Higher White Blood Cell Count Research Articles

Frequency of Occurrence of Leukocytosis in Patients with Acute Exacerbation of Copd at a Tertiary Centre

COPD is a major cause of chronic morbidity and mortality; it is currently the fourth highest cause of death in the world, and is predicted to be the third leading cause of mortality worldwide by the year 2020 [1-2]. COPD is identified mainly according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines; [post bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity ratio less than 0.7; severity determined by FEV1 alone] combined with a history of exposure to risk factors [2]. Exacerbations of respiratory symptoms in COPD are of major importance because of their profound and long lasting adverse effects on patients [3]. Frequent episodes accelerate loss of lung function, affect the quality of life of patients, and are associated with poor survival. There are some specific blood biomarkers for predicting lung function decline, acute exacerbation, or even mortality from big longitudinal cohort studies. However, their performance is depressing [4] . Peripheral blood leukocytosis has already been well investigated in the aspect of inflammatory biomarkers for COPD. The level of leukocytes is a key parameter in the clinical assessment of patients with COPD exacerbation, with and without fever. The presentation of high WBC count makes it important to distinguish the effect of the glucocorticosteroid from the effect of the possible infection [5-7].

Infantile B-cell acute lymphoblastic leukaemia with the highest recorded count of white blood cells in the literature: case report and literature review

Introduction: Infantile leukaemia is an uncommon haematological cancer that manifests within the first year of life. This malignancy is highly aggressive and possesses distinctive immunophenotypic, cytogenetic, and molecular attributes. It can originate from either myeloid or lymphoid cells. It often exhibits a higher incidence among females. Case presentation: A 1-month-old male infant, initially seemingly healthy, presented with irritability and feeding difficulties. Born without complications, routine neonatal assessments appeared normal, and physical examination revealed no abnormalities. However, laboratory tests indicated an extremely high white blood cell count, low platelets, and elevated haemoglobin. Further examinations showed a white blood cell count of 1450 × 106/l with a blood film revealing significant leukocytosis dominated by blast cells. Abdominal ultrasound confirmed hepatosplenomegaly which was not present during pregnancy. Subsequent bone marrow analysis and flow cytometry established a diagnosis of B-cell acute lymphoblastic leukaemia (B-ALL). Clinical discussion: It is rare for infantile ALL to manifest within the first month after birth. In most cases, the diagnosis is established before birth. When characteristic signs such as hepatosplenomegaly, leukaemia cutis, or infiltrative involvement of the extramedullary and central nervous systems are present, postnatal diagnoses are relatively straightforward. However, there are instances where children present with non-specific and ambiguous symptoms that resemble other medical conditions. Conclusion: This case underscores the importance of paediatricians being vigilant and attuned to the subtle indicators that differentiate common illnesses from serious conditions such as infantile ALL.

Real-Time PCR-Based Screening for Homozygous SMN2 Deletion Using Residual Dried Blood Spots.

The survival motor neuron 2 (SMN2) gene is a recognized modifier gene of spinal muscular atrophy (SMA). However, our knowledge about the role of SMN2-other than its modification of SMA phenotypes-is very limited. Discussions regarding the relationship between homozygous SMN2 deletion and motor neuron diseases, including amyotrophic lateral sclerosis, have been mainly based on retrospective epidemiological studies of the diseases, and the precise relationship remains inconclusive. In the present study, we first estimated that the frequency of homozygous SMN2 deletion was ~1 in 20 in Japan. We then established a real-time polymerase chain reaction (PCR)-based screening method using residual dried blood spots to identify infants with homozygous SMN2 deletion. This method can be applied to a future prospective cohort study to clarify the relationship between homozygous SMN2 deletion and motor neuron diseases. In our real-time PCR experiment, both PCR (low annealing temperatures) and blood (high hematocrit values and low white blood cell counts) conditions were associated with incorrect results (i.e., false negatives and positives). Together, our findings not only help to elucidate the role of SMN2, but also aid in our understanding of the pitfalls of current SMA newborn screening programs for detecting homozygous SMN1 deletions.

Hyperleukocytosis Increases the Risk of Early Relapses Independently of Genetics in AML

Background. Higher white blood cell (WBC) count at diagnosis is associated with specific gene lesions and higher early death rates in AML patients (pts) treated intensively. Whether higher WBC count at diagnosis affects outcome beyond remission independently of genetics is unknown. Methods. 1,371 AML pts treated intensively in 3 ALFA trials (0702 18-60y, 0701 50-70y, 1200 60y+) with centralized genetics were studied. Genetic alterations found in >5% of pts (n=22) were analyzed. Hyperleukocytosis (HL) was defined as WBC > 50 x10 9/L. NPM1 MRD was stratified as published (Balsat, J Clin Oncol 2017). All prognostic analyses were stratified on trial. Time-dependent effects were introduced in multivariable Cox models when the proportional hazard (PH) assumption was violated. Results. The median WBC count at diagnosis was 7.1 x10 9/L (range 0.3-546.6), and 235 pts (17.1%) had HL. HL pts had poorer performance status (p<0.001), lower platelet counts (p=0.003), higher frequency of de novo AML (p=0.006) and more favorable genetic risk (ELN 2022 criteria, p<0.001). In a multivariable model, HL was independently associated with more frequent NPM1, FLT3-ITD and -TKD mutations, and less frequent STAG2 and -17/17p- alterations (all p<0.05, Figure 1A). Complete remission (CR [including CR with incomplete platelet recovery, CRp]) and early death (ED) rates were 77.4 vs 80.0% (p=0.38) and 8.9 vs 5.0% (p=0.03) in pts with and without HL, respectively (resp). In a multivariable model accounting for ELN22 risk and age, HL was independently associated with more frequent ED (OR =2.20, 95%CI 1.26-3.75, p=0.004), and a trend to more frequent primary induction failure (OR=1.40, 95%CI 0.95-2.05, p=0.08). In the 1,091 pts achieving CR/CRp (182 and 909 with and without HL resp), 1-y and 2-y cumulative incidence of relapse were 39.0% vs 26.1% and 44.0% vs 40.2% resp, suggestive of a time-dependent effect of HL on post-remission outcome ( Figure 1B). Considering relapse and death as competing events, a multivariable model revealed a significant impact of HL on relapse (subdistribution hazard ratio, sHR=1.59, p=0.0003), independent of ELN22 risk and age, but not on non-relapse mortality (sHR=0.69, p=0.23). HL violated the PH assumption in a univariable Cox model for DFS (p=0.0003). We thus performed multivariable Cox models for DFS separating early (< 1 year from CR) and late (≥1 year) effects for HL. In a multivariable time-dependent model, HL significantly impaired early (HR=1.89, p<10 -4), but not late (HR=0.79, p=0.29) DFS, independently of ELN risk and age. These results were confirmed considering WBC count as a (log-transformed) continuous variable, accounting for all differentially represented genetic lesions instead of ELN22 risk or censoring at allogeneic HCT. In a validation cohort of 1,089 pts <60y reaching CR after intensive chemotherapy in the BIG-1 trial (NCT02416388) where median WBC was 7.7 x10 9/L and 16.1% of pts were HL, the adverse risk of HL on CIR (sHR=1.39, p=0.007) but not NRM (sHR=1.02, p=0.95) and on early (HR=1.42, p=0.01), but not late (HR=1.24, p=0.23) DFS independent of ELN22 risk and age was validated. Finally, to explore the mechanism underlying the higher early relapse rate of HL pts, we analyzed NPM1 MRD (n=152) and LSC17 (n=504) data from the 0702 trial. A higher WBC count was predictive of suboptimal MRD (OR=1.97, p=0.05) independently of FLT3-ITD status. A higher WBC count was significantly correlated to lower LSC17 score (Spearman rho=0.23, p<10-5). Conclusion. A high WBC count at diagnosis predicts higher rates of early, but not late relapse, independent of genetic risk. Our results strengthen the hypothesis that distinct biological mechanisms underpin early vs late chemoresistance in AML.

