Alternative splicing controls pan-neuronal homeobox gene expression

The pan-neuronally expressed and phylogenetically conserved CUT homeobox gene ceh-44/CUX orchestrates pan-neuronal gene expression throughout the nervous system of Caenorhabditis elegans. As in many other species, including humans, ceh-44/CUX is encoded by a complex locus that also codes for a Golgi-localized protein, called CASP (Cux1 alternatively spliced product) in humans and CONE-1 ("CASP of nematodes") in C. elegans How gene expression from this complex locus is controlled-and, in C. elegans, directed to all cells of the nervous system-has not been investigated. We show here that pan-neuronal expression of CEH-44/CUX is controlled by a pan-neuronal RNA splicing factor, UNC-75, the C. elegans homolog of vertebrate CELF proteins. During embryogenesis, the cone-1&ceh-44 locus exclusively produces the Golgi-localized CONE-1/CASP protein in all tissues, but upon the onset of postmitotic terminal differentiation of neurons, UNC-75/CELF induces the production of the alternative CEH-44/CUX CUT homeobox gene-encoding transcript exclusively in the nervous system. Hence, UNC-75/CELF-mediated alternative splicing not only directs pan-neuronal gene expression but also excludes a phylogenetically deeply conserved golgin from the nervous system, paralleling surprising spatial specificities of another golgin that we describe here as well. Our findings provide novel insights into how all cells in a nervous system acquire pan-neuronal identity features and reveal unanticipated cellular specificities in Golgi apparatus composition.

Quality-of-Life Assessment and Pharmacokinetic Study in Hemophilia A Patients Undergoing Prophylactic Treatment

This study evaluates the health-related quality of life (HRQoL) among patients with hemophilia A currently undergoing prophylactic treatment at the Hemophilia Center of Northern Greece. Using the Haem-A-QoL questionnaire, we assessed various HRQoL dimensions in a cohort of 29 adult male patients, analyzing the impact of age, disease severity, and treatment regimens. The results revealed that younger patients (18-30 years old) exhibited significantly better overall HRQoL scores (total score of 25.36) compared to older age groups (37.81 for the 31-45 group and 43.71 in the 45+ group), particularly in the physical health (29.16 vs. 48.43 vs. 58.57) and mental well-being domains (25 vs. 37.11 vs. 41.07). Interestingly, moderate hemophilia patients reported lower HRQoL (42.31) than those with severe form (34.85), suggesting unique challenges in managing their condition. The 'Sports/Free Time' domain had the highest scores (65.81), indicating significant limitations in physical activities in the everyday lives of affected individuals. However, better outcomes were observed in the mental dimension (36.09), work/study (34.88), family planning (10.68), and relationships aspects (16.67), where our cohort reported very low scores compared to similar studies, indicating a significantly better quality of life in these domains. These findings highlight the importance of personalized psychosocial support and targeted interventions to address the specific needs of hemophilia patients, particularly in enhancing physical activity opportunities and managing the psychological burden of moderate hemophilia. The study contributes valuable insights into the HRQoL of hemophilia patients and underscores the necessity for tailored approaches to improve patient outcomes across all dimensions of life.

Mitapivat for Acquired Pyruvate Kinase Deficiency

Pyruvate kinase (PK) activation is emerging as a promising treatment modality for numerous congenital hemolytic anemias of diverse pathophysiology, and one agent, mitapivat, is already licensed to treat patients with congenital PK deficiency. However, PK deficiency may also be acquired in the setting of clonal myeloid disorders and other pathologies, where it may result in severe hemolytic anemia and remains without known therapies. This case report describes the novel application of mitapivat therapy in a patient with acquired PK deficiency causing red cell transfusion dependence, liberating the patient from transfusions and resulting in marked improvement in symptoms and quality of life.

Gene Therapy in Hemophilia A: Achievements, Challenges, and Perspectives

Strides in advancements of care of persons with hemophilia include development of long-acting factor replacement therapies, novel substitution and hemostatic rebalancing agents, and most recently approved gene therapy. Several decades of preclinical and clinical trials have led to development of adeno-associated viral (AAV) vector-mediated gene transfer for endogenous production of factor VIII (FVIII) in hemophilia A (HA). Only one gene therapy product for HA (valoctocogene roxaparvovec) has been approved by regulatory authorities. Results of valoctocogene roxaparvovec trial show significant improvement in bleeding rates and use of factor replacement therapy; however, sustainability and duration of response show variability with overall decline in FVIII expression over time. Further challenges include untoward adverse effects involving liver toxicity requiring immunosuppression and development of neutralizing antibodies to AAV vector rendering future doses ineffective. Real-life applicability of gene therapy for HA will require appropriate patient screening, infrastructure setup, long-term monitoring including data collection of patient-reported outcomes and innovative payment schemes. This review article highlights the success and development of HA gene therapy trials, challenges including adverse outcomes and variability of response, and perspectives on approach to gene therapy including shared decision-making and need for future strategies to overcome the several unmet needs.

Thalassemias and Sickle Cell Diseases in Pregnancy: SITE Good Practice

Background: Hereditary hemoglobin disorders are the most common globally distributed monogenic red cell diseases. The rights of women with thalassemia or sickle cell disease (SCD) to motherhood need to be protected by creating a roadmap to guide her, and her family network, along all the phases of the event. In fact, pregnancy in these vulnerable patients requires special attention and guidelines from the counseling stage (giving information about the special requirement and risks posed by their pregnancy with respect to the general population) the pre-conception stage, the early and mid-late pregnancy stage, to labor and lactation. The biocomplexity of these diseases requires a multidisciplinary team synergizing with gynecologists and obstetricians. In addition, the presence of a multicultural scenario requires healthcare workers to overcome stereotypes and adopt appropriate anthropological tools that might help them integrate the different cultural models of disease and motherhood. Methods: The Management Committee of the Society for Thalassemia and Hemoglobinopathies (SITE) selected and brought together a multidisciplinary and multiprofessional group made up of experts in hemoglobinopathies and experts in anthropology, flanked along with by experts with methodological and organizational expertise in order to create recommendations based on the integration of available scientific evidence together with expert opinion. Results: The panelists critically analyzed the literature, combining in a single document practices developed over several years of managing young women with hemoglobinopathies in a sensitive phase of their lives. Conclusions: This good practice document is the result of a collegial effort by Italian experts on hemoglobinopathies who are members of SITE. (SITE).

Erythrocytapheresis as a strategy to manage anemia and iron overload in nondeletional hemoglobin H disease

Hemoglobin H (HbH) disease is associated with anemia, ineffective erythropoiesis, and iron overload. We report a case of a patient with HbH/Hb Constant Spring disease, who was maintained on chronic transfusions as an adult due to symptomatic anemia. Over time, he developed iron overload and was started on chelation therapy but did not have an adequate response to chelation. We then added erythrocytapheresis to chelation therapy and were able to successfully decrease his iron burden while managing his anemia. Therapeutic erythrocytapheresis may be an effective treatment strategy for iron overload in HbH disease that is refractory to chelation.

Impact of HbE mutation on the clinical severity of HbH disease: A multicentre study from Thailand

Haemoglobin (Hb) H disease and HbH disease with co-inherited HbE mutation are the most prevalent forms of α-thalassaemia in Southeast Asia. Data were limited when comparing clinical phenotypes between these two patient groups. We conducted a Thai multicentre study and enrolled 588 patients [median (IQR) age 13.0 (6.7-20.3) years], including those with deletional HbH disease with (n = 47) and without (n = 187) co-inherited HbE mutation and non-deletional HbH disease with (n = 101) and without (n = 253) co-inherited HbE mutation. Patients with HbH disease with co-inherited HbE mutation suffered more severe manifestations than those without. This observation was more pronounced in patients with non-deletional HbH disease. A greater proportion of patients with non-deletional HbH disease with co-inherited HbE mutation (43.6%) eventually required regular transfusions compared to those without (30.4%, p = 0.019). Among those with non-deletional HbH disease who did not require regular transfusions, Hb levels were lower in patients with co-inherited HbE mutation [8.1 (7.2-8.6) vs. 8.8 (8.2-9.5) g/dL, p < 0.001]. Among patients requiring regular transfusions who underwent splenectomy, 11/12 patients with non-deletional HbH disease stopped transfusion compared with 1/3 in non-deletional HbH disease with co-inherited HbE mutation group (p = 0.024). These findings provide insights for the clinical monitoring and management of HbH disease in the region.

