Congenital Hemoglobinopathies Research Articles

Extramedullary hematopoiesis in ribs and severe pulmonary hypertension disease following intermediate beta-thalassemia: a case report

BackgroundThalassemia is a type of congenital hemoglobinopathy that falls into the category of hemolytic anemias. Extramedullary hematopoiesis is a complication of this disease, which is a mechanism to compensate for chronic anemia in these patients, and imaging is the best diagnostic method.Case reportIn this report, a 36-year-old Caucasian female patient with intermediate beta thalassemia is presented who, at the time of referral, complained of exacerbated shortness of breath. Imaging showed diffuse expansion masses with soft tissue components in the ribs of both hemithoraxes, leading to the diagnosis of extramedullary hematopoiesis.ConclusionExtramedullary hematopoiesis in the ribs is an uncommon finding in patients with thalassemia and is a sign of the severity of the disease and a poor prognostic factor that might be preventable if blood transfusion begins at younger ages.

No Time for Empathy

Between 1956 and 1964, in Calcutta, India, at least seven young children with congenital hemoglobinopathies, perhaps more, were injected with various strains of malaria to test their possible immunity. Some of the children were tested on repeatedly. The experiments exposed the already sick children to additional risks and suffering. Strikingly, these experiments started less than a decade after decolonization and were conducted by Indian doctors, rather than colonial doctors. In this article I argue that such tragic practices can only be understood with reference to a set of entangled temporalities. Specifically, the temporal urgency of the postcolonial moment, the absent time of ethical regulations, and the familial tempo of caring for congenitally sick children. The entangled temporalities that authorized the pediatric experimentation, however, would not be visible without the reflexive hermeneutics developed by the Subaltern Studies scholars and nourished by the experiences of academic immigration.

Insights into Hepatocellular Carcinoma in Patients with Thalassemia: From Pathophysiology to Novel Therapies.

Thalassemia is a heterogeneous congenital hemoglobinopathy common in the Mediterranean region, Middle East, Indian subcontinent, and Southeast Asia with increasing incidence in Northern Europe and North America due to immigration. Iron overloading is one of the major long-term complications in patients with thalassemia and can lead to organ damage and carcinogenesis. Hepatocellular carcinoma (HCC) is one of the most common malignancies in both transfusion-dependent thalassemia (TDT) and non-transfusion-dependent thalassemia (NTDT). The incidence of HCC in patients with thalassemia has increased over time, as better chelation therapy confers a sufficiently long lifespan for the development of HCC. The mechanisms of iron-overloading-associated HCC development include the increased reactive oxygen species (ROS), inflammation cytokines, dysregulated hepcidin, and ferroportin metabolism. The treatment of HCC in patients with thalassemia was basically similar to those in general population. However, due to the younger age of HCC onset in thalassemia, regular surveillance for HCC development is mandatory in TDT and NTDT. Other supplemental therapies and experiences of novel treatments for HCC in the thalassemia population were also reviewed in this article.

Fetal allotransplant recipients are resistant to graft-versus-host disease

In utero hematopoietic cell transplantation (IUHCT) is an experimental treatment for congenital hemoglobinopathies, including Sickle cell disease and thalassemias. One of the principal advantages of IUHCT is the predisposition of the developing fetus toward immunologic tolerance. This allows for engraftment across immune barriers without immunosuppression and, potentially, decreased susceptibility to graft-versus-host disease (GVHD). We demonstrate fetal resistance to GVHD following T cell-replete allogeneic hematopoietic cell transplantation compared with the neonate. We show that this resistance is associated with elevated fetal serum interleukin-10 conducive to the induction of regulatory T cells (Tregs). Finally, we demonstrate that the adoptive transfer of Tregs from IUHCT recipients to neonates uniformly prevents GVHD, recapitulating the predisposition to tolerance observed after fetal allotransplantation. These findings demonstrate fetal resistance to GVHD following hematopoietic cell transplantation and elucidate Tregs as important contributors.