Genomic Characterization of Acute Myeloid Leukemia with Aberrations of Chromosome 7: A Multinational Cohort of 523 Patients

Introduction: Aberrations of chromosome 7 [abn(7)] are found in ≈ 10% of newly diagnosed acute myeloid leukemia (AML) and associate with a dismal prognosis. A large-scale comprehensive exploration of the underlying genetic heterogeneity in AML with abn(7) has yet to be performed and could add essential insights into the outcome of this poorly understood patient group. Methods: We collected diagnostic samples from 523 adult AML patients (median age 59 years) with abn(7). Whole-exome sequencing (WES) was performed to discover potentially underestimated genetic lesions in 61 paired diagnostic / remission samples. Subsequently, a gene panel including 66 genes and a SNP backbone for copy-number aberration (CNA) detection was designed and applied to the remaining 471 samples. The majority of patients (78%) were diagnosed with de novo (dn) AML, whereas 22% had secondary (s) or therapy-related (t) AML. Intensive induction treatment was administered to 80% of the patients, while 36 % underwent allogenic stem cell transplantation. Apart from 43% of patients with concomitant complex karyotype (abn(7)/CK+), 24% had -7 as a sole abnormality (-7 sole) and 13% del(7q) sole. Results: A mean of 15.3 single-nucleotide variants (SNVs) and 7.5 CNAs per patient were found by WES. Here, the most frequent recurrent SNVs were identified in TP53 (29.5%), followed by mutations (mut) in genes involved in epigenetic regulation ( DNMT3A, TET2, ASXL1, IDH2), transcription factors ( RUNX1), and genes affecting RAS-signaling ( NF1, KRAS), Figure 1. Targeted sequencing revealed 1829 SNVs with a VAF≥ 2% in 64 genes (mean: 3.8 SNVs / patient). 30% of patients harbored at least one mutation in genes located within the commonly deleted region of 7q, most frequently KMT2C, EZH2CUX1, SAMD9L, SAMD9, LUC7L2 and BRAF. The number of driver gene mutations was higher in CK- than in CK+ patients (4.5 vs. 3.3 SNVs). We found KRAS (OR 3.76, CI 1.17-16.87, P= .044) and RUNX1 (OR 3.61, CI 1.62-8.78, P= .003) mutations to be enriched in -7 sole patients, and FLT3 mutations to be associated with del(7q) sole status (OR 0.33, CI 0.13-0.82, P= .019). With respect to previously unknown lesions, a high amount of KMT2C mutations (16.6%) and recurrent alterations in FAT1 and TACC2 were discovered (6.4% each; Fig. 1). For KMT2C - located on chr7q36.1 - a total of 98 SNVs with mainly missense (73.5%) and truncating (20.4%) mutations at known cancer hotspots were noted. KMT2Cmut was associated with dnAML and AML with maturation morphology. In the entire cohort, the most common co-occurring chromosomal alterations discovered by high-resolution CNA analysis were deletions in chromosomes 5, 17, and 12. Our approach enabled the identification of small fragment deletions (≤10Mb) affecting the TP53, NF1, and ETV6 loci in 5-9% of all cases, which were missed by conventional G-banding. Cancer Cell Fraction and Bradley-Terry models were used to simulate the sequential order of genomic aberrations. While mutations in TP53 and epigenetic-related genes were early events, -7 and del(7q) were often subclonal and SNVs in NRAS, KMT2C very late events in leukemogenesis. Survival analyses in intensively-treated patients (n= 414) revealed that 61% reached complete remission, 67% relapsed, and median overall survival (OS) was 11.9 months. Abn TP53 and high WBC count were independently associated with shorter relapse-free survival (RFS). For OS, besides older age and high WBC count, we identified abn TP53, PTPN11mut, TET2mut,-5, and -18 as poor prognostic factors in multivariate analysis (Table 1). In contrast, IDH2mutconferred an independent favorable prognostic effect for RFS and OS. Notably, abn TP53 outcompeted the prognostic impact of CK+ (Table 1). Compared to TP53wt, patients with abn TP53/CK+ and abn TP53/CK- had a similar poor outcome with median RFS of 6 and 4 months (CK+/CK-, P<.001) and OS of 6.8 and 8.6 months (CK+/CK-, P<.001). In contrast to other genomic studies in myelodysplastic syndrome, we found abn TP53 to be associated with poor outcome irrespective of the single- or multihit mutation status following definitions of the latest ICC classification (Blood, 2022). Conclusion: Our results offer novel insights into the genomic landscape and clonal trajectory of AML with abn(7). This work unravels formerly underestimated genetic lesions ( KMT2Cmut) and alterations with high prognostic impact (abn TP53 and IDH2mut) for better future risk stratification.

Poor Outcome of Patients with Acute Myeloid Leukemia in First Relapse Underscores the Need for Effective Initial Treatment