Patient Perspective on Disease Burden and Gene Therapy for Hemophilia A and B: The "Haemvolution for Patients" Italian Survey

Hemophilia is a rare X-linked congenital bleeding disorder due to a deficiency of factor VIII (hemophilia A [HA]) or factor IX (hemophilia B [HB]). Replacement and nonreplacement treatments are available but have limitations. Gene therapy (GT) provides an effective, long-term, single-dose treatment option, now approaching clinical practice. This study aimed to understand patient perspectives on GT for HA and HB in Italy using a qualitative questionnaire distributed through Italian patient associations, addressing patient views on daily life, treatments, unmet needs, quality of life (QoL), and GT for hemophilia. In total, 141 participants had HA, and 14 had HB (severe 78.6%). Daily life was most affected by pain and/or joint function limitations (57.5% of participants), high infusion frequency (42.5%), management of breakthrough bleeding episodes (40.3%), and anxiety/fear of severe or sudden bleeding (38.8%). Despite current treatments, about half of the participants experienced three or more annual bleeding episodes. Most participants knew of GT (87.2%) and expected improvements in QoL (60.5%), reduced frequency of current treatments (53.5%), and a permanent cure (49.1%); 46.4% were unaware of its once-off dosage and 46.4% were not concerned about the costs they anticipated to be associated with GT. Although several fears were reported, 25.0% of participants were willing to undergo GT with the support of a multidisciplinary team. This survey provided valuable insight into patient perspectives on hemophilia and GT in Italy. Overall, relevant proportions of patients still experience limitations affecting their daily life. Most were positive about GT and anticipated improvements in their clinical outcomes and QoL.

Identification of a novel truncated pathogenic variant in PUS1 gene in two siblings of consanguineous Tunisian family: intrafamilial phenotypic variability related to mtDNA copy number

Congenital sideroblastic anemia (CSA) is a rare genetic disorder caused by defects on heme biosynthesis and mitochondrial energy production. This disease is characterized by the presence of ring sideroblasts in the bone marrow caused by excessive iron accumulation in mitochondria of erythroblasts and by anemia of varying severity. In addition to its clinical variability, CSA is also characterized by genetic heterogeneity which required next-generation sequencing technologies to identify responsible gene. In the present study, whole-exome sequencing followed by Sanger sequencing were performed on a consanguineous family including two patients with congenital sideroblastic anemia. Mitochondrial DNA deletion and copy number were tested respectively by long PCR and QPCR. Subsequent bioinformatic investigations were performed using several programs. WES and Sanger sequencing results revealed a novel pathogenic variant c.579-580insT (p.N194X) in the PUS1 gene. Several bioinformatic tools supported that this variant was disease-causing. This variation leads to an incomplete catalytic site which will be probably non-functional and could disturb heme biosynthesis. In addition, no mtDNA deletion was detected in the two patients whereas mtDNA quantification revealed a decrease of mtDNA copy number in P2 and its increasing in P1. The increase in mtDNA copy number, which is most likely connected to a compensatory mechanism, may be the cause of the moderate phenotypic severity observed in P1 with the same p.N194X variant with P2. In conclusion, we identified a novel truncated pathogenic variant in PUS1 gene in two siblings of consanguineous family with intrafamilial phenotypic variability related to mtDNA copy number.

Using weight-for-age as a screening tool for metabolic syndrome in apparently healthy adolescents

BACKGROUND

The increasing prevalence of metabolic syndrome (MetS) among adolescents necessitates a simple and easy-to-use screening tool. This study aimed to develop and validate a simple model based on age, sex, race, and weight-for-age or BMI-for-age to identify adolescents with MetS.

METHODS

A cross-sectional study of adolescents (aged 12-18 years) who participated in the American National Health and Nutrition Examination Survey (NHANES) was performed. Participants with pre-existing hypertension, diabetes or dyslipidemia were excluded. Data from 2005-2018 were randomly divided into training (70%) and validation (30%) sets. Anthropometric, demographic data, and MetS criteria were extracted.

RESULTS

The training group included 1974 adolescents (52% boys, median age 15 years), and the validation group included 848 adolescents (50% boys, median age 14 years). Both weight- and BMI-for-age demonstrated good discrimination ability in the training group (AUC = 0.897 and 0.902, respectively), with no significant difference between them (p = 0.344). Multivariable models showed similar discrimination ability. Therefore, weight-for-age was chosen and using Youden's index, the 93rd weight-for-age percentile (SDS 1.5) was identified as the optimal cut-off value for MetS. Similar values were observed in the validation group.

CONCLUSIONS

Among adolescents aged 12-18 years, weight-for-age percentiles are an easy-to-use primary screening indicator for the presence of MetS.

IMPACT

The prevalence of metabolic syndrome in adolescents is increasing. An early detection screening tool is required to prevent related adulthood morbidity. Screening adolescents for metabolic syndrome is challenging. This study suggests the use of weight-for-age as a single criterion for primary screening of adolescents aged 12-18. Using weight-for-age as a single predictor of metabolic syndrome is expected to increase screening rates compared to using BMI-for-age, due to its simplicity.

Post-Hoc Analysis of a Multicenter Clinical Trial: Correlation of Coagulation Factor Changes and MRI-Defined Treatment Outcomes After Sclerotherapy for Venous Malformations

Background/Objectives: The therapeutic efficacy of percutaneous sclerotherapy (PS) for venous malformations (VMs) based on volumetric magnetic resonance imaging (MRI) measurements and its association with early post-treatment coagulation markers remains unexplored. This study evaluates the therapeutic efficacy of 5% monoethanolamine oleate (EO)-based PS in treating difficult-to-resect VMs using volumetric MRI and investigates its association with early changes in coagulation markers. Methods: This post-hoc analysis utilized data from a prospective, open-label, multicenter clinical trial initiated on 1 January 2021. The correlation between MRI-determined volume reduction and post-sclerotherapy changes in coagulation markers was assessed. Results: Between January 2021 and April 2023, 44 patients underwent EO-based PS. Based on a ≥ 20% VM volume reduction, patients were classified into "achieved" (n = 26; 59.1%) and "non-achieved" (n = 18; 40.9%) groups. D-dimer levels significantly increased on postoperative day 1 (POD1) compared with pretreatment screening (p < 0.001), whereas fibrinogen and prothrombin international normalized ratio levels remained unchanged. In the achieved group, a significant correlation was observed between the volume reduction rate and the administered EO dose per lesion volume (mL/cm3; Spearman's ρ = 0.43, p = 0.03). The non-achieved group showed significantly higher D-dimer elevation than the achieved group (p = 0.03). Conclusions: This is the first multicenter study to evaluate EO-based PS efficacy for VMs using volumetric MRI and explore its relationship with early post-treatment coagulation markers. Elevated D-dimer levels on POD1 were not predictive of treatment efficacy, highlighting their limited clinical utility in assessing therapeutic response.

Cardiac injury caused by iron overload in thalassemia

Cardiac iron overload affects approximately 25% of patients with β-thalassemia major, which is associated with increased morbidity and mortality. Two mechanisms are responsible for iron overload in β-thalassemia: increased iron absorption due to ineffective erythropoiesis and blood transfusions. This review examines the mechanisms of myocardial injury caused by cardiac iron overload and role of various clinical examination techniques in assessing cardiac iron burden and functional impairment. Early identification and intervention for cardiac injury and iron overload in β-thalassemia have the potential to prevent and reverse or delay its progression in the early stages, playing a crucial role in its prognosis.

Seroconversion following PPSV23 vaccination in children with type 1 diabetes mellitus

OBJECTIVE

To evaluate whether children with type 1 diabetes mellitus (T1DM) have optimal humoral immune response to pneumococcal polysaccharide vaccination (PPSV23) and to study factors affecting that response.

METHODS

In this prospective pilot study, we recruited 29 children with T1DM who were vaccine naïve to PPSV23 and assessed serum-serotype specific IgG at baseline and 4-6 weeks post-immunization. We tested association between independent variables (age, gender, body mass index (BMI), hemoglobin A1c (HbA1c), glucose variability, and time in range assessed by continuous glucose monitors (CGM), insulin dose and outcome (log-2-fold change of immunoassay response between pre- and post-immunization testing) using linear regression.

