Efficacy and safety of immunosuppressive therapy combined with eltrombopag for severe aplastic anemia: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Immunosuppressive therapy (IST) is the first choice for severe aplastic anemia (SAA) patients with hematopoietic stem cell transplantation (HSCT) limitation, and the main factor limiting its efficacy is too few residual hematopoietic stem/progenitor cells (HSPC). Eltrombopag (EPAG), as a small molecule thrombopoietin receptor agonist, can stimulate the proliferation of residual HSPC and restore the bone marrow hematopoietic function of patients. In recent years, many studies have observed the efficacy and safety of IST combined with EPAG in the treatment of SAA, but the results are still controversial. The aim of this study is to systematically evaluate the efficacy and safety of IST combined with or without EPGA in the treatment of SAA.

METHODS

We conducted a systematic review of all relevant literature published up to January 19, 2024. Pooled odds ratio (OR) was calculated to compare the rates, along with 95% confidence intervals (CI) and p value to assess whether the results were statistically significant by Review Manager 5.4.1. The p values for the interactions between each subgroup were calculated by Stata 15.1. The Newcastle-Ottawa Scale and the Cochrane bias risk assessment tools were respectively used to evaluate the quality of the literature with cohort studies and randomized controlled trials. The Review Manager 5.4.1 and Stata 15.1 were used to assess bias risk and perform the meta-analysis.

RESULTS

A total of 16 studies involving 2148 patients were included. The IST combined with the EPAG group had higher overall response rate (ORR) than the IST group at 3 months (pooled OR = 2.10, 95% CI 1.58-2.79, p < 0.00001) and 6 months (pooled OR = 2.13, 95% CI 1.60-2.83, p < 0.00001), but the difference between the two groups became statistically insignificant at 12 months (pooled OR = 1.13, 95% CI 0.75-1.72, p = 0.55). The results of complete response rate (CRR) (pooled OR at 3 months = 2.73, 95% CI 1.83-4.09, p < 0.00001, 6 months = 2.76, 95% CI 2.08-3.67, p < 0.00001 and 12 months = 1.38, 95% CI 0.85-2.23, p = 0.19) were similar to ORR. Compared with the IST group, the IST combined with the EPAG group had better overall survival rate (OSR) (pooled OR = 1.70, 95% CI 1.15-2.51, p = 0.008), but there were no statistically significant differences in event-free survival rate (EFSR) (pooled OR = 1.40, 95% CI 0.93-2.13, p = 0.11), clonal evolution rate (pooled OR = 0.68, 95% CI 0.46-1.00, p = 0.05) and other adverse events between the two groups. The results of subgroup analysis showed that different ages were a source of heterogeneity, but different study types and different follow-up times were not. Moreover, all p-values for the interactions were greater than 0.05, suggesting that the treatment effect was not influenced by subgroup characteristics.

CONCLUSION

EPAG added to IST enables patients to achieve earlier and faster hematologic responses with a higher rate of complete response. Although it had no effect on overall EFSR, it improved OSR and did not increase the incidence of clonal evolution and other adverse events.

Incidence and risk factors for secondary graft failure in uniformly treated patients with severe aplastic anemia receiving fludarabine and cyclophosphamide for conditioning and matched sibling bone marrow graft as stem cell source

BACKGROUND AIMS

Graft failure after allogeneic transplant for aplastic anemia is problematic. The risk of graft failure depends on multiple variables, including the preparative regimen, donor type, stem cell dose and source among other variables.

METHODS

We performed a retrospective analysis of patients with aplastic anemia who underwent matched-sibling allogeneic transplant at a single center.

RESULTS

We identified 82 patients who fit the inclusion criteria. One had primary graft failure and was excluded from this analysis. The recipient median age was 22 years. The donor median age was 23 years. The median time from diagnosis to transplant was 1.6 months. The median number of red cell transfusions before transplant was nine. The median number of platelet transfusions before transplant was 18. Thirteen patients developed secondary graft failure, with a cumulative incidence at 5 years of 16% and median time to develop secondary graft failure of 129 days. All patients engrafted with a median time for neutrophil engraftment of 19 days and a median time for platelet engraftment of 22 days. The survival of patients with or without secondary graft failure was not different. Major or bidirectional ABO incompatibility and older recipient age were statistically significantly associated with greater risk of secondary graft failure.

CONCLUSIONS

Secondary graft failure is a significant complication after allogeneic transplant for SAA. Identification of recipients at risk and mitigating the potential risks of this complication is warranted.

Neonatal outcomes and related risk factors of 30 cases with aplastic anemia in pregnancy: A retrospective study

OBJECTIVE

To analyze the neonatal outcomes of pregnancies complicated by aplastic anemia (AA) and to investigate the underlying risk factors.

METHODS

A single-center retrospective study was performed. Thirty singleton gravidas with AA (AA group) and another thirty singleton gravidas (control group) without immune or blood system disorders who gave birth around the same time were selected. Neonatal outcomes were compared between the two groups. Meanwhile, multivariable analyses were utilized to investigate the association between underlying risk factors and adverse neonatal events.

RESULTS

No neonatal deaths occurred. Compared to the control group, the offspring of women with AA had a smaller gestational age (36 ± 1.9 vs. 39.1 ± 0.9 weeks; P < 0.001) and birth weight (2683.7 ± 479.9 vs. 3324.3 ± 394.1 g; P < 0.001). Newborns of women with AA had a higher risk of premature delivery (53.3 % vs. 3.3 %; P < 0.001), low birth weight (23.3 % vs. 0 %; P < 0.001) and NICU admission (53.3 % vs. 16.7 %; P = 0.003). Multivariate analysis showed neutropenia, anemia and thrombocytopenia as risk factors for premature delivery and admission to NICU. Anemia was independently associated with low birth weight (OR 0.94, 95 % CI 0.9-0.98, P = 0.01).

CONCLUSIONS

Neonatal complications such as premature delivery, low birth weight and NICU admission are more common in pregnant women with AA. Newborn babies' s hematopoietic system did not appear to have been affected. Maintaining a certain level of neutrophils, hemoglobin, and platelets in the mother can improve newborn outcomes.

Long-term reduction in the incidence of aplastic anemia and immune thrombocytopenia during the COVID-19 pandemic

Not available.

Real-world evidence of incidence and outcomes of aplastic anaemia following administration of immune checkpoint inhibitors

Aplastic anaemia (AA) is a rare immune-related adverse events (irAEs) after immune checkpoint inhibitors (ICIs) administration with poorly understood incidence and outcomes. We analysed an electronic health record database of 52 303 ICI-treated patients and found 77 (0.15%) cases of AA, with a median onset of 126 days (interquartile range, 58-363 days). The most used treatment for AA was systemic glucocorticoids 60 (77.9%) and 32 (41.6%) patients were able to resume ICI within 1 year. Patients diagnosed with AA had a steep decline in overall survival (OS) within the first 120 days; when compared to propensity score-matched patients without AA, they had a significantly worse OS (hazard ratio 1.72, 95% confidence interval 1.19-2.50; p = 0.003).

To determine the frequency of aldehyde dehydrogenase type 2 (aldh2) deficiency in aplastic anaemia: A single center experience from pakistan

BACKGROUND

Aplastic anaemia is a rare bone marrow failure syndrome and is defined by pancytopenia associated with a hypo-cellular bone marrow with no increase in reticulin and the absence of any abnormal infiltrate. The objective of the study was to determine the frequency of Aldehyde Dehydrogenase type 2 (ALDH2) deficiency in patients with Aplastic Anaemia and investigate its correlation with patient and disease characteristics. It was a descriptive cross-sectional study conducted at Armed Forces Bone Marrow Transplant Centre Rawalpindi from 01-08-2022-01-02-2023, over 6 months.

