Improvement In Hematological Parameters Research Articles

Antitumor potential of Citrus limetta fruit peel in Ehrlich ascites carcinoma bearing Swiss albino mice

<em>Citrus limetta </em>Risso (Rutaceae), commonly known as sweet lime in English and <em>Mousambi</em> in India, has been traditionally used for several medicinal purposes. This study explored the relationship between <em>Citrus limetta </em>fruit peel and its antitumor activity against Ehrlich ascites carcinoma (EAC) bearing mice. The antitumor activity of methanol extract of peel of <em>Citrus limetta</em> fruits (MECL) was evaluated against EAC cell line in Swiss albino mice. Twenty-four hours after intraperitoneal inoculation of tumor EAC cells in mice, MECL was administered at 200 and 400 mg/kg body weight i.p. daily for nine consecutive days. On the 10th day, half of the mice were sacrificed for the estimation of tumor growth (tumor volume, viable and non-viable tumor cell counts), and hematologic parameters (red blood cells, white blood cells and hemoglobin). The rest were kept alive for assessment of survival parameters, <em>i.e. </em>median survival time and percentage increase in life span of EAC bearing mice. Intraperitoneal administration of MECL at the doses of 200 and 400 mg/kg for nine days to the carcinoma induced mice demonstrated a significant (P<0.001) decrease in tumor volume, viable tumor cell count, tumor weight and a significant (P<0.001) improvement in hematological parameters and life span as compared to the EAC control mice. The present study establishes marked and dose dependant anti-tumor effect of <em>C. limetta </em>fruit peel against Ehrlich ascites carcinoma bearing Swiss mice.

Hematologic responses to deferasirox therapy in transfusion-dependent patients with myelodysplastic syndromes

Reductions in transfusion requirements/improvements in hematologic parameters have been associated with iron chelation therapy in transfusion-dependent patients, including those with myelodysplastic syndromes; data on there reductions/improvements have been limited to case reports and small studies. To explore this observation in a large population of patients, we report a post-hoc analysis evaluating hematologic response to deferasirox in a cohort of iron-overloaded patients with myelodysplastic syndromes enrolled in the Evaluation of Patients' Iron Chelation with Exjade(®) (EPIC) study using International Working Group 2006 criteria. Two-hundred and forty-seven, 100 and 50 patients without concomitant medication for myelodysplastic syndromes were eligible for analysis of erythroid, platelet and neutrophil responses, respectively. Erythroid, platelet and neutrophil responses were observed in 21.5% (53/247), 13.0% (13/100) and 22.0% (11/50) of the patients after a median of 109, 169 and 226 days, respectively. Median serum ferritin reductions were greater in hematologic responders compared with non-responders at end of study, although these differences were not statistically significant. A reduction in labile plasma iron to less than 0.4 μmol/L was observed from week 12 onwards; this change did not differ between hematologic responders and non-responders. This analysis suggests that deferasirox treatment for up to 1 year could lead to improvement in hematologic parameters in some patients with myelodysplastic syndromes.

Evaluation of hematological parameters in partial exchange and packed cell transfusion in treatment of severe anemia in pregnancy.

Objectives. Anemia is a major public health problem throughout the world which assumes prominence in pregnant mothers. Patients with severe anemia continue to present themselves at term or in labor. This study was conducted to compare the improvements in hematological parameters of patients receiving partial exchange blood transfusion and transfusion of packed cells without exchange. Methods. One hundred and twenty-five severely anemic antenatal mothers were admitted from outpatient service. Partial exchange transfusion was given to sixty-six patients while fifty-nine received transfusion of packed cells with frusemide cover. Results. The two groups were comparable in terms of age, height, weight, religion, diet, education, occupation of self and husband, and income. Hemoglobin level in Group 1 was comparatively less than Group 2 at prelevel (5.2 ± 1.5 versus 6.6 ± 2.3, P = 0.001) and postlevel (7.2 ± 1.5 versus 8.6 ± 1.8, P = 0.001), respectively, but there was no significant difference between the two modes of transfusion (2.09 ± 1.6 versus 2.01 ± 1.5, P = 0.78). Conclusion. The study produced an equally significant improvement in hematological parameters in partial exchange and packed cell transfusion. Platelet counts were significantly less in partial exchange as compared with packed cell transfusion.