Therapeutic approaches in patients with β-thalassemia

Beta-thalassemia (β-thal) is a congenital hemoglobinopathy explained by a decreased level (β+) or absence (βο) of β-globin gene expression. Microcytic hypochromic anemia and various clinical symptoms comprising severe anemia to clinically nonsymptomatic features. Treatment with an ordered blood transfusion and iron chelator agents can decrease transfusion iron overload that causes normal maturation. These patients also are at high risk for secondary iron overload because of erythropheron (GF15–TWSG1) release from erythroblasts resulting in erythroid hyperplasia. Based on the previous studies, chemicals such as hydroxyurea and 5-azacytidine are useful in treating β-hemoglobinopathy, including β-thal and sickle cell disease (SCD). Regarding both side effects and lifelong treatment of these chemical components, researchers have recently regarded gene-based treatments. These techniques, such as micro RNA gene silencing, viral-mediated gene editing, and clustered regulatory interspaced short palindromic repeats (CRISPR)-CAS9 systems, are the most commonly used gene therapy methods. Nowadays, ɣ-globin (fetal globin) gene reactivation is one of the most popular treatments for β-thal. Researches showed that these gene modification methods for γ-globin gene reactivation are also useful in increasing hemoglobin F (HbF) and helping patients with β-thal. In this review study, new therapeutic approaches to manage this disorder are regarded.

PTD-mediated delivery of \u03b1-globin chain into \u039a-562 erythroleukemia cells and \u03b1-thalassemic (HBH) patients\u2019 RBCs ex vivo in the frame of Protein Replacement Therapy

Backgroundα-Thalassemia, a congenital hemoglobinopathy, is characterized by deficiency and/or reduced levels of α-globin chains in serious forms of α-thalassemia (HbH disease/Hb Bart’s). This research work deals with a Protein Replacement Therapy approach in order to manage α-thalassemia manifestations, caused by the excess of β-globin chain into HbH RBCs. The main goal was to produce the recombinant human α-globin chain in fusion with TAT, a Protein Transduction Domain, to ex vivo deliver it into HbH patients RBCs, to replace the endogenous missing α-globin chain.ResultsCloning of the α-globin coding sequence, fused to the nucleotide sequence of TAT peptide was conducted and the human recombinant fusion proteins, 10xHis-XaSITE-α-globin-HA and 10xHis-XaSITE-TAT-α-globin-HA were produced. The ability of human recombinant 10xHis-XaSITE-α-globin-HA to interact in vitro with the previously produced 10xHis-XaSITE-TAT-β-globin-HA and form α-/β-globin heterodimers, was assessed and confirmed by size exclusion chromatography. The recombinant 10xHis-XaSITE-TAT-α-globin-HA was successfully delivered into human proerythroid K-562 cells, during the preliminary transduction evaluation experiments. Finally, the recombinant, TAT-fused α-globin was successfully transduced into RBCs, derived from HbH patients and reduced the formation of HbH-Inclusion Bodies, known to contain harmful β4-globin chain tetramers.ConclusionsOur data confirm the successful ex vivo transduction of recombinant α-globin chains in HbH RBCs to replace the missing a-globin chain and reduce the HbH-inclusion bodies, seen in α-thalassemias. These findings broaden the possibility of applying a Protein Replacement Therapy approach to module sever forms of α-thalassemia, using recombinant α-globin chains, through PTD technology.

Maternal microchimerism and cell-mediated immune-modulation enhance engraftment following semi-allogenic intrauterine transplantation.

Successful intrauterine hematopoietic cell transplantation (IUT) for congenital hemoglobinopathies is hampered by maternal alloresponsiveness. We investigate these interactions in semi-allogenic murine IUT. E14 fetuses (B6 females × BALB/c males) were each treated with 5E+6 maternal (B6) or paternal (BALB/c) bone marrow cells and serially monitored for chimerism (>1% engraftment), trafficked maternal immune cells, and immune responsiveness to donor cells. A total of 41.0% of maternal IUT recipients (mIUT) were chimeras (mean donor chimerism 3.0±1.3%) versus 75.0% of paternal IUT recipients (pIUT, 3.6±1.1%). Chimeras showed higher maternal microchimerism of CD4, CD8, and CD19 than non-chimeras. These maternal cells showed minimal responsiveness to B6 or BALB/c stimulation. To interrogate tolerance, mIUT were injected postnatally with 5E+6 B6 cells/pup; pIUT received BALB/c cells. IUT-treated pups showed no changes in trafficked maternal or fetal immune cell levels compared to controls. Donor-specific IgM and IgG were expressed by 1%-3% of recipients. mIUT splenocytes showed greater proliferation of regulatory T cells (Treg) upon BALB/c stimulation, while B6 stimulation upregulated the pro-inflammatory cytokines more than BALB/c. pIUT splenocytes produced identical Treg and cytokine responses to BALB/c and B6 cells, with higher Treg activity and lower pro-inflammatory cytokine expression upon exposure to BALB/c. In contrast, naïve fetal splenocytes demonstrated greater alloresponsiveness to BALB/c compared to B6 cells. Thus pIUT, associated with increased maternal cell trafficking, modulates fetal Treg, and cytokine responsiveness to donor cells more efficiently than mIUT, resulting in improved engraftment. Paternal donor cells may be considered alternatively to maternal donor cells for intrauterine and postnatal transplantation to induce tolerance and maintain engraftment.