METHODS

A total of 56 patients who were diagnosed with aplastic anaemia during this period, fulfilling inclusion criteria were enrolled. Patients were genotyped as GG (homozygous) and GA (heterozygous). GG had normal ALDH2, while GA were patients with ALDH2 deficiency. Data was collected on the patient's demographics, type and severity of anaemia, type of hematopoietic stem cell transplant (HSCT) and frequency of ALDH2 deficiency. Results were analyzed for ALDH2 deficiency and its correlation with patient and disease characteristics was investigated.

RESULTS

A total of 56 patients were included in the study. The median age of the patients was 28 years (20-39). According to the type of aplastic anaemia, 2 (3.6%) had Fanconi anaemia and 54 (96.4%) had acquired aplastic anaemia. In our study, 18 (32.1%) patients had undergone HSCT while the remaining 38 (67.9%) could not undergo HSCT. The frequency of the presence of ALDH2 deficiency was 2 (3.6%). There was no statistically significant correlation between the frequency of ALDH2 deficiency with variables like gender, age distribution, type of aplastic anaemia, the severity of aplastic anaemia and hematopoietic stem cell transplant.

CONCLUSIONS

We concluded from our study the frequency of ALDH2 was rare in patients with aplastic anaemia. There was no statistically significant correlation between the frequency of ALDH2 deficiency with variables like gender, age distribution, type of aplastic anaemia, the severity of aplastic anaemia and hematopoietic stem cell transplant.

Clinical characteristics of antithyroid drug-induced aplastic anemia cases over the past 30 years

OBJECTIVE

The authors aimed to investigate the clinical characteristics of antithyroid drug-induced aplastic anemia cases over the past 30 years.

METHODS

The data of patients with antithyroid drug-induced aplastic anemia were retrieved from PubMed and Wanfang Medical Network databases from 1992 to August 2022. The clinical characteristics, such as age distribution, gender tendency, common symptoms, blood cell count, bone marrow features, treatment strategy, and prognosis, were analyzed.

RESULTS

A total of 17 cases (male:female = 1:16) had been retrieved. Patients' age ranged from 16 to 74 years (median 50 years). Among them, 82.3% (14/17) of the patients were administered methimazole (MMI), and 78.6% of them had MMI ≥30 mg/day. In addition, 88.2% (15/17) of the patients had sore throat and fever, and 47.1% (8/17) of the patients had hemorrhagic symptoms. Aplastic anemia occurred within 6 months after initiation of the antithyroid therapy in 94.1% of the patients. Agranulocytosis (94.1%) was the most common and earliest blood cell change, and 47.1% of the patients experienced progressive platelet decline during the treatment process. The treatments include timely withdrawal of antithyroid drugs, broad-spectrum antibiotics, granulocyte colony-stimulating factor (G-CSF)/granulocyte-macrophage colony-stimulating factor (GM-CSF), glucocorticoids and other immunosuppressive agents, and supportive treatments such as erythrocyte transfusion and platelet transfusion. Moreover, 70.6% of the patients had complete or near-complete remission within 8 days to 6 weeks.

CONCLUSION

Aplastic anemia is a rare and serious adverse reaction of antithyroid drugs, which is more common in women. It usually occurs during early treatment with high-dose antithyroid drugs. Most patients have a good prognosis after timely drug ceasing and appropriate treatment.

The Incidence, Outcomes, and Risk Factors of Secondary Poor Graft Function in Haploidentical Hematopoietic Stem Cell Transplantation for Acquired Aplastic Anemia

Secondary poor graft function (sPGF) increases the risk of life-threatening complications after hematopoietic stem cell transplantation (HSCT). The incidence, clinical outcomes, and risk factors of sPGF have not been elucidated in haploidentical (haplo-) HSCT for acquired aplastic anemia (AA) patients. We retrospectively reviewed 423 consecutive AA patients who underwent haplo-HSCT between January 2006 and December 2020 and report a 3-year cumulative incidence of 4.62% (95% confidence interval [CI]: 3.92%-10.23%) of sPGF. While no primary PGF occurred. The median time to sPGF was 121 days (range 30-626 days) after transplantation. To clarify the risk factors for sPGF, 17 sPGF cases and 382 without PGF were further analyzed. Compared to patients without PGF, the 2-year overall survival was significantly poorer for sPGF patients (67.7% vs 90.8%, p =.002). Twelve sPGF patients were alive until the last follow-up, and 7 achieved transfusion independency. The multivariable analyses revealed that later neutrophil engraftment (OR 2.819, p=.049) and a history of refractory cytomegalovirus viremia (OR=7.038, p=.002) post-transplantation were associated with sPGF. There was weak evidence that a history of grade 3-4 acute graft-versus-host disease increased the risk of sPGF (p=.063). We advocated better post-transplantation strategies to balance the risk of immunosuppression and viral reactivation for haplo-HSCT in AA patients.

The incidence and prevalence of patients with paroxysmal nocturnal haemoglobinuria and aplastic anaemia PNH syndrome: A retrospective analysis of the UK's population-based haematological malignancy research network 2004-2018

OBJECTIVES

A retrospective population-based study to determine the incidence and prevalence of patients with the rare blood disease paroxysmal nocturnal haemoglobinuria (PNH).

METHODS

All patients were identified by flow cytometric detection of blood cells deficient in glycosylphosphatidylinositol (GPI) linked proteins at a single diagnostic reference laboratory that serves the Yorkshire based, Haematological Malignancy Research Network (HMRN) with a population of 3.8 million.

RESULTS

One hundred and ninety-seven patients with detectable PNH clones at a level of >0.01% in at least two lineages of cells (neutrophils, monocytes and/or red cells) were identified over a 15-year period (2004-2018). Of these, 88% had aplastic anaemia (AA), 8% classical PNH and 3% myelodysplastic syndrome. The overall incidence rate was estimated at 0.35 cases per 100 000 people per year. This equates to 220 cases newly diagnosed in the United Kingdom each year. The overall prevalence rate was 3.81 per 100 000, this equates to an estimated 2400 prevalent cases in the UK. The overall and relative 5-year survival rates were 72% and 82.7%, respectively.

CONCLUSIONS

This study showed that classical haemolytic PNH is a rare disease and represents only a small proportion overall of patients with detectable PNH cells, the majority of which have aplastic anaemia.

Effect of Stem Cell Source and Dose on Allogeneic Hematopoietic Stem Cell Transplantation in Adult Patients with Idiopathic Aplastic Anemia: Data from the Korean Aplastic Anemia Trials

OBJECTIVE

We aimed to evaluate the effect of stem cell source and dose on the survival of various donor subgroups, such as matched sibling donor (MSDs) and alternative donors (ADs), upon bone marrow (BM) or peripheral blood stem cell (PBSC) infusion in aplastic anemia (AA).

METHODS

We retrospectively investigated the effects of stem cell source and dose on allogeneic hematopoietic stem cell transplantation (alloHSCT) in AA.

RESULTS

A total of 267 patients were included in this analysis. The BM-treated group showed an association with low incidence of any-grade acute graft versus host disease (GvHD) (p < 0.001). A higher stem cell dose was related with a low incidence of extensive chronic GvHD in MSDs (p = 0.025). Multivariate analysis for overall survival (OS) revealed that only age at alloHSCT <31 years (p = 0.010) and prior platelet transfusion <86 U (p = 0.046) in MSDs and higher stem cell dose (hazard ratio = 2.596, p = 0.045) in ADs were favorable prognostic factors.