Introduction: The incorporation of novel targeted agents into combination regimens used in the treatment of patients with acute myeloid leukemia (AML) has improved their outcomes. However, disease relapse is still challenging and associated with a poor response rate, limited therapeutic options and poor outcome. Predictors of outcome for patients in first relapse include the duration of first remission, cytogenetic risk at diagnosis, age and whether they underwent an allogeneic stem cell transplantation (alloSCT) in first remission. The incorporation of genetic aberrations detectable at diagnosis has been useful in further stratifying prognosis, but their predictive value at the time of relapse is not well established. Herein we analyze a large cohort of frontline-treated AML patients, focusing on the outcomes of patients presenting a first disease relapse. Methods: This is a retrospective single-center study including patients diagnosed with AML from April 2017 to October 2022. Risk assessment and response to treatment were defined according to the ELN 2022 guidelines. Mutations were assessed using an 81-gene NGS panel. Survival analyses were estimated with the Kaplan-Meier method, using the log-rank test for comparison. Univariate and multivariate analysis were performed using Cox proportional hazards regression. Results: A total of 875 patients with AML were included in the study, with a median age of 65 years old (range,18-95). According to the ELN risk category, 171 (20%) patients had favorable disease, 200 (23%) patients intermediate and 473 (54%) adverse. Patients received intensive treatment (IT; 40% of patients, 41% of whom with the addition of venetoclax) or low intensity treatments (LIT; 60% of patients, 72% with venetoclax). The overall response rate including complete remission (CR)/CR with incomplete hematologic recovery (CRi) was 73%. Among responding patients, 201 (32%) underwent alloSCT in first remission. After a median follow-up of 25 months, the median OS was 53 months for patients receiving IT and 11 months for patients receiving LIT (Figure 1). The median OS for favorable, intermediate and adverse risk patients was not achieved, 24 and 11 months, respectively. During this follow up time, 337 patients were alive and maintaining CR. 197 patients have relapsed after having achieved CR/CRi, 36 of them after undergoing alloSCT. Available data for analysis was available in 164 of these patients. The median age at relapse was 67 (21-95) and 57 (35%) received prior IT whereas 107 (65%) received LIT. At diagnosis, 15%, 16% and 69% were favorable, intermediate and adverse risk, respectively. The median time from best response to relapse was 7.5 (range,1-35) and 6.3 (range, 1-49) months for patients treated with IT and LIT, respectively. At the time of relapse, 36% of patients had a complex karyotype, 4% had MECOM gene rearrangement and 3% had KMT2A gene rearrangement. The most common mutations at time of relapse were TP53 (34%), DNMT3A (34%), TET2 (23%) and RUNX1 (19%). After relapse, 32 (20%) and 132 (80%) received salvage IT and LIT treatment, respectively. The CR/CRi rate for IT and LIT were 31% and 27%, respectively. The mOS from relapse was 3.4 and 5.5 months for patients with salvage IT and LIT, respectively (p=0.6). Age at relapse (mOS of 6.5 vs 5.1 months for patients age <60 and ≥60, respectively [p=0.1]), type of induction therapy (mOS of 6.6 vs 4.9 for patients receiving IT and LIT, respectively [p=0.07]), or risk classification at relapse (mOS of 4.9, 6.3 and 5.1 months for favorable, intermediate and adverse risk, respectively [p=0.7]) did not stratify patients. Duration of first remission longer than 12 months was associated with a better OS (mOS 8.1 vs 4.3 months, p=0.008). Univariate and multivariate analysis was performed, including clinical and biological variables at diagnosis and relapse (Table 1). Importantly, high white blood cell count at relapse (HR 2.1), short first remission (HR 1.6), complex karyotype at relapse (HR 1.7) and KMT2A rearrangement at relapse (HR 3.8) were independent predictors of outcome after relapse. Conclusion: Although outcomes of patients with AML have improved, disease relapse remains a major obstacle with poor outcomes despite the availability of new salvage strategies. Highly effective induction and maintenance regimens are needed to reduce the risk of relapse.

Clinical Characteristics and Prognosis of Acute Myeloid Leukemia Patients with Protein Tyrosine Phosphatase Non-Receptor Type 11 Gene Mutation

Objective: The purpose of our study was to investigate the clinical characteristics, molecular biological characteristics and prognosis of patients with acute myeloid leukemia (AML) harboring protein tyrosine phosphatase non-receptor type 11 (PTPN11) gene mutation. Methods: The clinical data of 30 newly diagnosed adult AML patients with PTPN11 gene mutation were analyzed retrospectively. Prognostic analysis and screening of prognostic factors were conducted using the Kaplan-Meier method and Cox proportional hazards regression model. Results: High frequency mutation sites of PTPN11 gene were located in exon 3 of chromosome 12, which are D61 and A72（16.7%）, followed by E76 (13.3%). The median variant allele frequency (VAF) of PTPN11 mutant gene was determined to be 18.4%. The patients were divided into two groups according to PTPN11 VAF 35.3% (upper quartile). We observed that the peripheral blood leukocyte count in patients with VAF ≥35.3% was significantly higher than patients with VAF < 35.3% (p=0.019).Moreover, the higher VAF was closely related to M5 subtype AML (p=0.016) and internal tandem duplication (ITD) of FMS-like tyrosine kinase 3 (FLT3) (FLT3-ITD) mutation (p= 0.048). Taking PTPN11 VAF 20% and 35.3% as the cutoff value, the patients were divided into two groups, and the overall survival(OS) and event free survival (EFS) of these two groups were not significant. Multivariate analysis using the COX proportional hazards model identified that white blood cell count and Eastern Cooperative Oncology Group (ECOG) physical status score were independent risk factors affecting the prognosis of EFS. Conclusion: Our study suggests that PTPN11 VAF may not serve as a prognostic factor in patients with PTPN11 mut AML. However, newly diagnosed patients with high white blood cell count and poor performance status were identified as independent risk factors for EFS in PTPN11 mut AML. Keywords: Acute myeloid leukemia, PTPN11 mutation, clinical characteristics

Optimization of Idarubicin and Cytarabine Induction Regimen with Homoharringtonine for Newly Diagnosed AML Based on the Peripheral Blast Clearance Rate: First Result of the Multicenter, Randomized, Phase 3 Trial (RJ-AML 2016)

Background: Combination of idarubicin and cytarabine (IA) is still the basis of induction treatment for acute myeloid leukemia (AML). As previous reported in RJ-AML 2014 trial [1], day 5 peripheral blast clearance rate (D5-PBCR) can be used as an indicator of early treatment response, and for patients in the D5-PBCR (+) group, addition of homoharringtonine (HHT) to traditional IA induction showed good efficacy and safety. To further verify the efficacy in long-term outcome, we designed the RJ-AML 2016 trial. Here we report the latest response and survival results. Patients and Methods: The RJ-AML 2016 trial is a multicenter, randomized, phase 3 clinical trial, conducted to evaluate the efficacy of HHT in newly diagnosed young AML. Patients in D5-PBCR(+) group was eligible for addition of HHT, and were assigned in a 1:1 ratio, either to the intervention or control group. The primary end point was event-free survival (EFS). The secondary end points were composite complete remission (CR or CR with incomplete hematologic recovery), early death rate, measurable residual disease, drug toxicity, and safety. We hypothesized the 3-year EFS rate may increase from 30% to 50%, therefore the sample size of patients who enter randomization should be 250. Based on historical data, the rate of D5-PRCR(+) was 43%. Assume that 10% of patients may lost to follow-up, at least 638 eligible patients were needed. All patients enrolled in this study received induction regimen same as the RJ-AML 2014 trial. D5-PRCR(+) patients who assigned to the intervention group received additional chemotherapy (HHT 2 mg/m 2 on days 6-10). Favorable cytogenetic/molecular risks group received four courses of the HiDAC for consolidation. Patients with intermediate and unfavorable risks were recommended for allogeneic hematopoietic stem-cell transplantation. The trial is registered in the Chinese Clinical Trial Register, number ChiCTR-OIC-16007764. Results: From December 7, 2016, through April 29, 2023, a total of 747 patients underwent screening, 649 were included in the intention-to-treat (ITT) population and received IA induction from 6 sites in China. D5-PBCR were analyzed in 647 patients and 275 (42.5%) had D5-PBCR (+). Of the 275 D5-PBCR (+) patients, 145 were allocated to the intervention group, while 20 patients withdraw, of which 4 patients received additional FLT3 inhibitor and 16 cases continued IA induction; of the 130 patients allocated to the control group, 5 discontinued the IA regimen on day 6 or 7. Of the 372 D5-PBCR (-) patients, 2 patients discontinued IA. Baseline characteristics, including age, sex, blast counts in bone marrow, and cytogenetic parameters, were similar between two groups. While patients in D5-PBCR (-) group had higher white blood cell counts before treatment. Patients with CBFβ- MYH11 fusion, NPM1 and CEBPA bZIP mutations were more sensitive to IA induction. Meanwhile, high-risk gene mutations including ASXL1, RUNX1, TP53 and U2AF1 were more common in D5-PBCR (+) group. Details were showed in table. The overall composite CR rate after one course of induction was 73.2% in the ITT cohort. For patients in D5-PBCR (-) and D5-PBCR (+) groups, the CR rates were 82.8% and 60.4% , respectively (P<0.001). In the ITT cohort of D5-PBCR (+) group, CR rates were 51.1% and 68.3% for control and intervention arm, respectively (P=0.0046). In the Per-Protocol (PP) cohort, CR rates were 52.8% and 71.2% for IA and IA+HHT arm, respectively (P=0.0027). The overall early mortality rate was 4.9% in whole cohort, which were similar between two treatment arms. The last follow-up time was April 2023. Patients in the PP cohort who enrolled before April 2022 were included in this survival analysis (n=486), and the median duration of follow-up was 23.4 months. The median EFS was 40.6 months in the PP cohort, which showed significant difference between D5-PBCR (-) and D5-PBCR (+) groups [D5-PBCR (-): not reached, D5-PBCR (+): 16.0±1.9 months, P<0.001]. For patients in the D5-PBCR (+) group, no significant difference was found in 3-year EFS till the latest follow-up. While, the 3-year EFS was improved from 34.0±5.5% to 47.1±6.1% with the addition of HHT ( P=0.086). Conclusion: Current analysis indicated that addition of HHT can benefit young AML patients in the D5-PBCR (+) group. Complete follow-up combining with cytogenetic-molecular information can provide more reliable results. 1. Zhang Y, et al. Am J Hematol. 2022;97(1):43-51.