High Rate of Erythroid Response During Iron Chelation Therapy in a Cohort of 105 Patients Affected by Hematologic Malignancies with Transfusional Iron Overload: An Italian Multicenter Retrospective Study

Abstract 611▪▪This icon denotes a clinically relevant abstract Background:Improvements in hematologic parameters have been associated with iron chelation therapy (ICT) in transfusion-dependent patients with chronic anemia associated with hematologic malignancies. Data from a significant cohort of myelodysplastic syndromes (MDS) patients enrolled in the EPIC study and treated with deferasirox reported a percentage of 22.6% of erythroid responses. Several sporadic reports showed hematologic improvement in patients treated with deferoxamine or deferasirox in patients affected by myelofibrosis (PMF) and Aplastic Anemia (AA). The aim of this study was to retrospectively evaluate the hematologic response in the entire cohort of chronic anemias with iron overload receiving ICT with both deferasirox (DFX) or deferoxamine (DFO) in 6 hematological Italian centers from 1993 to 2011. Methods: 105 patients received ICT for at least 3 months. Sixteen were PMF, 8 AA, 75 MDS, 4 Chronic Myelomonocytic Leukemia (CMML), 2 Acute Myeloid Leukemia (AML). 30 patients received deferoxamine (6 PMF, 3 AA, 1 CMML, 2 AML, 18 MDS), and 68 deferasirox (9 PMF,5 AA, 3 CMML, 51 MDS), and 7 received deferasirox after a prior treatment with deferoxamine (1 PMF, 6 MDS). The median serum ferritin levels at the time of ICT was 1983 ng/ml and it was not significantly different between the two cohorts (p=0,8). Patients, at the time of ICT, had transfused a median of 30 Units of RBC (40 in the DFO cohort and 24.5 in DFX cohort, p=0.001). 25 out of 105 were receiving EPO therapy at the time of chelation, started at least 6 months before ICT, without a significant clinical improvement and three were receiving a JAK2 inhibitor started at least 1 year before ICT. Patients receiving any kind of therapy able to modify the erythroid response including azacitidine were excluded as well as patients receiving EPO started less than 6 months before ICT or JAK2 inhibitors or immunosuppressive therapy less than 12 months before. Hematological response (HR) was evaluated as follow: Achieving a RBC transfusion independency (complete HR) or Hematological improvement (HI-e) for patients showing a Hb increase of 1.5 g/dL or a reduction of 4 RBC transfusions/8 weeks (IWG 2006). Results: We retrospectively analyzed an unselected cohort of patients with transfusion dependent iron overload affected by different hematologic malignancies who received ICT outside clinical trials thus allowing the inclusion of high risk MDS/AML. 13 patients were not evaluable because they were receiving ICT for less than 3 months. 41 patients out of 92 (42.7%) evaluable patients achieved a hematologic response. In details: 18 (19,5%) became completely RBC transfusion independent. Six (1 AA, 3 RARS, 1 RCMD, 1 AML) were under DFO treatment and 12 (3 AA, 2 RA, 3 RARS, 1 RAEBII, 1 CMML, 2 PMF) under DFX. In addition, all 4 AA patients who achieved transfusion independency significantly increased the number of platelets ( median 17.000/mm3 before ICT and 35.000 and 55.000 after 6 and 12 months of ICT). Median time to response was 15 months for DFO and 3 months for DFX. 16 patients (17.3%) (6 RA, 4 RARS,1 RCMD, 1 RAEB, 4 PMF) obtained HI-e defined as a reduction of 4 U/8 weeks (5 in DFO and 11 in DFX cohorts) after a median of 6 months for both DFO and DFX. HI-e defined as an increased of 1.5 g/dL was observed in 7 patients (7.6%) ( 4 RA, 1 RARS, 1 RCMD, 1 PMF) after a median of 6 months for DFO and 3 for DFX. The hematologic improvement is not strictly related to an effective reduction of serum ferritin (p=0,4). Conclusions: Our data show a high rate of complete responses, mainly in AA and RARS but also in high risk MDS/AML representing 11% of those achieving complete transfusion independency. Notably 50% of AA achieved RBC and platelet transfusion independency. Despite the limitation due to the retrospective collection of data we suggest the ICT could result in hematologic improvement in a wide population including patients who are, at present, outside the published ICT guidelines. This study warrants further investigation on the mechanism of action of ICT in inducing erythroid response. Disclosures:Saglio:Novartis, Brystol Myers: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau.