CONCLUSION

PBSCs could be preferred in AD because high stem cell dose may be easily achieved to improve the OS at the expense of acute GvHD. However, BM stem cells are preferred in MSDs.

Multiple risks analysis for aplastic anemia in Zhejiang, China: A case-control study

To understand the risks associated with aplastic anemia (AA) in 4 cities of Zhejiang Province, China, with special focus on the joint contributions of multiple risks.Based on an Electronic Data Capture (EDC), a case control study was carried out. Data regarding socio-demographic, diseases history, living habits, and exposures to toxic substances, etc., were collected through survey questionnaires. t Test, chi-square test, or non-parametric rank sum test, and univariate and multivariate Logistic regression analysis were conducted to analyze data.The univariate logistic regression analysis results indicated that among all study participants (n = 1802), AA was associated with over 30 risks, in terms of their individual behaviors, daily and environmental exposures, diseases history, and family history. Multivariate logistic regression analysis further confirmed that the independent risks related to AA included presence of chemical factory within 3 km of living residence (odds ratio [OR] = 8.73, 95% CI: 1.42-53.74, P = .019), living in a newly decorated house/apartment (OR = 25.37, 95% CI: 4.44-144.81, P < .001), vegetarian diet (OR = 131.60, 95% CI: 3.45-5020.16, P = .009), preference of sugar (OR = 89.38, 95% CI: 7.22-1106.44, P < .001), preference of oily food (OR = 55.68, 95% CI: 5.12-605.26, P = .001), drinking lake water or pond water (OR = 58.05, 95% CI: 3.21-1049.81, P < .001), habit of staying up late (OR = 11.87, 95% CI: 3.43-41.02, P < .001), infection history (OR = 10.08, 95% CI: 2.75-36.93, P < .001). Result of receiver operating characteristic curve (ROC) analysis on the joint contribution of multiple risks indicated that AA was 13.835 times likely to occur when exposed to ≥1 risks than those exposed to 0 risks (95% CI: 9.995-19.149).Our study results demonstrated a comprehensive epidemiological pattern, in which the joint contributions of individual inherited health status, environment exposure, and individual behaviors lead to the occurrence of AA.

Autoimmune hemolytic anemia, autoimmune neutropenia and aplastic anemia in the elderly

The physiology of the immune system involves morphologic and functional changes occurring along ageing, with a decrease in immune response and an increase in autoimmune phenomena, even in the absence of overt disese. Autoimmune cytopenias, namely autoimmune hemolytic anemia (AIHA), chronic idiopathic neutropenia (CIN) and aplastic anemia (AA), show different epidemiologic predilection, but are increasingly diagnosed in the elderly, where complications and comorbidities are more frequent. A systematic review of recent literature, shows that comorbidities as well as underlying deficiencies, medications, neoplasms, and, pathophysiologic chronic organ failures, frequently challenge the differential diagnosis in this setting and should always be evaluated and excluded. Complications, particularly infections and thrombosis for AIHA, and bleeding for AA, should be monitored and promptly treated. Treatment choice should be carefully weighed on the individual general condition and comorbidities, granted that intense primary care and support (including evidence-based transfusion policies) are provided. Finally, bone marrow histology is highly advisable in the elderly, both at diagnosis to detect underlying conditions, and along the follow-up to monitor possible bone marrow failure or neoplastic evolution.

Recent Advances and Long-Term Results of Medical Treatment of Acquired Aplastic Anemia: Are Patients Cured?

Horse antithymocyte globulin plus cyclosporine remains standard immunosuppressive therapy in severe aplastic anemia, with hematologic response rates of 60% to 70%. In those refractory to this regimen, a second course of therapy with rabbit antithymocyte globulin plus cyclosporine or alemtuzumab produces responses in 30% to 40%. Eltrombopag, a thrombopoietin receptor agonist, showed activity as a single agent in those refractory to initial immunosuppression with hematologic response rates of 40% to 50%. When combined with immunosuppression as frontline therapy, eltrombopag increased the rate of overall and complete response rates. Longer follow-up is needed to better define these outcomes.

The consensus on indications, conditioning regimen, and donor selection of allogeneic hematopoietic cell transplantation for hematological diseases in China-recommendations from the Chinese Society of Hematology

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is widely used to treat malignant hematological neoplasms and non-malignant hematological disorders. Approximately, 5000 allo-HSCT procedures are performed in China annually. Substantial progress has been made in haploidentical HSCT (HID-HSCT), pre-transplantation risk stratification, and donor selection in allo-HSCT, especially after the establishment of the "Beijing Protocol" HID-HSCT system. Transplant indications for selected subgroups in low-risk leukemia or severe aplastic anemia (SAA) differ from those in the Western world. These unique systems developed by Chinese doctors may inspire the refining of global clinical practice. We reviewed the efficacy of allo-HSCT practice from available Chinese studies on behalf of the HSCT workgroup of the Chinese Society of Hematology, Chinese Medical Association and compared these studies to the consensus or guideline outside China. We summarized the consensus on routine practices of all-HSCT in China and focused on the recommendations of indications, conditioning regimen, and donor selection.

Polymorphisms of the TGF-β1 gene and the risk of acquired aplastic anemia in a Chinese population

Acquired aplastic anemia (AA) is a hematological disease characterized by failure of bone marrow hematopoiesis resulting in pancytopenia. While immune-mediated destruction of hematopoietic stem/progenitor cells (HSPCs) plays a central role in the pathophysiology of acquired AA, the transforming growth factor-β1 (TGF-β1) is crucial in adjusting the immune system. The aim of our study was to investigate the role of TGF-β1 gene polymorphisms rs1800469 and rs2317130 in susceptibility to acquired AA. Via the approach of SNaPshot, we genotyped rs1800469 and rs2317130 in 101 patients with acquired AA and 165 controls. It derived us to the conclusion that the genotype TT of rs1800469 (C/T) was significantly associated with decreased risk of acquired AA (adjusted OR = 0.39, 95% CI = 0.18-0.83, P = 0.014). Furthermore, this decreased risk was more pronounced among male patients (adjusted OR = 0.35, 95% CI = 0.13-0.95, P = 0.038) and SAA/vSAA (severe AA/very severe AA) patients (adjusted OR = 0.31, 95% CI = 0.12-0.77, P = 0.02) compared with controls in subgroup analysis. However, a significant increased risk was observed in the genotype distributions of rs2317130 for TT genotype (adjusted OR = 2.52, 95% CI = 1.03-6.19, P = 0.04) compared with the CC genotype among the SAA/vSAA patients and controls in the severity stratification analysis. Our results indicated that TGF-β1 gene polymorphisms might be involved in the munity of acquired AA in a Chinese population. This initial analysis provides valuable clues for further study of TGF-β1 pathway genes in acquired AA.

