The Italian multiregional thalassemia registry: Centers characteristics, services, and patients' population

Spanish registry of hemoglobinopathies and rare anemias (REHem-AR): demographics, complications, and management of patients with β-thalassemia

INTRODUCTION

The increase in the number of patients with hemoglobinopathies in Europe in recent decades highlights the need for more detailed epidemiological information in Spain. To fulfil this need, the Spanish Society of Pediatric Hematology and Oncology (SEHOP) sponsored the creation of a national registry of hemoglobinopathies known as REHem-AR (Spanish Registry of Hemoglobinopathies and Rare Anemias). Data from the transfusion-dependent (TDT) and non-transfusion-dependent (NTDT) β-thalassemia cohorts are described and analyzed.

METHODS

We performed an observational, multicenter, and ambispective study, which included patients of any age with TDT and NTDT, registered up to December 31, 2021.

RESULTS

Among the 1741 patients included, 168 cases of thalassemia were identified (103 TDT and 65 NTDT-patients). Survival at 18 years was 93% for TDT and 100% for NTDT. Regarding management, 80 patients with TDT (77.7%) and 23 patients with NTDT (35.4%) started chelation treatment during follow-up, with deferasirox being the most widely used. A total of 76 patients within the TDT cohort presented at least 1 complication (73.8%), the most frequent being hemosiderosis and osteopenia-osteoporosis. Comparison of both cohorts revealed significant differences in the diagnosis of hepatic hemosiderosis (p = 0.00024), although these were not observed in the case of cardiac iron overload (p = 0.27).

DISCUSSION

Our registry enabled us to describe the management of β thalassemia in Spain and to analyze the morbidity and mortality of the cohorts of patients with TDT and NTDT. Complications related to iron overload in TDT and NTDT account for most of the morbidity and mortality of the disease, which is associated with a considerable social, psychological, and economic impact, although cardiac, osteopathy and endocrinological complications requiring more attention. The convenience and simplicity of online registries make it possible to homogenize variables and periodically update data, thus providing valuable information on these diseases.

Thalassaemia

Thalassaemia is a diverse group of genetic disorders with a worldwide distribution affecting globin chain synthesis. The pathogenesis of thalassaemia lies in the unbalanced globin chain production, leading to ineffective erythropoiesis, increased haemolysis, and deranged iron homoeostasis. The clinical phenotype shows heterogeneity, ranging from close to normal without complications to severe requiring lifelong transfusion support. Conservative treatment with transfusion and iron chelation has transformed the natural history of thalassaemia major into a chronic disease with a prolonged life expectancy, albeit with co-morbidities and substantial disease burden. Curative therapy with allogeneic haematopoietic stem cell transplantation is advocated for suitable patients. The understanding of the pathogenesis of the disease is guiding therapeutic advances. Novel agents have shown efficacy in improving anaemia and transfusion burden, and initial results from gene therapy approaches are promising. Despite scientific developments, worldwide inequality in the access of health resources is a major concern, because most patients live in underserved areas.

Quality of Life and Burden of Disease in Italian Patients with Transfusion-Dependent Beta-Thalassemia

Lifespan treatment in transfusion-dependent β-thalassemia (TDT) is expected to impact quality of life. This study aimed at evaluating health-related quality of life (HRQoL), well-being, and the burden of TDT on Italian patients. Patients (≥14 years) were invited to complete a cross-sectional, online volunteer survey. HRQoL was measured by the 36-item short-form health survey (SF-36) and wellbeing was measured by the Italian version of the Psychological General-Well-Being-Index (PGWBI). A total of 105/167 completed questionnaires were analyzed (46% males; median age 44, (IQR = 11)). Patients reported lower HRQoL compared with the general population in all SF-36 domains (except for emotional well-being (p = 0.7024) and role limitations due to emotional problems (p = 0.1389)). PGWBI domains general health and vitality and the total PGWBI score were all significantly lower (p = 0.0001) compared with the general population. On average, patients spent 16.62 h/month engaged in care activities that were additional to the time required for completing transfusions. Of the 16.62 h/month, 11.7 h/month were required for therapy management and 4.92 h/month for family management. This study found lower HRQoL and well-being in physical and psychological domains compared with the general population. Further, patients were found to have a high perceived burden of disease.

Cardiac T2 * mapping: Techniques and clinical applications

Cardiac T₂* mapping is a noninvasive MRI method that is used to identify myocardial iron accumulation in several iron storage diseases such as hereditary hemochromatosis, sickle cell disease, and β‐thalassemia major. The method has improved over the years in terms of MR acquisition, focus on relative artifact‐free myocardium regions, and T₂* quantification. Several improvement factors involved include blood pool signal suppression, the reproducibility of T₂* measurement as affected by scanner hardware, and acquisition software. Regarding the T₂* quantification, improvement factors include the applied curve‐fitting method with or without truncation of the signals acquired at longer echo times and whether or not T₂* measurement focuses on multiple segmental regions or the midventricular septum only. Although already widely applied in clinical practice, data processing still differs between centers, contributing to measurement outcome variations. State of the art T₂* measurement involves pixelwise quantification providing better spatial iron loading information than region of interest‐based quantification. Improvements have been proposed, such as on MR acquisition for free‐breathing mapping, the generation of fast mapping, noise reduction, automatic myocardial contour delineation, and different T₂* quantification methods. This review deals with the pro and cons of different methods used to quantify T₂* and generate T₂* maps. The purpose is to recommend a combination of MR acquisition and T₂* mapping quantification techniques for reliable outcomes in measuring and follow‐up of myocardial iron overload. The clinical application of cardiac T₂* mapping for iron overload's early detection, monitoring, and treatment is addressed. The prospects of T₂* mapping combined with different MR acquisition methods, such as cardiac T₁ mapping, are also described.