Neurocognitive Testing in Pediatric Sickle Cell Disease: Full Scale IQ Assessment May Not be the Full Story

Introduction: Sickle Cell Disease (SCD) is a chronic, congenital hemoglobinopathy characterized by progressive multiorgan dysfunction (Vichinsky, ASH proceedings). The brain is one of the major organs affected by SCD. While it is known that neurocognitive defects can be seen even in the absence of overt stroke and silent cerebral infarcts, there are no specific guidelines for performing neurocognitive assessments on patients with SCD. We report our findings in 20 patients that received neurocognitive testing at our institution within the last 3 years Methods: Eligible participants were identified through the Chicago Sickle Cell Disease Research Group (CSCDRG) Registry in conjunction with the SCD medical team and pediatric psychologist. Enrolled subjects took part in child/caregiver interviews, caregiver questionnaires, and review of relevant medical and school records. Participants and caregivers completed a baseline neuropsychological evaluation, which included the Wechsler Intelligence Scale for Children (WISC). Questionnaires were also sent to participants' teachers. Medical chart review was used to collect information about genotype and relevant imaging. Results: Neurocognitive testing was performed on 20 pediatric patients ranging in age from 6 to 14 years of age. The majority of patients had sickle cell genotype Hgb SS (n=16, 80%). Five patients (25%) had an abnormal MRI prior to testing. Brain abnormalities included CVA (n=2), Moya Moya (n=2), and T2 signal intensity (n=4). Cohort average full scale IQ was 75. Average full-scale IQ scores did not differ between patients who had a known brain abnormality (75) and patients who did not have a known brain abnormality (76) prior to testing. Most of the patients (n=15, 75%) were in the grade appropriate for age but only about half of the patients had an Individualized Education Plan (IEP) at the school. Interestingly, we also found that prior to neurocognitive testing, only one patient had a known Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) diagnosis. Following testing, we identified ten additional patients who met criteria for at least one DSM-5 diagnosis. DSM-5 diagnoses in pediatric patients fell under primarily three categories including Neurodevelopmental Disorders (i.e., Attention-Deficit Hyperactivity Disorder, Specific Learning Disability in Mathematics), Trauma and Stressor Related Disorders (i.e., Adjustment Disorder with depressed mood), and Disruptive, Impulse Control and Conduct Disorders (i.e., Oppositional Defiant Disorder). Conclusion: We have described the differences in a pediatric sickle cell patient population who underwent neurocognitive testing. Our cohort of children with sickle cell disease exhibit significant neurocognitive deficits even in the absence of overt imaging findings or clinical stroke. Our findings also suggest that patients with SCD are at a higher risk of clinically significant mental health disorders which, if left undiagnosed, have the potential to hinder scholastic and occupational achievement. Individualized educational plans and specific interventions and addressing learning disabilities will help improve academic performance. Furthermore, neurocognitive testing should be a part of routine evaluation in patients with sickle cell disease. Disclosures No relevant conflicts of interest to declare.

