sperm quality in adult men

Background

Several studies have suggested that a healthy diet is associated with improved male fertility outcomes. However, the joint and individual associations between the status of multiple vitamins and sperm quality remain unclear.

Objectives

This study aimed to investigate the associations between serum vitamin levels and sperm quality parameters in adult men.

Methods

A cross-sectional study was conducted among 156 adult men seeking fertility care at a reproductive center from December 2023 to June 2024. Blood and semen were collected on the same day to determine the concentrations of nine kinds of vitamins (B1, B2, B6, B9, B12, C, A, D, E) and five parameters of sperm quality [total sperm number, sperm concentration, progressive motile sperm, morphologically normal rate, and DNA fragment index (DFI)]. The joint and individual associations between vitamin levels and sperm quality were analyzed using multiple linear regression and Bayesian kernel machine regression (BKMR) models.

Results

Increased tertiles of vitamin B1 and 1,25-dihydroxyvitamin D3 [1,25-(OH)2-D3] in serum were associated with higher sperm quality (all P for trends < 0.10). Compared with the lowest tertiles, the highest tertiles of vitamin B12 had β: 3.0 (95% CI: 0.8, 5.2) increasing in DFI, and vitamin A was negatively associated with progressive sperm motility (P for trends = 0.05). We generally found null results between multiple vitamin levels and the parameters of sperm quality in the BKMR models.

Discussion

These research findings imply that vitamins could have a dose-dependent dual effect on sperm quality. More specifically, the impact of vitamins varies according to their dosage levels and types. Personalized vitamin supplementation may be more effective than taking multivitamins in improving sperm quality.

Clinical Outcomes Among Patients With Sickle Cell Disease and Transfusion-Dependent Beta-Thalassemia Treated With Allogeneic Hematopoietic Stem Cell Transplantation: A Systematic Literature Review

Background

The purpose of this study is to synthesize evidence on disease-specific outcomes in patients with sickle cell disease (SCD) or transfusion-dependent beta-thalassemia (TDT) following allogeneic hematopoietic stem cell transplant (allo-HSCT).

Methods

A systematic literature review (SLR) was conducted in MEDLINE and Embase to identify publications up to May 2023, including patients with SCD or TDT treated with allo-HSCT. Occurrence of vaso-occlusive crises (VOCs) including acute pain, acute chest syndrome, priapism, and splenic sequestration in SCD, and red blood cell transfusion (RBCT) requirements in TDT were the main outcomes of interest. Transplant-related outcomes such as graft-versus-host disease (GVHD) and graft failure/rejection were summarized in the studies that reported main outcomes. Proportion of patients experiencing VOCs or RBCTs, GVHD, and graft failure/rejection after allo-HSCT were aggregated and descriptively reported with range across studies.

Results

Thirty-one SCD studies met inclusion criteria. Twenty-nine studies assessed for VOC and pain crisis events after allo-HSCT; 11 studies reported ≥1 VOCs after allo-HSCT in 6.9% of the 2,760 patients. Graft failure was reported in 14.4% (0.9%-18.8%, 14 studies) of patients, graft rejection in 5.5% (1.6%-100.0%, 12 studies) of patients, acute GVHD in 22.4% (1.6%-50.0%, 19 studies) of patients, and chronic GVHD in 20.4% (3.3%-57.1%, 14 studies) of patients. Seventy-eight TDT studies met inclusion criteria. Fifty-six studies reported that 8.8% of the 3,107 patients required RBCTs after allo-HSCT. Graft failure was reported in 5.4% (1.1%-80.0%, 21 studies) of patients, graft rejection in 7.5% (0.5%-42.9%, 50 studies) of patients, acute GVHD in 28.4% (5.2%-100.0%, 57 studies) and chronic GVHD in 15.2% (1.3%-50.0%, 51 studies) of TDT patients.

Conclusion

Based on this SLR, after allo-HSCT, a portion of patients with SCD continue to experience VOCs and a portion of patients with TDT continue to require RBCTs, in addition to experiencing GVHD and graft failure or rejection.

Immune thrombocytopenia in adolescents and young adults

Previous guidelines for the treatment of immune thrombocytopenia (ITP) have traditionally focused on a dichotomy between pediatric and adult ITP. Adolescents and young adults (AYAs) do not neatly fit into either the pediatric or adult ITP group. A deeper understanding of ITP's natural history, risk factors for chronicity, and outcomes in AYAs is a crucial first step toward developing tailored treatment algorithms. Such data could form the basis for recommendations targeting this underrepresented yet clinically distinct population. Ultimately, age-adapted trials may improve long-term outcomes, reduce toxicity, and enhance quality of life for AYAs with ITP. The AYAs collaboration-drawing on data from the Pediatric and Adult Registry on Chronic ITP (PARC-ITP), Registre Midi- Pyrénéen-France (CARMEN-France) adult registry in Toulouse, and the National Prospective Cohort for Children with Chronic Autoimmune Cytopenia (OBS'CEREVANCE) in Bordeaux, France-aims to address the information gap in AYAs with ITP. To date, four analyses have been undertaken (using data from 2004 to 2021), each addressing the major clinical aspects of ITP in patients aged 12-25 years: (1) newly diagnosed ITP, (2) chronic disease, (3) refractory courses, and (4) secondary (sITP) forms.

Zuogui Pills alleviate iron overload-induced osteoporosis by attenuating ROS-mediated osteoblast apoptosis via the PI3K-AKT pathway and mitigating mitochondrial damage

ETHNOPHARMACOLOGICAL RELEVANCE

Zuogui Pill (ZGP) is a classic herbal formula in Traditional Chinese Medicine, primarily used to tonify the kidney and replenish essence, and is widely applied in treating various kidney deficiency-related conditions. Over time, ZGP has demonstrated significant efficacy in addressing symptoms such as fatigue, weakness, and soreness of the lower back and knees, which are often caused by kidney deficiency. According to Traditional Chinese Medicine theory, the kidneys govern the bones, meaning that sufficient kidney essence is closely related to bone strength. By nourishing the kidneys and replenishing essence, ZGP helps to increase bone density and improve bone microstructure, making it an important therapeutic option for osteoporosis.

AIM OF THE STUDY

To investigate the protective effects of ZGP in iron overload-induced osteoporosis and elucidate its molecular mechanisms through the activation of the Phosphoinositide 3-Kinase (PI3K)/Protein Kinase B (AKT) and Nuclear Factor Erythroid 2-Related Factor 2 (Nrf2)/Heme Oxygenase-1 (HO-1) pathways, which reduce oxidative stress, inhibit osteoblast apoptosis, and promote osteoblast differentiation and mineralization.

MATERIALS AND METHODS

An in vivo mouse model of iron overload-induced osteoporosis and an in vitro MC3T3-E1 osteoblast model were used. In vitro experiments involved the use of ZGP containing-serum, along with transcriptomic analysis, Western blot, flow cytometry, TUNEL staining, and immunofluorescence, to assess the effects on oxidative stress, mitochondrial function, and apoptosis. In vivo experiments evaluated the effects of ZGP on bone mass, oxidative stress, and apoptosis using Micro-computed tomography (micro-CT), Hematoxylin and eosin staining (H&E), TUNEL staining, and immunohistochemistry.

RESULTS

The study found that ZGP containing-serum significantly enhanced the viability of osteoblasts induced by iron overload and reduced apoptosis through the reactive oxygen species (ROS)-mediated Phosphoinositide 3-Kinase (PI3K)/Protein Kinase B (AKT) pathway while mitigating mitochondrial damage. In vivo, micro-computed tomography results showed that ZGP improved bone mass, and decreased ROS and apoptosis, consistent with the in vitro findings.

CONCLUSION

ZGP demonstrates significant antioxidant and anti-apoptotic effects in iron overload-induced osteoporosis, primarily through the ROS-mediated PI3K/AKT pathway and by reducing mitochondrial damage. These findings suggest that ZGP may be a promising therapeutic agent for treating osteoporosis associated with iron overload.

The role of public health in rare diseases: hemophilia as an example

Introduction

The role of public health has evolved from addressing infectious diseases to encompass non-communicable diseases. Individuals with genetic disorders and rare diseases constitute a particularly vulnerable population, requiring tailored public health policies, practical implementation strategies, and a long-term vision to ensure sustainable support. Given the prolonged duration and significant costs often associated with these conditions, comprehensive, patient-centered, and cost-effective approaches are essential to safeguard their physical and mental well-being.

Aims

To summarize definitions and concepts related to health, public health, rare diseases, and to highlight the role of integrating public health interventions into routine care in improving patient outcomes. Hemophilia was selected as an exemplary rare disease due to its significant lifetime treatment costs and the recent approval and pricing of its gene therapy as the world's most expensive drug, highlighting the critical importance of public health policies in ensuring equitable access to care and treatment.

Methods

A narrative literature review was conducted between July 2023 and December 2024, searching PubMed, Google Scholar, and Google for various topics related to rare diseases, public health, and hemophilia.