RESULTS

Eighty-eight percent of children (22/25) who completed the study had overall appropriate response with a median 4.2-fold change following immunization. When assessing PPSV23-exclusive serotypes, there was a statistically significant correlation between increasing age and greater response (0.16 log2-fold change per year, 95 % CI (0.014 to 0.3), p = 0.033). Higher BMI for age (p = 0.085) and a lower coefficient of glucose variation from CGM following immunization (p = 0.067) also coincided with greater vaccine response, with correlation statistically significant for certain pneumococcal serotypes for both.

CONCLUSIONS

Response to pneumococcal vaccination has not previously been assessed in children with T1DM, and our study demonstrates robust humoral immune response to PPSV23 vaccination in these children. Larger studies with a diverse representation and longer follow up to assess how humoral seroconversion correlates with clinical response to PPSV23 in this vulnerable population are warranted.

Managing menstruation for medically complex paediatric patients

Physicians who care for children and adolescents need evidence-based information about how to manage menses for medically complicated patients. The use of many hormonal medications for menstrual management is considered 'off-label' because many of these medications have indications only for contraception. A growing body of evidence supports the use of particular medications or strategies for a wide variety of medical conditions, but this information has been slow to reach all paediatric patients, perhaps in part because of the off-label nature of prescribing. Specialists skilled in hormone management are in short supply and often not immediately available for consultation, and they may also be inexperienced prescribing for medically complex paediatric patients. Misconceptions about the necessity of menstruation or concerns regarding use of contraceptives in young patients may also limit the use of medically indicated off-label hormonal regimens. This review will outline current patient-centred strategies to inform physicians' choices about when and how to intervene medically to improve quality of life for medically complex girls with problematic periods-whether by making periods more predictable, preventing ovulation, reducing pain or eliminating menses altogether.

How I manage iron overload in the hematopoietic cell transplantation setting

ABSTRACT

The success of hematopoietic transplantation for hemoglobinopathies and hematological malignancies has been accompanied by the new challenge of how to identify, risk stratify, and treat iron overload and toxicity before and after transplantation. Substantial progress has been made in our understanding of iron metabolism and the pathophysiology of iron overload, making us aware that not only the total amount of iron in the body is important but also the effect of toxic iron species and duration of exposure are equally relevant. Challenges still remain in how to assess cellular and tissue damage and define the mechanism that may detrimentally affect the outcome of hematopoietic transplantation. In this article, I discuss the impact of iron toxicity in relation to the different phases of hematopoietic transplantation, before, during, and after, for both malignant and nonmalignant diseases. Different clinical scenarios and possibilities for therapeutic intervention are also outlined and discussed.

Management of iron overload: lessons from transfusion-dependent hemoglobinopathies

ABSTRACT

Before the advent of effective iron chelation, death from iron-induced cardiomyopathy and endocrine failure occurred in the second decade in patients with thalassemia major, and this experience has driven expectation of poor outcomes and caused anxiety in all disorders associated with iron loading to this day. To be clear, severe iron overload still causes significant morbidity and mortality in many parts of the world, but current understanding of iron metabolism, noninvasive monitoring of organ-specific iron loading in humans, and effective iron chelators have dramatically reduced morbidity of iron overload. Furthermore, clinical experience in hemoglobinopathies supports iron biology learned from animal studies and identifies common concepts in the biology of iron toxicity that inform the management of iron toxicity in several human disorders. The resultant significant increase in survival uncovers new complications due to much longer exposure to anemia and to iron, which must be considered in long-term therapeutic strategies. This review will discuss the management of iron toxicity in patients with hemoglobinopathies and transfusion-dependent anemias and how iron biology informs the clinical approach to treatment.

Metal Ion Signaling in Biomedicine

Complex multicellular organisms are composed of distinct tissues involving specialized cells that can perform specific functions, making such life forms possible. Species are defined by their genomes, and differences between individuals within a given species directly result from variations in their genetic codes. While genetic alterations can give rise to disease-causing acquisitions of distinct cell identities, it is now well-established that biochemical imbalances within a cell can also lead to cellular dysfunction and diseases. Specifically, nongenetic chemical events orchestrate cell metabolism and transcriptional programs that govern functional cell identity. Thus, imbalances in cell signaling, which broadly defines the conversion of extracellular signals into intracellular biochemical changes, can also contribute to the acquisition of diseased cell states. Metal ions exhibit unique chemical properties that can be exploited by the cell. For instance, metal ions maintain the ionic balance within the cell, coordinate amino acid residues or nucleobases altering folding and function of biomolecules, or directly catalyze specific chemical reactions. Thus, metals are essential cell signaling effectors in normal physiology and disease. Deciphering metal ion signaling is a challenging endeavor that can illuminate pathways to be targeted for therapeutic intervention. Here, we review key cellular processes where metal ions play essential roles and describe how targeting metal ion signaling pathways has been instrumental to dissecting the biochemistry of the cell and how this has led to the development of effective therapeutic strategies.

Primary versus Secondary Immune Thrombocytopenia (ITP): A Meeting Report from the 2023 McMaster ITP Summit

The McMaster Immune Thrombocytopenia (ITP) Summit, held on October 27, 2023, was an educational seminar from leading experts in immune thrombocytopenia and related disorders geared toward hematologists, internists, immunologists, and clinical and translational scientists. The focus of the Summit was to review the mechanisms, diagnosis, and treatment of primary versus secondary ITP. Specific objectives were to describe the unique features of secondary ITP, and to review its mechanisms in the context of autoimmune disease and infection. The key messages in this Summit were: (1) ITP is a heterogeneous disease, and genetic and immunologic insights may help classify patient subtypes; (2) exploring the autoimmune mechanisms and their association with hypogammaglobulinemia in patients with secondary ITP could improve our understanding of ITP and its subtypes; (3) investigating the mechanisms of ITP in the context of infections caused by viruses such as CMV, HIV, dengue, and hepatitis C, or bacteria such as H. pylori, or vaccinations could provide insight into the causes of ITP. A better understanding of secondary ITP could help elucidate the pathogenesis of ITP.

Impact of Thrombopoietin Receptor Agonists on Pathophysiology of Pediatric Immune Thrombocytopenia

Immune thrombocytopenia (ITP) in pediatric patients is a common cause of isolated thrombocytopenia. Various pathophysiological mechanisms are implicated in ITP pathogenesis, including the production of autoantibodies against components of platelets (PLTs) by B-cells, the activation of the complement system, phagocytosis by macrophages mediated by Fcγ receptors, the dysregulation of T cells, and reduced bone marrow megakaryopoiesis. ITP is commonly manifested with skin and mucosal bleeding, and it is a diagnosis of exclusion. In some ITP cases, the disease is self-limiting, and treatment is not required, but chronic-persistent disease can also be developed. In these cases, anti-CD20 monoclonal antibodies, such as rituximab and thrombopoietin (TPO) receptor agonists, can be used. TPO agonists have become standard of care today. It has been reported in the published literature that the efficacy of TPO-RAs can be up to 80% in the achievement of several end goals, such as PLT counts. In the current literature review, the data regarding the impact of TPO agonists in the pathogenesis of ITP and treatment outcomes of the patients are examined. In the era of precision medicine, targeted and individualized therapies are crucial to achieving better outcomes for pediatric patients with ITP, especially when chronic refractory disease is developed.

Gene therapy in transfusion-dependent non-β0/β0 genotype β-thalassemia: first real-world experience of beti-cel

ABSTRACT

Gene addition and editing strategies for transfusion-dependent β-thalassemia have gained momentum as potentially curative treatment options, with studies showcasing their efficacy and safety. We report, to our knowledge, the first real-world application of betibeglogene autotemcel (beti-cel; Zynteglo) during its period of active license in Europe from January 2020 to March 2022 for patients aged ≥12 years without a β0/β0 genotype and without a HLA-matched sibling donor, before beti-cel marketing authorization was withdrawn by its holder because of nonsafety reasons. Among 15 screened patients, 4 opted out for fertility and safety concerns, 2 were excluded because of marked hepatic siderosis, and 1 had apheresis collection failure. Eight patients received beti-cel after busulfan myeloablative conditioning, all achieving transfusion independence within 8 to 59 days, with posttreatment hemoglobin levels ranging from 11.3 to 19.3 g/dL. No deaths occurred, but acute toxicity mirrored busulfan's known effects. Posttreatment platelet management faced challenges because of HLA-antibodies in 3 patients. Monitoring up to month 24 revealed pituitary-gonadal endocrine dysfunction in all 3 female and in 2 of 5 male patients. Additionally, we observed unexpected posttreatment sequelae: 1 patient developed polycythemia that could not be explained by known genetic or acquired mechanisms, 1 patient developed posttreatment depression and anxiety prohibiting her from returning to work, and 1 patient developed fatigue severely compromising both quality of life and work capacity. This real-world experience corroborates beti-cel's efficacy and safety and provides information on adverse events observed during real-world use of the therapy.