Prevalence and Determinants of Anaemia among Infants Attending Well-baby Clinic at Primary Health Care Centres, Makkah Al-Mokarramah, January 2018: A Cross Sectional Study

Background. Anaemia is a global problem that can affect the neurodevelopment and behaviour of infants. A study shows that 52% of infants attending well-baby clinics in Saudi Arabia had iron deficiency anaemia, however limited works are done concerning its prevalence and determinants. Thus, this study aims obtain new helpful information towards anaemia among infants by determining its prevalence and determinants at the primary health care centers (PHCCs) in Makkah Al-Makaramah, KSA. Methods. A cross-sectional study was conducted at Makkah Al-Mokarramah primary healthcare centers (Al-khaldyah and Al-Ka’akyah) in January, 2018. Infants who visited the well-baby clinic for vaccination/routine follow-up were selected through convenience sampling technique. A questionnaire filled out by the researcher through an interview with the mother of infants was utilized for data collection. Results. The prevalence of anaemia among 99 infants was found to be 25.3%. Factors significantly associated with anaemia were determined as maternal educational level, job status, absence of post-partum maternity leave, increasing birth order, fetal history of chronic/acute diseases and hospital admission, congenital and parental haemoglobinopathies, later age of weaning, introducing solid/semisolid foods after age of 9 months, Conclusion. Anaemia is a common problem among infants aged one year in Makkah Al-Mokarramah as it affects almost one-quarter of them. Several predictors for anaemiahave been identified in relation to infants, mothers, nutrition and social aspects. Overall, the results may enhance the anaemia-related knowledge among infants and help the authorities to execute a more effective public health interventions in both regional and nation levels.

Pain Relief in the Sickle-Cell Crisis: Intravenous Morphine Versus Ketorolac; A Double-Blind, Randomized Clinical Trial

Background: Sickle cell disease (SCD) is a congenital hemoglobinopathy. A low Hb level and high hemoglobin-to-hematocrit ratio may lead to the vaso-occlusive crisis in patients, for the management of which hyperbaric oxygen, hydration, and pain relief therapy are proposed. Objectives: In this study, we sought to compare the effects of morphine and ketorolac on relieving painful sickle cell crisis. Methods: In this double-blind, randomized clinical trial, we recruited 92 SCD patients who referred to the Emergency Department of a university-affiliated hospital, in Mashhad, Iran, from December 2016 to May 2017. The patients were randomly assigned to two groups of ketorolac and morphine injections for relieving pain crisis according to the clinical conditions of the patients. Pain severity was measured by the visual analogue scale before and after the intervention. Data were analyzed using SPSS software. Results: A total of 92 SCD patients were evaluated, while, 19 (21%) were female and 73 (79%) were male, with the mean age of 20.77 ± 8.6 years. At the pre-injection phase, the mean pain scores were 9.1 ± 0.4 and 9.1 ± 0.7 in the ketorolac and morphine groups, respectively. After the intervention, the mean pain scores were 3.7 ± 1.2 and 4.9 ± 2.1 in the ketorolac and morphine groups, respectively. A significant association was found between the pain score after drug injection and the administered drug (P = 0.006). Conclusions: The management of pain crisis with ketorolac injection yielded the same results as the morphine injection in SCD patients. However, ketorolac was found to be associated with fewer side effects than morphine; thus, it can be beneficial for managing SCD patients suffering pain crisis.

Production and Transduction of a Human Recombinant β-Globin Chain into Proerythroid K-562 Cells To Replace Missing Endogenous β-Globin.

Protein replacement therapy (PRT) has been applied to treat severe monogenetic/metabolic disorders characterized by a protein deficiency. In disorders where an intracellular protein is missing, PRT is not easily feasible due to the inability of proteins to cross the cell membrane. Instead, gene therapy has been applied, although still with limited success. β-Thalassemias are severe congenital hemoglobinopathies, characterized by deficiency or reduced production of the adult β-globin chain. The resulting imbalance of α-/β-globin chains of adult hemoglobin (α2β2) leads to precipitation of unpaired α-globin chains and, eventually, to defective erythropoiesis. Since protein transduction domain (PTD) technology has emerged as a promising therapeutic approach, we produced a human recombinant β-globin chain in fusion with the TAT peptide and successfully transduced it into human proerythroid K-562 cells, deficient in mature β-globin chain. Notably, the produced human recombinant β-globin chain without the TAT peptide, used as internal negative control, failed to be transduced into K-562 cells under similar conditions. In silico studies complemented by SDS-PAGE, Western blotting, co-immunoprecipitation and LC-MS/MS analysis indicated that the transduced recombinant fusion TAT-β-globin protein interacts with the endogenous native α-like globins to form hemoglobin α2β2-like tetramers to a limited extent. Our findings provide evidence that recombinant TAT-β-globin is transmissible into proerythroid K-562 cells and can be potentially considered as an alternative protein therapeutic approach for β-thalassemias.

