Elevated Blood Cell Count Research Articles

The CHIP-clinic as the catalyst of preventive medicine

Clonal Hematopoiesis of Indeterminate Potential (CHIP) is associated with an increased risk of cardiovascular diseases (CVD) and is a precursor stage to the BCR-ABL negative chronic myeloproliferative neoplasms (MPNs). These diseases are acquired stem cell neoplasms, arising due to mutations in the hematopoietic stem cell. The most prevalent is the JAK2V617F (JAK2) mutation, which potently generates reactive oxygen species (ROS), and accordingly contributes greatly to the chronic inflammatory state and the increased risk of thrombosis in MPNs. The MPNs are largely underdiagnosed blood cancers with a long pre-diagnostic phase of several years, when the elevated blood cell counts are considered reactive to smoking, blood clots, infections or chronic inflammatory diseases. Since the JAK2 mutation as CHIP-JAK2 associates with an increased risk of CVD and an increased risk of hematological and non-hematological cancers there is an urgent need to explore and validate the JAK2 mutation as a novel risk factor for CVD and to establish CHIP-clinics, which in an interdisciplinary collaboration between experts from several disciplines, and ensure timely diagnosis of the undiagnosed MPN patient and associated comorbidities. We envisage studies of the JAK2 mutation in large CVD cohorts to deliver the “Proof of Concept” for the JAK2 mutation to be implemented as a novel, highly important risk factor for CVD. These novel preventive strategies are considered to have the potential of reducing morbidity and mortality in a large population of citizens and patients, carrying the thrombosis- and CVD-promoting JAK2 mutation.

Evaluating Risk Factors for Early-onset Neonatal Sepsis

Neonatal sepsis is a systemic infection that occurs in infants at 28 days of life and is a significant cause of morbidity and death in newborns. Early-onset neonatal sepsis (EONS) occurs within 72 hours after birth and is often associated with infections contracted before or during childbirth. The study aims to evaluate the risk factors of EONS. The study design was a case-control retrospective observational study that evaluated the medical records of neonates who were admitted to the neonatal care unit of Al Islam Hospital Bandung from January 2020 to December 2022. This study assessed the impact of independent variables such as gestational age, birth weight, premature rupture of membrane (PROM), miconeal amniotic fluid, APGAR score of 5 minutes, and the mother's white blood cell count elevation (>15,000/µl). The logistic regression analyses were employed to analyze the data. The logistic regression analyses were employed to analyze the data. The study included 3,103 neonates, of whom 124 met the inclusion criteria. Thirty-nine patients (31.35%) were diagnosed with sepsis, while 85 patients (68.55%) did not have sepsis. Based on bivariate analysis, EONS was significantly linked to low birth weight (p=0.027, 95% CI=0.184 to 0.902, OR=2.455), PROM (p=0.000, 95% CI=4.359 to 26.582, OR=10.764), and the mother's white blood cell count elevation (p=0.002, 95% CI=1.560 to 7.622, OR=3.448). On multivariate analysis, the risk factors were significantly associated (p<0.05), which had an influence of 38.4% on EONS (Nagelkerke R square=0.384). In conclusion, the risk factors for EONS were low birth weight, PROM, and elevation of white blood cell count in the mother, which increased by 38.4% with EONS.

Exploring the Molecular Aspects of Myeloproliferative Neoplasms Associated with Unusual Site Vein Thrombosis: Review of the Literature and Latest Insights.

Myeloproliferative neoplasms (MPNs) are the leading causes of unusual site thrombosis, affecting nearly 40% of individuals with conditions like Budd-Chiari syndrome or portal vein thrombosis. Diagnosing MPNs in these cases is challenging because common indicators, such as spleen enlargement and elevated blood cell counts, can be obscured by portal hypertension or bleeding issues. Recent advancements in diagnostic tools have enhanced the accuracy of MPN diagnosis and classification. While bone marrow biopsies remain significant diagnostic criteria, molecular markers now play a pivotal role in both diagnosis and prognosis assessment. Hence, it is essential to initiate the diagnostic process for splanchnic vein thrombosis with a JAK2 V617F mutation screening, but a comprehensive approach is necessary. A multidisciplinary strategy is vital to accurately determine the specific subtype of MPNs, recommend additional tests, and propose the most effective treatment plan. Establishing specialized care pathways for patients with splanchnic vein thrombosis and underlying MPNs is crucial to tailor management approaches that reduce the risk of hematological outcomes and hepatic complications.

Association of Leukocyte, Erythrocyte, and Platelet Counts with Metabolic Syndrome and Its Components in Young Individuals without Overt Signs of Inflammation: A Cross-Sectional Study.