Recombinant Erwinia asparaginase (JZP458) in ALL/LBL: complete follow-up of the Children's Oncology Group AALL1931 study

ABSTRACT

Children's Oncology Group study AALL1931 investigated the efficacy and safety of recombinant Erwinia asparaginase (JZP458) in patients with acute lymphoblastic leukemia/lymphoblastic lymphoma and hypersensitivity reactions/silent inactivation to Escherichia coli-derived asparaginases. Each pegylated Escherichia coli asparaginase dose remaining in a patient's treatment plan was replaced by intramuscular (IM) or IV JZP458 (6 doses) administered Monday/Wednesday/Friday (MWF). Three IM cohorts (1a [25 mg/m2 MWF], n = 33; 1b [37.5 mg/m2 MWF], n = 83; 1c [25/25/50 mg/m2 MWF], n = 51) and 1 IV cohort (25/25/50 mg/m2 MWF, n = 62) were evaluated. The proportion (95% confidence interval [CI]) of patients maintaining nadir serum asparaginase activity (NSAA) levels of ≥0.1 IU/mL at the last 72 (primary end point) and 48 hours during course 1 was 90% (95% CI, 81-98) and 96% (95% CI, 90-100) in IM cohort 1c, respectively, and 40% (95% CI, 26-54) and 90% (95% CI, 82-98) in the IV cohort. Population pharmacokinetic modeling results were comparable with observed data, predicting the vast majority of patients would maintain therapeutic NSAA levels when JZP458 is administered IM or IV 25 mg/m2 every 48 hours, or IM 25/25/50 mg/m2 MWF, or with mixed IM and IV administration (IV/IV/IM 25/25/50 mg/m2 MWF). Drug discontinuation occurred in 23% and 56% of patients in the IM and IV cohorts, respectively; 13% and 33% because of treatment-related adverse events (mainly allergic reactions and pancreatitis). JZP458 achieves therapeutic NSAA levels via multiple IM and IV dosing schedules based on combined observed and modeled data with a safety profile consistent with other asparaginases. This trial was registered at www.ClinicalTrials.gov as #NCT04145531.

Sustained hypoxia but not intermittent hypoxia induces HIF-1α transcriptional response in human aortic endothelial cells

Obstructive sleep apnea (OSA) is characterized by intermittent hypoxic environments at the cellular level and is an independent risk factor for the development of cardiovascular disease. Endothelial cell (EC) dysfunction precedes the development of cardiovascular disease; however, the mechanisms by which ECs respond to these intermittent hypoxic events are poorly understood. To better understand EC responses to hypoxia, we examined the effects of sustained hypoxia (SH) and intermittent hypoxia (IH) on the activation of HIF-1α in ECs. While SH stabilized HIF-1α and led to its nuclear localization, IH did not activate HIF-1α and the expression of its target genes. Using RNA-sequencing, we evaluated transcriptional responses of ECs to hypoxia. SH induced the expression of HIF-1α and hypoxia response genes, while IH affected cell-cycle regulation genes. A cytoscape protein-protein interaction network for EC response to hypoxia was created with differentially expressed genes. The network comprises cell-cycle regulation, inflammatory signaling via NF-κB and response to VEGF stimulus subnetworks on which SH and IH had distinct activities. As OSA is associated with elevated catecholamines, we investigated the effect of epinephrine on the EC response to SH and IH. Transcriptomic responses under IH and epinephrine revealed protein-protein interaction networks emphasizing distinct subnetworks, including cytokine-mediated TNFα signaling via NF-κB, Wnt/LRP/DKK signaling and cell cycle regulation. This study reveals differential transcriptomic responses under SH and IH characterised by HIF-1α transcriptional response induced only by SH, but not by IH. The study also features the potential molecular events that may occur at the vascular level in OSA.

An investigation of a hemophilia A female with heterozygous intron 22 inversion and skewed X chromosome inactivation

Objectives

Hemophilia A (HA) is an X-linked recessive inherited bleeding disorder that typically affects men. Women are usually asymptomatic carriers, and rarely presenting with severe or moderately severe phenotype. This study aims to describe a case of a 17-year-old girl with moderate HA, investigating the mechanisms of her condition and the genetic basis within her family.

Methods

We conducted coagulation tests and bleeding assessments to evaluate her bleeding phenotype. Molecular genetic examinations, karyotype analysis, X-chromosome inactivation testing, and targeted bioinformatic analysis were used to identify potential genetic etiologies.

Results

The proband exhibited a severe bleeding phenotype and was found to be a heterozygous carrier of an intron 22 inversion (Inv22) with a normal chromosomal karyotype. No other hemostatic defects were identified through whole exome sequencing. The proband's mother and monozygotic twin sister are also Inv22 carriers, yet remain asymptomatic with normal FVIII activity. X-chromosome inactivation experiments revealed unbalanced inactivation in the proband, leading to the silencing of the healthy X copy. Notably, several novel X-linked gene mutations (SHROOM2, RPGR, VCX3B, GAGE, GCNA, ZNF280C, CT45A, and XK) were identified in the proband compared to her monozygotic twin sister, though their impact on X-chromosome inactivation remains unclear.

Conclusion

Our findings suggest that the proband's bleeding phenotype results from unbalanced X-chromosome inactivation. This research marks the first analysis of X chromosome-related gene mutations among monozygotic twins who are carriers of hemophilia A, laying the groundwork for further investigations into the disorder's pathogenesis in women and highlighting the complexities in genetic counseling.

Daratumumab and Romiplostim Combined Therapy for a Long-Standing Refractory Primary Immune Thrombocytopenia - Case Report

Multi-refractory immune thrombocytopenia (ITP) is not uncommon and associated with high morbidity and mortality rates. Although the precise mechanism of ITP is not yet fully understood, a therapeutic approach that relies on using a single agent in each treatment line may not be sufficient in this population. We report the case of a 67-year-old female with long-standing multi-refractory ITP treated with a combination of Daratumumab and Romiplostim who achieved a durable response for more than 42 weeks. Owing to the presentation of chronic and refractory disease, we used a dual-agent approach to address early immune destruction and promote megakaryocyte platelet production. Three doses of Daratumumab were administered during the induction phase (weeks 0,1,5) and then at less frequent intervals - every 4-12 weeks for total of 4 doses during the maintenance phase. Romiplostim was administered weekly, with dose modification depending on the platelet count. We hypothesize that when combined with thrombopoietin receptor agonists (TPO-RAs), daratumumab administered at less frequent intervals over an extended period can be safely used, resulting in a prolonged response.

Network Analysis of Legg-Calve-Perthes Disease and Its Comorbidities

Background/Objectives: Legg-Calvé-Perthes disease (LCPD) is characterized by idiopathic avascular necrosis of the femoral head in children. There are several hypotheses regarding the cause of LCPD; however, the exact cause remains unclear. Studies on comorbidities can provide better insight into the disease. We aimed to perform a network analysis to identify the associations between LCPD and comorbidities. Methods: We analyzed patients aged ≤ 12 years with LCPD as defined by ICD-10 codes M91.1, M91.8, and M91.9 registered in the National Health Insurance Service cohort database from 2002 to 2015. A control group was designed using propensity score matching. Comorbidities were identified and network analysis was performed. The identified comorbidities were reclassified into clinical disease groups considering their clinical relevance, and a network map was created using odds ratios. Results: In total, 23 significant disease clusters were identified. Injury-related disease clusters with ICD-10 codes starting with "S" were the most frequent. They were reclassified into 11 disease groups based on clinical relevance. Among these, congenital deformities of hip (Q65) had the highest odds ratio. Congenital deformities of feet (Q66) and other anemia (D64) had a single association with LCPD in the comorbidity network analysis. Conclusions: We confirmed the association between LCPD and comorbidities using a network analysis. The LCPD comorbidity network identified in this study is expected to serve as the basis for future research on LCPD.