Integrated Analysis of KIT Exon 17 Mutations and Flow-MRD Refines Risk Stratification in Pediatric Acute Myeloid Leukemia with RUNX1:: RUNX1T1

INTRODUCTION: Pediatric acute myeloid leukemia (AML) with RUNX1:: RUNX1T1 is considered a favorable risk group, with a high probability of event-free survival (EFS) in recent clinical trials. However, 20-30% of patients still experience relapse within three years and some patients have poor outcome. Several prognostic factors, including secondary genetic abnormalities and treatment response, have been previously reported. Flow cytometry-based measurable residual disease (flow-MRD) has been suggested as a poor prognostic factor in AML with RUNX1:: RUNX1T1. Additionally, KIT mutations, particularly mutations of exon 17, have been associated with poor EFS in both adult and pediatric patients. However, the combined impact of KIT exon 17 mutations and flow-MRD on prognosis has not been thoroughly investigated. This study aims to evaluate the clinical and genetic features of pediatric patients with RUNX1:: RUNX1T1-positive AML enrolled in the Japanese Pediatric Leukemia/Lymphoma Study Group (JPLSG) AML-12 trial and determine if integrated analysis of flow-MRD and KIT exon 17 mutations can improve risk stratification. METHOD: A total of 101 pediatric AML patients with RUNX1:: RUNX1T1 were enrolled in the study. The patients were treated in the JPLSG AML-12 trial, and their clinical and genetic characteristics were analyzed. Targeted capture sequencing was performed on bone marrow samples obtained at diagnosis. The custom gene panel was designed for mutation profiling of pediatric AML, including 504 genes. Flow-MRD was centrally monitored at the end of induction 1 (EOI1) and the end of induction 2 but was not used to guide subsequent therapies. Leukemia-associated immunophenotypes were identified in diagnostic specimens and marker combinations that allowed detection of leukemia with a sensitivity of at least 0.1% were applied to subsequent samples. RESULTS: Patients with KIT exon 17 mutations had a higher white blood cell count at diagnosis and a significantly higher rate of MRD positivity (≥0.1%) at EOI1 compared to patients without KIT exon 17 mutations. Immunophenotypic analysis showed no significant differences in CD117 or CD33 expression between patients with and without KIT exon 17 mutations; whereas CD19 expression was observed less frequently and, although not significantly, CD56 expression was observed more frequently in the patients with KIT exon 17 mutations. The genetic landscape analysis revealed that KIT mutations were the most common and tended to coexist with ARID1B mutations, while NRAS mutations were mutually exclusive. The 5-year EFS and overall survival (OS) for the entire cohort were 67.3% and 82.7%, respectively. Negative MRD at EOI1 was associated with significantly superior 5-year EFS and OS (71.6% and 85.9%) compared to positive MRD (12.5% and 37.5%)(p<0.01). Patients with KIT exon 17 mutations had significantly inferior 5-year EFS and OS (46.9% and 62.2%) compared to those without KIT exon 17 mutations (76.8% and 92.4%) (p<0.01). Furthermore, we evaluated a prognostic impact of MRD within the KIT exon 17 mutated and non-mutated cases. As for the non-mutated cases, the 5-year OS in the patients with negative MRD was 92.2%. Among the KIT-mutated cases, the 5-year OS in the patients with negative and positive MRD was 68.0% and 33.3%, respectively. CONCLUSION: Patients with both non-mutated KIT exon 17 and negative MRD have the best prognosis, while positive MRD and KIT exon 17 mutations are associated with poorer outcomes. These findings indicated that integrated analysis of flow-MRD and KIT exon 17 status enables optimal risk assignment strategies in pediatric AML with RUNX1:: RUNX1T1.

The Tetraspanin CD9 Shapes Glucocorticoid Sensitivity in Pediatric B-Precursor Acute Lymphoblastic Leukemia