Pre-Existing Maternal Antibodies Cause Rapid Prenatal Rejection of Allotransplants in the Mouse Model of In Utero Hematopoietic Cell Transplantation.

In utero hematopoietic cell transplantation (IUHCT) is a nonmyeloablative nonimmunosuppressive alternative to postnatal hematopoietic stem cell transplantation for the treatment of congenital hemoglobinopathies. Anti-HLA donor-specific Abs (DSA) are associated with a high incidence of graft rejection following postnatal hematopoietic stem cell transplantation. We determine if DSA present in the mother can similarly cause graft rejection in the fetus following IUHCT. Ten million C57BL/6 (B6, H2kb) bone marrow cells were transplanted in utero into gestational day 14 BALB/c (H2kd) fetuses. The pregnant BALB/c dams carrying these fetuses either had been previously sensitized to B6 Ag or were injected on gestational days 13-15 with serum from B6-sensitized BALB/c females. Maternal-fetal Ab transmission, Ab opsonization of donor cells, chimerism, and frequency of macrochimeric engraftment (chimerism >1%) were assessed by flow cytometry. Maternal IgG was transmitted to the fetus and rapidly opsonized donor cells following IUHCT. Donor cell rejection was observed as early as 4 h after IUHCT in B6-sensitized dams and 24 h after IUHCT in dams injected with B6-sensitized serum. Efficient opsonization was strongly correlated with decreased chimerism. No IUHCT recipients born to B6-sensitized dams or dams injected with B6-sensitized serum demonstrated macrochimeric engraftment at birth compared with 100% of IUHCT recipients born to naive dams or dams injected with naive serum (p < 0.001). In summary, maternal donor-specific IgG causes rapid, complete graft rejection in the fetus following IUHCT. When a third-party donor must be used for clinical IUHCT, the maternal serum should be screened for DSA to optimize the chance for successful engraftment.

Fetal aneuploidy diagnosed at celocentesis for early prenatal diagnosis of congenital hemoglobinopathies.

Currently, prenatal diagnosis of genetic disorders requires chorionic villus sampling or amniocentesis carried out after 11 and 16weeks of gestation, respectively. Celocentesis is a procedure for prenatal diagnosis that could be used from as early as 7weeks. The present investigation evaluated the feasibility of performing diagnosis for monogenic diseases using celomic fluid containing cells of fetal origin. Analysis consisted of 489 singleton pregnancies undergoing celocentesis for the prenatal diagnosis of hemoglobinopathies (n=367) or before surgical termination of pregnancy for social indications (n=122). Embryo-fetal cells were isolated from celomic fluid using CD71 antibodies or by micromanipulation. Quantitative fluorescent polymerase chain reaction of short tandem repeat sequences of chromosomes 13, 18, 21, X and Y were used to determine the presence of maternal DNA. 357/489 (73%) of celomic fluid samples were contaminated with maternal cells. In two cases, diagnosis was not possible due to the high contamination of celomic fluid. Eighty-seven (23.8%) fetuses were affected by hemoglobinopathies and, in five cases, chromosomal aneuploidies were found, including three cases of trisomy 21, one of trisomy 13 and one of triploidy. In all cases, the diagnosis of hemoglobinopathies and chromosomal abnormalities was confirmed by molecular and traditional cytogenetic analysis after amniocentesis, chorionic villus or placental tissue collection following pregnancy termination. The findings of this study demonstrate that embryo-fetal cell selection from celomic fluid allows reliable and early prenatal diagnosis of hemoglobinopathies and can give more information on any fetal aneuploidy following the control of maternal contamination by quantitative fluorescent-PCR.

Allogeneic hematopoietic stem cell transplantation in congenital hemoglobinopathies with myeloablative conditioning and rabbit anti-thymocyte globulin.