Clinicopathological and Radiological Study of Egyptian β-Thalassemia Intermedia and β-Thalassemia Major Patients: Relation to Complications and Response to Therapy

The clinico epidemiological characteristics, frequency of complications, and response to various therapeutic modalities in 80 Egyptian β-thalassemia intermedia (β-TI) patients were compared with 70 β-thalassemia major (β-TM) patients. β-Thalassemia intermedia patients had a higher incidence of left atrium dilatation, right ventricular dilatation and pulmonary hypertension, whereas, β-TM patients showed a higher incidence of left ventricular (LV) dilatation, restrictive LV filling and impaired LV contractility, with an overall higher incidence of heart disease (p <0.001). Short stature, delayed puberty, osteoporosis, bone fractures, diabetes mellitus and viral hepatitis was frequently observed in β-TM patients compared with β-TI patients (p <0.05). Administration of hydroxyurea (HU) alone was associated with significant improvement in hematological parameters and quality of life for β-TI patients. In conclusion, the risk of complications still burdens the life of Egyptian thalassemia patients and their frequency varies between β-TI and β-TM. We provide evidence that calls for the use of HU in β-TI patients.

Hematologic Responses In Myelodysplastic Syndromes (MDS) Patients Treated with Deferasirox: An EPIC Post-Hoc Analysis Using International Working Group (IWG) 2006 Criteria