Results

Public health can play an important role in improving the health outcomes of people with rare diseases by implementing conceptual and applied models to accomplish a set of objectives. Over the past two decades, legislative and regulatory support in high income countries (HICs) has facilitated the development and approval of diagnostics and treatments for several rare diseases leading to important advancements. In contrast, many low- and middle-income countries (LMICs) face obstacles in enacting legislation, developing regulations, and implementing policies to support rare disease diagnosis and treatment. More investment and innovation in drug discovery and market access pathways are still needed in both LMICs and HICs. Ensuring the translation of public health policies into regulatory measures, and in turn implementing, and regularly evaluating these measures to assess their effectiveness is crucial. In the case of hemophilia, public health can play a pivotal role.

Conclusion

Enhancing public health surveillance, policies, and interventions in hemophilia and other rare diseases can bridge data gaps, support access to equitable treatment, promote evidence-based care, and improve outcomes across the socioeconomic spectrum.

Schizosaccharomyces pombe pus1 mutants are temperature sensitive due to decay of tRNAIle(UAU) by the 5'-3' exonuclease Dhp1, primarily targeting the unspliced pre-tRNA

The pseudouridylase Pus1 catalyzes pseudouridine (Ψ) formation at multiple uridine residues in tRNAs, and in some snRNAs and mRNAs. Although Pus1 is highly conserved, and mutations are associated with human disease, little is known about eukaryotic Pus1 biology. Here, we show that Schizosaccharomyces pombe pus1Δ mutants are temperature sensitive due to decay of tRNAIle(UAU), as tRNAIle(UAU) levels are reduced, and its overexpression suppresses the defect. We show that tRNAIle(UAU) is degraded by the 5'-3' exonuclease Dhp1 (ortholog of Saccharomyces cerevisiae Rat1), as each of four spontaneous pus1Δ suppressors had dhp1 mutations and restored tRNAIle(UAU) levels, and two suppressors that also restored tRNAIle(UAU) levels had mutations in tol1 (S. cerevisiae MET22 ortholog), predicted to inhibit Dhp1. We show that Pus1 modifies U27, U34, and U36 of tRNAIle(UAU), raising the question about how these modifications prevent decay. Our results suggest that Dhp1 targets unspliced pre-tRNAIle(UAU), as a pus1Δ strain in which the only copy of tRNAIle(UAU) has no intron [tI(UAU)-iΔ] is temperature resistant and undergoes no detectable decay, and the corresponding pus1Δ tI(UAU)-WT strain accumulates unspliced pre-tRNAIle(UAU) Moreover, the predicted exon-intron structure of pre-tRNAIle(UAU) differs from the canonical bulge-helix-loop structure compatible with tRNA splicing, and a pus1Δ tI(UAU)i-var strain with intron mutations predicted to improve exon-intron structure is temperature resistant and undergoes little decay. These results suggest that decay of tRNAIle(UAU) by Dhp1 in pus1Δ strains occurs at the level of unspliced pre-tRNAIle(UAU), implying a substantial role for one or more of the Ψ residues in stabilizing the pre-tRNA structure for splicing.

Outcomes of heparin-induced thrombocytopenia type II in aneurysmal subarachnoid hemorrhage patients: A US nationwide analysis

BACKGROUND

Despite the widespread use of heparin during and following endovascular procedures in the management of aneurysmal subarachnoid hemorrhage (SAH) patients, limited research has explored the incidence and impact of heparin-induced thrombocytopenia (HIT) on SAH.

METHODS

Descriptive statistics, multivariate regressions, and propensity score-matching were employed to compare clinical characteristics, comorbidities, interventions, complications, and outcomes of HIT in SAH patients identified within the US National Inpatient Sample database from 2010 to 2019.

RESULTS

Among 76 387 SAH patients from 2010 to 2019, 166 (0.22%) developed HIT. HIT was identified as a significant predictor of prolonged length of stay (OR 6.799, 95% CI 3.985 to 11.6, P<0.01) and poor functional outcomes (OR 2.541, 95% CI 1.628 to 3.966, P<0.01) after adjusting for relevant factors. HIT incidence was higher in patients with elevated SAH severity scores (1.42 vs 1.06, P<0.01), younger patients (58.04 vs 61.39 years, P=0.01), overweight individuals (0.4% vs 0.2%, P<0.01), those on long-term anticoagulants (10.84% vs 5.72%, P<0.01), or with a cerebrospinal fluid drainage device (external ventricular drain, ventriculoperitoneal shunt; P<0.01). HIT patients showed increased rates of endovascular coiling, ventricular drain placement, shunt placement, deep vein thrombosis, urinary tract infection, acute kidney injury, pulmonary embolism, venous sinus thrombosis, pneumonia, and cerebral vasospasm (all P<0.01).

CONCLUSION

SAH patients with HIT exhibited various comorbidities and increased rates of complications, which may contribute to extended hospital stays. This nationwide study aids clinical suspicion and highlights HIT's impact on SAH patients.

Comparative analysis of mortality patterns and treatment strategies in thalassaemia and sickle cell disease patients: A 12-year study

This study examined mortality rates among 2475 patients with thalassaemia and sickle cell disease (SCD) per year over 12 years in Greece, recording 335 deaths (27.92/year), with an overall mortality rate of 1.13% per year. The primary aim was to identify causes of death, comorbidities, treatment efficacy and iron overload prevalence. Of the deaths, 239 were attributed to thalassaemia and 96 to SCD. For thalassaemia patients, cardiac failure, hepatocellular carcinoma and sepsis were the leading causes of death, with no neoplasms observed in β+/β+ genotypes. In SCD, sepsis, liver failure and stroke were the predominant causes, with sepsis-related deaths higher in frequently transfused patients. The median age of death was significantly lower in thalassaemia (50 years) compared to SCD (58.49 years, p < 0.001). Differences in comorbidities and treatment effectiveness highlight the need for improved management strategies. Addressing iron overload, optimizing chelation therapy and expanding hydroxyurea use in SCD patients could enhance survival and quality of life. Strengthening treatment protocols and monitoring may reduce mortality, emphasizing the importance of targeted interventions in haemoglobinopathies.

Association between Platelet Count and Bleeding during Central Line Placement in Critically Ill Children

OBJECTIVE

To evaluate the association between platelet count and procedure-related bleeding at the time of central venous line (CVL) placement in critically ill children.

STUDY DESIGN

A retrospective cohort study was performed capturing patient admissions to the pediatric intensive care unit between January 1, 2012 to March 1, 2022. Critically ill children between 0 months and 19 years who underwent bedside CVL placement were included. A total of 363 were included in the final analysis.

RESULTS

Patients' platelet counts prior to line placement ranged from 11 000/uL to 735 000/uL. Bleeding was identified in 26 of 363 (7.2%) of patients, and was categorized as 24 (92%) minimal, 2 (8%) moderate, and none severe. Platelet count and platelet transfusion before line placement were both significantly different between bleeding and non-bleeding patients (P = .04 and P = .032). Patients with lower platelet counts had a higher proportion of bleeding events. There were no significant differences between the bleeding and non-bleeding groups in age, sex, history of bleeding, or number of attempts at CVL. Patients with bleeding were not significantly sicker. Regression analysis determined that female sex and transfusion before CVL placement were both significantly associated with bleeding.

CONCLUSIONS

We found that the platelet count prior to CVL placement was not associated with bleeding events in critically ill pediatric patients. Bleeding was more common in patients receiving platelet transfusions. Additional studies are needed to evaluate further the effect of platelet transfusions on procedure-related bleeding.

Engineering mtDNA deletions by reconstituting end joining in human mitochondria

Recent breakthroughs in the genetic manipulation of mitochondrial DNA (mtDNA) have enabled precise base substitutions and the efficient elimination of genomes carrying pathogenic mutations. However, reconstituting mtDNA deletions linked to mitochondrial myopathies remains challenging. Here, we engineered mtDNA deletions in human cells by co-expressing end-joining (EJ) machinery and targeted endonucleases. Using mitochondrial EJ (mito-EJ) and mito-ScaI, we generated a panel of clonal cell lines harboring a ∼3.5 kb mtDNA deletion across the full spectrum of heteroplasmy. Investigating these cells revealed a critical threshold of ∼75% deleted genomes, beyond which oxidative phosphorylation (OXPHOS) protein depletion, metabolic disruption, and impaired growth in galactose-containing media were observed. Single-cell multiomic profiling identified two distinct nuclear gene deregulation responses: one triggered at the deletion threshold and another progressively responding to heteroplasmy. Ultimately, we show that our method enables the modeling of disease-associated mtDNA deletions across cell types and could inform the development of targeted therapies.

Thrombocytopenia following kidney transplantation: a frequent, underestimated and potentially severe complication

Introduction

Cytopenias occur frequently after kidney transplantation but posttransplantation thrombocytopenia (PTTCP) frequency has rarely been reported.