The presence of metabolic syndrome (MetS) increases the risk of developing type 2 diabetes, cardiovascular diseases, and mortality. MetS is associated with increased leukocyte or erythrocyte counts. In 16- to 20-year-old males (n = 1188) and females (n = 1231) without signs of overt inflammation, we studied whether the presence of MetS and its components results in elevated blood cell counts. The leukocyte, erythrocyte, and thrombocyte counts significantly but weakly correlated with the continuous MetS score, MetS components, uric acid, and C-reactive protein levels both in males (r = -0.09 to 0.2; p < 0.01) and females (r = -0.08 to 0.2; p < 0.05). Subjects with MetS had higher leukocyte (males: 6.2 ± 1.3 vs. 6.9 ± 1.2 × 109/L; females 6.6 ± 1.5 vs. 7.5 ± 1.6 × 109/L; p < 0.001), erythrocyte (males: 5.1 ± 0.3 vs. 5.3 ± 0.3 × 1012/L; females: 4.5 ± 0.3 vs. 4.8 ± 0.3 × 1012/L; p < 0.001), and platelet counts (males: 245 ± 48 vs. 261 ± 47 × 109/L; females: 274 ± 56 vs. 288 ± 74 × 109/L; p < 0.05) than those without MetS. With the exception of platelet counts in females, the blood counts increased with the number of manifested MetS components. Phenotypes with the highest average leukocyte, erythrocyte, or platelet counts differed between sexes, and their prevalence was low (males: 0.3% to 3.9%; females: 1.2% to 2.7%). Whether functional changes in blood elements accompany MetS and whether the increase in blood counts within the reference ranges represents a risk for future manifestation of cardiometabolic diseases remain unanswered.

Sole DNMT3A/TET2/ASXL1 Mutations Define a Distinct Clinical Trajectory for Patients with Clonal Hematopoiesis

Background: Clonal hematopoiesis of indeterminate potential (CHIP) is a clinically defined entity that is recognized by the 2022 International Consensus Classification and the 5 th Edition of the WHO. While the Clonal Hematopoiesis Risk Score (CHRS) incorporates 8 variables that underlie a prognostic framework for prediction of risk for progression to myeloid neoplasm (MN) (Weeks LD et al., NEJM Evidence 2023), there remains debate as to the role of mutations in epigenetic regulators, such as DNMT3A, TET2 and ASXL1 (“DTA”), with respect to clinical outcomes in the real-world setting. Although DTA mutations often occur early in myeloid pathogenesis, the persistence of these mutations as age-related clonal hematopoiesis (CH) might not significantly influence clinical course (Jongen-Lavrencic M et al., NEJM 2018). We have previously observed impaired clearance of DTA-mutant clones with hypomethylating agent or intensive chemotherapy for myelodysplastic neoplasms and acute myeloid leukemia (ASH abstract 4122; Blood (2022) 140 (Supplement 1): 9150-9151), and we now seek to understand the impact of sole DTA mutations in patients with CH. Methods: We studied a pre-selected group of patients who had an indication for undergoing bone marrow evaluation. Such indications included cytopenia(s), elevated blood cell count(s), staging/workup for lymphoma, and radiographic marrow abnormalities. Patients with CH were identified via concurrent morphologic, cytogenetic, and molecular diagnostics of bone marrow aspirates reviewed by UMass and Stanford Hematopathology from 2013 to 2023. CH was defined as presence of a somatic mutation with variant allele frequency (VAF) ≥ 2% on molecular diagnostics or non-myelodysplastic syndrome (MDS)-defining clonal cytogenetic aberration in a patient without morphologic evidence of MN. A total of 79 patients with CH were identified, then segregated based on presence or absence of sole DTA mutations. Results: We assessed the clinical trajectory of patients with CH who did not exclusively have DTA mutations (“non-sole DTA;” n = 58) (Panel A) compared to patients with CH who had DTA mutations alone without any other concurrent mutations (“sole DTA;” n = 21) (Panel B). The median age at detection of CH for sole DTA vs. non-sole DTA was 71.0 ± 2.11 years vs. 71.5 ± 1.45 years, respectively ( p = 0.454). Median number of mutations for sole DTA vs. non-sole DTA patients was 1.24 ± 1.2 vs. 2.24 ± 0.18, respectively ( p &amp;lt; 0.0001). Median follow-up for all patients was 450 days, and the median overall survival was not reached for either group. For non-sole DTA patients, 44 of 58 patients (76%) did not progress, while 14 of 58 patients (24%) progressed to frank MN at the time of analysis. Types of frank MN in the 14 progressors included MDS (50%), MDS/myeloproliferative neoplasm (MPN) overlap (28.6%), AML (14.3%), and MPN (7.1%). For sole DTA patients, 0 of 21 patients (0%) progressed. Regarding distribution of VAFs for sole DTA patients vs. non-sole DTA patients, mean VAF was 13.5% ± 1.91% vs. 31.6% ± 2.18%, respectively ( p &amp;lt; 0.001). For patients with both DTA mutations plus additional mutations, mean VAF for non-progressors vs. progressors was 30.4% ±1.47% vs. 38.6% ± 2.97%, respectively ( p = 0.206). For patients without any DTA mutations but with other somatic mutations, mean VAF for non-progressors vs. progressors was 29.7% ±1.67% vs. 35.2% ± 2.26%, respectively ( p = 0.160). Conclusion: In this study of pre-selected patients with CH, DTA mutations alone were insufficient for progression to frank MN. Progressors included patients with either (1) DTA mutations plus concurrent mutations, or (2) patients without DTA mutations but presence of mutations in other gene clusters. The clinical trajectory of patients with CH in our study differs from that of patients from large consortia possibly because our patients presented with an indication for testing, reflecting real-world data. A limitation of our analysis is the variability in time to recognition and diagnosis of CH, which reflects the high heterogeneity of these patients. Still, our data suggest the need for large-scale studies in the real-world setting to better prognosticate the relevance of DTA mutations for this patient population.