BackgroundAllogeneic hematopoietic stem cell transplantation (HSCT) is a curative therapy for β-thalassemia major (TM) and sickle cell disease (SCD) in children. Graft-versus-host disease (GVHD) and treatment-related mortality (TRM) remain significant challenges to improving survival after HSCT. Here, we analyzed the outcome of TM and SCD patients, who received allogeneic HSCT with myeloablative conditioning at our institution.MethodsTwenty-two patients (15 TM, 7 SCD), with a median age of 9 years (range, 1.6–16.9), underwent allogeneic HSCT using busulfan, cyclophosphamide and rabbit anti-thymocyte globulin-based conditioning. Cells were derived from either the bone marrow (8 patients), or peripheral blood stem cells (14 patients). The majority of patients received HSCT from a matched sibling donor (N=18). GVHD prophylaxis included cyclosporine and short course methotrexate.ResultsAll patients achieved donor engraftment. Two SCD patients died from TRM-related grade IV gut GVHD (N=1) or severe bronchiolitis obliterans (BO) (N=1). Cumulative incidence of acute and chronic GVHD was 36.4% and 32.7%, respectively. Veno-occlusive disease (VOD) occurred in 8 patients (36.4%), but resolved in all instances. Epstein-Barr virus (EBV)-related post-transplantation lymphoproliferative disease (PTLD) occurred in 1 patient. The overall survival (OS) was 90.9% (TM 100%, SCD 71.4%), with all patients achieving transfusion independence, while 8 achieved complete donor chimerism.ConclusionBusulfan, cyclophosphamide, and ATG-based conditioning for HSCT of TM and SCD patients did not result in graft failure, although modifications may be required to reduce VOD incidence. Further changes to donor type and cell source prioritization are necessary to minimize TRM and morbidity caused by GVHD.

A Case of a Successful Gestation in a Patient with an Unclassified Transfusion Dependent Congenital Dyserythropoietic Anemia and Hemoglobinopathy

A Case of a Successful Gestation in a Patient with an Unclassified Transfusion Dependent Congenital Dyserythropoietic Anemia and Hemoglobinopathy

Low Pulsoximetry as a Manifestation of Congenital Hemoglobinopathies. The Case of Hemoglobin Bonn in the Tver Region

Pulse oximetry is the most common method of monitoring respiratory failure. A decrease in SpO2 indices is a sign of hypoxemia. Abnormal hemoglobins, with a hereditary mutation in α-globin or in β-globin, can lead to falsely low saturation of hemoglobin with oxygen. The frequency of this pathology occurrence in the population is unknown. This article reviews international publications on this issue and cites the case of hereditary hemoglobinopathy (Hb Bonn) in the parturient, her father and her son. All patients showed a decrease in osmotic resistance of red blood cells by 30%. The son of the woman at the age of three years suffered from the hemolytic-uremic syndrome, which required renal replacement therapy. The knowledge of abnormal hemoglobins accompanied by low pulsoximetry will help to avoid medical errors.

Determination of toral antioxidant capacity of saliva in sickle cell anemic patients - A cross-sectional study.

Sickle cell anemia is a congenital hemoglobinopathy characterized by deformed red blood cells. Oxidative stress plays an important role in the pathophysiology of sickle cell anaemia as it destroys free radicals, and thereby depleting the protective mechanisms such as antioxidants in serum. These antioxidants are essential to protect against harmful oxidation-reduction reactions preventing oxidative damage to the cells. To evaluate and compare the Total Antioxidant Capacity (TAC) of serum and saliva in sickle cell anemia patients. A total of 150 children aged 4-12 yrs were selected and divided into two equal groups: Children suffering from sickle cell anemia and healthy controls. Blood and saliva samples were collected aseptically from both groups and were subjected to phosphomolybdenum method. Absorbance was read spectrophotometrically at 695 nm. The concentration of total antioxidants was obtained by plotting absorbance of the test against the standard graph. TAC levels in serum (0.29±0.19) and saliva (0.29±0.14) of sickle cell anaemic patients was reduced when compared with serum (0.32+ 0.18) and saliva (0.33+ 0.16) of the healthy children. The correlation between levels of TAC in saliva and serum was found to be statistically significant in sickle cell anaemic patients. A significant correlation of the TAC was found in saliva and serum of the patients with SCA suggests that saliva could be used as a non invasive alternative for assessing the antioxidant status in patients with SCA.

