Thalassemia Carriers Research Articles

Experience with Low Dose Thalidomide in Transfusion Dependent Beta Thalassaemia in a Resource Limited Setting

Introduction Thalassemia is the most prevalent inherited hemoglobinopathy characterized by defective synthesis of β chain, leading to ineffective erythropoiesis. In India, 3.2% (1 in every 25 people) are carriers of beta thalassemia. Management of thalassemia includes transfusion support, adequate iron chelation and prevention of undue extramedullary erythropoiesis. Red blood cell aggregation, aggregate strength and oxygen transport potential of blood are abnormal in both homozygous sickle cell anemia and sickle - hemoglobin C disease. Both clinicians and families of these patients realize that the main challenge is obligation of life long blood transfusion and iron chelation therapy in order to have a normal life. Thalidomide, an immunomodulatory drug, has therapeutic effect in fetal Hemoglobin (HbF) induction but exact mechanism of action is not known yet. Hence, this drug has been tried in thalassemia intermedia (TI) and had shown significant effect in decreasing transfusion requirement. Primary aim of our study was to evaluate the clinical response of thalidomide and/or Hydroxyurea (HU) in transfusion dependent beta thalassemia (TM and TI). The secondary aim is to study the toxicity profile of this drug in our study population. Methods It is a retrospective study which included beta TM and TI patients from August-2015 to November-2018, who received thalidomide with or without hydroxyurea. Dose used was 10-20 mg/kg/day & 25-100 mg/day for HU and thalidomide respectively. Study was approved by Institutional Review Board. Results We studied 167 patients (TM=129 and TI=38) with males (n= 111) and median age 14 (0.5-31) years. At presentation, median size of liver and spleen was 4 (1-12) cms and 3 (1-16) cms respectively. Nineteen patients were post splenectomy. Median age at first transfusion was 9 (1-144) months. Median duration between transfusions was 20 (10-180) days. Median packed cell transfusion per year was 18.2 (2-36.5). (Table-1). Median dose of HU was 500 (250-500) mg & thalidomide was 50 (25-100) mg. Median duration of thalidomide therapy was 9 (1-73) months and HU was 8 (1-183) months. Median Hb post treatment at day 90 for TI was 9.1 gm/dl (6.7-13) gm/dl and TM was 9.1 (6.2-13) gm/dl. Median duration of transfusion free period was 15 months (1-38 months) till last follow-up. Post treatment median size of liver and spleen was 3 (2-11) cms & 2 (1-14) cms respectively. Increased duration between transfusions was observed in 17 patients with median duration of 40 (18-90) days between transfusions. Most common toxicities observed were constipation=1, neutropenia=9, deranged liver function =6 followed by skin rash=4. Thrombosis, Hepatitis-A and excessive fatigue was seen in 1 patient each. At last follow-up, 78 (46.7%) patients were transfusion free whereas 37 (22.1%) were transfusion dependent, duration of transfusion increased in 17 (10.2%) patients, 3 (1.2%) patients abandoned treatment and 6 (3.6%) patients to be assessed yet as they didn't complete their 3 months of therapy at last follow-up. No follow-up records available for 26 (15.5%) patients so response could not be assessed. Conclusion With the use of minimal doses of thalidomide, transfusion independency and thereby reduction in iron overload can be achieved in patients with transfusion dependent beta thalassemia patients. But one needs to be cautious to monitor the side effects commonly encountered in our study. Large population studies and longer follow ups are required to define the potential use of this immunomodulatory drug in hemoglobinopathies, which can be an effective and affordable treatment option for transplant ineligible patients. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: Thalidomide is an HbF inducer, which by increasing HbF levels, decreases ineffective erythropoiesis and reduces transfusion burden in patients with TDT

Identification of Optimal Thalassemia Screening Strategies for Migrant Populations in Thailand: A Mixed-Methods Approach