The gut microbiota in patients with polycythemia vera is distinct from that of healthy controls and varies by treatment.

Chronic inflammation is believed to play an important role in the development and disease progression of polycythemia vera (PV). Because an association between gut microbiota, hematopoiesis, and inflammation is well established, we hypothesized that patients with PV have a gut microbiota distinct from healthy control participants (HCs). Recombinant interferon alfa 2 (IFN-α2)-treatment of patients with PV is reportedly disease modifying in terms of normalization of elevated blood cell counts in concert with a reduction in the JAK2V617F allelic burden. Therefore, we hypothesized that patients treated with IFN-α2 might have a composition of the gut microbiota toward normalization. Herein, via amplicon-based next-generation sequencing of the V3 to V4 regions of the 16S ribosomal RNA gene, we report on an abnormal gut microbiota in 102 patients with PV compared with 42 HCs. Patients with PV had a lower alpha diversity and a lower relative abundance of several taxa belonging to Firmicutes (45%) compared with HCs (59%, P <.001). Furthermore, we report the composition of the gut microbiota to differ between the treatment groups (IFN-α2, hydroxyurea, no treatment, and combination therapy with IFN-α2 and ruxolitinib) and the HCs. These observations are highly interesting considering the potential pathogenetic importance of an altered gut microbiota for development of other diseases, including chronic inflammatory diseases. Our observations call for further gut microbiota studies to decipher potential causal associations between treatment and the gut microbiota in PV and related neoplasms.

Myeloproliferative neoplasms - blurring the lines between cancer and chronic inflammatory disorder.

Myeloproliferative Neoplasm (MPN) is a group of chronic blood cancers that arise from a hematopoietic stem cell (HSC) clone with somatic mutations causing constitutive activation of myeloid cytokine receptor signaling. In addition to elevated blood cell counts, MPN typically presents with increased inflammatory signaling and inflammation symptoms. Therefore, while being a clonally derived neoplasm, MPN has much in common with chronic non-cancerous inflammatory conditions, such as rheumatoid arthritis, lupus, and many more. MPN and chronic inflammatory disease (CID) share similar chronicity, symptoms, dependency on the immune system, environmental triggers, and treatments. Overall, we will highlight the similarities between an MPN and CID. We highlight that while MPN is classified as a cancer, its behavior is more aligned to that of a chronic inflammatory disease. We propose that MPN should inhabit a fluid/spectrum between auto-inflammatory disease and cancer.

Myeloproliferative neoplasms and splanchnic vein thrombosis: Contemporary diagnostic and therapeutic strategies.

Myeloproliferative neoplasms (MPNs) are the most common etiologies of primary splanchnic vein thrombosis, present in almost forty percent of patients with Budd-Chiari syndrome or portal vein thrombosis. Diagnosis of MPNs can be difficult in these patients because key characteristics, such as elevated blood cell counts and splenomegaly, are confounded by portal hypertension or bleeding complications. In recent years, diagnostic tools have improved to provide more accurate diagnosis and classification of MPNs. Although bone marrow biopsy findings remain a major diagnostic criterion, molecular markers are playing an increasing role not only in diagnosis but also in better estimating prognosis. Therefore, though screening for JAK2V617F mutation should be the starting point of the diagnostic workup performed in all patients with splanchnic vein thrombosis, a multidisciplinary approach is needed to accurately diagnose the subtype of myeloproliferative neoplasm, recommend the useful additional tests (bone marrow biopsy, search for an additional mutation using targeted next-generation sequencing), and suggest the best treatment strategy. Indeed, providing a specific expert care pathway for patients with splanchnic vein thrombosis and underlying myeloproliferative neoplasm is crucial to determine the optimal management to reduce the risk of both hematological and hepatic complications.

Comparison of diagnosis and treatment of MSSA and MRSA osteomyelitis in children: a case–control study of 64 patients

BackgroundWe aimed to compare the clinical characteristics of acute osteomyelitis caused by methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA) in children.MethodsWe retrospectively analyzed the data of 64 children treated between September 2017 and June 2021. Based on the bacterial culture results, they were divided into MRSA and MSSA infection groups. Both groups were treated with debridement and vacuum-assisted closure for negative pressure drainage. Parameters including clinical manifestations, number of operations, length of hospital stay, inflammatory indicators, and concurrent arthritis were compared between the two groups.ResultsIn the MRSA infection group, there was one case each of residual joint stiffness and pathological fracture. Conversely, the MSSA group had two cases of residual joint stiffness. The MRSA infection group was more prone to high fever (t = 3.61, P = 0.001), white blood cell count elevation (t = 2.41, P = 0.022), arthritis (X2 = 7.48, P = 0.013), metastatic abscess (X2 = 4.78, P = 0.042), and a shorter length of progression from onset to admission (t = − 2.04, P = 0.046); however, it required more surgeries (t = 2.68, P = 0.009) and longer hospital stay (t = 2.04, P = 0.045).ConclusionsPediatric acute osteomyelitis caused by MRSA is more prone to cause high fever and markedly elevated of white blood cell count, and is often accompanied with suppurative infection of adjacent joints and metastatic abscesses, thus requiring more surgeries and longer hospital stay.