Background: De novo or acquired resistance to glucocorticoids (GCs), the common therapeutic regimens for remission-induction in pediatric B-precursor acute lymphoblastic leukemia, confronts treatment success and is a strong predictor for disease relapse. Discovery of predictive markers and underlying mechanisms of GC resistance could lead to new treatment and prognostic modalities. Aims: This study aims: (1) to demonstrate the association between CD9 expression and GC sensitivity in childhood BCP-ALL; (2) to dissect the underlying mechanisms driving GC resistance; and (3) to discover the possible therapeutic modalities for restoring GC susceptibility. Methods: Ex vivo drug sensitivity profiling to prednisone (Pred) and dexamethasone (Dex) was performed on 6 BCP-ALL cell lines and 18 patient samples with differential CD9 expression. Association of CD9 expression with patient responses to Pred prophase was analyzed in a pediatric BCP-ALL cohort (n=182). Functional impact of CD9 on GC susceptibility was dissected by gain- and loss-of-function experiments in BCP-ALL cells. Mechanistic basis of CD9-driven GC response was investigated through genomics, transcriptomics, and proteomics. Reversal of GC resistance by pathway-targeted agents were explored on BCP-ALL cells and xenograft models. Results: Distinctive differences in the drug sensitivity pattern were found between CD9- and CD9+ BCP-ALL cell lines, with the former showing resistance to GCs but not other chemotherapeutic agents. Concurrently, CD9- primary lymphoblasts exhibited resistance to Dex (IC50s: 2,761 vs. 31 nM) and Pred (IC50s: 8,185 vs. 268 nM) compared with CD9+ samples (positivity defined by the presence of ≥ 20% CD9+ blasts). More Pred poor responders (defined by the presence of ≥ 1×10 9/L circulating lymphoblasts on day 8) were found in CD9- than CD9+ patients (19.4% vs. 6.2%, P=0.018). Subgroup analyses revealed more poor responders with CD9- phenotype were enriched in patients with older age (60% vs. 3.7%, P=0.008), male gender (21.7% vs. 6.7%, P=0.045), higher white blood cell count (66.7% vs. 15.4%, P=0.004), and in those with BCR-ABL1 translocation (100% vs. 12.5%, P=0.024), or not otherwise cytogenetically specified BCP-ALL (30.8% vs. 5.8%, P=0.019). Univariate and multivariate analyses further confirmed CD9 negativity as an independent predictor for GC resistance (OR=5.1, P=0.009). Overexpression of CD9 in CD9- cells (SEM, KOPN-8) by lentiviral transduction significantly enhanced GC sensitivity by 2.8-62.3-fold ( P<0.024), whereas CD9 knockout in CD9+ cells (697) using CRISPR-Cas9 decreased GC susceptibility ( P<0.003). No significant differences in mRNA or protein expression of the GC receptor NR3C1 were identified between CD9+ and CD9- cells, as well as its isoforms or mutants. The cytoplasm-to-nucleus translocation of GC receptor was consistent among cell lines regardless of CD9 expression status, but CD9 was physically interacted with NR3C1. Upon GC stimulation, the presence of CD9 increased the number of DEGs (110 vs. 82 DEGs) and magnitude of GC-responsive genes exclusively detected in the background of CD9 (1.3-18.6-fold; e.g. AKAP13, STAT5A, EZR). CD9- cells showed constitutive activation of the MAPK pathway and could be preferentially restored for GC susceptibility by the MEK1/2 inhibitor trametinib in vitro. BCP-ALL xenograft modeling revealed that, compared to single agent Dex treatment, combination with trametinib significantly reduced the leukemic load in animal transplanted with CD9- SEM but not CD9+ BV-173 cell lines. Ex vivo drug testing further showed that the resistance to GCs in some CD9+ cases could be partially reversed by combination of trametinib and the JAK inhibitor ruxolitinib due to the activation of STAT5. Conclusions: This study provides a definitive linkage of CD9 with GC sensitivity in childhood BCP-ALL mediated through a NR3C1-independent mechanism. CD9- cases could be prone to trametinib combination therapy, whereas CD9+ cases might need a third drug such as ruxolitinib to counteract GC resistance.

Persistent Albuminuria and Chronic Kidney Disease in Adults with Sickle Cell Disease: Results from a Multicenter Natural History Study

Background: Patients with sickle cell disease (SCD) are at high risk for developing kidney disease. Albuminuria, an early marker of kidney injury, may be initially transient in patients with SCD. Existing guidelines propose confirming albuminuria at multiple timepoints before intervention. A recent study suggests a urinary albumin-creatinine ratio (UACR) ≥ 100 mg/g correlates highly with persistent albuminuria and subsequent decline in estimated glomerular filtration rate (eGFR). We examined a cohort of patients with SCD to assess those characteristics associated with persistent albuminuria and chronic kidney disease (CKD). Methods During routine clinical visits, we enrolled patients with HbSS or HbSß 0 thalassemia between 18 and 65 years at 4 centers into a prospective study to assess the natural history of kidney disease in SCD. We excluded patients if they had bone marrow transplantation, cancer, connective tissue disease, diabetic nephropathy, other glomerular diseases, hepatitis (B or C), HIV, or were on dialysis. Blood and urine were collected for routine clinical laboratory assessments. Serum cystatin C was measured by commercially available ELISA, and eGFR was calculated using the CKD-EPI-2012 cystatin C equation. We defined CKD as an eGFR < 60 mL/min/1.73m 2 or presence of albuminuria. Glomerular hyperfiltration was defined as an eGFR>130 in females and >140mL/min/1.73m 2 in males, respectively. Persistent albuminuria was considered present if 2 or 3 UACR values were ≥30 mg/g or if initial baseline value was ≥100 mg/g (PMID: 32289161). We utilized generalized linear models adjusting for age and sex to identify characteristics associated with persistent albuminuria and CKD. For multivariable selection, we fit binomial or multinomial LASSO regression models adjusted for age, sex, hemoglobin, %Hemoglobin F, hemoglobinuria, and hydroxyurea to identify those variables associated with outcomes of interest. Results Of 284 enrolled patients, 268 had complete data for UACR, cystatin C and serum creatinine at baseline; 104 (38.8%) of these had persistent albuminuria (Table 1). CKD was present in 40.7% of patients and 26.5% exhibited hyperfiltration. In analyses adjusted for age and sex, several factors were associated with the likelihood of persistent albuminuria. Higher hemoglobin, higher %Hemoglobin F, higher serum bicarbonate and use of NSAIDs were associated with decreased likelihood of persistent albuminuria. Higher systolic and diastolic blood pressure, elevated serum alkaline phosphatase, total bilirubin, and white blood cell count (WBC) were associated with an increased likelihood of persistent albuminuria as were presence of hemoglobinuria and use of angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB). In multivariable selection, higher systolic and diastolic blood pressure, ACEi/ARB use, leg ulcers, higher WBC, higher aspartate transaminase (AST) remained associated with higher likelihood of persistent albuminuria. Presence of avascular necrosis, NSAID use, and higher serum bicarbonate were associated with lower likelihood of persistent albuminuria. When evaluating baseline UACR, individuals with UACR≥100 mg/g had similar probability of subsequent albuminuria as compared to those with severe albuminuria (UACR≥300 mg/g) [Table 2]. Conclusion Persistent albuminuria in this cohort was associated with multiple clinical features. Lower use of NSAIDs in this cohort likely represents counseling of patients to avoid these due to their kidney disease. The relationship with serum bicarbonate suggests a propensity for metabolic acidosis in these patients which could exacerbate the underlying SCD. These data confirm the predictive value of a single UACR value ≥100 mg/g for persistent albuminuria, suggesting this may be a sufficient trigger to warrant intervention. CKD, hyperfiltration and albuminuria were extraordinarily common, consistent with prior studies and validate use of this cohort for additional longitudinal assessment of kidney disease in SCD.