AbstractAbstract 2912 Background:Improvements in hematologic parameters and/or reductions in transfusion requirements have been associated with iron chelation therapy in transfusion-dependent patients with MDS; however, data has been limited to case reports/small studies (Jensen P et al. Br J Hematol 1996; Messa E et al. Acta Haematol 2008; Okabe H et al. Rinsho Ketsueki 2009; Oliva E et al. Transfusion 2010; n=1–11). The 1-year prospective EPIC study (Cappellini MD et al. Haematologica 2010) enrolled 341 transfusion-dependent MDS patients with iron overload. Patients were chelated with deferasirox leading to reductions in serum ferritin, an indicator of body iron burden (Gattermann N et al. Leuk Res 2010). During the EPIC study, transfusions were recorded and pretransfusion blood counts were assessed. Here we report a post-hoc analysis evaluating hematologic responses in a large cohort of MDS patients enrolled in EPIC using the IWG 2006 criteria (Cheson B et al. Blood 2006). Methods:Full study design and inclusion/exclusion criteria for EPIC have previously been described (Cappellini MD et al. Haematologica 2010; Gattermann N et al. Leuk Res 2010). Patients with a life expectancy of <1 year were excluded. Deferasirox dose was initiated at 20 mg/kg/day with adjustments of 5–10 mg/kg/day up to 40 mg/kg/day. MDS patients with pretreatment hemoglobin (Hb) levels <11 g/dL or red blood cell (RBC) transfusion requirements >4 units every 8 weeks and not receiving erythropoietin were eligible for erythroid response analysis. Patients with pretreatment platelet counts of <100 × 109/L or platelet-transfusion dependence, and absolute neutrophil counts of <1.0 × 109/L and not receiving GCSF were selected to assess platelet and neutrophil responses, respectively. Erythroid response: Hb increase '1.5 g/dL or reduction of ≥4 RBC transfusions/8 weeks compared with previous 8 weeks before treatment start. Platelet response: increase ≥30 × 109/L for patients with >20 × 109/L platelets, increase from <20 × 109/L to >20 × 109/L and by at least 100%. Neutrophil response: ≥100% increase and an absolute increase >0.5 × 109/L. All responses to last ≥8 weeks (IWG 2006). Results:Of the 341 iron-overloaded MDS patients enrolled in the EPIC study, 279, 121 and 56 patients were included in erythroid, platelet and neutrophil response analyses, respectively. Mean deferasirox dose for erythroid, platelet and neutrophil analysis groups were 19.2, 19.4 and 18.4 mg/kg/day, respectively; no significant difference in dose was observed between responders and non-responders. During deferasirox treatment, erythroid responses were observed in 22.6% (63/279) of patients. Median time to response was 113.0 days. Of these erythroid responses, a transfusion reduction-only response with maintenance of Hb level was observed in 10.8% (n=30) of patients, Hb improvement-only response in 10% (n=28) of patients and both transfusion and Hb response observed in 1.8% (n=5) of patients. Platelet and neutrophil responses were observed in 14.0% (n=17) of patients after a median of 169.0 days and 19.6% (n=11) of patients after a median of 226 days, respectively. Conclusions:This is the first large study to show that, alongside reducing iron overload, deferasirox may affect hematologic parameters in MDS patients. Overall erythroid response was 22.6% with deferasirox; although cross-trial comparisons should be interpreted with caution, a study in patients with low- and intermediate-1-risk MDS (IPSS) treated with valproic acid for a median of 4 months showed a major hematological response (IWG 2000 criteria) of 29% (Kuendgen A et al. Ann Hematol 2005). A limitation of the current analyses is the lack of a control arm comparing to best supportive care. The exact mechanism by which deferasirox can lead to improved hematological response in MDS remains to be determined. The effect may be attributed to reduction in iron overload, a specific pharmacological effect of the drug on hematopoiesis such as the ability to inhibit nuclear factor κB (Messa E et al. Haematologica 2010; Epub), or both. Other implicated mechanisms include the ability to sequester iron in a particular target or to affect the neoplastic clone or bone marrow microenvironment (Messa E et al. Acta Haematol 2008). Confirmation of these results and greater insights into mechanisms will require larger prospective trials specifically investigating hematologic responses in deferasirox-treated patients. Disclosures:Gattermann:Novartis: Honoraria, Research Funding. Finelli:Celgene: Consultancy. Fenaux:CELGENE: Honoraria, Research Funding; JANSSEN CILAG: Honoraria, Research Funding; AMGEN: Honoraria, Research Funding; ROCHE: Honoraria, Research Funding; GSK: Honoraria, Research Funding; NOVARTIS: Honoraria, Research Funding; MERCK: Honoraria, Research Funding; CEPHALON: Honoraria, Research Funding. Guerci-Bresler:Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees. Habr:Novartis: Employment. Marcellari:Novartis: Employment. Roubert:Novartis: Employment.