BACKGROUND: Severe thalassemia is common in Southeast Asia (SEA) and can lead to transfusion dependent anemia, growth retardation, and perinatal death. Prevention and control of thalassemia can be approached either preconceptionally (through carrier screening, reproductive planning, or preimplantation diagnosis) or antenatally (through prenatal screening and diagnosis and termination of pregnancy). Thailand's national thalassemia program focuses on antenatal interventions, provided free to citizens. However, there is a growing population of migrant workers from neighboring countries who face barriers to healthcare and likely have varied beliefs towards pregnancy termination. We conducted a mixed-methods study using survey, interview, and focus group data to identify key barriers to and optimal strategies for thalassemia screening in migrant communities in Thailand. METHODS: Myanmar and Cambodian migrant workers and agents, Thai healthcare providers, and Thai adults (aged 18-49 years) at Laem Chabang Hospital (Chonburi, Thailand) participated in a knowledge, attitudes, and practices (KAP) survey, interviews, and focus groups. All sessions were conducted in Thai or English, audio recorded, transcribed and translated into English, and analyzed thematically using MAXQDA. Codes were developed iteratively and used to answer key explanatory questions arising from the KAP survey. Ethical approval for the study was obtained from Mahidol and Duke Universities. RESULTS: Both quantitative and qualitative data showed dramatically lower thalassemia awareness in migrants vs Thai (Table 1). Furthermore, providers perceived migrants to be disinterested in thalassemia screening, though migrant narratives illustrated significant language barriers, economic barriers, lack of health literacy, and competing social stressors - all of which may contribute to perceived indifference towards thalassemia screening. Both Thai and migrants had misconceptions about thalassemia, believing it to be contagious and sexually transmitted, or equating thalassemia carrier status with disease and vice versa (Table 1). These misconceptions may contribute to the stigmatization and isolation of individuals with thalassemia and disincentivize carrier screening for fear of discrimination. Participants supported thalassemia prevention and identified antenatal care (ANC) as the main access point for thalassemia education, screening, and prevention. However, they described key limitations of this antenatal approach, including the inability to offer termination in pregnancies presenting late to ANC; couples' hesitation to terminate; cost of prenatal testing (for migrants); and reliance on male partners to present for prenatal testing. In addition, migrants expressed more negative attitudes towards termination of pregnancy on the survey (Table 1). Participants associated this attitude with the perception that migrants were more religious, less educated, less knowledgeable about genetic disease risk, and more eager to have children. Participants proposed a number of solutions, including targeted education, delivered in migrants' native languages through ANC or public media, and universal carrier screening as a more acceptable approach to thalassemia prevention and control in migrant communities. Recommended settings for screening include schools or universities, hospitals, and workplaces. Migrants also reported relying heavily on employers for access to healthcare. Therefore, employer engagement in thalassemia education and screening efforts is critical, though employment discrimination remains a concern. CONCLUSION: This study provides insight from a variety of stakeholders into potential barriers and strategies for thalassemia screening in SEA migrant populations. Findings highlight a profound lack of thalassemia awareness among migrants leading to apparent disinterest in thalassemia screening, misconceptions and stigma surrounding thalassemia, and negative attitudes towards termination of pregnancy. Promotion of public education and carrier screening is an optimal strategy for migrant populations in Thailand. Furthermore, this approach can be adopted regionally and cooperatively by member states of the Association of SEA Nations (ASEAN) to better address the shared public health problem of thalassemia. Disclosures Telen: Pfizer: Other: Member of a clinical trial steering committee; Novartis: Other: Member of a safety monitoring committee; Forma Therapeutics: Research Funding.

Mapping of Thalassemia Carriers in Sabah and Kedah: A Unique Diversity of Thalassemia Carrier Distribution in Malaysia

Mapping of Thalassemia Carriers in Sabah and Kedah: A Unique Diversity of Thalassemia Carrier Distribution in Malaysia

Awareness and Willingness to be Screened for Thalassemia Carrier Status of Medical Students from Bandung, Indonesia

"Awareness and Willingness to be Screened for Thalassemia Carrier Status of Medical Students from Bandung, Indonesia." Hemoglobin, 43(6), p. 360

Is Hemoglobin D Trait Hematologically Silent: Comparison With Healthy Controls and β-thalassemia Carriers

Hemoglobin D-Los Angeles, a recessively inherited hemoglobin variant, has been introduced as hematologically silent in the heterozygous state. However, as its compound heterozygosity with other hemoglobinopathies may lead to a severe clinical phenotype, with hemoglobin S being the most serious, the detection of carriers is important. To clarify the hematologic picture, we assessed erythrocyte parameters in D carriers and compared values in healthy controls and β-thalassemia carriers. Although values in D carriers, in the absence of confounding factors, significantly differed from thalassemia carriers (P<0.05 for all), they were not similar to healthy controls. Microcytosis (absent in healthy controls) (mean corpuscular volume: 80.7 vs. 83.5 fL, P=0.038) and erythrocytosis (6 times more than in healthy controls) (red blood cell: 5.2 vs. 4.7×10/L, P=0.002) were detected, making questionable the true silence of the D trait.