Progression to Myelofibrosis in Patients with Essential Thrombocythemia: A Real-World Analysis from the Prospective MOST Study

Background: Essential thrombocythemia (ET) is a myeloproliferative neoplasm (MPN) characterized by clonal blood cell proliferation, excessive platelet production, constitutional symptoms, and increased risk of vascular complications, as well as a risk of progression to myelofibrosis (MF). Previous prognostic studies of patients with ET have largely been based on retrospective analyses, and limited prospective data exist regarding disease progression. The prospective Myelofibrosis and Essential Thrombocythemia Observational Study (MOST) collected real-world data from patients with ET. This analysis evaluates disease progression in patients with ET enrolled in MOST. Methods: MOST (NCT02953704) enrolled patients with ET aged ≥60 years, or with a history of thromboembolic events, or who were receiving ET-directed therapy (excluding aspirin only). Baseline clinical characteristics data were collected as previously described (Yacoub A. CLML. 2021). For this analysis, progression from ET to MF was defined as meeting 1 or more of the following criteria during the study period: 1) Bone marrow biopsy with fibrosis grade ≥2 or pathologic diagnosis of MF; 2) death owing to MF/myelodysplastic syndrome/acute myeloid leukemia; 3) circulating blasts >1% and new/worsening splenomegaly (SPM); 4)new/worsening SPM and ≥2 of white blood cell (WBC) count >11×10 9/L, hemoglobin (Hb) <10 g/dL, and platelet count <100×10 9/L. Median (range) follow-up was 57.3 months (42-70). Results: Of the 1237 patients with ET enrolled in MOST; 53 (4.3%) met criteria for progression to MF. Among patients with progression, most had progressed due to fibrosis (criteria 1, 56.6%); 15.1%, 11.3%, and 28.3% of patients progressed due to criteria 2, 3, and 4, respectively. Notably, only 176 patients (14.2%) enrolled in the study had bone marrow data available. Comparison of the enrollment characteristics of patients with and without progression identified no differences in age at enrollment or diagnosis (Table 1). However, time from diagnosis to enrollment and from diagnosis to end of study were significantly longer in patients with progression than those without (median 7.9 vs 4.2 years, median 12.7 vs 9.0 years, respectively; both P=0.001). Of all enrolled patients with vs without progression tested for known driver mutations, a higher percentage with progression were JAK2-positive vs those without progression (80.6% [29/36] vs 69.7% [598/858]). At enrollment, the percentages of patients with vs without progression receiving ET-directed therapies were similar (94.3% vs 94.8%). Among patients with vs without progression, mean baseline Hb was significantly lower (12.5 g/dL vs 13.1 g/dL; P=0.026), mean WBC counts were significantly higher (10.4×10 9/L vs 7.4×10 9/L; P<0.001), and mean platelet counts were comparable (418.6×10 9/L vs 455.0×10 9/L; P=0.466). MPN-SAF TSS was similar for patients with vs without progression at baseline. Fewer patients with vs without progression had ≥1 thrombotic events (1.9% [1/53] vs 3.7% [44/1184]) during the study, whereas a higher percentage of patients had ≥1 hemorrhagic events (7.5% [4/53] vs 1.3% [15/1184]). Conclusions: This real-world analysis of data from MOST showed that 4.3% of patients with ET progressed to MF during the study period. Compared with patients without progression, patients with ET to MF progression had longer duration of disease, higher WBC count, and lower Hb at enrollment; symptom burden at enrollment was similar between the 2 groups. One limitation of this study is the lack of bone marrow data for the majority of patients, suggesting a possible underestimation of progression to MF. These findings and further analysis of MOST data will add insight into disease progression in patients with ET and facilitate clinical management of this patient population.

Homozygous CEBPA Mutations Predict Favorable Outcomes in AML Patients

Background: Loss of heterozygosity (LOH) of CEBPA has been sporadically reported in acute myeloid leukemia (AML), resulting in a complete or nearly complete homozygosity of CEBPA mutations ( CEBPA homo). However, its clinical significance has been underappreciated. Methods: We retrospectively analyzed the prognostic impact of CEBPA homo in 1223 adult AML patients, where CEBPA mutations were detected using whole exome sequencing (n=296) or targeted sequencing (n=927) technology. CEBPA homo is defined as the variant allele frequency (VAF) of a CEBPA mutation over 50%, and CEBPA heter is the opposite. Propensity score matching was used to reduce selection bias when comparing the survival difference between two groups. Results: CEBPA mutations were identified in 106 patients (8.7%), 47(44.3%) of which carried the C-terminal DNA-binding or basic leucine zipper region ( CEBPA bZIP). Compared to patients with other CEBPA mutations ( CEBPA others), patients carrying CEBPA bZIP were significantly younger (40.38±14.80 vs. 52.05±17.44 years, P<0.001) and had higher hemoglobin [89(65.5, 98) vs 70(58, 81) g/dL, P=0.001], lower platelet counts [35(17.5, 43) vs. 44(24, 78.5) 10 9/L, P=0.019) and higher proportion of peripheral blast cells [80(52.5, 90.5) vs. 51(14, 86.5) %, P=0.001] at diagnosis. CEBPA bZIP was associated with a higher complete remission rate (CR; 85% vs. 61%, P=0.012) in AML patients but did not reduce the relapse rate (32% vs. 39%, P=0.582). CEBPA bZIP significantly improved 4-year overall survival (OS; 0.70±0.09 vs. 0.30±0.13, P=0.013), 2-year event-free survival (EFS; 0.47±0.09 vs. 0.2±0.09, P=0.01), and 3-year pre-transplantation survival (PTS; 0.54±0.09 vs. 0.38±0.09, P=0.003) in AML patients compared to those with CEBPA others. These data are consistent with previous reports, suggesting the representative of this cohort. We further evaluated the clinical significance of CEBPA homo in this cohort and found that patients with CEBPA homo had higher white blood cell counts [29.37 (9.16, 76.11) vs. 10.37 (3.38, 43.43) 10 9/L, P=0.048] than those with CEBPA heter. Although CEBPA homo was not associated with CR rate (65% vs. 80%, P=0.145), it did reduce relapse rate (26% vs. 47%, P=0.045) in AML patients compared to those with CEBPA heter. CEBPA homo was significantly associated with improved 5-year OS (0.68±0.10 vs. 0.29±0.10, P=0.006), 5-year EFS (0.30±0.09 vs. 0.10±0.08, P=0.018), and 5-year PTS (0.40±0.10 vs. 0.14±0.07, P=0.046) compared to CEBPA heter. There is no difference in CEBPA VAF between patients carrying CEBPA bZIP and CEBPA other, suggesting similar distribution of CEBPA homo between these two groups. Conclusions: The clinical significance of CEBPA homo is different from CEBPA bZIP, which suggests a distinct biological meaning. Our study would add one new layer to the current stratification of CEBPA-mutated AML based on the prognosis. More cases are needed to further examine the clinical significance of the concurrency of CEBPA homo and CEBPA bZIP.