Development of a disease-specific quality of life questionnaire for patients with aplastic anemia and/or paroxysmal nocturnal hemoglobinuria (QLQ-AA/PNH)-report on phases I and II

Acquired aplastic anemia (AA) and paroxysmal nocturnal hemoglobinuria (PNH) are interrelated ultra-rare diseases. Quality of life (QoL) evaluation tools used in studies for AA and PNH are unspecific and designed for cancer patients (e.g., the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, EORTC QLQ-C30). Given the complexity of AA and PNH, variation in symptoms and treatments, younger age of many patients, and the fact that AA and PNH are not classified as malignant diseases, it is likely that cancer-specific questionnaires are inappropriate. We generate an AA/PNH-specific QoL questionnaire (QLQ-AA/PNH), performed according to EORTC guidelines. QoL issues were obtained from the literature and interviews with patients and physicians (phase I), then ranked by patients and physicians. In phase II, items were created. Patients in more than 25 German and Swiss cities were interviewed face to face. In phase I, interviews of 19 patients and 8 physicians specialized in AA/PNH treatment resulted in 649 QoL issues; these were condensed to 175 and graded according to their importance by 30 patients and 14 physicians (phase II). Five physicians took part in phases I and II. Altogether, 97 issues were rated important. Twelve EORTC QLQ-C30 items were not rated important, while several new QoL aspects were brought up. Modifications in wording and phrasing led to two questionnaires with 77 items regarding general QoL aspects and 20 items regarding medical care. Important QoL aspects of PNH/AA patients are inappropriately captured with available QoL tools. Developing a new QoL questionnaire specific for this patient group is warranted.

Intracranial Hemorrhage in Patients with Hematologic Disorders: Prevalence and Predictive Factors

BACKGROUND

Intracranial hemorrhage (ICH) is an uncommon complication in patients with hematologic disorders although high fatality rates have been shown in these patients. At present, no epidemiological data regarding ICH in patients with hematologic disorders has been collected and/or reported in Thailand.

OBJECTIVE

The purpose of this study was to determine the incidence of ICH in hospitalized patients with hematologic disorders and to identify predictive factors associated with ICH in these patients.

MATERIAL AND METHOD

The medical records of all patients with hematologic disorders admitted to Siriraj Hospital (Bangkok, Thailand) between January 2002 and September 2011 were reviewed. Patients with ICH were identified and factors associated with ICH were investigated using a retrospective case-control design.

RESULTS

Of 9,62 patients identified with hematologic disorders, ICH was diagnosed in 106 (1.1%). The ICH rate was higher in acute myeloid leukemia (AML) patients than in patients with other hematologic malignancies (4.29% vs. 0.78%; p<0. 001) and higher in aplastic anemia (AA) patients than in patients with other benign hematologic disorders (4.00% vs. 0.97%; p<0.001). Cortical hemorrhage was the main presentation in all hematologic disorders, with a single lesion in the parietal area as the most common site. The overall mortality rate was 85% with most patients succumbing within two days of onset. The independent predictors of ICH were hyperleukocytosis and a low platelet count in AML patients, and ecchymosis, upper gastrointestinal hemorrhage, hematuria, and a low platelet count in AA patients.

CONCLUSION

AML and AA patients had the highest risk of ICH compared with other hematologic disorders and several predictive factors for ICH were identified.

[Meta-analysis of association between organophosphorus pesticides and aplastic anemia]

OBJECTIVE

To evaluate the association between organophosphorus pesticides and aplastic anemia, and provide scientific evidence for the primary prevention of aplastic anemia.

METHODS

The published papers of case control studies on the association between organophosphorus pesticides and aplastic anemia from January 1990 to August 2014 were collected from Chinese BioMedical Literature Base (CBM), Chinese National Knowledge Infrastructure (CNKI), PubMed and EMBASE. The papers which met the inclusion criteria were evaluated. The pooled odds ratios (OR) and 95% confidence interval (CI) of organophosphorus pesticides were calculated with software Review Manager 5.0. Subgroup analysis were conducted for different population and different usage of organophosphorus pesticides.

RESULTS

A total of 9 papers were selected, involving 5 833 subjects (1 404 cases and 4 429 controls). The results showed that organophosphorus pesticides could increase the risk of aplastic anemia (OR=1.97, 95% CI: 1.60-2.44) . Subgroup analysis showed that Asian (OR=2.01, 95% CI: 1.52-2.66) had higher risk of aplastic anemia than American or European (OR=1.93, 95% CI: 1.39-2.67) . Using pure organophosphorus pesticides (OR=2.15, 95% CI: 1.60-2.88) was more prone to cause aplastic anemia than using the mixture of organophosphorus pesticides (OR=1.82, 95% CI: 1.34-2.47).

CONCLUSION

The analysis indicated that organophosphorus pesticides might be a risk factor for aplastic anemia. Reducing organophosphorus pesticides exposure in daily life and industrial or agricultural production could prevent the incidence of aplastic anemia.

Epidemiology, Clinico-Haematological Profile and Management of Aplastic Anaemia: AIIMS Experience

BACKGROUND

The incidence of aplastic anaemia (AA) is higher in Asia than in the West. The precise incidence of AA in India is not known due to lack of epidemiological study. 20-40% of pancytopenic patients in referral centres are of aplastic anaemia.

PATIENTS AND METHODS

This was an analysis of 1501 patients diagnosed with aplastic anaemia over a period of seven and half years (January 2007- June 2014) attending the Aplastic clinic of department of haematology of All India Institute of Medical Sciences, New Delhi. The details regarding medical history, physical examination, complete blood count, bone marrow aspirate and biopsy, treatment received, were retrieved. Inherited bone marrow failure was screened in patients below 35 years. Treatment response was analysed for various treatment modalities.

RESULTS

1501 patients of AA from 20 different states of India were analysed. The bulk of patients were from Uttar Pradesh (28.7%), Bihar (23.6%), Delhi/NCR (20%) and Haryana (7%).The average number of new aplastic anaemia patients enrolled per year 214 (range: 101 -263). The median age at presentation was 25 years (range 2-83),with M;F - 2.3:1. Severity of AA revealed: severe (SAA): 75%, very severe (VSAA): 15%, non-severe (NSAA): 10%. Inherited bone marrow failure syndromes constituted 5% (75 patients) of all aplastic anaemia patients. The most common clinical presentations were pallor (97%), bleeding manifestations (69.6%) and fever (54%). The haematological parameters showed: median level of haemoglobin level: 5.9 gm/dL, WBC: 2700/mm3, ANC: 380/mm3, platelet: 1 0000/mm3. PNH clone was present in 13.5% of patients. 107 patients (7%) were lost to follow up or expired before any treatment was initiated. Only 69 patients (4.5%) received treatment with HLA-matched sibling stem cell transplantation and another 232 (15.5%) patients received ATG plus cyclosporine as immunosuppressive therapy. Seven hundred thirteenpatients (47.5%) received cyclosporine. The overall response to various treatment modalities was: HLA matched sibling haematopoietic stem cell transplant: 75.3%, Anti-thymocyte globulin plus cyclosporine: 58.7%, cyclosporine plus androgen: 45.6%, cyclosporine alone: 32.2%.

CONCLUSION

Management of AA is a real challenge in developing countries.This is one of the largest case series from a single centre from India. It is our endeavour to reduce the detrimental outcome by increasing awareness among patients and referring physicians to reduce the delay between diagnosis and treatment.