Prevalence and genetic analysis of thalassemia in neonates in Wuhan area: a national megacity in central China

Background Thalassemia is one of the most common genetic diseases in southern China. Accurate population frequency data regarding the occurrence and distribution of thalassemia is important for designing appropriate prevention strategies of thalassemia. Objective The aim of this study is to reveal the prevalence and the mutation spectrum of thalassemia in neonates in the Wuhan region of central China. Methods About 3796 neonates in Wuhan area of China were analyzed by hematological and genetic analysis. Results About 2174 subjects were genetically diagnosed as thalassemia carriers or patients, including 1415 cases of α-thalassemia (65.89%), 731 cases of β-thalassemia (33.62%), and 28 cases of α-composite β-thalassemia (1.29%). A total of 11 genotypes and 6 gene mutations were identified in α-thalassemia anomalies, with —SEA/deletion (50.72%), -α3 . 7/deletion (36.36%), and -α4 . 2/deletion (7.38%) being the most common α-thalassemia mutations. β-thalassemia anomalies were associated with 17 genotypes and 12 gene mutations; IVS-2-654 mutation was the most common (41.18%), followed by CD41-42 (23.14%), CD17 (14.64%), CD26 (7.32%), and CD27-28 (4.58%) mutations. In addition, 13 genotypes were identified in α-composite β-thalassemia in thalassemia carrier, with the top six genotypes being IVS-2-654/N/—SEA/αα (17.86%), CD17/N/-α3 . 7/αα (17.86%), IVS-2-654/N/-α3 . 7/αα (14.29%), CD41-42/N/—SEA/αα (10.71%), CD71-72/N/-α3 . 7/αα (7.14%), and Cap/N/—SEA/αα (7.14%). Conclusion There was high heterogeneity and extensive spectrum of thalassemia in the neonates in Wuhan populations. The findings will be useful for genetic counseling and prenatal diagnosis of thalassemia in the Wuhan region.

Shine & Lal index as a predictor for early detection of \u03b2-thalassemia carriers in a limited resource area in Bandung, Indonesia

sBackgroundThalassemia is the most common inherited disease in the world, involving α- or β-globin in red blood cells. Thalassemia cases rank fifth in the list of national catastrophic diseases in Indonesia; however, nationwide screening for thalassemia carriers is not yet mandatory. This study aimed to assess whether blood count metrics, such as the Shine & Lal index (SLI; MCV*MCV*MCH/100), might serve as a predictor to screen thalassemia carriers in a limited resource area where molecular methods are not readily available.MethodsDuring a family gathering of thalassemia patients, family members (n196) underwent a complete blood count test. Those with MCV < 80 fL and/or MCH < 27 pg and/or SLI < 1530 were further examined for Hb analysis. Only samples with HbA2 fraction > 4% or with a peak in the HbE fraction were sequenced to confirm β-globin gene mutations.ResultsOf 196 family members, 117 (59.6%) had low MCV and/or low MCH and/or low SLI. The HbE fraction (mean 24.06% ± 0.95, range 22.4–26.5) was found in 27 (13.7%) cases, and all had a mutation at codon (CD)26 (c.79G > A). The mean HbA2 fraction in these samples was 3.18% ± 0.62 (range 2.6–3.8). For samples with HbA2 > 4% (n30; 15.3%), all had mutations at IVS1nt5 (c.92 + 5 G > C; n28), CD8/9 (c.27_28insG; n1) and CD19 (c.59A > G; n1). The mean HbA2 fraction with a mutation at IVS1nt5 (c.92 + 5 G > C) was 4.65% ± 0.77 (range 4.0–5.6). Interestingly, anaemia was only present in 25 and 57% of β-thalassemia carriers with mutations at CD26 (c.79G > A) and at IVS1nt5 (c.92 + 5 G > C), respectively.ConclusionsThe Shine & Lal index is helpful in the early screening of β-thalassemia carriers, since this index confirms mutations at CD-26 (c.79G > A) and at IVS1nt5 (c.92 + 5 G > C), which are both common mutations in Bandung, Indonesia. Further DNA analysis is a topic of interest to map variants in globin genes and their distribution across populations.