Methods

This monocenter, retrospective study aimed to describe PTTCP frequency, causes, treatments and outcomes. PTTCP was defined as thrombocytopenia with ≥2 platelet counts <100×109/L after first month posttransplantation.

Results

Among 2118 kidney-transplant recipients between 2002 and 2018, 189 (8.9%) developed PTTCP. Their mean platelet-count nadir was 51×109/L [range 4-96×109]; nadir was <50×109/L for 87 (46.0%) patients. Main identified PTTCP etiologies were drugs (24.3%), or infectious diseases (20.1%; cytomegalovirus causing 79.4% of them), or unknown for 26 (13.7%). Bleeding rate was high (32.7%), with 40 (64.5%) severe episodes. During follow-up, 103 (54.5%) patients suffered graft loss or died at a median of 5.41 years post-PTTCP episode. Multivariate analyses retained a severe bleeding episode as being significantly associated with antiplatelet or anticoagulation therapy and pancytopenia, and age, creatininemia, transplantation-to-PTTCP interval and severe bleeding as significant risk factors for death or graft loss.

Conclusion

PTTCP is frequently associated with severe bleeding, which is a risk factor for graft loss and death. Those findings suggest that the risk/benefit ratio of antiplatelet or anticoagulation therapies should be systemically evaluated for PTTCP patients.

Evaluating Health-Related Quality of Life in Thalassemia: Low-Dose Thalidomide vs. Standard Care-Insights from a Comparative Study

Thalassemia is a hemoglobinopathy that affects many people worldwide. Although treatments such as iron chelation and safe transfusions have improved life expectancy, patients still experience complications. Thalidomide, with its immunomodulatory and anti-angiogenic properties, has been found to increase the expression of the γ-globin gene and promote erythroid cell proliferation. Our study compared thalidomide-treated and standard therapy groups, assessing health-related quality of life in thalassemia patients using the SF-36 questionnaire tailored for the Indian population. A total of 84 patients (Thalidomide: 50, Standard: 34) were enrolled. Sixty-four percent of patients on thalidomide became transfusion-free within 4-6 months. The mean duration of transfusion requirement in the thalidomide group increased from 20 to 35 days in 30% of patients. Patients aged ≤ 20 years, without splenectomy, and unemployed had significantly better physical health component (PHC) scores with thalidomide therapy compared to standard therapy (P = 0.027, P = 0.0007, and P = 0.045, respectively). On the other hand, patients aged >20 years and with intact spleen had significantly better mental health component (MHC) scores with thalidomide therapy compared to standard therapy (P = 0.006 and P < 0.00001, respectively). Thalidomide therapy showed significantly better MHC scores than standard therapy on all four scales. Thalidomide therapy shows significant promise in improving the HRQoL for thalassemia patients, particularly in those with early initiation, as indicated by enhanced physical and mental health component scores and improved vitality, emotional well-being, role-emotional, and social functioning compared to standard care.

In-human clinical experience with direct stick embolization of low-flow vascular malformations using a mammalian target of rapamycin inhibitor

BACKGROUND

Although direct stick embolization (DSE) of low-flow vascular malformations (LFVMs) with off-label embolotherapeutic compounds is the current mainstay of therapy, systemic oral mammalian target of rapamycin (mTOR) inhibition has evolved into an important adjunctive therapy that is associated with frequent blood draws, systemic toxicity, and rebound signs and symptoms upon cessation. We herein report our experience with in-human DSE of LFVMs with an mTOR inhibitor for direct, intralesional targeting of the culprit mutated pathway without repeated systemic exposure.

METHODS

Since 2020, 33 procedures involving DSE were performed in 25 patients with LFVMs using a patented formulation and technique involving the intravenously compatible mTOR inhibitor Yale-OCR7737, used as a liquid compound in a collagen matrix emulsion for added viscosity and intralesional residence. Data were maintained prospectively and reviewed retrospectively for technical success (successful catheterization of the lesion and intralesional delivery of compound), clinical success (improvement in signs/symptoms with radiologically documented reduction in flow and/or volume of treated lesion), complications, side effects, and reinterventions.

RESULTS

From 2020 to 2023, 33 procedures involving DSE were performed using Yale-OCR7737 in 25 patients (10 men [40%]; 15 women [60%]; mean age, 28 years [range, 1-70 years]) with LFMVs involving the head/neck (48%) and limbs (40%); 88% were nonsyndromic and 12% had Klippel-Trenaunay syndrome; 68% exhibited venous malformations, and 32% had lymphatic malformations. Technical and clinical success rates were 100%. Mean DSE sessions per patient was 1.4 (range, 1-5). Localized intravascular coagulopathy was present after 16 DSE procedures (49%); D-dimer improved after DSE in 7 cases. No perioperative or delayed complications occurred. Side effects were seven cases (21%) of self-limited, transient, oral aphthous ulcers.

CONCLUSIONS

Our findings suggest that DSE of LFVMs with mTOR inhibitors (Yale-OCR7737) may be safe and effective. This may represent the new embolotherapeutic frontier in the endovascular treatment of LFMVs.

Abnormalities in Chromosomes 5 and 7 in Myelodysplastic Syndrome and Acute Myeloid Leukemia

Chromosomes 5 and 7 are large chromosomes that contain close to 1,000 genes each. Deletions of the long arms or loss of the entire chromosome (monosomy) are common defects in myeloid disorders, particularly MDS and AML. Loss of material from either chromosome 5 or 7 results in haploinsufficiency of multiple genes, with some implicated in leukemogenesis. Abnormalities of one or both occur in up to 15% of MDS and AML cases and co-segregate in half of these. Generally, these chromosomal abnormalities are harbingers of adverse risk in both myeloid disorders. A notable exception is del(5q) in 5q- syndrome, a subtype of MDS. In this review, we describe the pathogenesis and genetic consequences of deletions in chromosomes 5 and 7. Furthermore, we provide an overview of current testing methodologies used in the assessment of these chromosomal defects in hematological malignancies and describe the disease associations and prognostic implications of aberrations in chromosomes 5 and 7 in both MDS and AML.

Alloimmunization in β-Thalassemia and Sickle Cell Disease in Middle Eastern Countries: A Systemic Review

Sickle cell disease and β-thalassemia are important health problems in Middle Eastern countries. Transfusion is the cornerstone of the management in these disorders, and red blood cell alloimmunization is among the well-recognized adverse effects associated with it. We reviewed the literature on published studies on alloimmunization prevalence, its associated risk factors, and transfusion policies employed in these countries. Our review included 39 studies on thalassemia (including 9005 patients), and 19 on sickle cell disease (including 3867 patients). The mean alloimmunization prevalence rate in thalassemia was 13.0% (95% CI: 10.0-15.0%), while that in sickle cell disease was 14.0% (95% CI: 10.0 - 19.0%). The distribution of the prevalence rates showed considerable heterogeneity in both diseases. The most frequent alloantibodies detected were anti-K (25.9%), Anti-E (21.8%), and Anti-D (9.2%), with Rhesus and K antibodies comprising 74.2% of all antibodies detected. Some risk factors were significant in several studies, including older age, female sex, older age at first transfusion, number of transfused units, and splenectomy. The prevalence of alloimmunization was significantly higher in retrospective studies compared to cross-sectional ones, in both thalassemia and sickle cell disease (P = 0.04 in each). This review reaffirmed the need to provide ABO+Rhesus + K matched blood to hemoglobinopathy patients in the Middle East, and the need for more research on Rhesus variants in this part of the world.

State-of-the-Art Quantification of Liver Iron With MRI-Vendor Implementation and Available Tools

The role of MRI to estimate liver iron concentration (LIC) for identifying patients with iron overload and guiding the titration of chelation therapy is increasingly established for routine clinical practice. However, the existence of multiple MRI-based LIC quantification techniques limits standardization and widespread clinical adoption. In this article, we review the existing and widely accepted MRI-based LIC estimation methods at 1.5 T and 3 T: signal intensity ratio (SIR) and relaxometry (R2 and R2*) and discuss the basic principles, acquisition and analysis protocols, and MRI-LIC calibrations for each technique. Further, we provide an up-to-date information on MRI vendor implementations and available offline commercial and free software for each MRI-based LIC quantification approach. We also briefly review the emerging and advanced MRI techniques for LIC estimation and their current limitations for clinical use. Lastly, we discuss the implications of MRI-based LIC measurements on clinical use and decision-making in the management of patients with iron overload. Some of the key highlights from this review are as follows: 1) Both R2 and R2* can estimate accurate and reproducible LIC, when validated acquisition parameters and analysis protocols are applied, 2) Although the Ferriscan R2 method has been widely used, recent consensus and guidelines endorse R2*-MRI as the most accurate and reproducible method for LIC estimation, 3) Ongoing efforts aim to establish R2*-MRI as the standard approach for quantifying LIC, and 4) Emerging R2*-MRI techniques employ radial sampling strategies and offer improved motion compensation and broader dynamic range for LIC estimation. EVIDENCE LEVEL: 1 TECHNICAL EFFICACY: Stage 2.