An erythroid-specific lentiviral vector improves anemia and iron metabolism in a new model of XLSA

ABSTRACT

X-linked sideroblastic anemia (XLSA) is a congenital anemia caused by mutations in ALAS2, a gene responsible for heme synthesis. Treatments are limited to pyridoxine supplements and blood transfusions, offering no definitive cure except for allogeneic hematopoietic stem cell transplantation, only accessible to a subset of patients. The absence of a suitable animal model has hindered the development of gene therapy research for this disease. We engineered a conditional Alas2-knockout (KO) mouse model using tamoxifen administration or treatment with lipid nanoparticles carrying Cre-mRNA and conjugated to an anti-CD117 antibody. Alas2-KOBM animals displayed a severe anemic phenotype characterized by ineffective erythropoiesis (IE), leading to low numbers of red blood cells, hemoglobin, and hematocrit. In particular, erythropoiesis in these animals showed expansion of polychromatic erythroid cells, characterized by reduced oxidative phosphorylation, mitochondria's function, and activity of key tricarboxylic acid cycle enzymes. In contrast, glycolysis was increased in the unsuccessful attempt to extend cell survival despite mitochondrial dysfunction. The IE was associated with marked splenomegaly and low hepcidin levels, leading to iron accumulation in the liver, spleen, and bone marrow and the formation of ring sideroblasts. To investigate the potential of a gene therapy approach for XLSA, we developed a lentiviral vector (X-ALAS2-LV) to direct ALAS2 expression in erythroid cells. Infusion of bone marrow (BM) cells with 0.6 to 1.4 copies of the X-ALAS2-LV in Alas2-KOBM mice improved complete blood cell levels, tissue iron accumulation, and survival rates. These findings suggest our vector could be curative in patients with XLSA.

Severe Thrombocytopenia in the Post-surgical Context and Administration of Factor VIIII (FVIII)/von Willebrand Factor (VWF) Concentrate in a Patient With von Willebrand Disease Type 2M

Von Willebrand disease (VWD) is the most common inherited bleeding disorder. It can be associated with a life-threatening risk of excessive bleeding in surgical procedures, and may require prophylactic treatment with a combined factor VIIII (FVIII)/von Willebrand factor (VWF) concentrate. Management of these patients may be challenging when trying to achieve the balance between avoiding the risk of haemorrhage and causing a risk of thrombosis with the treatment. We present a complex case of severe thrombocytopenia in a post-surgical setting, in which the timeline suggests a direct relationship between the worsening of platelet count and wilate administrations.

A phase 2 clinical trial of luspatercept in non-transfusion-dependent patients with myelodysplastic syndromes

Luspatercept has shown durable clinical efficacy for the treatment of anemia in transfusion-dependent patients with lower-risk myelodysplastic syndromes (LR-MDS). We report the results of a prespecified primary analysis of a phase 2 trial of luspatercept in non-transfusion-dependent (NTD) Japanese patients with anemia due to LR-MDS. Luspatercept (starting dose 1.0 mg/kg) was administered subcutaneously once every 3 weeks. The primary endpoint was the proportion of patients who achieved hematological improvement-erythroid (HI-E) response (≥ 1.5 g/dL increase in hemoglobin level for 8 weeks) without transfusions within the first 24 weeks of treatment. At the primary analysis data cutoff, 21 patients had been enrolled/treated; 17 and 10 patients had completed 24 and 48 weeks of treatment, respectively. HI-E response occurred within 24 weeks in 10 patients (47.6%; 95% confidence interval, 25.7-70.2; P < 0.0001), which was significantly higher than the predefined threshold (10%). By week 48, HI-E response occurred in 12 patients (57.1%) and 17 patients (81.0%) remained NTD. Luspatercept was well tolerated. Three patients (14.3%) had grade 3-4 treatment-related treatment-emergent adverse events. Luspatercept resulted in statistically and clinically significant improvements in hemoglobin levels, and may help delay the need for transfusions in NTD patients with LR-MDS.

Prevalence of metabolic syndrome in children and adolescents with obesity: a systematic review and meta-analysis

OBJECTIVE

This study investigated the prevalence trends of metabolic syndrome (MetS) in children and adolescents with obesity by systematically analyzing global data. Additionally, it aimed to compare regional disparities and criteria used to identify at-risk subpopulations among this demographic group.

METHODS

We searched three major databases, i.e., PubMed-Medline, Scopus, and Web of Science, from inception to August 31, 2023, yielding 2432 articles. We included original research papers reporting MetS prevalence among children and adolescents with obesity, irrespective of their regions and MetS diagnostic criteria used. We aggregated prevalence estimates using random-effects models to obtain the overall prevalence and conducted subgroup analyses for MetS criteria and study regions.

RESULTS

We included 57 studies, amounting to 27,923 participants. The overall prevalence of MetS in participants with obesity varied greatly across studies, ranging from 2.1% to 74.4%, with an average prevalence of 29.4%. This high prevalence of MetS was further supported by a meta-analysis comprising 57 studies that further strengthened the observation of a high prevalence of MetS, revealing an overall prevalence of 26% (95% CI: 0.22-0.30; I2 = 98%).

CONCLUSIONS

Children and adolescents with obesity face a heightened risk of developing MetS. There is a pressing need for heightened attention to this issue, particularly in low- and middle-income countries such as those in sub-Saharan Africa.

An emerging double‑edged sword role of ferroptosis in cardiovascular disease (Review)

The pathophysiology of cardiovascular disease (CVD) is complex and presents a serious threat to human health. Cardiomyocyte loss serves a pivotal role in both the onset and progression of CVD. Among various forms of programmed cell death, ferroptosis, along with apoptosis, autophagy and pyroptosis, is closely linked to the advancement of CVD. Ferroptosis, a mechanism of cell death, is driven by the buildup of oxidized lipids and excess iron. This pathway is modulated by lipid, amino acid and iron metabolism. Key characteristics of ferroptosis include disrupted iron homeostasis, increased peroxidation of polyunsaturated fatty acids due to reactive oxygen species, decreased glutathione levels and inactivation of glutathione peroxidase 4. Treatments targeting ferroptosis could potentially prevent or alleviate CVD by inhibiting the ferroptosis pathway. Ferroptosis is integral to the pathogenesis of several types of CVD and inhibiting its occurrence in cardiomyocytes could be a promising therapeutic strategy for the future treatment of CVD. The present review provided an in‑depth analysis of advancements in understanding the mechanisms underlying ferroptosis. The present manuscript summarized the interplay between ferroptosis and CVDs, highlighting its dual roles in these conditions. Additionally, potential therapeutic targets within the ferroptosis pathway were discussed, alongside the current limitations and future directions of these novel treatment strategies. The present review may offer novel insights into preventive and therapeutic approaches for CVDs.

Efficacy and Safety of Mitapivat in Pyruvate Kinase Deficiency: A Systematic Review and Meta-analysis of Clinical Trials

Background

Pyruvate kinase deficiency (PKD), a rare autosomal recessive disease, often leads to chronic hemolytic complications stemming from mutations in the PKLR gene. Mitapivat, an innovative, allosteric activator of the pyruvate kinase enzyme in red blood cells, has emerged as a potential therapeutic agent. This systematic review aims to meticulously evaluate the efficacy and safety of Mitapivat in treating PKD patients.

Methods

We conducted a comprehensive search across three major databases-PubMed, Web of Science, and Scopus-up to November 2023, utilizing a single-arm meta-analysis methodology.

Results

Our analysis included three clinical trials comprising 94 PKD patients. Hemoglobin (HB) levels improved, with an average increase of 1.05 g/dl (95% Confidence Interval [CI]: -0.22 to 2.33). In terms of hemolysis indicators, there was a notable decrease in indirect bilirubin (mean change: -1.36 mg/dl, 95% CI: -3.67 to 0.95) and an increase in haptoglobin (mean change: 0.26 g/L). Patient-reported outcomes (PROs), assessed via the Pyruvate Kinase Deficiency Diary and Pyruvate Kinase Impact Assessment, showed significant improvements, with mean changes of -4.95 (95% CI: -6.711 to -3.19) and - 5.97 (95% CI: -9.87 to -2.06), respectively. Adverse effects were generally mild, with the most common being headache, nausea, elevated alanine aminotransferase, and nasopharyngitis.