Hematological study of iron deficiency anemia and β thalassemia trait in Sindhi community of Bundelkhand region of Madhya Pradesh with predictive value of red cell indices to discriminate them

Background: Ethnic groups like Sindhis, Kutchis, Lohanas, Punjabis, few Muslim groups as well as few tribal populations have higher prevalence of hemoglobinopathy esespecially β thalassemia carriers. β Thalassemia traits are commonly misdiagnosed as iron deficiency anemia. Red cell indices are helpful to discriminate anemia and to detect subjects who have high probability of requiring appropriate follow up and to reduce unnecessary investigation cost. Aims and objectives: 1) To study red blood cell indices in all cases of microcytic hypochromic anemia. 2) Estimation of HbA2 levels and serum ferritin levels to confirmiron deficiency anemia and β thalassemia trait. 3) To evaluate the diagnostic values of various red cell indices in discriminating iron deficiency anemia and β thalassemia trait. Materials and methods: It is a prospective observation study carried out on Sindhi individuals of Sagar District of Bundelkhand region of Madhya Pradesh. Hemoglobin, RBC count, MCV, MCH and RDW were determined. Serum ferritin levels and HbA2 levels were detected. Result: Out of total 200 cases of Sindhi individuals 25 patients (12.5%) were grouped in β thalassemia trait while 175 patients (87.5%) were grouped in iron deficiency anemia group on the basis of HbA2 and serum ferritin level. Significant difference was found inmean MCV, MCH, RDW and RBC count and showed high sensitivity and specificity to discriminate iron deficiency anemia from β thalassemia. Conclusion: Sindhi community of Sagar district of Madhya Pradesh showed high prevalence of β thalassemia trait. Mass awareness and proper pre marriage genetic counseling and prenatal diagnosis should be done to reduce the burden of disease.

Knowledge and Beliefs Regarding Thalassemia in an Urban Population.

Background: Thalassemia is one of the most common genetic blood disorders in Asia. Consanguineous marriages and avoiding pre-marital and antenatal screening are common in Pakistan due to psychosocial, cultural, and religious factors. Few studies have investigated the beliefs regarding thalassemia, especially in a developing country. The aim of this study was to assess the knowledge, beliefs, and practices regarding thalassemia in an urban population.Method: A cross-sectional descriptive study was conducted in the urban areas of Karachi, Pakistan over a period of six months during March 2016 through August 2016. Participants selected by representative sampling were interviewed face-to-face using a pre-designed, pre-tested questionnaire. The questionnaire was divided into four parts. The first part inquired about general demographic variables, while the second part assessed knowledge of the participant regarding thalassemia. The third and fourth parts were concerning the beliefs and practices regarding thalassemia. Data were entered and analyzed using the Statistical Package for Social Sciences (SPSS) Statistics, v. 24.0 (IBM SPSS Statistics, Armonk, NY).Results: Only 53% (n = 720) of the respondents had heard about thalassemia. The mean knowledge score was 5.8. The total possible score ranged between 0 - 12 with the higher scores indicating better knowledge. About three-quarters (70%) of the sample did not know that an individual can be a carrier of thalassemia. Less than half (38%) of the participants viewed premarital screening for thalassemia as necessary, with only 10% agreeing that thalassemia carriers should not marry. There was no pre-marriage counseling done in 98% of the families. Conclusion: Our study highlights the prevalence of numerous myths and a low level of knowledge regarding thalassemia in an urban population of Pakistan.

Prevalence of beta thalassemia mutations in population of Gujarat using amplification-refractory mutation system–polymerase chain reaction

Background: Beta thalassemia is the most common genetic disorder in India. Its trait, coinheritance and mutations vary from mild to severe condition, resulting in thalassemia minor (heterozygous), intermediate and major depending upon many factors. The objective of this study was to find out the prevalence rate and the carrier of beta thalassemia in population of Gujarat using molecular genetic analysis of beta thalassemia patients by targeted mutation assay (ARMS-PCR).Methods: A total 105 samples for beta thalassemia were analysed for IVS 1-5 (G→C) and CD 15 (G→A) mutations. These two common mutations of thalassemia in Gujarat were carried out using amplification refractory mutation system–polymerase chain reaction (ARMS-PCR) and gel electrophoresis method.Results: A total 105 samples referred to us for molecular genetic analysis. The occurrence of positive mutations of IVS 1-5 (G→C) and CD 15 (G→A) were found in 48 and 15 samples respectively. The rest were negatives.Conclusions: Present study concludes that the prevalence rate of Beta thalassemia was widespread among the Gujarat population. The identification of IVS 1-5 (G→C) and CD 15 (G→A) mutations was carried out. The analysis revealed that, mutational patterns of IVS 1-5 (G→C) was the most frequent among other mutations in Gujarat region.