Immunosuppressive Therapy and Bone Marrow Transplantation for Aplastic Anaemia--The CMC Experience

This is a single centre experience on the use of immunosuppressive therapy (IST) and stem cell transplantation (SCT) in patients with aplastic anaemia. Between 1985 and December 2013, 530 patients underwent IST while 214 underwent allogeneic SCT. Overall response rate with the use of IST was 58% with higher responses seen in adults (65.1%) compared to children (35.8%) [p = 0.001]. At a median follow up of 34 months (range: 1 - 264), 5 year KM estimates for OS for the entire group is 68.2 ± 2.2%. Loss of response or relapse was seen in 27 responders while clonal evolution to PNH was seen in 8 patients and transformation to MDS or AML was seen in 3. The 5 yr OS for children (45.7 ± 4.7%) was significantly lower than the OS of age groups 16-30 (75.6 ± 3.6%), 31-50 years (76.2 ± 4.2%) and > 50 years (73.0 ±4.2%) (p = 0.0001). SCT was performed in 214 patients with engraftment seen in 91%. The incidence of grade II-IV acute graft versus host disease (GVHD) was 38.4% with grade III-IV GVHD in 11.7%. Chronic GVHD was seen in 47.5% of evaluable patients with majority (73%) being limited chronic GVHD. At a median follow up of 32 months (range: 1 - 244), the 5 year KM estimates of OS for the entire cohort is 64.8 ± 3.3%); The 5 yr OS was significantly higher with the use of Flu/Cy (5 yr OS of 73.8 ± 3.6%) compared to Cy/ATG (5 yr OS of 44.4 ± 9.6%) or Flu/Bu conditioning (5 yr OS of 52.4 ± 8.9%) [p = 0.001]. Imp: SCT and IST offer good response rates and survival in Indian patients with AA except in children receiving IST.

Analysis of 754 cases of antithyroid drug-induced agranulocytosis over 30 years in Japan

BACKGROUND

Agranulocytosis is a rare but serious complication of antithyroid drug (ATD) therapy. Characteristics of agranulocytosis have been reported in only a small number of patients.

METHOD

We studied 754 cases of ATD-induced agranulocytosis reported over 30 years. The age distribution and sex ratio were compared with those in 12 503 untreated Graves' patients at Kuma Hospital. The annual number of new Graves' patients in Japan was estimated from the Japan Medical Data Center Data Mart-Pharmacovigilance health insurance receipt database.

RESULTS

Agranulocytosis developed within 90 days after starting ATD therapy in most patients (84.5%). The methimazole dose given at onset was 25.2 ± 12.8 mg/d (mean ± SD). The mean age was 43.4 ± 15.2 years, and the male to female ratio was 1:6.3. When compared with patients at Kuma Hospital, patients with agranulocytosis were older (P < .001) and more females (P < .0001). Of 211 patients with more than 1 granulocyte measurement before onset, 131 (62%) showed normal counts (>1000/μL) within 2 weeks before onset, demonstrating real sudden onset of agranulocytosis. In contrast, some of the 20 patients with more than 4 measurements showed gradual decreases in granulocyte counts. Analysis of physician reports for 30 fatal cases revealed that some deaths might have been prevented. The number of new Graves' patients treated with ATD was estimated at about 35 000 per year, and the incidence rate of agranulocytosis was 0.1% to 0.15% in Japan.

CONCLUSION

This is the largest study of agranulocytosis. Agranulocytosis tends to occur abruptly within 3 months after initiation of ATD therapy, although it develops gradually in some patients. Providing every patient with sufficient information on agranulocytosis is critical.

Clinicohaematological profile of aplastic anaemia in a rural medical college of Northern West Bengal

There is a scarcity of clinical data in the field of aplastic anaemia from rural India. Present study was conducted in North Bengal Medical College to find out the clinicohaematological profile and the possible aetiological factors in patients with aplastic anaemia. The study population (n = 83) included 21 children with male to female ratio 4.93:1. Weakness was present in all cases and pallor was present in 74.70% cases. Fever, bleeding episodes and localised infection were found in 55.42%, 48.19% and 27.71% cases respectively. There was no difference in clinical manifestations between children and adult except occurrence of fever (p = 0.0365). We identified possible aetiological factors in 32.53% cases as relevant drug intake in 10.84%, exposure to chemicals in 13.25% and hepatitis in 8.43% cases. We found low mean haemoglobin (3.81 +/- 1.71 g/dl), leucocyte and platelet (3.05 +/- 1.3 and 37.30 +/- 35 x 10(3)/cmm), neutrophil (30.28 +/- 21.76%) and high lymphocyte (67.27 +/- 22.50%) in peripheral blood. At the time of presentation, aplastic anaemia was moderate in 59.04% cases, severe in 48.19% cases and mild in 4.82% cases. We estimated the prevalence of aplastic anaemia in 4 districts of West Bengal including tea garden areas was 2.98/million populations per year. It was concluded that aplastic anaemia is a major non-malignant haematological disease in this part of India, and an increasing use of chemicals in agricultural and tea garden areas might be the responsible factor. Larger population based study is suggested.

Incidence of Aplastic Anemia in a Defined Subpopulation from Mexico City

Aplastic anemia (AA) is a hematological disease characterized by the deficient production of blood cells. The incidence of AA worldwide is low (1-5 new cases per 10(6) individuals per year). In contrast to other countries, no current reports exist on the incidence of this disorder in Mexico. In the present study, we have determined the incidence of AA in a defined subpopulation from Mexico City during the period 1996-2000. For the purpose of this study, we focused on the experience from a single medical institution: the Mexican Institute of Social Security (IMSS), which covers around 50% of Mexico's population. The incidence of AA was determined based on the actual number of patients diagnosed with this disease at the IMSS in Mexico City in a given year and the total number of individuals registered at the IMSS in Mexico City in the same year. Considering the IMSS population as a whole, the annual incidence of AA was 3.9 new cases per 10(6) individuals per year. In the pediatric population, the annual incidence was 4.2 new cases per 10(6) individuals per year, whereas in people 15-years-old and older the incidence was 3.8 new cases per 10(6) individuals per year. These incidences were higher than those reported in most studies from the USA, Europe and Israel. Compared to the incidence in Thailand, the incidence we observed in children was considerably higher, whereas the one in adults was similar to the one in that country. The results of the present study suggest that the incidence of AA in Mexico City is one of the highest worldwide, particularly in terms of the pediatric population; however, these results must be taken with caution since this study comprises only a subpopulation from Mexico City and not the entire population. Thus, further studies including a broader population, both in Mexico City and other urban and rural areas of this country, will be necessary in order to obtain better and more complete estimates of the actual incidence of AA in Mexico.

Bone marrow examination in pancytopenia

Pancytopenia is defined by reduction of all the three formed elements of blood below the normal reference. It may be a manifestation of a wide variety of disorders, which primarily or secondarily affect the bone marrow. Haematological investigation forms the bedrock in the management of patients with pancytopenia and therefore needs detailed study. The total number of cases studied were 100 over a period of two years in the department of pathology, JSS Hospital, Mysore. Megaloblastic anaemia (33%) was the commonest cause of pancytopenia. Other causes were nutritional anaemia (16%), aplastic anaemia (14%), hypersplenism (10%), sepsis (9%) and leukaemia (5%). Less common causes were alcoholic liver disease, haemolytic anaemia, HIV, dengue, systemic lupus erythematosus, viral hepatitis, disseminated TB and multiple myeloma. Most of the patients were in the age group of 11-30 years with a male:female ratio of 1.6:1.Generalised weakness and fatigue (88%) were the commonest presenting complaints. Haemoglobin level varied from 1-10 g/dl with majorIty (70%) of them in the range of 5.1-10 g/dI. TLC was in the range of 500-4000 cells/cmm. Most (34%) of them had 3100-4000 cells/cmm. Platelet count was in the range of 4000-1,40,000 cells/cmm. Reticulocyte count varied from 0.1%-15% with majority (82%) of them ranging from 0.1%-2%. The bone marrow cellularity was hypocellular in 14%, hypercellular in 75%, and normocellular in 11% of the patients. Pancytopenia is a relatively common entity with inadequate attention in Indian subcontinent. A comprehensive clinical and haematological study of patients with pancytopenia will usually help in the identification of the underlying cause. However in view of wide array of aetiologies, pancytopenia continues to be a diagnostic challenge for haematologists.