Prevalence and Associated Factors of Zinc and Vitamin D Deficiencies in Pediatric and Young Adult Patients with Non-Transfusion-Dependent Thalassemia

Micronutrient deficiencies pose significant long-term risks in non-transfusion dependent thalassemia (NTDT) patients. Zinc deficiency can impair growth, cause atopic dermatitis, and increase susceptibility to respiratory infections, while vitamin D deficiency disrupts bone mineralization and metabolism. This study aimed to determine the prevalence of zinc and vitamin D deficiencies and investigate associated factors in pediatric to young adult NTDT patients. A cross-sectional study was conducted at Chiang Mai University Hospital, enrolling NTDT patients aged 5 to 25 years who received fewer than three transfusions annually. Serum zinc and vitamin D levels were measured. Patients and parents completed a 3-day food diary and a sun exposure questionnaire. Zinc deficiency was defined as levels below the reference level for age. Vitamin D deficiency was defined as levels <20 ng/mL. Clinical and hematologic parameters were compared between groups with and without deficiencies. Forty-five patients with NTDT were enrolled, including 23 males (51.1%) males, with a mean age of 12.8 ± 5.3 years. Zinc deficiency affected 13 patients (28.9%), while 23 patients (51.1%) had vitamin D deficiency. Thinness was observed more frequently in patients with zinc deficiency. However, this finding did not reach statistical significance. Older age and inadequate sun exposure were associated with vitamin D deficiency. This study underscores a high prevalence of zinc and vitamin D deficiencies in pediatric and young adult NTDT patients and identifies the associated factors. Addressing and monitoring these deficiencies are crucial for optimizing long-term health outcomes in this patient group.

Hereditary disorders of ineffective erythropoiesis

Under steady state conditions, humans must produce ∼2 million red blood cells per second to sustain normal red blood cell counts and hemoglobin levels. Ineffective erythropoiesis, also termed dyserythropoiesis, is a process by which erythroid precursors die or fail to efficiently differentiate in the bone marrow. Ineffective erythropoiesis is characterized by expanded bone marrow erythropoiesis and increased erythroferrone production by bone marrow erythroblasts, with the latter resulting in reduced hepcidin production and increased iron absorption. Ineffective erythropoiesis may result from acquired and congenital conditions. Inherited causes of ineffective erythropoiesis include β-thalassemia, sideroblastic anemias, pyruvate kinase deficiency, and congenital dyserythropoietic anemias. This manuscript reviews the definition and evidence for ineffective erythropoiesis and describes the most common hereditary disorders of dyserythropoiesis.

Treatment Beliefs Reflect Unmet Clinical Needs in Lysosomal Storage Diseases: An Opportunity for a Patient-Centered Approach

Despite life-long pharmacotherapy for many people affected by lysosomal storage diseases, no data are available on their beliefs about their treatments. Therapeutic options range from disease-specific, with varying levels of effectiveness, to purely supportive. This spectrum is illustrated by the three diseases Gaucher disease type 1 (effective disease-specific therapies), Fabry disease (disease-specific therapies with variable effectiveness), and mucopolysaccharidosis type III A/B (supportive care only). Employing the Necessity-Concerns Framework of the Beliefs in Medicine Questionnaire, we investigated intra- and intergroup variability in adults with Gaucher disease type 1, Fabry disease, and parents of children with mucopolysaccharidosis type III A/B. Participants rated necessity and concern items on a Likert scale, leading to categorization as accepting, skeptical, indifferent, or ambivalent. Self-reported demographic, disease-, and therapy-related data were also obtained. Eighty-one surveys were completed. Gaucher disease respondents (n = 15) were overwhelmingly categorized as accepting (high necessity, low concern). Female Fabry disease respondents (n = 43) were almost equally distributed over all categories except accepting. Male Fabry disease respondents (n = 16) were mostly ambivalent or accepting, indicating overall high necessity scores but varying concern. All mucopolysaccharidosis type III participants (n = 7) were categorized as indifferent (low necessity, low concern). The Beliefs in Medicine Questionnaire emerged as a valuable and feasibly employable tool for individual and group assessments in these populations. It reveals differences in beliefs aligned with current unmet medical needs. Expansion of this approach is warranted to optimize personalized counseling on therapeutic choices and to align drug development with the needs and beliefs of potential recipients.

The Multifaceted Roles of BACH1 in Disease: Implications for Biological Functions and Therapeutic Applications

BTB domain and CNC homolog 1 (BACH1) belongs to the family of basic leucine zipper proteins and is expressed in most mammalian tissues. It can regulate its own expression and play a role in transcriptionally activating or inhibiting downstream target genes. It has a crucial role in various biological processes, such as oxidative stress, cell cycle, heme homeostasis, and immune regulation. Recent research highlights BACH1's significant regulatory roles in a series of conditions, including stem cell pluripotency maintenance and differentiation, growth, senescence, and apoptosis. BACH1 is closely associated with cardiovascular diseases and contributes to angiogenesis, atherosclerosis, restenosis, pathological cardiac hypertrophy, myocardial infarction, and ischemia/reperfusion (I/R) injury. BACH1 promotes tumor cell proliferation and metastasis by altering tumor metabolism and the epithelial-mesenchymal transition phenotype. Moreover, BACH1 appears to show an adverse role in diseases such as neurodegenerative diseases, gastrointestinal disorders, leukemia, pulmonary fibrosis, and skin diseases. Inhibiting BACH1 may be beneficial for treating these diseases. This review summarizes the role of BACH1 and its regulatory mechanism in different cell types and diseases, proposing that precise targeted intervention of BACH1 may provide new strategies for human disease prevention and treatment.

Does Childhood Cochlear Implantation Spill Over to Carers' Employment Status?

OBJECTIVES

Carers of children with disabilities, especially primary carers, tend to have poorer labor market outcomes than carers of typically developing children. However, the extant literature has been largely silent on whether interventions for children's disabilities spill over to carers' employment outcomes, if at all. We aimed to fill this gap.

DESIGN

We analyzed data from the Longitudinal Outcomes of Children with Hearing Impairment study, which is a unique panel dataset of Australian children who are deaf or hard-of-hearing (DHH). The Longitudinal Outcomes of Children with Hearing Impairment dataset includes information about 449 DHH children. We used 3 waves covering the same children at ages 0 to 3, 5 to 7, and 8 to 10 years during 2005 and 2018. We used a panel random-effects model, the use of which was supported by the Hausman specification test to control for time-invariant individual heterogeneity.

RESULTS

We found that primary carers (typically mothers) of DHH children with cochlear implants (CI) were more likely to be employed relative to DHH children without a CI. The positive association was stronger among carers from a lower socioeconomic background.

CONCLUSIONS

The association between childhood CI and carer employment may potentially be due to relaxed primary carers' time constraints to care for the child, increased self-efficacy, and reduced carer stress, enabling them to engage in other activities, including employment. Further research through large-scale, longitudinal studies is warranted to solidify the findings of this research.

Therapeutic applications and challenges in myostatin inhibition for enhanced skeletal muscle mass and functions

Myostatin, a potent negative regulator of skeletal muscle mass, has garnered significant attention as a therapeutic target for muscle dystrophies. Despite extensive research and promising preclinical results, clinical trials targeting myostatin inhibition in muscle dystrophies have failed to yield substantial improvements in muscle function or fitness in patients. This review details the mechanisms behind myostatin's function and the various inhibitors that have been tested preclinically and clinically. It also examines the challenges encountered in clinical translation, including issues with drug specificity, differences in serum myostatin concentrations between animal models and humans, and the necessity of neural input for functional improvements. Additionally, we explore promising avenues of research beyond muscle dystrophies, particularly in the treatment of metabolic syndromes and orthopedic disorders. Insights from these alternative applications suggest that myostatin inhibition may hold the potential for addressing a broader range of pathologies, providing new directions for therapeutic development.

Association between mothers' working hours and metabolic syndrome in children and adolescents: data from the Korea National Health and Nutrition Examination Survey, 2016-2020

BACKGROUND

Prevention and management of metabolic syndrome (MetS) during childhood are crucial. Recently, obesity among children and adolescents has increased with an increase in mothers' working hours. The present study was conducted to determine the relationship between mothers' working hours and MetS in their children.

METHODS

Data from the 2016-2020 National Health and Nutrition Examination Survey were used, and 2,598 children and adolescents aged 10-18 years were included. Logistic regression analysis was conducted to confirm the association between MetS and mothers' working hours for each risk factor. Linear regression analysis was conducted to confirm the association between mothers' working hours and the number of risk factors for MetS.

RESULTS

Abdominal obesity in children was higher when the mothers' working hours were 53 hours or more (odds ratio [OR], 2.267; 95% confidence interval [CI], 1.21-4.25). In the trend analysis, the OR of children's abdominal obesity increased significantly as mothers' working hours increased (P-value <0.05). Additionally, sex-stratified analysis revealed a significant trend between maternal work hours and the presence of MetS in female children (P=0.016). The adjusted OR of the presence of MetS in female children with mothers working 53 hours or more weekly was 6.065 (95% CI, 1.954-18.822).