Colonic Perforation in Percutaneous Nephrolithotomy: A Case Report

We aim to report a rare case of colonic perforation post percutaneous nephrolithotomy (PCNL) and its conservative management. We report a 63-year-old Malay, thalassemia carrier male who underwent an uncomplicated left PCNL for a left renal stone. On second postoperative day, clinically evidence of subcutaneous emphysema. Serial CXR imaging confirmed presence of air under diaphragm. Small colonic perforation was diagnosed which subsequently developed localized collection retroperitoenally. He was successfully treated with non-operative management including intravenous antibiotic, surgical drainage and good nutrional has successfully support healed the collection. Serial CT renal protocol showed a healed retroperitoneal collection and patient made a good clinical recovery. PCNL has promising stone clearance rate. However, it carries complications. A rare yet important complication; colonic perforation is a serious complication that if detected earlier, good clinical recovery can be achieved conservatively.

PB2413 HAEMOGLOBIN AGHIA SOPHIA (HBA1:C.187_189DELGTG) IN NORTHERN GREECE. IMPLICATIONS IN CLINICAL PHENOTYPE OF HBH

Background: Alpha-thalassaemia is inherited as an autosomal recessive disorder characterised by a microcytic hypochromic anaemia, and the clinical phenotype varies from almost asymptomatic to a lethal haemolytic anaemia. It is probably the most common monogenic gene disorder in the world. Several mutations have been described that can affect globin gene expression in any step and many of those mutations are rare causes of alpha thalassaemia. Aims: 28 patients have been diagnosed with Hb H disease (14 males and 14 females) from 1986 to 2019 at the regions of Central and Western Macedonia in Northern Greece with a population of around 2.5 million. The most prevalent genotype was the -α 3.7/—med, (5 cases), 2 cases of –α 3,7/-α5,2, 1 case of –med/αPoly A, 1 case of –α 3,7/Hb Adana and 1 case of Hb Aghia Sophia/--med. The phenotype suggests that HbH disease in Greece has in general a moderate presentation. The molecular characterization of the patients with Hb H disease is useful for the prediction of the clinical outcome and the genetic counselling of the couples at risk. Methods: Hb Aghia Sophia carriers are asymptomatic with normal or nearly normal Hb levels and red cell indices similar to α+ thalassaemia carrier as it was shown in 2 members of a family that this mutation was also detected in our region. Haemoglobin (Hb) Aghia Sophia in interaction with deletional α-thalassaemia mutations leads to HbH. We report a case of Hb Aghia Sophia with co-inheritance with the a-thalassaemia – med deletion, a rare double heterozygosity case. Results: The case presented, concerns a 40 year old woman followed in our Thalassemia Clinic who was diagnosed at the age of 8 with Hb H. At diagnosis, totally incidental findings were compatible with a typical phenotype of Hb H, anaemia being mild and growth not having been impaired. As a girl, she retained a mild hypochromic microcytic anaemia until the age of 10 that a splenectomy was decided due to marked splenomegaly and anemia. During the following years her hemoglobin was maintained around 8gr/dl and she had normal growth. At the age of 35 she had an abortion. She was transfused each month during the next two pregnancies. Lately she was complaining for fatigue and her hemoglobin value was 7gr/dl. The investigation of hemoglobin deterioration did not reveal any significant cause. Bone marrow aspiration showed increased erythroid hyperplasia. Molecular examination revealed Aghia Sophia with co-inheritance with the a-thalassaemia – med deletion. As she denied transfusion, erythropoietin therapy was started with good results maintaining Hb level to 9gr/dl. Additionally, she receives deferasirox due to iron overload. Summary/Conclusion: The co-inheritance of Hb Aghia Sophia with –med, is extremely rare and the severity is due to the interaction of a hyper unstable mutant of the a1 gene with an α0-thal determinant. Hb Aghia Sophia causes instability to the polypeptide chain and is rapidly catabolized. Long follow-up of such rare cases is necessary in order to gain as much information as possible, so as to offer the best management to the patients and the most accurate counseling to their families.