Research progress on the red cell diseases in China

In recent years, there have been lots of progresses in the studies on red cell diseases in China, especially bone marrow failure diseases including immuno-related pancytopenia, aplastic anemia, myelodysplastic syndrome, and paroxymal nocturnal hemoglobinuria. Numerous laboratory experiments as well as clinical researches have been carried out by Chinese hematologists, which brought about much clearer pathogenesis, more rational diagnosis methods and more effective therapies for red cell diseases.

[Etiological profile of pancytopenia in adults in Marrakesh, Morocco]

This retrospective study evaluated the frequency of different causes of pancytopenia in all adult patients with pancytopenia presenting to the Department of Haematology of Mohamed VI Hospital, Marrakesh from 1 January 2008 to 31 December 2010. A total of 118 cases of pancytopenia were found (average of 39 cases per year). The mean age of patients was 52 years (range 18-82 years) and 52.5% were male. The main clinical signs were pallor (100%), asthenia (100%) and fever (30.5%). Mean haemoglobin was 6.5 g/dL (range 2.9-9.2 g/dL), mean white blood cell count was 2360/mm3 (range 840-3360/mm3) and platelet count 66 000/mm3 (range 3000-123 000/mm3). Bone marrow aspiration was performed in 112 patients; megaloblastosis was found in 32.2% and marrow blasts in 23.7%. Anaemia due to vitamin B12 deficiency (32.2%), acute leukaemia (23.7%) and aplastic anaemia (15.2%) were the main causes of pancytopenia. Given the incidence of acute leukemia among our cases, patients presenting with pancytopenia require urgent diagnosis and treatment.

[Incidence of adult aplastic anemia in Shanghai, China]

OBJECTIVE

To survey the incidence of acquired adult aplastic anemia (AA) in Shanghai, China. Meanwhile, we compared it with the previous data from China in 1986 and other countries in order to explore the trends.

METHODS

Newly diagnosed AA patients were registered in 6 districts (Jingan, Xuhui, Huangpu, Changning, Putuo, Yangpu) in Shanghai from 2004 to 2006. Then we calculated the crude and age-adjusted incidence of AA according to the population data from Shanghai Statistic Yearbook.

RESULTS

There were 38 adult patients with acquired AA. The average crude incidence of AA was 0.33/100 000 from 2004 to 2006. The incidences per 100 000 persons per year were 0.40, 0.14 and 0.64 in 18 - 34, 35 - 59 and ≥ 60 years, respectively. The rate of severe AA was 0.17/100 000.

CONCLUSION

The incidence of severe AA has no marked change, but the total rate is a little decreased compared with the data from China in 1986.

Epidemiology of acquired aplastic anaemia in Pakistan

BACKGROUND

Acquired aplastic anaemia is a rare disease which results in morbidity and mortality at a young age. This study was carried out to determine the clinical presentation, haematological parameters and association factors of acquired aplastic anaemia in a cohort of Pakistani patients.

METHODS

This was a cross-sectional study conducted at Haematology Department, Shaikh Zayed Hospital, Lahore over 7 years from June 2000 to July 2007. Eighty-two patients of acquired aplastic anaemia were enrolled in the study by non-probability purposive sampling. Their diagnosis was confirmed by complete blood count, bone marrow aspirate and trephine biopsy. The cohort was classified on the basis of severity and the epidemiological, clinical and haematological parameters were analysed.

RESULTS

Of the 82 enrolled patients of acquired aplastic anaemia, 49 (59.8%) were males and 33 (40.2%) were females. Mean age of the patients was 27.93 +/- 18.7 years with a range of 1-80 years. The male to female ratio was 1.48:1. Bone marrow cellularity was less than 25 % in 31 (38.0%) cases and between 25-30% in 51 (62%) of patients. Most of the cases were clinically severe aplastic anaemia (68%). In 62 (76%) of the cases no association factors predisposing to aplastic anaemia could be identified.

CONCLUSION

Acquired Aplastic anaemia is a disease of all ages. In the second decade and the elderly predominantly severe clinical stages were seen. Males presented at a younger age while females presented at all ages with a somewhat similar incidence. No association factors of Aplastic Anaemia could be identified in majority of the patients.

Retrospective survey on the prevalence and outcome of prior autoimmune diseases in patients with aplastic anemia reported to the registry of the European group for blood and marrow transplantation

BACKGROUND

Aplastic anemia (AA) is rarely described after a diagnosis of autoimmune disease (aID).

AIMS

To assess the prevalence of prior aID in patients with AA recorded in the registry of the European Group for Blood and Marrow Transplantation (EBMT) and to evaluate treatment and outcome.

METHODS

1,251 AA patients from 18 EBMT centers were assessed.

RESULTS

Fifty patients (4%) were eligible: 22 males and 28 females with a median age of 46 years at the diagnosis of aID and of 51 years at the diagnosis of AA. Information on the treatment of AA was available in 49 patients: 38 received only immunosuppressive therapy (IST), 8 patients underwent hematopoietic stem cell transplantation (HSCT) - 6 as first-line therapy and 2 after failure of IST - whilst 3 patients had a spontaneous recovery. After a median follow-up of 3.19 years, 32 patients were alive, including 7 of the 8 patients who underwent HSCT. Only 6 of 32 patients who were alive at the last follow-up were receiving IST for AA.

CONCLUSIONS

Most cases of AA following aID benefitted from IST or HSCT if a matched donor was available. Further prospective investigation is needed to assess the effects of IST on the outcome of underlying aID.

A hospital-based case control study of aplastic anemia in Shanghai, China

We report results of a hospital-based case control study of 137 consecutive patients diagnosed with aplastic anemia (AA) in participating hospitals over a 4-year period. Diagnoses were made by a single laboratory, subjects were age- and gender-matched to two controls and interviewed concerning previous disease, work histories and exposures to potential etiologic agents. Analysis was conducted on two distinct subgroups: severe aplastic anemia (SAA) and moderate aplastic anemia (MAA). In univariate regression models, the strongest associations were observed for exposure to benzene and SAA (OR=3.12, 95% CI=1.12-8.65) and life on a farm and MAA (OR=3.08, 95% CI=1.44-6.56). Benzene exposure did not show a strong dose-response relationship with either subtype. When accounting for all of the potential confounders we considered in conditional regression models, the previous relationships persisted. Other explanatory variables included hair-dye use for MAA and farm exposures, such as livestock for SAA, although most of these additional variables fell just short of statistical significance. Adjusted R-squared values were only 10% for each subtype, leaving 90% of AA occurrence unexplained. Our results suggest that: (a) benzene exposure is more strongly related to SAA than MAA, (b) farm and livestock exposures are related to both forms of AA, confirming some previous results, and (c) a large percentage of AA remains unexplained, which may indicate that individual susceptibility has a major influence on AA occurrence.

Drug-related blood dyscrasias in a Swedish reporting system, 1985-1994

Drug-related blood dyscrasias as reported in Sweden during a 10-yr period have been analysed in relation to sales and prescription data. The number of cases reported were as follows: agranulocytosis 390, thrombocytopenia 391, pancytopenia 50 and aplastic anaemia 36. The annual incidence rates per 10(6) inhabitants were: agranulocytosis 4.8, thrombocytopenia 5.6, pancytopenia 1.1 and aplastic anaemia 0.5. Incidences in the elderly were higher for all dyscrasias except aplastic anaemia. The most commonly reported drugs for all dyscrasias were sulphonamides and diuretics, but when related to sales data the risk of agranulocytosis was high for clozapine, dapsone, mianserin and sulphasalazine, while the risk did not seem to be increased for furosemide. For thrombocytopenia, furosemide, co-trimoxazole and the measles, mumps and rubella vaccine were most commonly reported. The risk for pancytopenia and aplastic anaemia was increased for acetazolamide and co-trimoxazole. As spontaneous reporting systems are primarily set up for signalling purposes, such data must always be interpreted with utmost care.