CONCLUSION

Mothers' working hours were highly correlated with the risk of abdominal obesity in their children. The OR of the presence of MetS significantly increased in female children with mothers having longer working hours compared with those with stay-at-home mothers.

Inherited disorders of vitamin metabolism

Vitamins are essential cofactors of various enzyme reactions in amino acid, neurotransmitter, nucleotide and energy metabolism. Over the past decade a number of inborn errors of metabolism have been identified, that affect different steps in vitamin absorption, transport, activation or recycling and repair of active vitamin cofactors. According to the respective cofactor function this may result in acute or chronic multisystem disease or in disorders that selectively affect the nervous system. Most of these disorders are amenable to specific treatment with excellent results, but diagnostic delay can lead to rapid, irreversible damage or even death. Therefore, especially in case of acute and severe neurologic presentations compatible with one of the here discused disorders, a vitamin trial should be considered while awaiting results of biochemical and genetic testing. Diagnosis of these disorders is especially rewarding, as treatment is often per oral, available worldwide and comparably cheap. This article will review current knowledge of the clinical presentation, biomarkers and specific treatment of inborn errors of vitamin metabolism and illustrates why child neurologists should have vitamins in their pockets.

Molecular signatures associated with venous thromboembolism in children with acute lymphoblastic leukemia

BACKGROUND

Venous thromboembolism (VTE) is a frequent complication of childhood acute lymphoblastic leukemia (ALL).

OBJECTIVES

We aimed to identify molecular markers and signatures of the leukemia microenvironment associated with VTE in childhood ALL by the dual-omics approach of gene expression and DNA methylation profiling.

METHODS

Eligible children aged 1 to 21 years old with newly diagnosed ALL were enrolled in the Dana-Farber Cancer Institute 16-001 trial with available RNA sequencing data from bone marrow at diagnosis. The primary outcome was VTE requiring medical intervention, divided between early events (ETs), within 6 weeks from ALL diagnosis, or late events otherwise. We compared differential gene expression and DNA methylation in children with and without VTE and in the subgroup of children with ETs. The DNA methylation cis-regulation was explored by dual-omics integration. Functional gene set enrichment analyses were performed to assess dysregulated pathways associated with thrombosis. Gene expression profiling-based signature for the thrombosis-free interval was determined using the Kaplan-Meier estimator and log-rank tests.

RESULTS

We included 248 patients (median age, 7.5 years; 78% precursor B-cell ALL), of whom 56 (23%) developed VTE. Genes and metabolic pathways involved in coagulation, platelet activation, and neutrophil extracellular trap formation were associated with ETs. Dual-omics analysis indicated that methylation reprogramming might be responsible for the overexpression of genes involved in neutrophil extracellular trap formation and coagulation in patients with ETs. A prothrombotic gene signature, based on VWF, PF4, and CXCL8 expression, predicted a thrombosis-free interval.

CONCLUSION

This suggests that gene markers and epigenetic regulation of the leukemic microenvironment are drivers of VTE, notably ETs in childhood ALL.

The Feasibility of Personalized Endpoints in Assessing Treatment Outcomes for Rare Diseases: A Pilot Study of Goal Attainment Scaling in SCN2A-Associated Developmental Epileptic Encephalopathy

OBJECTIVES

For individuals living with rare neurodevelopmental disorders, particularly those who are at the most severe end of the spectrum, standardized outcome measures may lack the sensitivity to capture small but meaningful changes. Personalized endpoints such as goal attainment scaling (GAS) allow the assessment of treatment response across variable baseline states and disease manifestations and, thus, provide a highly sensitive measure of efficacy. The current study tested the feasibility of using GAS in rare SCN2A-associated developmental and epileptic encephalopathy (SCN2A-DEE).

METHODS

The caregivers of 10 individuals with SCN2A-DEE (Mage = 8.2 years, SD = 5.62, range 3.4-20.4; Nmale = 8) took part in in-person goal setting and remote follow-up interviews facilitated by 4 clinical researchers. Implementation was standardized using clinician training, patient orientation, and an electronic data capture platform, GoalNav®; surveys were used to evaluate implementation.

RESULTS

All 10 caregivers completed the goal-setting interviews and were able to set scale 3 goals, and assess attainment levels at follow-up interviews. The mean (SD) times to conduct the goal setting and follow-up interviews were 59.4 (14.5) and 18.4 (10.5) minutes, respectively. Participants set a variety of goals relating to communication (n = 10), feeding (n = 4), gross and fine motor abilities (n = 6), behavior (n = 5), gastrointestinal function (n = 3), sleep (n = 1), and seizures (n = 1). Data completeness, interview time, and the presence of high-quality goals (29/30) indicated the feasibility of using GAS in this population, whereas survey responses indicated its acceptability.

CONCLUSIONS

This pilot project provided evidence supporting the feasibility of GAS as a method for assessing treatment outcomes for patients with rare neurodevelopmental disorders.

Prevalence and Risk Factors of L-Asparaginase-Related Thrombosis Among Acute Lymphoblastic Lymphoma Patients in a Resource-Limited Setup of Sub-Saharan Region

BACKGROUND

L-asparaginase is an important component of acute lymphoblastic leukemia (ALL) treatment. However, it is associated with an increased risk of thrombosis which in turn increases the risk of morbidity and mortality and also poses a negative effect on leukemia-related outcomes.

AIMS

To assess the prevalence of thrombotic events and their associated factors in patients with ALL treated with L-asparaginase-containing regimens in Tikur Anbessa Specialized Hospital (TASH) from November 2020 to November 2023.

METHODS

A single-center retrospective cross-sectional study was conducted at TASH. A total of 152 ALL patients who have been treated or were on treatment with L-asparaginase-containing regimens from November 2020 to November 2023 were included in the study. Data were collected from the patient's medical records. Data were entered and analyzed with SPSS version 26, and a chi-square test was used to assess the association of independent variables with the dependent variable. Bivariate and multivariate logistic regression analyses were used to determine the presence of significant correlation between dependent and independent variables and those with p-value of 0.25 were included in the multivariate analysis. For multivariate analysis a p-value < 0.05 was considered as statistically significant.

RESULTS

The median age of the participants was 22.5 years (IQR 18, 30.8), and 59.9% of them were male. The majority (84.2%) of patients were treated with pediatric-inspired ALL CALGB10403 protocol. Eleven point two percent of the patients developed a documented thrombotic event. All of the events were venous and, cerebral venous thrombosis was the most common site (41.2%). Thrombosis occurred during remission induction in 44.4%. On multivariate logistic regression analysis, age ≥ 40 years and longer time to achieve complete remission (CR) of > 4 weeks (Age ≥ 40 years, p = 0.019; adjusted odds ratio [AOR] 10.4, 95% confidence interval [CI] = 1.47-75.0 and, time to achieve CR > 04 weeks p = 0.037; AOR 4.8, 95% CI = 1.10-20.72) were significantly associated with increased risk of thrombosis. Patients who developed thrombosis had a statistically non-significant higher rate of mortality compared with those without thrombosis (47% vs. 41.4%, p = 0.618). Around a third (29.4%) of the deaths in the patients with thrombosis were direct effects of the thrombotic event.

CONCLUSION

This study showed that the risk of L-asparaginase-associated thrombosis in resource-limited settings like ours is comparable with previous reports from other parts of the world, but the mortality directly attributed to thrombosis is remarkably higher. Older age above 40 years and longer time to achieve CR are independent predictors of higher thrombosis risk. Future prospective studies need to look into the contributing factors, and preventive and treatment strategies.

Long-term safety and efficacy of fostamatinib in Japanese patients with primary immune thrombocytopenia

Fostamatinib had superior efficacy to a placebo and acceptable safety profiles for at least 1 year in a phase 3 study of Japanese patients with primary immune thrombocytopenia. Here, we report the 3-year safety and efficacy of fostamatinib in that study. Data from 33 patients who received at least one dose of fostamatinib were analyzed. A platelet response > 50,000/µL (at two consecutive visits at least 28 days apart while receiving fostamatinib) was achieved in 16 patients (48%). The median total duration of a platelet response > 50,000/µL was 589 (range: 106-1003) days. Gastrointestinal disorders, such as diarrhea, hypertension, and hepatic enzyme elevation, were the most common fostamatinib-related adverse events. Most events occurred within 12 weeks of treatment. No thromboembolisms, treatment-related infections, or moderate or severe treatment-related bleeding events were observed. In summary, this extension study of a clinical trial found a sustained platelet response without new safety signals during 3-year treatment with fostamatinib.