PB2417 SPECTRUM OF HAEMOGLOBINOPATHIES;A TERTIARY CARE HOSPITAL EXPERIENCE

Background:Inherited abnormalities of hemoglobin synthesis include a myriad of disorders ranging from thalassemia syndromes to structurally abnormal hemoglobin variants.Identification of these disorders is immensely important epidemiologically and aid in prevention of more serious hemoglobin disorders.Aims:This study presents the pattern of haemoglobinopathies amongst the referred patients of anaemia in a 1 year period, it helps to identify the cases of different hemoglobin disorders.Methods:Inherited abnormalities of hemoglobin synthesis include a myriad of disorders ranging from thalassemia syndromes to structurally abnormal hemoglobin variants. Identification of these disorders is immensely important epidemiologically and aid in prevention of more serious hemoglobin disorders.Results:Out of 747 cases, 558 (74.6%) were normal and 189 (25.3%) cases had abnormal haemoglobin pattern. 356 (47.6%) were males and 391 (52.3%) were females. Of all cases of Anaemia 278 (49.8%) were microcytic hypochromic, 22 (3.9%) macrocytic and the rest 258 (46.2%) had normocytic normochromic picture. Of the 189 abnormal cases, Spectrum of haemoglobinopathies prevalent were Beta Thalassemia trait 117 (61.9%), followed by Beta thalassaemia major 27 (14.2%). Other haemoglobinopathies in descending order of frequency were sickle cell disease 15 (7.9%), Hb D Disease 16 (8.4%), sickle cell trait 01 (0.5%), Sickle/beta thalassaemia in 02 (1.0%) and Hb E in 04 (2.1%).Summary/Conclusion:Our study showed higher frequency of Beta Thalassaemia trait. It is suggested that detection of HbA2 should be carried out in all the high‐risk groups with anaemia. Further larger studies are needed to screen our population to detect thalassaemia carrier state and Iron deficiency Anaemia.

PB1971 STEPWISE APPROACH TO UNDIAGNOSED ANEMIA IN CHILDREN: A MODEL FOR LIMITED RESOURCES SETTINGS

Background:Undiagnosed inherited anemia is a unique clinical entity in tertiary hematology centers. Reaching confirmed diagnosis is challenging and requires series of complex expensive investigations.The high prevalence of iron deficiency and thalassemia carriers makes the diagnosis of other classes of anemia more challenging.Aims:we aimed at plotting a stepwise diagnostic approach in children with undiagnosed anemia which can be applied in restricted resource settings.Methods:A cross‐sectional study involved 45 still undiagnosed anemia patients after routine panel of investigations. They were classified based on mean corpuscular volume (MCV) into 3 groups; microcytic (n = 19),normocytic (n = 14) and macrocytic group(n = 12). An algorithm was plotted for each category including 4 levels of investigations. The fourth level analysis included genetic based analysis in appropriate setting.Results:After applying a systematic approach; 24 (54%) were probably diagnosed, 8 (18%) confirmed diagnosis,3 (6%) combined diagnosis and 10 (21%) patients remain undiagnosed. By primary, second, third levels; 9 patients were (5 microcytic,3 normocytic,1 macrocytic),8 (4 microcytic,2 normocytic,2 macrocytic) and 18 patients (5 microcytic, 8 normocytic,5 macrocytic) were diagnosed respectively; while 10 patients necessitated a fourth line level (8 microcytic and 2 normocytic).The diagnoses attained in microcytic group were hemoglobinopathies (42%),iron refractory iron deficiency anemia (IRIDA) (15%), membrane defect (10%), sideroblastic anemia (10%),hypotransferrenemia (5%), 15 % combined diagnosis (iron deficiency anemia and beta thalassemia minor, one sickle cell disease with pyropoikilocyosis and one alpha thalassemia and hereditary spherocytosiswhile15% remained undiagnosed. In normocytic group, the diagnosis washerediatary spherocytosis (20%), pyruvate kinase deficiency(15%), CDA type II (28%), beta thalassemia major (7%),Diamond Blackfan anemia (7%), vitamin B12 deficiency (15%) and 30% with no confirmed diagnosis,. In the macrocytic group, vitamin B12 deficiency (25%), PK deficiency(8%), sideroblastic anemia(8%) CDA II (16%) and 40% undiagnosed;by applying the four level of investigation, diagnosis was changed in 2,7 and 7 in microcytic, normocytic and macrocytic respectively.Summary/Conclusion:Setting a stepwise approach with different levels of may help to reach diagnosis of difficult anemia without performing unnecessary investigation showed that microcytic anemia was more frequent.High frequency of B12 deficiency presented either as normocytic or macrocytic was reported in this study. 40% remained with indefinite diagnosis after series of investigations