Conclusion

Mitapivat substantially improves hemoglobin levels, hemolysis markers, and PROs, maintaining an acceptable safety profile. Nevertheless, additional, larger-scale randomized controlled trials across diverse age groups remain necessary to further corroborate these findings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12288-024-01830-x.

Bivalirudin anticoagulation for cardiopulmonary bypass during cardiac surgery

INTRODUCTION

Heparin is the primary anticoagulant for cardiopulmonary bypass (CPB) support during cardiac surgery. While widely used, ∼2% of cardiac surgery patients develop heparin-induced thrombocytopenia (HIT) and 4-26% develop heparin resistance. Bivalirudin is an alternative anticoagulant mainly used for percutaneous coronary interventions. Given the challenges associated with heparin anticoagulation, we conducted a review to explore the use of bivalirudin for CPB surgery.

METHODS

PubMed and Embase scoping review included 2 randomized controlled trials, a retrospective comparison study, 3 pilot studies, and 30 case reports. To provide a contemporary series, we searched for articles published from 2010 to 2023. Our review included studies from both adult and pediatric populations.

RESULTS

While data is limited, bivalirudin seems to supply similar effectiveness and safety as heparin for CPB anticoagulation. Across the three comparative studies, the heparin cohorts had a 0-9% mortality rate and 0-27% rate of major bleeding/reoperation compared to a 0-3% mortality and 0-6% major bleeding/reoperation rate for the bivalirudin cohorts. Bivalirudin was successfully used as an anticoagulant in a wide range of CPB surgeries (e.g., heart transplants, ventricular assisted device placements, and valve repairs). Successful patient outcomes were reported with bivalirudin infusion of ∼2 mg/kg/hour, activated clotting time monitoring (target >400 s or 2.5× baseline), use of cardiotomy suctions, minimization of stagnant blood, and post-bypass modified ultrafiltration.

CONCLUSION

Bivalirudin is a safe and effective anticoagulant for CPB, especially for patients with HIT or heparin resistance. Further comparative research is called for to optimize bivalirudin utilization for CPB during cardiac surgery.

Cellular mechanisms of acute rhabdomyolysis in inherited metabolic diseases

Acute rhabdomyolysis (RM) constitutes a life-threatening emergency resulting from the (acute) breakdown of skeletal myofibers, characterized by a plasma creatine kinase (CK) level exceeding 1000 IU/L in response to a precipitating factor. Genetic predisposition, particularly inherited metabolic diseases, often underlie RM, contributing to recurrent episodes. Both sporadic and congenital forms of RM share common triggers. Considering the skeletal muscle's urgent need to rapidly adjust to environmental cues, sustaining sufficient energy levels and functional autophagy and mitophagy processes are vital for its preservation and response to stressors. Crucially, the composition of membrane lipids, along with lipid and calcium transport, and the availability of adenosine triphosphate (ATP), influence membrane biophysical properties, membrane curvature in skeletal muscle, calcium channel signaling regulation, and determine the characteristics of autophagic organelles. Consequently, a genetic defect involving ATP depletion, aberrant calcium release, abnormal lipid metabolism and/or lipid or calcium transport, and/or impaired anterograde trafficking may disrupt autophagy resulting in RM. The complex composition of lipid membranes also alters Toll-like receptor signaling and viral replication. In response, infections, recognized triggers of RM, stimulate increased levels of inflammatory cytokines, affecting skeletal muscle integrity, energy metabolism, and cellular trafficking, while elevated temperatures can reduce the activity of thermolabile enzymes. Overall, several mechanisms can account for RMs and may be associated in the same disease-causing RM.

Contemporary approaches to treat people with hemophilia: what's new and what's not?

The care of people with hemophilia with access to treatment has evolved over the past 70 years, with an average life expectancy like unaffected peers. For people with hemophilia living in low- and middle-income countries, the same is not true because of the lack of access to diagnosis and treatment. It is imperative to close gaps in care that exist throughout the world. Here, we provide a narrative review of hemophilia and the treatments available to people with hemophilia A and B with the goal of achieving a hemophilia-free state. We aim to provide information on what is new and what gaps remain that preclude equitable outcomes for everyone with hemophilia. Information on the current state of hemophilia care and outcomes, the products available for the treatment of people with hemophilia, comprehensive interdisciplinary care of people with hemophilia, and the remaining gaps in care for people with hemophilia were assembled by the authors using relevant literature. Research must focus on preventing all bleeding, and new approaches to detect joint bleeding are needed. Training on and implementation of comprehensive interdisciplinary care is needed to elevate the standards of care in low- and middle-income countries. The development and introduction of improved factor replacement and nonfactor products, such as second-generation bispecific monoclonal antibodies and targeted inhibitors of the anticoagulant mechanisms along with genetic therapies, have the possibility of normalizing hemostasis and achieving health equity for people with hemophilia. Improved outcomes and, ultimately, health equity, can only be realized if diagnosis, education, and care are accessible to everyone living with hemophilia worldwide.

An extremely rare case of Rogers syndrome or thiamine responsive megaloblastic anemia

ABSTRACT

Rogers syndrome is an extremely rare autosomal recessive syndrome of which only 100 cases are known worldwide. It is characterized by thiamine-responsive megaloblastic anaemia, diabetes mellitus and sensorineural deafness. It results from the deficiency of a thiamine transporter protein. We herein report a 16-year-old Indian male referred to our centre with complaints of refractory anaemia, deafness, diabetes pulmonary arterial hypertension and tricuspid regurgitation. Based on the clinical features and haematologic picture and dramatic response of anaemia to thiamine therapy the possibility of a TRMA was considered. Sequencing analysis for TRMA revealed a homozygous c.242dup (p.Tyr81Ter) mutation of the SLC19A2 gene.

Lipemia retinalis following FLAG-Ida protocol in an 11-year-old patient with acute myeloid leukemia

INTRODUCTION

We report a case of early-onset lipemia retinalis secondary to the FLAG-Ida protocol in the treatment of acute myeloid leukemia (AML) in an 11-year-old girl.

CASE REPORT

An 11-year-old patient, diagnosed with AML at four months old, experienced a relapse and was treated with the FLAG-Ida protocol (fludarabine, idarubicin, granulocyte-colony stimulating factor, and high-dose cytarabine). Prior to allogeneic stem cell transplantation, she underwent a pre-transplantation eye examination. The patient exhibited normal visual acuity in both eyes. Fundus examination revealed cream-white retinal vessels and a salmon-pink retina, indicative of grade 3 lipemia retinalis. Laboratory tests, normal before treatment initiation, showed significantly elevated serum cholesterol (727.6 mg/dL) and triglyceride (6015.6 mg/dL) levels post-treatment. After receiving fenofibrate, these levels decreased markedly, and the retinal vessels normalized on follow-up fundus examination.

CONCLUSION

Lipemia retinalis, characterized by creamy-white retinal vessels resulting from hypertriglyceridemia, can develop as a secondary condition to chemotherapy. Early detection and treatment of hyperlipidemia are crucial to prevent severe ocular and systemic complications. This case highlights the importance of monitoring lipid levels and conducting thorough ophthalmologic examinations in patients undergoing chemotherapy.

Thromboprophylaxis with intermediate dose enoxaparin during asparaginase containing induction for young adults with acute lymphoblastic leukemia

Thrombosis rates among young adults receiving asparaginase (ASP) for acute lymphoblastic leukemia (ALL) can reach 34%, with highest risk during induction. Our institution implemented a standard practice of 1 mg/kg/day enoxaparin administered to young adults with ALL who are treated with ASP during induction. We performed a retrospective analysis of patients who received thromboprophylaxis with enoxaparin 1 mg/kg/day during ASP-containing induction for ALL at Oregon Health & Science University from 2012 to 2023. The primary outcome was the cumulative incidence of thrombosis during induction. Bleeding events were assessed. Sixty-two patients were included in our analysis. Four patients (6.5%; 95% CI 1.8%-15.7%) experienced a thrombotic event. Three events were catheter-associated and 1 event was a distal lower extremity deep vein thrombosis related to myositis. No cerebral sinus thromboses, thrombosis-related deaths or major bleeding events occurred. Intermediate-dose enoxaparin is a promising thromboprophylaxis strategy and warrants further prospective research.