Acute Inflammation Redirect Bone Marrow Hematopoietic Stem Cell Cycling and Differentiation Program By Reshaping Their Chromatin Architecture at Long-Term

Background: Acute and persistent inflammation induced by microbial infections/sepsis or by therapeutic interventions, such as whole-body irradiation and CAR-T therapy, triggers a rapid overwhelming immune response in the host. While these responses are well defined in the short-term, the long-term impact of the inflammatory injury on the hematopoietic system still needs to be unveiled. Using a murine model of severe inflammation induced by bacteria P. aeruginosa ( P. aer.) or LPS, our group has previously reported that bone marrow (BM) hematopoietic stem cells (HSC) respond to infections with an aberrant expansion associated with their transitory inability to generate the downstream myeloid progenitors. Such dysfunctions correlated with the suppression of transcription factors governing stem-cell self-renewal and myeloid differentiation. Furthermore, when transplanted into healthy mice, the “inflamed” HSC showed reduced ability to contribute to the myeloid lineage and to engraft at long-term, suggesting that they retain memory of the LPS-mediated insult and maintain long-lasting changes. Thus, we hypothesized that severe inflammation alters the HSC epigenome, reshaping their transcriptional programs and affecting cell fate decisions and differentiation. Methods: We performed time-course experiments in WT mice challenged with a single dose of LPS or PBS, as control, and investigated 1) the kinetics of hematopoietic recovery by flow-cytometric immunophenotypic characterization, including cell-cycle 2) changes in the chromatin landscape of Lin- sorted BM subpopulations identified by the expression of the CD150 and CD48 markers as Long-Term (LT-HSC), Short-Term (ST-HSC), and Multipotent Progenitors (MPP1/2 and MPP3/4) using ATAC-seq. Results: Our studies revealed that the LPS challenge resulted in a significant increase in the cell-cycle of LT-HSC, ST-HSC, MPPs, common myeloid progenitors (CMP), and granulocyte-monocyte progenitors (GMP), which persisted up to 3 days from the inflammatory injury. Immunophenotypic analysis showed that while HSC frequencies returned to baseline at 5 days from LPS, the abundance and cell-cycle of myeloid progenitors and mature cells remained altered. Surprisingly, at 15 days post LPS, the cell-cycle of HSC markedly decreased, and such dysregulation was maintained until our last observation at 30 days from LPS. The pool of BM HSC was severely depleted and associated with exhaustion of T-cells but increased B-cells. GMP and Gr1+Mac1+ cells were also significantly decreased in the BM whereas mature lineages were increased in the peripheral blood, exhibiting high WBC, lymphocytes, and platelet count, neutrophilia, monocytosis, basophilia, and eosinophilia. ATAC-seq analysis revealed prominent differences in the chromatin architecture of the four HSC subpopulations at steady state (PBS). In all of them, LPS induced both i) a transient reorganization of the chromatin in some loci, and ii) the formation of persistently reshaped regions. Deeper investigations into the long-term changed sites revealed that chromatic accessibility was altered in proximity of CTCF-enriched regions fundamental to mediate chromatin reorganization and drive gene expression. Moreover, LPS modified the accessibility of genomic loci involved in the maintenance of HSC stemness and quiescence as well as regulation of their cell-cycle, self-renewal, and cell fate decision. Conclusions: Taken together these results suggest that LPS-mediated acute inflammation has long-lasting effects on HSC epigenetic regulation, influencing their cell-cycle and multilineage decisions. Relevance: The association between the resulting phenotype and the persistency of epigenetically remodeled HSC loci identified here may provide potential insights for future therapeutic approaches to re-direct “inflamed” HSC to a normal differentiation program, thereby enabling an efficient innate host response. Disclosures: No relevant conflicts of interest to declare.

Rate of Cardiotoxicity in Childhood Acute Lymphoblastic Leukemia Treated with Daunorubicin Using Echocardiography and Troponin I

Background and Aim: Acute lymphoblastic leukemia (ALL) is the commonest malignancy in childhood. Childhood ALL Survivors have a lifelong increased risk for cardiovascular morbidity and mortality compared to the general population, mainly caused by chemotherapy with daunorubicin. The aim of the study is to detect the rate of daunorubicin induced cardiotoxicity in children with acute lymphoblastic leukemia during induction phase chemotherapy. Meterials & Methods : This prospective observational study was conducted in the department of Pediatric Hematology and Oncology, Bangabandhu Sheikh Mujib Medical University (BSMMU) on 40 newly diagnosed patients of ALL aged between 1 to17.9 years who got daunorubicin during induction. Complete blood count and echocardiography were done and troponin I was measured in all patients before and after completion of induction period. Result: Of the 40 patients, 8 patients (20%) had developed cardiotoxicity evidenced by reduction of left ventricular ejection fraction (LVEF) in echocardiography. Baseline LVEF was 68.80±5.98% which was then reduced to 65.32±7.07% after induction phase of chemotherapy (p=0.023). No significant alteration of troponin I was seen (P= 0.581) between baseline and after completion of induction. Total WBC count and hemoglobin had a significant difference (P<0.05) between baseline and after induction period. Male patients had a greater risk of developing cardiotoxicity than females but statistically was not significant (P=0.643). There was no significant association between age of the patients and cardiotoxicity (P=0.112).Cardiotoxicity was seen higher in patient with initial high WBC count (p=0.039). Echocardiography also reveled increased tendency of mitral regurgitation and left ventricular hypertrophy after induction phase chemotherapy. Conclusion: This study showed the rate of cardiotoxicity was 20% in ALL patients treated with daunorubicin. It also found that LVEF was decreased during therapy.Echocardiography can be used to detect early cardiotoxicity induced by daunorubicin. University Heart Journal 2023; 19(1): 20-25

Epidemiological, Clinical, and Laboratory Findings of 235 Hospitalized COVID-19 Adult Patients (Survivors and Non-Survivors) at Sohar Hospital in Oman.

The aim of this study was to describe the epidemiological and clinical characteristics and laboratory findings of coronavirus disease 2019 (COVID-19) patients at the Sohar Hospital, Sohar, Oman. This retrospective study of admitted COVID-19 patients at Sohar Hospital in Oman was carried out from March to October 2020. Demographics and laboratory data of 19 tests for 235 COVID-19 patients, of which 202 were survivors and 33 were non-survivors, were collected from the hospital information system after ethics approval. Thirteen factors were significantly correlated with in-hospital mortality, including older age, having chronic disease, high neutrophil count, high troponin T, high creatinine, low albumin (p < 0.0001), high white blood cell (WBC) count, low hemoglobin, high D-dimer (p < 0.001), high C-reactive protein (CRP) (p < 0.002), low lymphocyte count (p < 0.003), high alkaline phosphatase (ALP) enzyme (p < 0.007) and high ferritin (p < 0.045). The most common laboratory blood test abnormalities that were highly correlated with mortality were increased values of CRP (100% of non-survivors), D-dimer (94.1% of non-survivors), ferritin (88.2% of non-survivors), and troponin T (85% of non-survivors) and reduced lymphocyte count (73.9% of non-survivors). These findings could help in categorizing COVID-19 patients for risk-based assessment and early identification of patients with poor prognosis.