Phase Ⅱ,Open-Label, Multicenter, Single-Arm Study Investigating the Efficacy and Safety of Ropeginterferon Alfa-2b in Chinese Patients with Polycythemia Vera Resistant or Intolerant to Hydroxyurea(HU)

Background: Polycythemia vera (PV) is a common type of BCR-ABL-negative myeloproliferative neoplasms. It often harbors a Janus kinase 2 (JAK2) gene mutation and is associated with elevated blood cell counts, symptoms that can be debilitating over time and risks of thrombosis and hemorrhage, and disease progression to myelofibrosis and acute myeloid leukemia. Ropeginterferon alfa-2b, a novel, site-selective, mono-pegylated proline-interferon alfa-2b, has improved pharmacokinetic properties, allowing dosing every 2 to 4 weeks, with improved tolerability and convenience. The safety and efficacy of ropeginterferon alfa-2b for the treatment of PV has been demonstrated in clinical studies conducted in Europe (PEGINVERA, PROUD-PV, CONTINUATION-PV) and Japan. The approved dosing scheme of ropeginterferon alfa-2b is 100 μg (or 50 μg in patients under another cytoreductive therapy) as a starting dose, with dose increment of 50 μg to the maximum recommended dose of 500 μg. Faster dose escalation may help patients achieve control of hematologic parameters quicker. Aims: The aim of this phase Ⅱ, single-arm study (A20-202) was to assess the safety and efficacy of ropeginterferon alfa-2b in Chinese PV patients utilizing an accelerated dose titration schedule. Methods: Chinese patients 18 years or older with a PV diagnosis according to World Health Organization 2016 criteria and were resistant or intolerant to hydroxyurea (HU) were enrolled. Ropeginterferon alfa-2b was administered subcutaneously every 2 weeks for 52 Weeks at a starting dose of 250 μg, followed by 350 µg at Week 2, and a target dose of 500 μg at Week 4. Patients received the target dose, if tolerated, for the remainder of the 52-week treatment. The primary endpoint was the proportion of patients who reach a complete hematologic response (CHR) at Week 24 (CHR: hematocrit <45% without phlebotomy or erythrocyte apheresis in the preceding 12 weeks, platelet≤400×109/L, leukocyte <10×109/L). Secondary endpoints included changes in hematologic parameters and JAK2V617F allele burden, time to first complete hematologic response, and duration of response. Safety endpoints included the incidence of treatment-emergent adverse events (TEAEs) and adverse events of special interest (AESI). Results: As of the data cut-off date of 01 July 2022, a-total of 49 patients, 31 males and 18 females, with a median age of 56 years, were enrolled in this study. Mean baseline values were hematocrit 45.95%, leukocyte count 11.35×109/L, and platelet count 478.5×109/L. All patients had the JAK2V617F mutation (mean allele burden: 58.49%). One patient withdrew consent and discontinued the study. The data of 27 patients were available to evaluate the CHR at Week 24. Fourteen out of the 27 (51.85%) patients achieved a CHR at Week 24 of the treatment. This was comparable to the CHR rate of 43.1% at Week 52 observed in the PROUD-PV study. Hematocrit, leukocyte and platelet levels decreased over time with mean change ± SD from baseline to Week 24: -3.63± 6.14%, -5.77± 12.22×109/L, and -254.0± 177.23×109/L, respectively. JAK2V617F allele burden decreased over time with mean change ± SD from baseline to week 24: -13.95±16.74% (n=26); consistent with an increase in molecular response. The JAK2V617F allele burden in two patients became undetectable after the treatment, as measured by Next-Generation Sequencing with a lower limit of quantitation at 3% by the central laboratory. TEAEs occurred in 47 patients (95.9%). Grade≥3 AEs occurred in 8 of the patients (16.3%) and among them, possibly treatment-related Grade ≥ 3 AEs occurred in five patients (10.2%). Serious adverse events (SAE) occurred in 4 of the patients (8.2%), and possibly treatment-related SAE occurred in two patients (4.1%). The most common TEAEs were alanine aminotransferase increase (38.8%), leukopenia (36.7%) and aspartate aminotransferase increase (36.7%). Preliminary result did not show significant AESIs (e.g., cardiovascular and psychiatric events) in all the patients who received the treatment. Summary/Conclusion: The interim results of our study demonstrate that Ropeginterferon alfa-2b using a 250-350-500 μg dosing scheme was safe, well tolerated, and efficacious in Chinese patients with PV. The data suggest that using an accelerated dosing scheme helps patients achieve a CHR earlier.