Characterization of Thrombocytopenia in Pediatric Patients in Noncritical Hospital Setting: An Institutional Review From Pakistan

Pediatric thrombocytopenia is frequently observed in critical care and oncology settings with an increased risk of bleeding and platelet transfusions. However, little is known about low platelets in childhood during seasonal influence. This study aimed to evaluate the frequency and severity of pediatric thrombocytopenia in the postflood period. The patients 1 to 18 years of age with thrombocytopenia (platelet count <150×109/L) were studied from August to December 2022 after institutional ethical approval (ERC-Path-2022-8044-23395). Data was collected from electronic health records and laboratory information systems. Of 2318 admitted patients, 192 (8.3%) including 128 males and 64 females had thrombocytopenia. The median (IQR) age was 12 (8 to 15) years. Mild, moderate, and severe thrombocytopenia were seen in 109 (56.8%), 76 (39.5%), and 7 (3.6%) patients, respectively. Concomitant leucopenia was observed in 77 of 192 patients (40.1%). Infection was the predominant cause of low platelets (N=175 or 91.1%). Only 15 patients (7.8%) had grade 1/2 bleeding. Overall, 176 patients (92%) were discharged in stable conditions and no mortality was observed. The frequency of pediatric thrombocytopenia in the noncritical and nononcological care settings was <10% and mostly observed in association with underlying infections. The frequency of bleeding manifestation and platelet transfusions was minimal in this group.

Hypercoagulability in hemoglobinopathies: Decoding the thrombotic threat

Beta (β)-thalassemia and sickle cell disease (SCD) are characterized by a hypercoagulable state, which can significantly influence organ complication and disease severity. While red blood cells (RBCs) and erythroblasts continue to play a central role in the pathogenesis of thrombosis in β-thalassemia and SCD, additional factors such as free heme, inflammatory vasculopathy, splenectomy, among other factors further contribute to the complexity of thrombotic risk. Thus, understanding the role of the numerous factors driving this hypercoagulable state will enable healthcare practitioners to enhance preventive and treatment strategies and develop novel therapies for the future. We herein describe the pathogenesis of thrombosis in patients with β-thalassemia and SCD. We also identify common mechanisms underlying the procoagulant profile of hemoglobinopathies translating into thrombotic events. Finally, we review the currently available prevention and clinical management of thrombosis in these patient populations.

A case report of refractory immune thrombocytopenia: Challenges in choice of therapies in resource limiting center

INTRODUCTION AND IMPORTANCE

Refractory immune thrombocytopenic purpura (ITP) is a rare but serious condition causing significant morbidity and mortality due to inadequate response to standard treatments, resulting in persistent thrombocytopenia and increased bleeding risk.

CASE PRESENTATION

An 18-year-old female patient, diagnosed with ITP two years prior following excessive vaginal bleeding and fatigue, was initially treated with oral prednisolone for two months and discharged in improved condition. Eighteen months after treatment cessation, she presented with recurrent excessive vaginal bleeding, intermittent bilateral nasal bleeding, skin rash, blurred vision, fatigue, tinnitus, vertigo, and intermittent headaches (one-month duration). Following a one-month admission during which she proved unresponsive to steroids, she received rituximab 500 mg IV weekly for four weeks, along with supportive care.

CLINICAL DISCUSSION

Refractory ITP in conjunction with COVID-19 is a rare and serious condition associated with significant morbidity and mortality, and a low survival rate. Effective, coordinated medical and surgical management, along with comprehensive rehabilitation from COVID-19, are crucial for improving outcomes in this severe condition.

CONCLUSION

Refractory ITP is a challenging and rare condition that can result in significant health complications, economic burdens, and a reduced quality of life for those affected.

Correlation study between magnetic resonance imaging-quantitated cardiac iron deposition and left ventricular function in patients with β-thalassemia major in China

OBJECTIVE

To explore the correlation between cardiac iron deposition and left ventricular function indicators, such as left ventricular end-diastolic volume index, left ventricular end-systolic volume index, and left ventricular ejection fraction, and to evaluate the accuracy of predicting patients with cardiac iron deposition by using left ventricular ejection fraction as an index.

METHODS

This quantitative cross-sectional study involved one hundred and fifty transfusion-dependent patients with β-thalassemia major who were evaluated by magnetic resonance imaging to obtain T2* values, left ventricular end-diastolic volume index, left ventricular end-systolic volume index, and left ventricular ejection fraction. The relationship between cardiac R2* values and left ventricular end-diastolic volume index, left ventricular end-systolic volume index, and left ventricular ejection fraction was analyzed.

RESULTS

Out of the 150 patients, cardiac iron overload was not observed for 92 patients, 42 patients exhibited mild to moderate cardiac iron overload, and 16 patients were severe cardiac iron overloaded. A linear correlation was not observed between the cardiac R2* values and left ventricular end-diastolic volume index, left ventricular end-systolic volume index, and left ventricular ejection fraction (P > 0.05). For the left ventricular ejection fraction index, the sensibility, specificity, positive predictive value, negative predictive value, and the agreement rate were 83.3%, 63.2%, 8.6%, 98.9%, and 64.0%, respectively; also, the area under the receiver operating characteristic curve was 0.348.

CONCLUSIONS

A linear correlation was not observed between cardiac R2* values and left ventricular end-diastolic volume index, left ventricular end-systolic volume index, and left ventricular ejection fraction in patients with β-thalassemia major. Therefore, using left ventricular ejection fraction as an indirect index to predict cardiac iron deposition may be not reliable in clinical practice.

Upregulation of miR‑6747‑3p affects red blood cell lineage development and induces fetal hemoglobin expression by targeting BCL11A in β‑thalassemia

In β‑thalassemia, excessive α‑globin chain impedes the normal development of red blood cells resulting in anemia. Numerous miRNAs, including miR‑6747‑3p, are aberrantly expressed in β‑thalassemia major (β‑TM), but there are no reports on the mechanism of miR‑6747‑3p in regulating red blood cell lineage development and fetal hemoglobin (HbF) expression. In the present study, RT‑qPCR was utilized to confirm miR‑6747‑3p expression in patients with β‑TM and the healthy controls. Electrotransfection was employed to introduce the miR‑6747‑3p mimic and inhibitor in both HUDEP‑2 and K562 cells, and red blood cell lineage development was evaluated by CCK‑8 assay, flow cytometry, Wright‑Giemsa staining and Benzidine blue staining. B‑cell lymphoma/leukemia 11A (BCL11A) was selected as a candidate target gene of miR‑6747‑3p for further validation through FISH assay, dual luciferase assay and Western blotting. The results indicated that miR‑6747‑3p expression was notably higher in patients with β‑TM compared with healthy controls and was positively related to HbF levels. Functionally, miR‑6747‑3p overexpression resulted in the hindrance of cell proliferation, promotion of cell apoptosis, facilitation of cellular erythroid differentiation and γ‑globin expression in HUDEP‑2 and K562 cells. Mechanistically, miR‑6747‑3p could specifically bind to the 546‑552 loci of BCL11A 3'‑UTR and induce γ‑globin expression. These data indicate that upregulation of miR‑6747‑3p affects red blood cell lineage development and induces HbF expression by targeting BCL11A in β‑thalassemia, highlighting miR‑6747‑3p as a potential molecular target for β‑thalassemia therapy.

The effect of mobile application based genetic counseling on the psychosocial well-being of thalassemia patients and caregivers: A randomized controlled trial

OBJECTIVE

This study was carried out to investigate the effects of mobile application based genetic counseling on the psychosocial well-being of thalassemia patients and caregivers.

METHODS

A randomized controlled trial was conducted with 80 patients, divided equally between the intervention and control groups. Additionally, 192 caregivers were included, with an equal distribution of 96 in the two groups. The intervention group received mobile application based genetic counseling, while the control received standard routine care. Assessments of quality of life, satisfaction, depression, and anxiety were conducted at baseline (T0), one-month post-intervention (T1), and three months post-intervention (T2). Furthermore, data analysis was performed using the Generalized Estimation Equation Model (GEE) approach in SPSS version 25.0.