PB2401 GENETICS OF IRANIAN ALPHA THALASSEMIA PATIENTS; COMPREHENSIVE ORIGINAL STUDY

Please indicate where the abstract has been published before: The full paper was published in Biochemical genetics journalBackground:Alpha thalassemia is the most prevalent monogenic gene disorder in the world and especially in Mediterranean countries. In the current hematological phenotype of patients with different genotypes, and also the effect of missense mutations on the protein function and stability were evaluated in a large cohort study.Aims:To evaluate the genetics of large populations of Iranian alpha thalassemia patientsMethods:One thousand five hundred and sixty subjects were participated in the study and divided into two groups; 259 normal subjects and 1301 alpha thalassemia carriers. Genomic DNA was extracted and analyzed using ARMS PCR, Multiplex Gap, and direct sequencing. The effects of single nucleotide change on the protein function and stability were predicted by free available databases of human polymorphisms.Results:Sixty‐three different genotypes were seen in the patients. The more prevalent was heterozygote form of ‐α3.7 (41.4%) followed by ‐α3.7 homozygote(11.6%) and ‐ ‐MED(3.8%). The significant differences were seen in mean hemoglobin level [F = 20.5, p &lt; 0.001] between the Alpha globin genotypes when adjusted for gender. Moreover, 28 different mutations were found in our study. A significant relationship was seen between ethnicity and the alpha globin mutation frequency X2 (df;8) = 38.36, p &lt;0.0001).Summary/Conclusion:Different genotypes could be displayed as different phenotypes. The mutation frequency distributions in our region are different from other parts of Iran. Significant differences are seen in the spectrum of mutation frequency between various ethnicity. Finally, some missense mutations maybe did not considerably effect on the proteins and could be a neutral mutation.image

Gene spectrum analysis of thalassemia for people residing in northern China

BackgroundSouthern China provinces have high incidence of thalassemia, however, sporadic cases can be found in northern China as well.MethodsPeople resided in north China who were suspected to have thalassemia were detected mutations by gap-polymerase chain reaction (Gap-PCR) and reverse dot blot (RDB) analyses. Those with positive findings from 2012 to 2017 were further analyzed for basic clinical data and ancestral information either by medical records or by telephone follow-up or both.ResultsMost people enrolled in our study had no or mild symptoms. For those with positive gene findings, people originated from the north had higher percentage of β-thalassemia gene mutations compared with those originated from the south (72.8% vs. 62.4%, χ2 = 9.92, P = 0.001). Analysis of the individual gene distribution of people from south and north areas did not show significant difference either in α- thalassemia (P = 0.221) or β-thalassemia (P = 0.979). No significant difference was found in the frequency of α mutation in people living in different altitudes. However, for β-thalassemia, the frequency of the 6 most common mutations was significantly different in people living in different provinces with altitude below 500 m, 500–1000 m, and above 1000 m (χ2 test, P < 0.05).ConclusionMost of people in north China with thalassemia mutation gene were thalassemia carriers. People originated from the north had higher frequency of β mutation than those originated from the south, but the north people had similar individual gene mutation profile compared with south people both for α and β mutations. People lived in different altitudes had different spectrum of β mutations.

Hemoglobinopathy Evaluation in Routine Carrier Testing: Results to Inform Guidelines and Protocols [5O

INTRODUCTION: ACOG guidelines recommend red blood cell indices followed by hemoglobin electrophoresis to assess carrier status for hemoglobinopathies. However, data is limited on outcomes of these recommendations, and the role of DNA testing. METHODS: Our database was queried for abnormal hemoglobin evaluations from 42,166 consecutive samples of mixed ethnicities. Hemoglobin evaluation consisted of red blood indices and, high-performance liquid chromatography followed by, if necessary, hemoglobin electrophoresis. A subset (n= 2,863) also had DNA genotyping. Abnormal reports were evaluated individually, and test metrics and interpretations were tabulated. RESULTS: Of the 42,166 samples, 2,278 (5.4%) had abnormal hemoglobin evaluation results. Of the 2,278 abnormal results, the most common interpretation (32%) was 'possible alpha thalassemia trait', followed by 'sickle cell trait' (22%), 'possible beta thalassemia trait' (10%), 'elevated hemoglobin F' (10%), and 'hemoglobin C trait' (5%). Of the 2,863 samples that had genotyping, 146 (5.1%) had abnormal molecular results. Genotyping confirmed 100% (5/5) of samples with abnormal hemoglobin evaluation indicating 'consistent with alpha thalassemia trait' and 41% (17/41) indicating 'possible alpha thalassemia trait'. Sixteen percent (14/89) of samples with abnormal molecular results, and normal hemoglobin evaluation for alpha thalassemia, were silent alpha thalassemia carriers. CONCLUSION: Our study estimates a 5% positivity rate for hemoglobin evaluation. However, some results are non-specific and require molecular follow up. Forty-one percent of hemoglobin evaluation results interpreted as 'possible alpha thalassemia trait' were confirmed as genetic carriers. Concurrent DNA testing provides information and results more quickly to patients, and better identifies those patients truly at risk to be carriers of alpha thalassemia.