Analysis of the Platelet Proteome Reveals Insights into the Pro-Inflammatory and Pro-Thrombotic State Associated with the Philadelphia Chromosome-Negative Myeloproliferative Neoplasms

Introduction: Hypercoagulability, thrombosis and microvascular dysfunction are hallmarks of the Philadelphia chromosome-negative myeloproliferative neoplasms (MPN). Elevated peripheral blood cell counts appear to contribute to thrombotic risk but the precise underlying mechanisms remain to be fully elucidated. The interplay between haemostatic and pro-inflammatory pathway activity ('thrombo-inflammation') has emerged in recent years as a source of hypercoagulability in MPN. Platelets are recognised as being mediators of thrombo-inflammation in other diseases and may also be effectors of pro-inflammatory/pro-coagulant activity in MPN. We hypothesized that the platelet proteome is altered in MPN and that its characterisation would reveal insights into the pathophysiology of the disease and the associated thrombotic risk. Aim: To determine if differences exist in the pattern of platelet protein expression in patients with polycythaemia vera (PV) and essential thrombocythaemia (ET) in contrast to healthy donors. Methods: 62 patients (ET, n=38; PV, n=24) and 9 healthy volunteers were recruited at Papa Giovanni XXIII Hospital, Bergamo, Italy and the Mater Misericordiae University hospital, Dublin, Ireland. Platelets were isolated from platelet rich plasma, washed in Krebs Ringer buffer and resuspended at 1x 109 platelets/mL in phosphate buffered saline. Whole platelets were lysed in RIPA buffer and differential proteomic signatures established using label-free quantification (LFQ) mass spectrometry (MS), where platelet lysate proteins were double digested using the commercially available PreOmics kit and analysed in a Bruker TimsTOF mass spectrometer connected to a EvoSep liquid chromatography system. Identified peptides were searched against a human FASTA using MaxQuant. For statistical analysis, proteins identified in a minimum of 70% of samples in at least one group were included. Differences in protein expression were determined using an unpaired t-test with a false discovery rate of 5% and a minimal fold change of 0.1 within the Perseus software; p- values below 0.05 were considered significant. Results: 2,180 proteins from platelet lysates were quantified across all patient and control samples. In MPN platelet lysates, 49 proteins were found to be differentially expressed in comparison to controls (p< 0.05) (Figure 1), including increased expression of markers of platelet activity such as vesicle-associated membrane protein 7 (VAMP-7; regulator of granule exocytosis and actin cytoskeleton activity) and CD109 (a GPI-linked glycoprotein expressed by activated platelets). Bioinformatical analysis revealed a cohort of mitochondrial, cytoskeletal & ribosomal proteins as well as potential effectors of thrombopoiesis and thrombo-inflammation which were significantly upregulated in the MPN cohort. Strikingly, protein disulfide-isomerase (PDI, a member of the thioredoxin superfamily of redox proteins) was increased in MPN lysates. PDI has been shown to contribute to thrombosis, platelet activation and platelet-neutrophil interactions in vivo; plasma levels of PDI have been shown to be increased in MPN and are associated with thrombosis risk. Conclusion: The platelet proteome is altered in MPN and is suggestive of an activated platelet phenotype with over-expression of proteins with known pro-coagulant activity. To our knowledge the over expression of PDI in MPN platelets has not previously been described. The identification of differentially expressed proteins, such as PDI, provides mechanistic insights into the pathophysiology underlying the substantial burden of arterial and venous thrombosis in MPN and may also assist in the identification of novel therapeutic targets. Additional proteomic analysis of platelet releasate and plasma extracellular vesicles is currently ongoing and may provide additional pathophysiological insights. Figure 1: Volcano plot of MPN versus control platelet lysate proteomes (x-axis, t-test difference between the mean log2 of the LFQ values; y-axis, the negative log transformed p-value) representing the proteins significantly altered in MPN. Black hyperbolic curves show the threshold for statistical significance. 36 proteins were found to be increased in MPN platelet lysates (including CD109, PDIA4 and VAMP-7) in comparison to control lysates (red) while 13 proteins were decreased in MPN platelet lysates (blue). Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

A novel integrated biomarker index for the assessment of hematological responses in MPNs during treatment with hydroxyurea and interferon-alpha2.

Conventional cytoreductive therapy for patients with chronic Philadelphia-negative myeloproliferative neoplasms (MPNs) includes hydroxyurea (HU), interferon-alpha2 (IFN), and anagrelide. HU is worldwide the most used cytoreductive agent, which lowers elevated blood cell counts within days in the large majority of patients. However, some patients may experience rebound cytosis when HU is reduced due to cytopenia, thereby potentially giving rise to fluctuating cell counts during therapy. Such rapid oscillations may be harmful and potentially elicit thrombosis. Treatment with IFN gradually lowers elevated cell counts within weeks and when the dosage is reduced, the cell counts do not rapidly increase but are sustained within the normal range in the large majority of patients. Conventional hematological response criteria are among others based upon single absolute cell count values and do not take into account the relative decreases toward normal for each cell count. Using serial data from the Danish DALIAH trial, we herein describe a novel integrated biomarker index for the assessment of hematological and molecular (JAK2V617F) responses in patients with MPNs during treatment with IFN or HU. This novel tool convincingly displays the superiority of IFN versus HU in normalizing elevated cell counts. Our results need to be validated in larger studies but already now call for studies of the safety and efficacy of combination therapy during the initial treatment of patients with MPNs.