Nervous System Involvement in Hospitalized Patients With COVID-19

Abstract Background COVID-19 patients with neurological manifestations have poorer outcomes. We investigated the association between clinicodemographic and laboratory findings with poorer outcomes among COVID-19 inpatients with neurological manifestations. Methods This was a retrospective study of consecutive medical records (March–April 2020). Neurological manifestations (altered level of consciousness, acute cerebrovascular disease, ataxia, seizure, headaches, dizziness/vertigo, muscle weakness, and peripheral neuropathies) were categorized into serious and nonserious. Results Of 119 COVID-19 inpatients, 38 with neurological manifestations were included (age, 63.7 ± 13.4 years; male, 65.8%), of whom 27 (71.1%) had serious manifestations. Muscle weakness (57.9%), impaired consciousness (47.4%), and acute cerebrovascular disease (23.7%) were the most frequent manifestations. The in-hospital mortality rate was 28.9%. Patients with serious manifestations were significantly older (66.9 vs 55.7, P = 0.018), with significantly higher white blood cell count (6.8 vs 5.1 × 103/μL, P = 0.023), direct bilirubin (0.3 vs 0.2 mg/dL, P = 0.030), prothrombin time (PT) (15.4 vs 14.4 seconds, P = 0.006), international normalized ratio (1.2 vs 1.1, P = 0.005), and model for end-stage liver disease (MELD) scores (10 vs 7, P = 0.011), compared with those with nonserious manifestations. In addition, the nonsurvivors had higher potassium (4.5 vs 4.0 mEq/L, P = 0.021), total bilirubin (1.1 vs 0.6 mg/dL, P = 0.008), and MELD scores (12 vs 8, P = 0.025) compared with the survivors. After adjustment, we found significant impacts of age (adjusted odds ratio [aOR], 1.11; P = 0.032), PT (aOR, 5.04; P = 0.019), and MELD score (aOR, 1.27, P = 0.047) on poorer outcomes. Conclusions Older age, higher white blood cell count, bilirubin, PT, international normalized ratio, potassium, and MELD scores were associated with poorer outcomes in COVID-19 inpatients with neurological manifestations.

Characteristics of Inflammatory Markers in Diabetic Foot Patients and Their Relationship With Prognosis of Diabetic Foot Ulcers

To explore the characteristics of baseline inflammatory markers in diabetic foot patients and their relationship with the prognosis of diabetic foot ulcers. The clinical data of diabetic foot patients (n=495) admitted to West China Hospital, Sichuan University since 2016 were retrospectively collected through the hospital electronic medical record system to analyze the characteristics of inflammatory markers and their relationship with the prognosis of diabetic foot ulcers. White blood cell count (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6 (IL-6) levels were significantly higher in patients defined as grade 4 on the Wagner Scale than those in patients defined as grade 0-3 on the Wagner Scale. Neutrophil percentage (NE%) was higher in Wagner grade-4 patients than those in Wagner grade-0 and grade-1 patients and higher in Wagner grade-3 patients than those in Wagner grade-0 patients. NE%, CRP, PCT, and IL-6 levels were positively correlated with the severity of diabetic foot, with the respective odds ratio (OR) at 95% confidence interval (CI) being 1.038 (1.019-1.056), 1.019 (1.012-1.026), 8.225 (2.015-33.576), and 1.017 (1.008-1.025). Using Wagner grade-0 patients as the reference, patients with higher WBC were more likely to progress to Wagner grade 2, 3, and 4, with the respective OR (95% CI) values being 1.260 (1.096-1.447), 1.188 (1.041-1.356), and 1.301 (1.137-1.490); patients with higher ESR were more likely to progress to Wagner grade 3 and 4, with the respective OR (95% CI) values being 1.030 (1.006-1.054) and 1.045 (1.019-1.071). Baseline ESR (P=0.008), CRP (P=0.039), and IL-6 (P=0.033) levels were lower in patients who had received antibiotics prior to their admission than those in patients who had not received antibiotics before admission. The levels of WBC, NE%, ESR, PCT, and IL-6 were lower in the full recovery group than those in the group of patients who did not respond to treatment. The higher the levels of NE% and IL-6, the worse the prognosis of diabetic foot ulcers became, with the respective OR (95% CI) values being 1.030 (1.010-1.051) and 1.008 (1.002-1.013). The severity of diabetic foot ulcers increased with the rise in baseline levels of inflammatory markers. Elevated baseline NE% and IL-6 levels suggest a poor prognosis. Our findings suggest that early assessment of diabetic foot infection and standardized antibiotic therapy should be implemented to improve the prognosis.

Knee osteoarthritis with a high grade of Kellgren–Lawrence score is associated with a worse frailty status, KNHANES 2010–2013

Frailty as a syndrome of physical decline in late life is associated with adverse health outcomes. Knee osteoarthritis (KOA) could contribute to frailty conditions. The objective of this study was to evaluate the impact of KOA on frailty risk in a Korean National Health and Nutrition Examination Survey (KNHANES) cohort. In this study (N, total = 11,910, age; 64.10 years old [63.94–64.27; mean 95% CI], sex (female, %); 6,752 (56.69)), KOA patients were defined as those with knee joint pain and grade 2 Kellgren–Lawrence (K–L) or more on plain radiographic images who were 40 years old or older in Korean population data of KNHANES. The frailty index was calculated using 46 items related to co-morbidities and laboratory parameters. The impact of KOA on frailty risk was evaluated with logistic regression analyses. The prevalence of KOA patients was 35.6% [95% CI 34.7–36.46]. In polytomous logistic regression, the relative risk ratio (RRR) of KOA was significantly increased in the pre-frail group (2.76, 95% CI 2.30–3.31) and the frail group (7.28, 95% CI 5.90–8.98). RRR of frailty was significantly increased in patients with K–L grade 3 (1.36, 95% CI 1.13–1.63) and K-L grade 4 (2.19, 95% CI 1.72–2.79). Older age, higher BMI, smoking status, alcohol intake, low-income status, higher WBC count, higher platelet count, higher serum creatinine level and low estimated GFR were significantly associated with increased frailty risk. High hemoglobin and regular walking habits were associated with decreased frailty risk in KOA patients. In this large observation population- based survey cohort, KOA is linked to an increased risk of frailty syndrome. We found a significant connection between KOA and frailty syndrome. These results show that we need to think about the overall health of people with KOA and give them special care to prevent frailty syndrome.

Unsupervised machine learning models reveal predictive clinical markers of glioblastoma patient survival using white blood cell counts prior to initiating chemoradiation.

Glioblastoma is a malignant brain tumor requiring careful clinical monitoring even after primary management. Personalized medicine has suggested the use of various molecular biomarkers as predictors of patient prognosis or factors utilized for clinical decision-making. However, the accessibility of such molecular testing poses a constraint for various institutes requiring identification of low-cost predictive biomarkers to ensure equitable care. We collected retrospective data from patients seen at Ohio State University, University of Mississippi, Barretos Cancer Hospital (Brazil), and FLENI (Argentina) who were managed for glioblastoma-amounting to 581 patient records documented using REDCap. Patients were evaluated using an unsupervised machine learning approach comprised of dimensionality reduction and eigenvector analysis to visualize the inter-relationship of collected clinical features. We discovered that the serum white blood cell (WBC) count of a patient during baseline planning for treatment was predictive of overall survival with an over 6-month median survival difference between the upper and lower quartiles of WBC count. By utilizing an objective PD-L1 immunohistochemistry quantification algorithm, we were further able to identify an increase in PD-L1 expression in glioblastoma patients with high serum WBC counts. These findings suggest that in a subset of glioblastoma patients the incorporation of WBC count and PD-L1 expression in the brain tumor biopsy as simple biomarkers predicting glioblastoma patient survival. Moreover, machine learning models allow the distillation of complex clinical data sets to uncover novel and meaningful clinical relationships.