Economic Burden of Haemophilia from a Societal Perspective: A Scoping Review

INTRODUCTION

Haemophilia is a rare genetic bleeding disorder that leads to musculoskeletal complications. The high cost of haemophilia treatment necessitates a thorough evaluation of its economic burden. However, due to the difficulty of estimating direct non-medical, indirect, and intangible costs, studies often underestimate the actual economic burden of haemophilia. This scoping review aims to summarise economic studies in haemophilia conducted from a societal perspective.

METHODS

A systematic search across eight scholarly databases, grey literature, and reference lists until the 5th of July 2023 was conducted to identify relevant studies. The inclusion criteria encompassed full-text, English-language publications of economic analyses in congenital haemophilia from a societal perspective. Model-based studies and those adopting a payer perspective were excluded. Costs were adjusted to international dollars (I$) and US dollars (US$) in 2022 for comparability.

RESULTS

Out of 2993 potential sources identified, 25 studies met the inclusion criteria, covering 7226 persons with haemophilia across 22 countries. All studies reported direct medical costs, with four excluding the cost of haemostatic therapy. Fifteen studies reported direct formal non-medical costs, while eight reported direct informal non-medical costs. All but one study reported the indirect costs. The average annual costs of haemophilia varied widely based on treatment modality, disease severity, geographical location, and included cost categories. When including the cost of clotting factor replacement therapy (CFRT), the total cost for severe haemophilia without inhibitors ranged from 1566 I$ to 700,070 I$ per person per year (lowest value reported in India and highest in the United States). CFRT represented up to 99.9% of the total cost for those receiving prophylaxis and up to 95.1% for episodic treatment. Haemostatic therapies accounted for 82% of the total cost in patients with inhibitors.

CONCLUSION

There is a significant heterogeneity in defining cost categories required for a comprehensive economic analysis from a societal perspective. While haemostatic therapies constitute a substantial portion of the overall cost, direct non-medical and indirect costs are crucial as they are often paid out-of-pocket and may impede access to treatment. It is essential for haematologists and economists to establish a standardised costing framework for future studies, particularly in the era of novel therapies.

Long-term efficacy and safety of luspatercept for the treatment of anaemia in patients with transfusion-dependent β-thalassaemia (BELIEVE): final results from a phase 3 randomised trial

BACKGROUND

Treatments to reduce red blood cell (RBC) transfusion burden among patients with transfusion-dependent β-thalassaemia remain limited. Here, we report long-term follow-up data from the phase 3 BELIEVE trial of luspatercept for transfusion-dependent β-thalassaemia.

METHODS

BELIEVE was a phase 3, randomised, double-blind, placebo-controlled study performed at 65 sites in 15 countries. The trial included adults with transfusion-dependent β-thalassaemia or haemoglobin E/β-thalassaemia and Eastern Cooperative Oncology Group score of 0-1. Patients were randomly assigned (2:1) using integrated response technology stratified by region to luspatercept (1·0-1·25 mg/kg) or placebo administered subcutaneously once every 21 days. After study unblinding, patients could receive luspatercept in the open-label extension phase (crossover allowed). The primary endpoint results (proportion of patients with reduction in transfusion burden of ≥33% and ≥2 RBC units during weeks 13-24) are described elsewhere; herein we present an update to the primary endpoint analysis consequent to late-reported transfusion events. We also report long-term efficacy (intention-to-treat population) and safety data (safety population) for patients followed up for approximately 3 years. This trial is registered on ClinicalTrials.gov (NCT02604433) and is completed.

FINDINGS

Between May 2, 2016, and May 16, 2017, 336 patients were randomly assigned to luspatercept (n=224) or placebo (n=112). The median age of patients was 30 years (IQR 23-40); 195 (58%) were female and 141 (42%) male. As of Jan 5, 2021, the median duration of treatment in the luspatercept group was 153·6 weeks (IQR 81·0-171·0) and median study follow-up was 163·1 weeks (140·5-176·2). Due to the difference in treatment duration between the luspatercept and placebo groups, no comparative analyses between the two groups were performed after week 96. Patients in the luspatercept group showed a sustained reduction in RBC transfusion burden from baseline through week 192, with mean decreases of 6·2 RBC units (SD 5·7) during weeks 97-144 and 6·4 RBC units (4·3) during weeks 145-192. In the luspatercept group, a 33% or greater reduction in transfusion burden from baseline was observed in 173 (77%) patients over any 12-week interval and in 116 (52%) patients over any 24-week interval. The median total duration of 33% or greater transfusion burden reduction response during any period of at least 12 weeks was 586·0 days (IQR 264·0-1010·0). The most common grade 3 or worse treatment-emergent adverse events (TEAEs) among all patients who received luspatercept (n=315, including 92 patients who crossed over after study unblinding) were anaemia (nine [3%]), increased liver iron concentration (seven [2%]), and bone pain (seven [2%]); serious TEAEs occurred in 71 (23%) patients. No treatment-related deaths occurred in any group during the study.

INTERPRETATION

These long-term results affirm luspatercept's efficacy in addressing key unmet needs of patients with transfusion-dependent β-thalassaemia with a manageable safety profile.

FUNDING

Celgene and Acceleron Pharma.

Establishment of an α-thalassemia mouse model through fetal liver cell transplantation and analysis of hematological parameters

Clinically, α-thalassemia is stratified into mild, intermediate, and severe forms, differentiated by the degree of anemia severity. Specifically, severe α-thalassemia manifests in homozygous individuals, characterized by a profound α globin deficit. The presence of two α0 alleles, resulting in a complete four-gene defect (α--/--), constitutes a lethal in utero condition known as Hemoglobin (Hb) Barts hydrops fetalis syndrome. This arises from the inability of hemoglobin, deficient in α chains, to adequately transport oxygen. Consequently, this severe variant typically onsets during fetal development, often culminating in intrauterine death towards the end of gestation or dying shortly postpartum due to the compounded effects of severe anemia and resultant hypoxia. This study endeavors to establish an α-thalassemia mouse model via transplantation of embryonic liver cells harboring a dual α allele knockout, with a subsequent focus on comprehensively characterizing its hematological parameters and associated phenotypic indicators. To generate an α-globin chain-deficient mouse model, we transplanted fetal liver cells (harvested at embryonic day 13.5 from homozygous C57BL/6J-CD45.2-HBA-DKO mice) into C57BL/6 wild-type recipients preconditioned with 800 cGy irradiation. Multiple blood routine indicators, blood smear assessments, and spleen weight measurements, were subsequently conducted to characterize the model. Initially, model mice exhibited elevated white blood cell and lymphocyte counts relative to controls, potentially indicative of a possible immune reaction, though this response waned over time. Characteristic of the disease, these mice displayed significantly diminished mean corpuscular hemoglobin content and concentration, alongside heightened numbers of HbH inclusions and spleen weights. Furthermore, red blood cellindices, such as red blood cell count, hematocrit, red cell distribution width-coefficient of variation, and red cell distribution width-standard deviation, were all markedly increased in the model mice. Notably, model mice demonstrated significantly elevated values for mean platelet volume, platelet distribution width, and platelet large cell ratio percentage, reflective of aberrant platelet characteristics. Concurrently, a time-dependent increase in basophil percentages accompanied decreases in platelet count, platelet crit, and platelet larger cell count, collectively implying a progressively severe anemic state. Moreover, the progression from low to high levels of reticulocyte percentage and absolute reticulocyte count further corroborated an escalating tendency towards hemolysis. The model mice also experienced a substantial decline in body weight, underscoring the profound impact of disease progression on their health.

Recent advances in the clinical management of intoxication by five heavy metals: Mercury, lead, chromium, cadmium and arsenic

Metals have been used for many centuries, but their nutritional and toxic effects have been investigated since the last century. The common toxic heavy metals (THM) include mercury, lead, chromium cadmium, and arsenic. As human exposure to THM increasingly causes systemic and organ complications, it seems required to review the recent advances of treatment of the toxic metals. Despite the current knowledge of the hazards of heavy metals, there is still high incidents of their poisonings particularly in developing countries. In this review, after an introduction, we briefly describe the routes of exposure, clinical features and prognosis of each metal poisoning. Then, review the different treatments for each metal with particular attention to recent advances in the treatment of both acute and chronic poisonings. The main antidotes for all THM are still chelating agents, but new agents were developed over the past decades and have been used successfully for the THM poisonings. Dimercaptosuccinic acid (DMSA) known as succimer has been prescribed as a safe oral chelator in lead poisoning. Similarly, dimercapto-propanesulfonic acid (DMPS) has also revealed fewer side effects than the old chelating agents. The two are currently gaining increased acceptance among clinical toxicologists. However, there is no specific antidote for mercury poisoning. Dimercaprol is almost no longer used as an antidote of choice in the treatment of chronic THM poisoning. Comparison of clinical management of intoxication by the five heavy metals reveals similar treatment strategies. On the other hand, some of them require specific interventions to reduce the toxicity. Because of drawbacks in the application of commonly known chelating agents, treatment with bioactive compounds which have antioxidant and anti-inflammatory properties has been the subject of much interest in recent research. However, despite the promising results observed in experimental animals, clinical trials on their clinical therapeutic benefits have not been yet successful and need further studies to determine their efficacy and safety in humans. Development of less toxic chelating agents are still under investigations. Moreover, the development of orally administrable chelating agents for home health care would likely be of great interest for future research.