Effect of Tribulus terrestris L. supplementation on Exercise-Induced Oxidative Stress and Delayed Onset Muscle Soreness Markers: A Pilot Study

Tribulus terrestris L. contains compounds with antioxidant and anti-inflammatory properties, but its effects on exercise-induced oxidative stress and inflammatory responses are unclear. The aim of this study was to examine whether Tribulus terrestris L. supplementation can attenuate oxidative stress and inflammatory responses to acute aerobic exercise and improve DOMS. In a randomized, double-blind, crossover design study, thirteen healthy men received either a daily supplement of Tribulus terrestris L. or a placebo for 4 weeks (2-week wash-out period between trials). Before and after the supplementation periods, participants performed an exercise test to exhaustion (75% VO2max). DOMS, thigh girth, and knee joint range of motion (KJRM) were assessed before and after the exercise (2, 24, and 48 h). Blood samples were analyzed for reduced (GSH) and oxidized (GSSG) glutathione, GSH/GSSG ratio, protein carbonyls, total antioxidant capacity, creatine kinase activity, white blood cell count, and TBARS. Acute exercise to exhaustion induced inflammatory responses and changed the blood redox status in both Tribulus and Placebo groups (p < 0.050). Tribulus terrestris L. improved GSH fall (p = 0.005), GSSG rise (p = 0.001) and maintained a higher level of GSH/GSSG ratio at the 2 h point (p = 0.034). TBARS were lowered, protein carbonyls, creatine kinase activity, and white blood cell count elevation diminished significantly (p < 0.050). Tribulus terrestris L. administration did not affect DOMS, thigh girth, or KJRM (p > 0.050). 4-weeks of Tribulus terrestris L. supplementation effectively attenuates oxidative stress responses but cannot improve DOMS.

Erythroid lineage Jak2V617F expression promotes atherosclerosis through erythrophagocytosis and macrophage ferroptosis.

Elevated hematocrit is associated with cardiovascular risk; however, the causality and mechanisms are unclear. The JAK2V617F (Jak2VF) mutation increases cardiovascular risk in myeloproliferative disorders and in clonal hematopoiesis. Jak2VF mice with elevated WBCs, platelets, and RBCs display accelerated atherosclerosis and macrophage erythrophagocytosis. To investigate whether selective erythroid Jak2VF expression promotes atherosclerosis, we developed hyperlipidemic erythropoietin receptor Cre mice that express Jak2VF in the erythroid lineage (VFEpoR mice). VFEpoR mice without elevated blood cell counts showed increased atherosclerotic plaque necrosis, erythrophagocytosis, and ferroptosis. Selective induction of erythrocytosis with low-dose erythropoietin further exacerbated atherosclerosis with prominent ferroptosis, lipid peroxidation, and endothelial damage. VFEpoR RBCs had reduced antioxidant defenses and increased lipid hydroperoxides. Phagocytosis of human or murine WT or JAK2VF RBCs by WT macrophages induced ferroptosis, which was prevented by the ferroptosis inhibitor liproxstatin-1. Liproxstatin-1 reversed increased atherosclerosis, lipid peroxidation, ferroptosis, and endothelial damage in VFEpoR mice and in Jak2VF chimeric mice simulating clonal hematopoiesis, but had no impact in controls. Erythroid lineage Jak2VF expression led to qualitative and quantitative defects in RBCs that exacerbated atherosclerosis. Phagocytosis of RBCs by plaque macrophages promoted ferroptosis, suggesting a therapeutic target for reducing RBC-mediated cardiovascular risk.

Asymptomatic deep venous thrombosis identified on routine screening in patients with hospitalized neurological diseases

PurposePatients with neurological diseases are potentially at high risk for developing deep venous thrombosis (DVT). We sought the prevalence and clinical background of patients with neurological diseases in whom DVT was detected during hospitalization. MethodsConsecutive patients admitted due to neurological diseases were prospectively registered. Those who were at risk for DVT were screened using venous duplex ultrasonography of the lower extremities. Predictors for DVT detection were analyzed. ResultsDuring the study period, 192 of 785 patients received duplex ultrasonography. There were 34 patients with DVT identified (18%, age 63 ± 17 years). Three patients had DVT in the popliteal or femoral vein and the others had below the knee; all of the DVT were asymptomatic. DVT was observed most frequently in patients with systemic vasculitis, followed by demyelinating disease. In patients with DVT, the median D-dimer level was 2.1 µg/mL. On multiple logistic regression analysis, female ([odds ratio, 95% confidence interval] 3.2, 1.2–8.4), supine or sitting position for > 48 h (5.3, 1.8–15.0), D-dimer level ≥ 2.0 µg/mL (6.2, 2.3–16.4), and white blood cell count ≥ 7,600 (4.2, 1.6–11.3) were independent predictors of DVT detection at the first screening ultrasonography. DVT was detected in 1, asymptomatic pulmonary embolism was detected in 2, and both in 1 on chest computed tomography. ConclusionDVT is not rare in patients with neurological diseases. Clinicians should be mindful of subclinical DVT in hospitalized neurological disease patients with decreased daily activity and elevated D-dimer levels or blood cell counts, especially in women.