Drugs in the aetiology of agranulocytosis and aplastic anaemia

Agranulocytosis and aplastic anaemia are rare but serious conditions known to be caused by numerous drugs. Most of what is known or suspected about the aetiology is based on case reports, with only a few formal epidemiological studies that provide quantitative estimates of risk. Updated results have been obtained from a combined analysis of data from 3 case-control studies that used similar methods: the International Agranulocytosis and Aplastic Anemia Study (IAAAS), conducted in Israel and Europe; a study conducted in the northeast US; and a study conducted in Thailand. Totals of 362 cases of agranulocytosis, 454 cases of aplastic anaemia and 6458 controls were included in the analyses. The IAAAS and Thai study were population-based, providing estimates of the incidence of the 2 dyscrasias. The overall annual incidence of agranulocytosis in the ambulatory population was 3.4/10(6) in the IAAAS and 0.8/10(6) in Thailand; by contrast the incidence of aplastic anaemia was 2.0/10(6) in the IAAAS and 4.1/10(6) in Thailand. A total of 21 compounds were significantly associated with an increased risk of agranulocytosis in the IAAAS and US studies. Excess risks ranged from 0.06 to 13 cases/10(6) users/wk; the most strongly associated drugs were procainamide, anti-thyroid drugs and sulphasalazine. An association with drugs that had previously been suspected was also seen in Thailand. The overall aetiologic fractions of agranulocytosis due to drug use were 62% in the IAAAS, 72% in the US and 70% in Thailand. Eleven drugs were significantly associated with an increased risk of aplastic anaemia, with excess risks ranging from 1.4 to 60 cases/10(6) users in a 5-month period. The most strongly associated drugs were penicillamine, gold and carbamazepine. Aetiologic fractions were 27% in the IAAAS, 17% in the US and 2% in Thailand, which paralleled the prevalence of use of associated drugs in the 3 populations. The present results confirm that agranulocytosis is largely a drug-induced disease, with similar proportions accounted for in 3 disparate geographic regions. By contrast, although many of the expected associations were observed for aplastic anaemia, most of the aetiology is not explained by drugs. For all associated drugs, the excess risks are sufficiently low that blood dyscrasias should not figure prominently in the balancing of risks and benefits.

An epidemiological study of aplastic anaemia: relationship of drug exposures to clinical features and outcome

Two hypotheses were examined in the combined data from 3 case-control studies of aplastic anaemia, conducted in Thailand, Europe/Israel and the US: 1. Cases exposed to drugs associated with a significantly increased risk of aplastic anaemia are more likely to present with thrombocytopenia (e.g. petechiae, easy bruising); and 2. cases exposed to these drugs are more likely to recover quickly than non-exposed cases. After excluding all cases who lacked information on timing of symptoms and those whose symptoms began > or = 180 d before hospital admission, 392 cases remained for analysis. A total of 51 (13%) had been exposed to one of the significantly associated drugs; the remaining 341 (87%) had not. Among the former, 31% reported thrombocytopenia either before or at the same time as non-bleeding symptoms (e.g. pallor, fatigue); the corresponding proportion among the non-exposed was 53%. Data on time to recovery (return of the 3 blood cell lines to normal levels) were not available for the Thai cases; among the others, the median time to recovery for the non-fatal cases was 7 and 6 months in the 29 exposed and the 83 non-exposed cases, respectively. The data do not support either hypothesis: the two groups of aplastic anaemia cases appeared to be similar in both the presenting symptoms and the recovery time.

Incidence and cause of aplastic anemia, hemolytic anemia, agranulocytosis and thrombocytopenia

A total of 745 patients with cytopenia (aplastic anemia 157, hemolytic anemia 101, agranulocytosis 136, thrombocytopenia 351) were diagnosed during a 5-year period in a health care region comprising 16% of the Swedish population. The total incidence was for aplastic anemia 24.6, hemolytic anemia 15.8, agranulocytosis 21.3 and thrombocytopenia 55.0 cases per 10(6) and year. Compared to 10 years earlier, aplastic anemia and agranulocytosis have become more common, thrombocytopenia occurs with unchanged frequency while hemolytic anemia is rarer. The overall incidence is 5 times higher in elderly (greater than 65 y.) than in younger patients and 1.3 times higher in women than in men, figures that make total incidence figures rather meaningless. The most common cause is "unknown" (45%), the next drug-induced (25-36% including cytostatic drugs). Disregarding cytostatics, the drugs most often encountered are oral diuretics, analgesics, antiphlogistics and sulfonamides.

Incidence and non-drug aetiologies of aplastic anaemia in Thailand. The Thai Aplastic Anaemia Study Group

A population-based, case-control study of aplastic anaemia has been conducted in Thailand since 1989. Up to December 1994, the overall annual incidence was 3.9/10(6) in Bangkok, 5.0/10(6) in Khonkaen and 3.0/10(6) in Songkla. In Bangkok, the incidence peaked in 2 age groups (at 15-24 yr and > or = 60 yr), whereas in Khonkaen and Songkla there was a consistent increase in incidence with increasing age. The results of case-control analyses for non-drug risk factors indicate a strong inverse association with socio-economic status present in all 3 areas; a strong association with grain farming in the 2 rural areas that does not appear to be explained by pesticides; an association with occupational exposure to solvents in Bangkok; and a positive association with hepatitis A seropositivity.

Drug use and aplastic anaemia: the French experience. French Cooperative Group for the Epidemiological Study of Aplastic Anaemia

The cause of the rare and severe condition of aplastic anaemia is largely unknown, although certain drugs have been implicated as possible aetiological factors, mostly through the evidence of case reports. A case-control study was conducted in metropolitan France between 1985 and 1988 to investigate aetiological factors in aplastic anaemia. It was conducted in parallel with the establishment of a national register of the incidence of aplastic anaemia, which started in May 1984. The controls used in the study consisted of 2 hospitalized controls (i.e. patients admitted to hospital at the same time as the case) and a neighbour control named by the case. All three controls were matched for age and sex, and were interviewed by the same investigator as the case. A total of 147 cases, 287 hospitalized controls and 108 neighbour controls were interviewed. An association of varying degrees was noted between aplastic anaemia and the following conditions or treatments: clinical hepatitis during the past 6 months; history of chronic immune disorder (mainly rheumatoid arthritis); gold salts and D-penicillamine; colchicine and allo-thiopurinol; acetaminophen and salicylates. This survey confirmed the vanishing role of previously known toxic agents in the aetiology of aplastic anaemia. Some differences observed between the results of the present study and those published previously suggest that targeted studies on each category of drug according to specific disease areas should be initiated.