RESULTS

Mobile application based genetic counseling had significant effects on various aspects of the well-being of thalassemia patients and caregivers. These effects include improvements in quality of life, patient satisfaction, reduction in depression, and alleviation of anxiety (p < 0.05).

CONCLUSION

Mobile application based genetic counseling showed a significant effect in improving psychosocial well-being among patients and caregivers.

PRACTICE IMPLICATIONS

The results obtained practical implications for the integration of genetic counseling interventions, particularly through the application of information technology such as Cyber Gen application.

Substrate transport and drug interaction of human thiamine transporters SLC19A2/A3

Thiamine and pyridoxine are essential B vitamins that serve as enzymatic cofactors in energy metabolism, protein and nucleic acid biosynthesis, and neurotransmitter production. In humans, thiamine transporters SLC19A2 and SLC19A3 primarily regulate cellular uptake of both vitamins. Genetic mutations in these transporters, which cause thiamine and pyridoxine deficiency, have been implicated in severe neurometabolic diseases. Additionally, various prescribed medicines, including metformin and fedratinib, manipulate thiamine transporters, complicating the therapeutic effect. Despite their physiological and pharmacological significance, the molecular underpinnings of substrate and drug recognition remain unknown. Here we present ten cryo-EM structures of human thiamine transporters SLC19A3 and SLC19A2 in outward- and inward-facing conformations, complexed with thiamine, pyridoxine, metformin, fedratinib, and amprolium. These structural insights, combined with functional characterizations, illuminate the translocation mechanism of diverse chemical entities, and enhance our understanding of drug-nutrient interactions mediated by thiamine transporters.

Sustained remission at long term follow-up in adolescents and young adults with chronic primary immune thrombocytopenia

ABSTRACT

Adolescents and young adults (AYAs) with immune thrombocytopenia (ITP) exhibit distinct clinical features and needs, defying categorization as either adults or children. Previous findings revealed a 50% risk of chronic disease at 12 months, yet the long-term course remains unclear. This study aimed to delineate the clinical and laboratory characteristics of AYAs with chronic primary ITP. Data from patients aged 12 to 25 years with chronic disease at 1 year were extracted from 3 registries (Pediatric and Adult Registry on Chronic ITP, CEREVANCE, and Cytopénies Auto-immunes Registre Midi-Pyrénéen), covering the period from 2004 to 2021. Sustained complete remission off treatment (SCROT) occurring beyond 12 months was defined as platelet count of >100 × 109/L without treatment for at least 12 months, independently of the previous treatment strategy. A total of 427 AYAs (64% female) with chronic primary ITP were included. Clinical information was available for ∼100% of patients at initial diagnosis and at 6- and 12-month follow-ups (FUs); and for 88%, 77%, and 59% at 24, 36, and 48 months, respectively. Over time, clinical features improved gradually, with fewer patients requiring treatment. Throughout the FU period, second-line drug use increased steadily among treated patients, without affecting the need for corticosteroids and IV immunoglobulins. The proportion of new patients achieving SCROT at 24-, 36-, and 48-month FU was 10% (38/375), 9.5% (31/327), and 12% (30/250), respectively, including 23 who underwent splenectomy. AYAs achieving SCROT between 12 and 36 months displayed higher platelet counts in the first year (excluding the initial period) and received fewer IV immunoglobulin treatments beyond 12 months compared with those with ongoing disease.

Baricitinib in pediatric chronic immune thrombocytopenia and associated autoimmune conditions: a case report

Immune thrombocytopenia (ITP) is a disease characterized by platelet destruction, presenting substantial challenges in clinical practice. The classic first line therapeutic management includes corticosteroids and intravenous immunoglobulins. Although it is less frequent in children than in adults, there is a significant percentage of patients, up to 47% according to the Pediatric and Adult Registry on Chronic ITP, who require second-line or further treatment, due to non-response to the first line treatment or persistence of disease, among other reasons. Several second line approaches for its treatment are currently in use, including increasing platelet production with thrombopoietin receptor agonists. We report the case of a 16-year-old patient with ITP and alopecia areata successfully treated with baricitinib, a reversible and selective JAK 1/2 inhibitor. Baricitinib is currently in use for the treatment of several autoimmune conditions and has been shown to increase platelet counts in these patients. This phenomenon has been linked to increased TPO signaling and reduced platelet destruction. There are promising preliminary results of adult ITP patients treated with baricitinib. This case report is the first reported use of baricitinib in ITP in the pediatric and adolescent setting, potentially leading to its use in this condition.

IFRD1 is required for maintenance of bladder epithelial homeostasis

The maintenance of homeostasis and rapid regeneration of the urothelium following stress are critical for bladder function. Here, we identify a key role for IFRD1 in maintaining urothelial homeostasis in a mouse model. We demonstrate that the murine bladder expresses IFRD1 at homeostasis, particularly in the urothelium, and its loss alters the global transcriptome with significant accumulation of endolysosomes and dysregulated uroplakin expression pattern. We show that IFRD1 interacts with mRNA-translation-regulating factors in human urothelial cells. Loss of Ifrd1 leads to disrupted proteostasis, enhanced endoplasmic reticulum (ER stress) with activation of the PERK arm of the unfolded protein response pathway, and increased oxidative stress. Ifrd1-deficient bladders exhibit urothelial cell apoptosis/exfoliation, enhanced basal cell proliferation, reduced differentiation into superficial cells, increased urothelial permeability, and aberrant voiding behavior. These findings highlight a crucial role for IFRD1 in urothelial homeostasis, suggesting its potential as a therapeutic target for bladder dysfunction.

Dental Considerations in Children with Inherited Bleeding Disorders and Inhibitors: A Systematic Review

Background/Objectives: This systematic review evaluates the effectiveness of various hematological treatment protocols and local hemostatic measures in preventing oral bleeding and other complications during and after dental treatments in children with inherited bleeding disorders and inhibitors. Methods: This study was registered in the PROSPERO database. The comprehensive search strategy for this systematic review was conducted across five databases, namely, PubMed, Google Scholar, Web of Science, Scopus, and Cochrane Library. The search was aimed at identifying relevant literature published from January 2000 up to February 2024. Eligible studies included those with various designs, such as randomized controlled trials (RCTs), observational studies, cohort studies, case-control studies, and cross-sectional studies. Data extraction was carried out systematically, and relevant information on study characteristics, interventions, treatment protocols, local measures, complications, and outcomes was collected. Results: The systematic review included a total of five studies, encompassing participants ranging from ages of 2 to 18 years. These studies varied in their scope, with some focusing on hemophilia A with inhibitors while others addressed broader inherited bleeding disorders. The interventions examined included various prophylactic and treatment measures such as Emicizumab, recombinant factor VIIa, and local hemostatic measures. The study outcomes primarily assessed the efficacy of these interventions in preventing postoperative bleeding and improving quality of life. Emicizumab has significantly shifted the treatment paradigm for children with inherited bleeding disorders and inhibitors. This prophylactic treatment has been associated with a marked reduction in the frequency of bleeding episodes, fewer hospital admissions for bleeding management, and enhanced participation in daily activities. Conclusions: This review highlights gaps in the management of dental care in children with inherited bleeding disorders and inhibitors. It underscores the need for standardized protocols that integrate new prophylactic treatments such as Emicizumab. Our findings suggest that adopting updated protocols can significantly reduce bleeding complications during dental procedures.

Sex and Gender Differences in Iron Chelation

BACKGROUND/OBJECTIVES

In the absence of physiological mechanisms to excrete excessive iron, the administration of iron chelation therapy is necessary. Age and hormones have an impact on the absorption, distribution, metabolism, and excretion of the medications used to treat iron excess, resulting in notable sex- and gender-related variances.

METHODS

Here, we aimed to review the literature on sex and gender in iron overload assessment and treatment.

RESULTS

The development of iron chelators has shown to be a successful therapy for lowering the body's iron levels and averting the tissue damage and organ failure that follows. Numerous studies have described how individual factors can impact chelation treatment, potentially impact therapeutic response, and/or result in inadequate chelation or elevated toxicity; however, most of these data have not considered male and female patients as different groups, and particularly, the effect of hormonal variations in women have never been considered.

CONCLUSIONS

An effective iron chelation treatment should take into account sex and gender differences.