Long-Term Outcome After Tacrolimus-Related Neurotoxicity in Pediatric Living Donor Liver Transplantation

Tacrolimus-related neurotoxicity is a serious complication. Posterior reversible encephalopathy syndrome, which is severe neurotoxicity after pediatric living donor liver transplantation (LDLT), is a medication-induced complication related to calcineurin inhibitors. The purpose of this study was to evaluate the long-term outcome of tacrolimus-related neurotoxicity after pediatric LDLT. Pediatric patients who underwent LDLT between 2007 and 2020 at our institution and developed neurologic symptoms with tacrolimus were included in the study. Tacrolimus-related encephalopathy was defined as encephalopathy that resolved after tacrolimus was discontinued. All patients received tacrolimus and a steroid for immunosuppression starting just after LDLT. During the study period, 128 patients underwent LDLT. All patients received tacrolimus and a steroid. Six patients (5%) developed tacrolimus-related encephalopathy. The median age at transplant was 1.6 years. The original diseases were biliary atresia (n=5) and progressive familial intrahepatic cholangiopathy type 2 (n=1). Patients developed encephalopathy at a median of 9 days after LDLT. All patients recovered with conversion to cyclosporine. Posterior reversible encephalopathy syndrome was confirmed by magnetic resonance imaging in 3 patients. The mean tacrolimus level at encephalopathy was 11 ng/dL (range, 5.6-14.6 ng/dL). White blood cell count elevation was observed in all patients. One patient died of pancreatitis. Surviving patients (n=5) were followed for a median of 9 years. All patients resumed tacrolimus a median of 8 months from onset. No neurologic complications were observed after resuming tacrolimus. We observed tacrolimus-induced encephalopathy in 5% of patients after pediatric LDLT. Patients can resume tacrolimus safely without further neurologic symptoms.

Abstract 14224: JAK2V617F Red Blood Cells Promote Atherosclerosis and Thrombosis

Elevated hematocrit is associated with cardiovascular risk; however, the causality and mechanisms are unclear. The JAK2V617F (JAK2VF) mutation markedly increases cardiovascular risk both in myeloproliferative disorders with elevated blood cell counts and in the much more prevalent clonal hematopoiesis of indeterminate potential with normal blood cell counts. Jak2VF mouse models with elevated white blood cells (WBC), platelets and red blood cells (RBCs) display accelerated atherosclerosis. However, whether Jak2VF RBCs promote atherogenesis and thrombosis independently from increased WBC and platelets remains uncertain. We used Erythropoietin Receptor (EpoR) Cre recombinase to generate a conditional knock-in of murine Jak2VF (VFEpoR) in the RBC lineage. Hyperlipidemic VFEpoR mice without elevated blood cell counts showed accelerated arterial thrombosis and increased atherosclerotic plaque necrosis. Induction of erythrocytosis with low dose erythropoietin (EPO) without concomitant leukocytosis or thrombocytosis further worsened thrombosis and atherosclerosis. VFEpoR atherosclerotic lesions featured endothelial barrier breakdown, RBC infiltration, iron deposition, lipid peroxidation, macrophage erythrophagocytosis and macrophage ferroptosis. VFEpoR RBCs had reduced antioxidant defenses and contained increased ROS and lipid hydroperoxides. Phagocytosis of murine or human WT or Jak2 VF RBCs by WT macrophages induced lipid peroxidation and ferroptotic death that was prevented by the ferroptosis inhibitor Liproxstatin-1. Ferroptosis inhibition reversed increased atherosclerosis and necrotic core formation in VFEpoR mice but had no impact in controls. These studies demonstrate that both qualitative and quantitative defects in Jak2VF RBCs accelerate atherosclerosis and thrombosis. Phagocytosis of WT or Jak2VF RBCs by macrophages leads to ferroptotic cell death, suggesting ferroptosis as a new therapeutic target to reduce RBC-mediated cardiovascular risk.