Delivering the "Blueprints" or "DNA Repairing Kits" Instead of Drugs in the Treatment of Congenital Hemoglobinopathies

Hemoglobinopathies, such as β-thalassemia and sickle cell disease (SCD), are among the most common congenital diseases in the world, with high mortality and morbidity rates. The most straightforward approach to correct the main culprit in hemoglobinopathies - the imbalance between the amounts of alpha-like globins/betalike globins- will need to target directly the gene structure or their regulatory elements in order to obtain a sustained therapeutic effect. Keywords: Genetic therapy, nucleic acids delivery strategies, hemoglobinopathies, DNA repairing, DNA editing, viral and non-viral vectors, nanoparticles.

Treatment of 100 chronic thalassemic leg wounds by plasma-rich platelets.

Thalassemia is a heterogeneous group of congenital hemoglobinopathies caused by mutations in the globin gene complex that result in an unbalanced globin synthesis. Unmatched globin chains bind to the cytosolic surface of red blood cell membrane where they cause oxidative damage that might in part be responsible for membrane weakness. The deformability of red blood cells and hypercoagulable state in thalassemic patients have been incriminated in leg ulcer formation, as this might cause ischemia to the skin and consequently friability and ulceration. Platelet-rich plasma (PRP) gel is considered an advanced wound therapy for chronic and acute wounds. PRP gel consists of cytokines, growth factors, chemokines, and a fibrin scaffold derived from a patient's blood. In this study, we treated 100 thalassemic leg wounds using PRP. There was wound size reduction in patients after 4 weeks of treatment. In wounds with 2-3.5cm2 surface area, complete closure happened after 12.5weeks, 5-12cm2 wounds completely closed after 13.2weeks, and finally, 4.5-6cm2 wounds healed completely after 14weeks. None of the wounds reopened after 8months of monitoring. This study will help extrapolation of the use of PRP for at least thalassemic leg wound treatment.

Allogeneic Stem Cell Transplantation in Congenital Hemoglobinopathies Using a Tailored Busulfan-Based Conditioning Regimen: Single-Center Experience

Hematopoietic stem cell transplantation (HSCT) is the only proven curative option for patients with hemoglobinopathies, both thalassemia and sickle cell anemia (SCA). A busulfan-based myeloablative conditioning regimen is the standard of care for HSCT in these patients, although increased treatment-related morbidity, including veno-occlusive disease (VOD), has been demonstrated. Thirty-eight pediatric patients, median age 8 years (range, 6 months to 22 years), suffering from hemoglobinopathy were treated at Rambam Medical Center in Haifa, Israel, between 1998 and 2011. Thirty-four patients had thalassemia major and 4 had SCA. The 38 patients underwent 40 HSCTs, 34 of which were first transplants and 6 second transplants. Most transplants (32/40) were from matched sibling donors. Sources of stem cells were peripheral blood in 30 transplants, bone marrow in 7 transplants, and cord blood in 3 transplants. All received different customized busulfan-based conditioning regimens tailored by pharmacokinetic analysis of busulfan levels. Primary engraftment occurred in 37 of 40 transplants. Neutrophil engraftment (>.5 × 109/L) occurred at a median of 15.3 days post-transplantation (range, 10 to 45). Platelet transfusion independence (>20 × 109/L) occurred at a median of 22.3 days (range, 11 to 60). The rate of 5-year overall survival for thalassemia patients after first transplantation was 90.5% ± 5.3%. The rate of 5-year thalassemia-free survival was 81.7% ± 6.8%. Cumulative incidence of acute graft-versus-host disease (GVHD) was 17.6%. Rate of grades III to IV GVHD was 8.8%. Cumulative incidence of chronic GVHD was 23.5%, with 11.8% incidence of extensive chronic GVHD. One patient developed VOD. Full donor chimerism occurred in 36.4% of patients with class 1 + 2 thalassemia, compared with 78.6% in class 3 thalassemia (P = .049). Overall survival above 90% in patients undergoing their first transplant was demonstrated using busulfan-based conditioning regimens. The low incidence of VOD was probably due to busulfan area under the curve measurements and dose adjustment.