Level of Evidence: 4

Technical Efficacy Stage: 5

J. Magn. Reson. Imaging 2019.

International Comparison of Thalassemia Registries: Challenges and Opportunities

Background:

Patient registries use standardized methods to systematically gather uniform data for specific groups of patients managed in clinical practice to evaluate specified outcomes.

Aim:

The objective of this study was to identify and describe structures of the identified thalassemia registries in worldwide and summarize their key characteristics.

Methods:

We reviewed the literature on thalassemia registries. A search of PubMed, Scopus, ProQuest, and Science Direct databases was conducted in September 2018. We also reviewed the existing thalassemia registry websites in different countries. The keywords used to our search were as follows: Thalassemia, Hemoglobinopathy, Registry, Database, and Registration System. Some features such as the name of registry, funding source, objectives of the registry, minimum data set, and methods of data collection were determined.

Results:

We identified 16 thalassemia registries operating on a multinational, national, or regional level between1984 and 2016. Most of these aimed to improve the diagnosis and management of control programs. Government funding was the most common funding source for registries. Furthermore, the most common method of data submission was Web-based data entry. The data were entered by a member of the clinical team or a nominated data manager.

Conclusion:

Registries provide a positive return on investment; their establishment and maintenance require ongoing support by government, policy makers, research funding bodies, clinicians, thalassemia patients and their caregivers. However, the results of research suggest the establishment of an international network for coordination and collaboration between thalassemia registries.

Population Screening for Hemoglobinopathies

Hemoglobinopathies are the most common single-gene disorders in the world. Their prevalence is predicted to increase in the future, and low-income hemoglobinopathy-endemic regions need to manage most of the world's affected persons. International organizations, governments, and other stakeholders have initiated national or regional prevention programs in both endemic and nonendemic countries by performing population screening for α- and β-thalassemia, HbE disease, and sickle cell disease in neonates, adolescents, reproductive-age adults (preconceptionally or in the early antenatal period), and family members of diagnosed cases. The main aim of screening is to reduce the number of affected births and, in the case of sickle cell disease, reduce childhood morbidity and mortality. Screening strategies vary depending on the population group, but a few common screening test methods are universally used. We discuss the salient features of population-screening programs around the globe as well as current and proposed screening test methodologies.

Pattern of complications and burden of disease in patients affected by beta thalassemia major

OBJECTIVES

Despite the correct application of blood transfusions and chelation treatments, beta thalassemia patients have many complications. Systematic population analyses on types and frequency of these complications are very few. The aim of this study is to characterize the complications, their risk factors and their clinical and economic impact.

METHODS

Complications at baseline and events occurring during one observational year were analyzed in 272 patients aged >12 years. Risk factors were analyzed through chi-squared and unpaired t tests. Logistic regression was applied to perform the risk factors multivariate analysis.

RESULTS

A total of 554 complications (1-6 per patient) affected 82.3% of patients. Cardiac complications were less represented than expected. Musculoskeletal diseases were the most represented complications followed by hepatic, sexual and endocrine diseases. Splenectomized patients, born before 1970 and aged >40 years, starting iron chelation therapy when aged >4 years or after receiving more than 20 blood transfusions, presented a significantly higher number of complications. A total of 885 adverse events requiring 34125 additional medical services occurred in 1 year. Of these, 34.9% were related to treatments and 65.1% to other causes. Event numbers, additional medical interventions and cost increased progressively in patients affected by one or more complication compared to patients with no complications.

CONCLUSIONS

The pattern of complications changes according to birth cohort and differentiates older from younger patients. The burden of the disease and its costs increase after the onset of the first complication, therefore prevention of complications is fundamental in these patients.

Roads to Health in Developing Countries: Understanding the Intersection of Culture and Healing

Background

The most important attribute to which all human beings aspire is good health because it enables us to undertake different forms of activities of daily living. The emergence of scientific knowledge in Western societies has enabled scientists to explore and define several parameters of health by drawing boundaries around factors that are known to influence the attainment of good health. For example, the World Health Organization defined health by taking physical and psychological factors into consideration. Their definition of health also included a caveat that says, “not merely the absence of sickness.” This definition has guided scientists and health care providers in the Western world in the development of health care programs in non-Western societies.

Objective

However, ethnomedical beliefs about the cause(s) of illness have given rise to alternative theories of health, sickness, and treatment approaches in the developing world. Thus, there is another side to the story.

Method

Much of the population in developing countries lives in rural settings where the knowledge of health, sickness, and care has evolved over centuries of practice and experience. The definition of health in these settings tends to orient toward cultural beliefs, traditional practices, and social relationships. Invariably, whereas biomedicine is the dominant medical system in Western societies, traditional medicine—or ethnomedicine—is often the first port of call for patients in developing countries.

Results

The 2 medical systems represent, and are influenced by, the cultural environment in which they exist. On one hand, biomedicine is very effective in the treatment of objective, measurable disease conditions. On the other hand, ethnomedicine is effective in the management of illness conditions or the experience of disease states. Nevertheless, an attempt to supplant 1 system of care with another from a different cultural environment could pose enormous challenges in non-Western societies.

Conclusion

In general, we, as human beings, are guided in our health care decisions by past experiences, family and friends, social networks, cultural beliefs, customs, tradition, professional knowledge, and intuition. No medical system has been shown to address all of these elements; hence, the need for collaboration, acceptance, and partnership between all systems of care in cultural communities. In developing countries, the roads to health are incomplete without an examination of the intersection of culture and healing. Perhaps mutual exclusiveness rather inclusiveness of these 2 dominant health systems is the greatest obstacle to health in developing countries.