IT'S BEEN ON MY NECK FOR YEARS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Initial patient encounters with patients who are poor historians can be extremely challenging. Physical exam is of utmost importance. The nature, history and prognosis of exophytic melanoma has been extremely controversial and uncertain. CASE PRESENTATION: A 91 year old Caucasian female with no apparent medical comorbidities who had not seen a physician in 30 years presented to the emergency department after her family stated they could no longer care for her. Initial chest X-ray revealed a large mass like opacity over the left lung apex. She also had a urinary tract infection. She was started on Ceftriaxone and admitted to internal medicine. Upon our exam, after examining her neck and removing her bandage, we found an external exophytic, pedunculated mass from the inferior lateral left neck measuring 4.6 x 3.7 x 5.7 cm which was concerning for malignancy. The mass was pulsatile and bleeding from certain areas without evidence of frank hemorrhage. A CT scan was then pursued which reinforced our physical exam findings. Upon further questioning of the patient and her family, it was reported that said mass had been present for 10 + years and they had always covered it up with abdominal pads without seeking medical attention. There was no white blood cell count elevation indicating infectious foci. General surgery was consulted for excision and pathology. She was taken to the operating room the next day and the lesion was excised at skin zone 2 of the neck with a margin of skin and normal subcutaneous tissue around it. The excised mass measured 15 x 15 x 20 cm (L x W x H). The patient was discharged to a nursing home in a stable fashion. Her pathology came back for ulcerated malignant melanoma with negative margins. Histologic type was nodular melanoma. Maximum Breslow thickness of 17mm with no microsatellites. The distance of invasive melanoma from closest peripheral margin of 10mmwith mitotic rate of 8 per mm2. Tumor infiltrating lymphocytes were present with no tumor regression. The tumor cells demonstrated strong positivity for SOX10 and Melan-A stain and focally positive for HMB-45. DISCUSSION: Nodular melanoma accounts for less than 15% of all melanomas. Usual prognostic indicators in melanoma are driven by histologic subtype with thickness being neglected. Nodular melanoma, however, has been known to include thickness as a prognostic factor. Majority of these cases have reported metastasis and poor prognosis. CONCLUSIONS: With our patient being neglected, she still had only local disease and after tumor removal, no adjunctive therapy was needed. Clinicians should be made aware and on the lookout for different types of melanomas and their respective presentations. REFERENCE #1: Clark WH, Elder DE, Guerry D, Epstein MN, Greene MH, Van Horn M. A study of tumor progression: The precursor lesions of superficial spreading and nodular melanoma. Hum Pathol. 1984;15(12):1147-1165. doi:10.1016/S0046-8177(84)80310-X REFERENCE #2: Shaikh WR. The Contribution of Nodular Subtype to Melanoma Mortality in the United States, 1978 to 2007. Arch Dermatol. 2012;148(1):30. doi:10.1001/archdermatol.2011.264 DISCLOSURES: No relevant relationships by Ahmad Abu Hashyeh, source=Web Response No relevant relationships by Mohamed Suliman, source=Web Response no disclosure on file for Toufeeq Suliman

Data-driven analysis of the kinetics of the JAK2V617F allele burden and blood cell counts during hydroxyurea treatment of patients with polycythemia vera, essential thrombocythemia, and primary myelofibrosis.

Hydroxyurea (HU) treatment of patients with essential thrombocythemia (ET), polycythemia vera (PV), and primary myelofibrosis (PMF) (MPNs) normalizes elevated blood cell counts within weeks in the large majority of patients. Studies on the impact of HU upon the kinetics of the JAK2V617F allele burden, leukocyte, and platelet counts over time are scarce. Using data-driven analysis as a novel tool to model the kinetics of the JAK2V617F allele burden and blood cell counts over time during treatment with HU. Using serial measurements of JAK2V617F and correlation analysis of routine hematological values (the Hb-concentration, leukocyte count, platelet count, and lactic dehydrogenase), we present a detailed description and analysis of the kinetics of the JAK2V617F, leukocyte, and platelet counts and lactic dehydrogenase in 27 patients (PV=18; ET=7; PMF=2), who were followed in the Danish randomized trial (DALIAH). To further analyze the JAK2V617F kinetics, we use a machine learning clustering algorithm to group the response patterns. Response patterns were highly heterogeneous, with clustering resulting in 3 groups and 3 outliers. In the large majority of patients, HU treatment was initially associated with a modest decline in the JAK2V617F allele burden in concert with a decline in leukocyte and platelet counts. However, HU did not induce a sustained and continuous decrease in the JAK2V617F allele burden. Using data-driven analysis of the JAK2V617F allele burden, leukocyte, and platelet kinetics during treatment with HU, we have shown that HU does not induce a sustained decrease in the JAK2V617F allele burden and neither induces sustained normalization of elevated cell counts in MPN patients. Our results may explain why MPN patients during treatment with HU still have a substantially increased risk of thrombosis.

Myeloproliferative neoplasms: Classifications and an approach to diagnosis.

Myeloproliferative neoplasms (MPNs) are a group of illnesses that share a tendency to transform into myelofibrosis and acute leukaemias. Their initial presenting symptoms may be non-specific, which can make diagnosis difficult without astructured approach. The aim of the article is to provide general practitioners (GPs) insight intothe classification and clinical approach to diagnosis of MPNs. An elevated peripheral blood cell count is often among the first presenting features of an MPN. Although MPNs are rare illnesses, the GP is well placed to identify suspicious features and initiate investigations and referral. It is therefore important for GPs to have an approach todifferentiating between reactive and neoplastic causes of elevated blood cellcounts.