Iron homeostasis and ferroptosis in muscle diseases and disorders: mechanisms and therapeutic prospects

The muscular system plays a critical role in the human body by governing skeletal movement, cardiovascular function, and the activities of digestive organs. Additionally, muscle tissues serve an endocrine function by secreting myogenic cytokines, thereby regulating metabolism throughout the entire body. Maintaining muscle function requires iron homeostasis. Recent studies suggest that disruptions in iron metabolism and ferroptosis, a form of iron-dependent cell death, are essential contributors to the progression of a wide range of muscle diseases and disorders, including sarcopenia, cardiomyopathy, and amyotrophic lateral sclerosis. Thus, a comprehensive overview of the mechanisms regulating iron metabolism and ferroptosis in these conditions is crucial for identifying potential therapeutic targets and developing new strategies for disease treatment and/or prevention. This review aims to summarize recent advances in understanding the molecular mechanisms underlying ferroptosis in the context of muscle injury, as well as associated muscle diseases and disorders. Moreover, we discuss potential targets within the ferroptosis pathway and possible strategies for managing muscle disorders. Finally, we shed new light on current limitations and future prospects for therapeutic interventions targeting ferroptosis.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Feasibility of Intensive Chemotherapy in Hereditary Spherocytosis

BACKGROUND

This study presents a young man with hereditary spherocytosis (HS) who underwent intensive chemotherapy for newly diagnosed diffuse large B-cell lymphoma (DLBCL) and achieved complete remission. This case challenges the idea of HS as a barrier to standard DLBCL treatment.

DISCUSSION

By meticulously monitoring blood counts and providing timely transfusions, the team successfully mitigated potential complications associated with chemotherapy-induced stress on red blood cells.

CONCLUSIONS

This experience underscores the importance of a multidisciplinary approach and tailored treatment plans for patients with co-existing conditions, suggesting that HS should not automatically disqualify them from potentially curative therapies for aggressive lymphomas.

Most major bleeds in preterm infants occur in the absence of severe thrombocytopenia: an observational cohort study

OBJECTIVE

To describe the incidence of major bleeds according to different platelet counts in very preterm infants, and to explore whether this association is influenced by other risk factors for bleeding.

DESIGN

Observational cohort study.

SETTING

A Dutch tertiary care neonatal intensive care unit.

PATIENTS

All consecutive infants with a gestational age at birth <32 weeks admitted between January 2004 and July 2022.

EXPOSURE

Infants were stratified into nine groups based on their nadir platelet count (×109/L) during admission (<10, 10-24, 25-49, 50-99, 100-149, 150-199, 200-249, 250-299 and ≥300), measured before the diagnosis of a major bleed and before any platelet transfusion was administered.

MAIN OUTCOME MEASURE

Incidence of major bleeds during admission. Logistic regression analysis was used to quantify the relationship between nadir platelet count and incidence of major bleeds.

RESULTS

Among 2772 included infants, 224 (8%) developed a major bleed. Of the infants with a major bleed, 92% (206/224) had a nadir platelet count ≥50×109/L. The incidence of major bleeds was 8% among infants with and without severe thrombocytopenia (platelet count <50×109/L), 18/231 (95% CI 5 to 12) and 206/2541 (95% CI 7 to 9), respectively. Similarly, after adjustment for measured confounders, there was no notable association between nadir platelet counts below versus above 50×109/L and the occurrence of major bleeds (OR 1.09, 95% CI 0.61 to 1.94).

CONCLUSION

In very preterm infants, the vast majority of major bleeds occur in infants without severe thrombocytopenia.

Analysis of genotypic distribution and rare variants of patients with α/β-thalassemia screened in one hospital in Beijing, China

OBJECTIVE

Thalassemia is among the most common inherited diseases worldwide. We aimed to analyze the genotype and frequency distribution of thalassemia in a general hospital in Beijing and provide a reference for genetic counseling and prenatal diagnosis.

METHODS

A total of 3196 cases of thalassemia screened at Peking Union Medical College Hospital (PUMCH) between January 2018 and January 2022 were collected. Thalassemia genotypes were tested using gap polymerase chain reaction (gap-PCR), PCR, reverse dot blot (RDB), and Sanger sequencing analyses. The pathogenicity of the rare variants was analyzed using bioinformatics approaches.

RESULTS

Total of 1936 positive routine α/β-thalassemia were detected from 3196 blood samples, including 733 α-thalassemia variants, 1170 β-thalassemia variants, and 33 cases with concurrent α- and β-thalassemia variants. Two novel variants, HBA2:c.300+82G>C and HBB:codon85(-T), were identified in HBA2 and HBB genes, respectively, and were not detected in the ExAC, gnomAD, HbVar, and HGMD databases.

CONCLUSIONS

The genotype distribution of thalassemia in a general hospital in Beijing is complex and heterogeneous. The novel variants in HBA2 and HBB are likely to underlie α/β-thalassemia in these patients.

Leukemia and risk of stroke: a Mendelian randomization analysis

BACKGROUND

Observational studies suggest an association between leukemia and stroke, but causality remains unclear. Certain leukemia types may increase stroke risk, but variations exist in stroke and mortality rates across leukemia subtypes. This study employed Mendelian randomization (MR) to investigate links between leukemia subtypes and stroke.

METHODS

We conducted a two-sample Mendelian randomization (TSMR) study utilizing genetic variants linked to various subtypes of leukemia as instruments to investigate their causal effects on stroke, specifically ischemic stroke (IS) and intracerebral hemorrhage (ICH). The leukemia dataset comprised 456,276 subjects from the UK Biobank, while the stroke dataset was sourced from the FINNGEN consortium, encompassing 212,774 participants.

RESULTS

In the present study, there was suggestive evidence that genetically predicted chronic lymphocytic leukemia (CLL) is associated with ischemic stroke (odds ratio, 1.02; 95% confidence intervals, 1.01-1.05; P = 0.024), but no significant association was observed with intracerebral hemorrhage (ICH) (0.74; 0.99-1.03; P = 0.237). Additionally, chronic myeloid leukemia (CML), acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) was no significant associations between with stroke according to genetical prediction even if heterogeneity test and pleiotropic test was performed.

CONCLUSIONS

Our Mendelian randomization analysis revealed that chronic lymphocytic leukemia (CLL) was associated with an increased risk of ischemic stroke (IS) but not intracerebral hemorrhage (ICH). Conversely, there was no evidence supporting causal associations of chronic myeloid leukemia (CML), acute lymphoblastic leukemia (ALL), or acute myeloid leukemia (AML) with either type of stroke. These findings enhance our comprehension of the intricate interplay between various leukemia subtypes and the risk of stroke. Further research is essential to delve into the underlying mechanisms and potential clinical implications of these observed associations.

Weight-Specific Grip Strength as a Novel Indicator Associated With Cardiometabolic Risk in Children: The EMSNGS Study

CONTEXT

Handgrip strength (HGS) is an important indicator of sarcopenia and adverse health outcomes. However, evaluating HGS in children presents challenges, and its association with metabolism remains incompletely understood.

OBJECTIVE

To establish grip strength reference values for Chinese children and adolescents, as well as to evaluate the relationship between HGS and cardiometabolic risk.

METHODS

Data were collected from 4 072 participants aged 6-18 as part of the Evaluation and Monitoring on School-based Nutrition and Growth in Shenzhen (EMSNGS) study. HGS was measured, and relative HGS (RHGS) was normalized by body mass index. Age- or weight-specific HGS and RHGS were derived using the generalized additive model of location, scale, and shape model, and participants' values were categorized into quartiles, defining low strength as the lowest quartile. The cardiometabolic risk index (CMRI) z-score was calculated, with high risk defined as a z-score of ≥1.

RESULTS

Both boys and girls exhibited similar increases in age- and weight-specific grip strength. Low grip strength, classified by weight-specific HGS and RHGS, was linked to higher CMRI z-scores than classifications based on age-specific references in both sexes. A dose-dependent relationship was observed between weight-specific grip strength and cardiometabolic risk, particularly in boys. Compared with the middle category (P25th-P75th), the odds ratios for high cardiometabolic risks associated with low grip strength increased in both sexes.

CONCLUSION

This study established grip strength reference values for Chinese youth, introduced the concept of weight-specific HGS and RHGS, and demonstrated a dose-dependent relationship between weight-specific grip strength and cardiometabolic risk. These findings highlighted the association between low muscle strength and increased cardiometabolic risk.