Thalassemia Carriers among Healthy Blood Donors

Thalassemia is a common hereditary anaemia in Southeast Asia which may also be found among healthy blood donors. The established screening method is less sensitive and can miss donors with clinically silent Thalassemia. The Thalassemia screening tests may help in selection of truly healthy blood donors, hence providing the most functional red cell concentrates for blood transfusion. This is an extension study from our previous work, aiming to detect thalassemia trait among clinically asymptomatic blood donors. We performed Thalassemia screening in 738 healthy blood donors who were allowed for blood donation using full blood count and haemoglobin (Hb) analysis. After screening analyses using high performance liquid chromatography, capillary zone electrophoresis and agarose gel electrophoresis, 85 samples were excluded from the study due to inadequate volume for DNA analysis. Five hundred twelve (512/653; 78.4%) samples were within normal limit and 74 (74/653; 11.3%) samples with Hb less than 12.5 g/dl. Thirty eight donors were found to have Thalassemia and/or haemoglobinopathies by Hb analysis. The remaining 105 blood donors samples with value of MCV less than 80 fl and/or MCH lower than 27 pg with no detectable abnormal pattern from Hb analysis subjected to multiplex PCR that was capable of detecting deletional and nondeletional of the α-globin gene. Majority (79/653; 2.1%) of them had no identified mutation while 23 (23/653; 3.5%) of them had heterozygous α-3.7 deletion, 2 (2/653; 0.3%) had heterozygous α--SEA deletion and only one (1/653; 0.1%) had heterozygous α-4.2 deletion. This data indicates that 74 (74/653; 11.3%) of our blood donors were anaemic, 64 (64/65; 39.8%) had haemoglobinopathies and 79 (79/653; 12.1%) were presumptively had iron deficiency anaemia based on red blood cell indices. Provision of best quality pack red cells should be selected for patients who require regular blood transfusion in order to maintain appropriate Hb level.

Mentzer Index Diagnostic Value in Predicting Thalassemia Diagnosis

Thalassemia diagnosis requires gen examination using Polymerase Chain Reaction (PCR) device or hemoglobin (Hb) electrophoresis using electrophoresis or High Performance Liquid Chromatography (HPLC) device which is only available in certain hospitals. Therefore, it is important to develop easily examined parameters which are useful to assess thalassemia carrier diagnosis. This study aims at figuring out the diagnostic value of Mentzer Index in predicting beta-thalassemia carrier compared to the results of HB electrophoresis examination. Data were taken from 37 anemia patients at Prof. Dr. Margono Soekarjo Regional Public Hospital in Purwokerto who underwent Hb electrophoresis examination using electrophoresis instrument and routine blood count. Furthermore, Mentzer Index was calculated, odds ratio (OR) was analyzed, and diagnostic values were compared to the results of Hb electrophoresis. Mentzer index OR value was 2.4 (0.5 - 11.5, CI95%). Mentzer Index sensitivity (Sn) was 0.36 with specificity (Sp) at 0.81, positive predictive value (PPV) at 0.44 and negative predictive value (NPV) at 0.75. Mentzer index could be used to predict the diagnosis of beta-thalassemia carrier.

Next-generation sequencing improves molecular epidemiological characterization of thalassemia in Chenzhou Region, P.R. China.

ObjectivesThalassemia is a highly prevalent monogenic inherited disease in southern China. It is important to collect epidemiological data comprehensively for proper prevention and treatment.MethodsIn this study, blood samples collected from 15 807 residents of Chenzhou were primarily screened by hematological tests. A total of 3973 samples of suspected thalassemia carriers were further characterized by combined next‐generation sequencing (NGS) and Gap‐PCR.ResultsIn total, 1704 subjects were diagnosed as thalassemia carriers with a total prevalence rate of 10.78%, including 943 α‐thalassemia carriers, 708 β‐thalassemia carriers, and 53 composite α and β‐thalassemia carriers. The prevalence rates of α‐thalassemia, β‐thalassemia, and composite α and β‐thalassemia were 5.97%, 4.48%, and 0.34%, respectively. Meanwhile, we characterized 19 α‐thalassemia variations and 21 β‐thalassemia variations in thalassemia carriers. Approximately 2.88% of thalassemia carriers would be missed by traditional genetic analysis. In addition, four novel thalassemia mutations and one novel abnormal hemoglobin mutation were identified.ConclusionsOur data suggest a high prevalence of thalassemia and a diverse spectrum of thalassemia‐associated variations in Chenzhou. Also, combined NGS and Gap‐PCR is an effective thalassemia screening method. Our findings might be helpful for prevention and treatment of thalassemia in this region.