Clinicohaematological analysis of aplastic anaemia among children of northern districts of West Bengal

Though aplastic anaemia in children is an important haematological disorder, not many studies have been undertaken in India and especially in the northern districts of West Bengal. The present study was carried out at North Bengal Medical College and Hospital to find the occurrence, clinical and hematological profile of children with aplastic anaemia. All the children (less than 15 years) having relevant history and clinical features underwent a complete blood count and bone marrow aspiration study (smear and histological sections) and trephine biopsy. Total number of children diagnosed were 21 (M = 17, F = 4), having an age range of 6-14.5 years (mean 11.36). Relevant aetiological factors were noted in 10 cases (47.61%), including history of exposure to insecticides, fungicides and fertilisers in 5 cases (23.81%). The common symptoms were due to anaemia (weakness, pallor in all cases), leucopoenia [fever in 16 cases (76.19%)] and thrombocytopenia [bleeding in 10 cases (47.61%)]. Severe and moderate aplastic anaemia were noted in 7 (33.33%) and 12 (57.14%) cases respectively. The calculated occurrence of aplastic anaemia is 1.96/million population of children/year in the four northern districts of West Bengal. The bone marrow aspiration was satisfactory in all cases. Histological sections of aspirated marrow particle produced better architectural relationship among different components. Aplastic anaemia is a major hematological problem among the children of northern districts of West Bengal. Simultaneous examination of smear and histological sections of marrow particles is a satisfactory method for detection of aplastic anaemia.

Clinical description of intracranial hemorrhage associated with bleeding disorders

BACKGROUND

Intracerebral hemorrhage (ICH) is an unusual but serious complication of bleeding disorders. ICH is believed to follow thrombocytopenia, alterations in coagulation, and vascular fragility. Information regarding its distribution is nonconclusive, and the mechanism of bleeding is not fully understood. The aim of this study was to examine the clinical and neuroimaging features of ICH in patients with bleeding disorders to predict risk factors for this condition.

METHODS

All cases of ICH diagnosed from 1987 to 2004 were retrospectively identified using the centralized database of our institution. Cases were included whenever ICH was caused by a primary hematologic disorder. The clinical characteristics, neuroimages, and outcome were analyzed.

RESULTS

A total of 31 patients were identified. ICH was the initial presentation of the bleeding disorder in 9 patients. Overall, 71% had systemic bleeding concurrent to the ICH. All patients had altered mental status. In 45.2% of the patients simultaneous intracranial hemorrhages were found. Eight patients had recurrent ICH. Severe thrombocytopenia (platelet count < 10,000/mm(3)) was present in 41% and very low platelets (</=1000/mm(3)) in 3%. Death occurred in 71%.

CONCLUSIONS

Multiple ICH is not an unusual presentation in patients with primary bleeding disorders developing brain hemorrhage. Although low platelet counts can be blamed for the bleeding, factors different from thrombocytopenia should be considered as the principal mechanism. The best predictor of cerebral bleeding is the presence of systemic bleeding.

[Prevalence of anemia in Japan]

The frequency of anemia in Japan is statistically higher than that of foreign countries. Especially, Japanese females frequently fall ill with iron deficiency anemia(IDA) because of decreased intake of iron. Secondary anemia is of the second-highest frequency. While primary hematological disorders account for only a small fraction of whole anemic patients, aplastic anemia is relatively frequent in the world-wide statistics. The frequency of myelodysplastic syndromes is now increasing with aging of the population. It is important to sustain our effort in assembling the data as to the prevalence of anemia.

Leukaemia and aplastic anaemia in patients irradiated for ankylosing spondylitis. 1957

Reported here is a seminal study of leukaemia among patients who had been treated with x-rays for ankylosing spondylitis. The findings were first published in a Medical Research Council (MRC) report in 1957. The report is now published in a scientific journal for the first time, 50 years after it first appeared.

Treatment of severe aplastic anemia with antithymocyte globulin and cyclosporin A with or without G-CSF in adults: a multicenter randomized study in Japan

We report the results of a randomized study to elucidate whether addition of granulocyte colony-stimulating factor (G-CSF) to immunosuppressive therapy is valuable for the treatment of severe aplastic anemia (SAA) in adults. A total of 101 previously untreated patients (median age, 54 years; range, 19 to 75 years) were randomized to receive antithymocyte globulin (ATG) and cyclosporin A (CyA) (G-CSF- group) or ATG, CyA, and G-CSF (G-CSF+ group). In the G-CSF+ group, the hematologic response rate at 6 months was higher (77% vs 57%; P = .03) than in the G-CSF- group. No differences were observed between the groups in terms of the incidence of infections and febrile episodes. There were no differences between the G-CSF- group and the G-CSF+ group in terms of survival (88% vs 94% at 4 years), and the development of myelodysplastic syndrome (MDS)/acute leukemia (AL) (1 patient vs 2 patients). However, the relapse rate was lower in the G-CSF+ group compared with the G-CSF- group (42% vs 15% at 4 years; P = .01). Further follow-up is required to elucidate the role of G-CSF in immunosuppressive therapy for adult SAA.

Parvovirus B19 infection in children with a variety of hematological disorders

This study was carried out to detect Parvovirus B19 (PB19) DNA together with its antibodies in the sera of children with a range of hematological disorders to clarify the contribution of this infection to changes observed in hematological picture in those populations. This study included 85 pediatric patients with different hematological disorders. Twenty healthy subjects with matched age and sex were included as controls. Patients were classified into four groups; group I included 25 patients with hemolytic anemia in aplastic crisis, group II included 20 patients with hemolytic anemia without aplastic crisis, group III included 20 acute leukemia patients under chemotherapy, group IV included 20 patients with recently diagnosed acute leukemia. Virological study for PB19 included determination of specific IgG & IgM together with viral DNA by polymerase chain reaction (PCR). In all groups of patients with positive markers for PB19, there were statistically significant differences in the mean Hb concentration and RBC count (P < 0.001 for each), presence of neutropenia (P = 0.003) and lymphocytosis (P < 0.001) compared to controls. There was statistically significant difference in the prevalence of PB19 IgM, IgG and PCR among studied groups compared to control group. In group I and group II IgG had the highest positive rate (56 and 35%, respectively). In group III IgG also had a high positive rate (45%). However, in group IV IgM had the highest positive rate (50%) followed by PCR (45%) then IgG (40%). In conclusion, PB19 infection is detected in high rates among children with hematological disorders. PB19 must be suspected and screened for when there is anemia in those patients associated with neutropenia and lymphocytosis. In patients with acute leukaemia under chemotherapy who have unexpected anemia, neutropenia and lymphocytosis Parvovirus infection should be considered before a change of chemotherapy protocol. Screening of blood for PB19 may be helpful in understanding the epidemiology of infection with this virus. The direct detection of DNA by PCR in sera needs to be coupled with serology for a more reliable diagnosis of PB19 infections in these children.

Specific antibodies to moesin, a membrane-cytoskeleton linker protein, are frequently detected in patients with acquired aplastic anemia

To identify novel autoantibodies in acquired aplastic anemia (AA), we screened the sera of patients with AA possessing small populations of paroxysmal nocturnal hemoglobinuria (PNH)–type cells for the presence of antibodies (Abs) which recognize proteins derived from a leukemia cell line, UT-7. Immunoblotting using proteins derived from lysates or culture supernatants of UT-7 cells revealed the presence of IgG Abs specific to an 80-kDa protein. Peptide mass fingerprinting identified this 80-kDa protein as moesin. Enzyme-linked immunosorbent assay (ELISA) using recombinant moesin showed high titers of antimoesin Abs in 25 (37%) of 67 patients with AA. Moesin was secreted from several myeloid leukemia cell lines other than UT-7, such as OUN-1 and K562, as an exosomal protein. The presence of antimoesin Abs was significantly correlated with the presence of PNH-type cells and antidiazepam-binding inhibitor-related protein-1 (DRS-1) Abs. Patients with AA that did not show any of these 3 markers tended to respond poorly to immunosuppressive therapy. These findings suggest that a B-cell response to moesin, possibly derived from hematopoietic cells, frequently occurs in patients with AA and that detection of antimoesin Abs in combination with other markers may be useful in diagnosing immune pathophysiology in patients with AA.