Single-sample, multi-omic mass spectrometry for investigating mechanisms of drug toxicity

Poor therapeutic index is a principal cause of drug attrition during development. A case in point is L-asparaginase (ASNase), an enzyme-drug approved for treatment of pediatric acute lymphoblastic leukemia (ALL) but too toxic for adults. To elucidate potentially targetable mechanisms for mitigation of ASNase toxicity, we performed multi-omic profiling of the response to sub-toxic and toxic doses of ASNase in mice. We collected whole blood samples longitudinally, processed them to plasma, and extracted metabolites, lipids, and proteins from a single 20-µL plasma sample. We analyzed the extracts using multiple reaction monitoring (MRM) of 500+ water soluble metabolites, 750+ lipids, and 375 peptides on a triple quadrupole LC-MS/MS platform. Metabolites, lipids, and peptides that were modulated in a dose-dependent manner appeared to converge on antioxidation, inflammation, autophagy, and cell death pathways, prompting the hypothesis that inhibiting those pathways might decrease ASNase toxicity while preserving anticancer activity. Overall, we provide here a streamlined, three-in-one LC-MS/MS workflow for targeted metabolomics, lipidomics, and proteomics and demonstrate its ability to generate new insights into mechanisms of drug toxicity.

Management of Bleeding Diathesis in Elective and Orthopaedic Trauma: A Review

There is a general need among orthopaedic surgeons for practical advice on managing patients with bleeding disorders. Appropriate diagnosis and management of these disorders is paramount once discovered before, during, or after the patient's surgical course. Bleeding disorders disrupt the body's ability to control bleeding, commonly through platelet function and blood clotting. Normally, the vessel contracts and retracts once disruption of blood vessels occurs, limiting blood loss. Blood platelets adhere to exposed collagen, aggregate at the site, and obstruct blood loss. Because platelet aggregates are temporary, blood clotting is needed to back up the platelet plug and provide a milieu for the healing process that completes the hemostatic events. Disorders that interfere with any of these events can result in hemorrhage, drainage, or rebleeding. Bleeding disorders are a group of conditions, either hereditary or acquired, marked by abnormal or excessive bleeding and/or bruising. The most effective methods for assessing coagulation disorders include a detailed history and a series of blood tests. Clinical examination findings are notable but may be less specific. If a surgical patient has a bleeding disorder discovered preoperatively, postoperatively, or intraoperatively, treatments exist with medications, surgical management, interventional radiology procedures, and replacement therapy.

Real-World Effectiveness, Safety, and Tolerability of Facilitated Subcutaneous Immunoglobulin 10% in Secondary Immunodeficiency Disease: A Systematic Literature Review

Background: Secondary immunodeficiency disease (SID) is a complex, heterogeneous condition that occurs when extrinsic factors weaken the immune system. Expert consensus guidelines recommend immunoglobulin replacement therapy to manage immunoglobulin G (IgG) levels and mitigate severe, recurrent, and persistent infections. Hyaluronidase-facilitated subcutaneous immunoglobulin (fSCIG) 10% is a dual-vial unit of IgG and recombinant human hyaluronidase; the latter enables absorption of higher volumes of IgG than conventional subcutaneous therapies. Methods: For this systematic literature review, Embase, MEDLINE®, and the Cochrane Library were searched on 9 August 2023, with supplemental congress searches. Results: Eight studies fulfilled the inclusion criteria, reporting real-world evidence of the clinical effectiveness, safety, and tolerability of fSCIG 10% in 183 patients with SID in Europe from September 2014 to August 2021. The potential causes of SID were primarily hematological malignancies, most commonly chronic lymphocytic leukemia. Treatment was typically administered at 4-week or 3-week intervals, with doses of approximately 0.4 g/kg/month. Infections were rare during follow-up, with numerical reductions observed after fSCIG 10% treatment initiation compared with the period before initiation. Adverse reactions, including local infusion site reactions, and tolerability events were uncommon. Conclusions: Given the recency of fSCIG 10% use in patients with SID, there are opportunities for future research to better understand survival and patient-reported outcomes after receiving this treatment. Despite SID heterogeneity, this study demonstrates the feasibility of fSCIG 10% treatment for this condition.

Post-marketing safety concerns with luspatercept: a disproportionality analysis of the FDA adverse event reporting system

BACKGROUND

Luspatercept, approved for treating beta thalassemia, myelodysplastic syndromes (MDS) associated anemia, and MDS with ring sideroblasts or myelodysplastic/myeloproliferative neoplasm with ring sideroblasts and thrombocytosis associated anemia, has uncertain long-term safety in large populations. This study analyzed adverse events (AEs) linked to luspatercept using data from the FDA Adverse Event Reporting System (FAERS) with data mining techniques.

RESEARCH DESIGN AND METHODS

We collected and analyzed luspatercept-related reports from the FAERS database from the first quarter of 2022 through the first quarter of 2024. Disproportionality analysis was used in data mining to quantify luspatercept-related AE signals.

RESULTS

A total of 46 AE signals were detected in 13 SOCs (system organ classes). In addition to the AEs identified during the clinical trial stage, this study also identified some unexpected and important AEs, such as product preparation error, prescribed overdose, product preparation issue, prescribed underdose, and acute hepatitis.

CONCLUSIONS

Our study provides a comprehensive description of the post-marketing safety of luspatercept and identifies new potential AEs. Healthcare workers must be vigilant in avoiding product preparation errors, an adverse event that highlights the need for enhanced training and the participation of pharmacists in assessing medication utilization scenarios.

Different Chemical Forms of Thiamine, Riboflavin, and Folate in Human Milk as a Function of Lactation Stages-A Cohort Study on Breastfeeding Women from Beijing

Background: The function and bioavailability of water-soluble vitamins in human milk (HM) is contingent upon their specific molecular configurations. This study aims to investigate the concentrations of different forms of thiamine, riboflavin, and folate in HM and to elucidate the temporal variations of these nutrients across different stages of lactation. Methods: A cohort of 35 healthy mother-infant pairs from Beijing was recruited, and 214 HM samples were collected. The concentrations of water-soluble vitamins in these samples were analyzed using high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS). A mixed linear regression model was employed to examine the relationship between HM vitamin levels and lactation stages. Results: This study analyzed the concentrations of free thiamine, thiamine monophosphate (TMP), thiamine pyrophosphate (TPP), free riboflavin, flavin adenine dinucleotide (FAD), flavin mononucleotide (FMN), 5-methyl-tetrahydrofolate (5-MTHF), tetrahydrofolate (THF), 5-formyl-tetrahydrofolate (5-fTHF), 5,10-methenyl-tetrahydrofolate (5,10-MTHF), and unmetabolized folic acid (UMFA) at various lactation stages (0-7 days, 15 days, 30 days, 60 days, 90 days, 120 days, 150 days, and 180 days). Free thiamine concentrations increased from colostrum to 180 days, while total thiamine rose during the first month and then stabilized. Free and total riboflavin levels remained relatively constant throughout lactation. Free and total folate concentrations peaked at 90 days and subsequently declined. Significant correlations were observed between follow-up time and changes in free thiamine, free folate, and total folate concentrations over 180 days. Conclusions: This study provides detailed data on the concentrations and trends of free and total thiamine, riboflavin, and folate in HM from 0 to 180 days postpartum, highlighting the dynamic nature of vitamin concentrations in HM. No deficiencies in these HM vitamins were detected in the surveyed population. Future further research will be conducted to reveal the correlation between different forms of water-soluble vitamins in HM and dietary factors.

Ironomycin induces mantle cell lymphoma cell death by targeting iron metabolism addiction

Rationale: Mantle-cell lymphoma (MCL) remains an aggressive and incurable cancer. Accumulating evidence reveals that abnormal iron metabolism plays an important role in tumorigenesis and in cancer progression of many tumors. Based on these data, we searched to identify alterations of iron homeostasis in MCL that could be exploited to develop novel therapeutic strategies. Methods: Analysis of the iron metabolism gene expression profile of a cohort of patients with MCL enables the identification of patients with a poor outcome who might benefit from an iron homeostasis-targeted therapy. We analyzed the therapeutic interest of ironomycin, known to sequester iron in the lysosome and to induce ferroptosis. Results: In a panel of MCL cell lines, ironomycin inhibited MCL cell growth at nanomolar concentrations compared with conventional iron chelators. Ironomycin treatment resulted in ferroptosis induction and decreased cell proliferation rate, with a reduced percentage of cells in S-phase together with Ki67 and Cyclin D1 downregulation. Ironomycin treatment induced DNA damage response, accumulation of DNA double-strand breaks, and activated the Unfolded Protein Response (UPR). We validated the therapeutic interest of ironomycin in primary MCL cells of patients. Ironomycin demonstrated a significant higher toxicity in MCL cells compared to normal cells from the microenvironment. We tested the therapeutic interest of combining ironomycin with conventional treatments used in MCL. We identified a synergistic effect when ironomycin is combined with Ibrutinib, Bruton's tyrosine kinase (BTK) inhibitor, associated with a strong inhibition of B-Cell receptor (BCR) signaling. Conclusion: Altogether, these data underline that MCL patients my benefit from targeting iron homeostasis using ironomycin alone or in combination with conventional MCL treatments.