Results of a Prospective Multicenter Phase II Study of Initial Treatment with Methotrexate In LGL Leukemia (ECOG Protocol E5998)

AbstractAbstract 702 Background:Large granular lymphocyte (LGL) leukemia is characterized by clonal expansion of cytotoxic T cells. Prominent clinical features include neutropenia, anemia, and rheumatoid arthritis. The terminal effector memory phenotype (CD3+/CD8+/CD57+/CD45RA+/CD62L-) of leukemic LGL suggest a pivotal chronic antigen driven immune response. LGL survival is then promoted by PDGF and IL-15 (Proc Natl Acad Sci USA 105:16308, 2008), resulting in global dysregulation of apoptosis and resistance to normal pathways of activation-induced death (Blood 112:770, 2008). These pathogenic features explain why treatment of LGL leukemia is based on immunosuppression therapy. However, no standard therapy has been established due to the absence of large prospective trials. Methods:Eligibility criteria included increased number of LGL (CD3+CD57+ cells > 400/ul or CD8+ cells >650/ul) plus evidence of clonal rearrangement of T cell receptor gene. Treatment indications included the following categories: a) severe neutropenia (ANC < 500/ul); b) neutropenia associated with recurrent infections; c) symptomatic anemia; and, d) transfusion-dependent anemia. Initial Treatment:(Step 1) consisted of methotrexate (MTX) at 10 mg/m2 po in divided doses once weekly. Prednisone was given at 1 mg/kg po × 30 days and then tapered off in the subsequent 24 days. Patients not responding to MTX received cyclophosphamide (CY) at 100 mg po daily with the same prednisone schedule (Step 2). Treatment response was assessed after four months of therapy as: complete remission (CR): normal CBC (ANC ≥ 1,500/ul, lymphocyte count <4,000/ul, hemoglobin ≥ 11 g/dl, and platelet count > 100,000/ul. In addition, LGL counts needed to be within normal range. Partial response (PR) was defined as improvement in hematologic parameters in the absence of CR: 1) ANC > 500, as long as this represented 50% increase (category a); 2) improvement in ANC ≥ 50% over baseline (category b); 3) increase in hemoglobin by ≥ 1 g/dl for at least four months duration (category c); and, 4) decrease in monthly transfusion requirement of > 50% for at least four months (category d). Progressive disease (PD) was defined as worsening of hematologic parameters in patients previously achieving PR/CR. No response (NR) was defined as lack of CR/PR. Results:Response data are shown for Step 1 (Table 1) and for Step 2 (Table 2). Overall response rate (CR/PR) for MTX was 37%. In patients failing MTX, the overall response to CY was 64%. There were two infectious deaths during Step 1 therapy.Table 1Response Outcome in Step OneResponseNeutropenia Patients (N=26)Anemia Patients (N=30)All Patients (N=56)n%n%n%CR281335PR9359301832NR114112402341PD001412Unvaluable3127231018Unknown140012Table 2Response Outcome in Step TwoResponseNeutropenia Patients (N=8)Anemia Patients (N=6)All Patients (N=14)n%n%n%CR113233321PR337350643NR22500215Unvaluable225117321 Conclusion:Data documenting efficacy of immunosuppressive therapies commonly utilized in LGL leukemia (MTX, CY, Cyclosporine) are limited to 300 patients published primarily as small retrospective studies. Such data show an overall response rate to MTX of 58% (56/96 patients). Here in the only large prospective trial we observed an overall response rate of 37%. Overall response rate of 64% for CY was not statistically different than MTX. However, given that CY response rate was observed in MTX failures, future studies should consider evaluation of CY as initial therapy. Disclosures:Off Label Use: Immunosuppressive therapies for LGL leukemia including Methotrexate and Cyclophosphamide.

Phase I and Pharmacologic Study of SNS-032, a Potent and Selective Cdk2, 7, and 9 Inhibitor, in Patients With Advanced Chronic Lymphocytic Leukemia and Multiple Myeloma

SNS-032 is a highly selective and potent inhibitor of cyclin-dependent kinases (Cdks) 2, 7, and 9, with in vitro growth inhibitory effects and ability to induce apoptosis in malignant B cells. A phase I dose-escalation study of SNS-032 was conducted to evaluate safety, pharmacokinetics, biomarkers of mechanism-based pharmacodynamic (PD) activity, and clinical efficacy. Parallel cohorts of previously treated patients with chronic lymphocytic leukemia (CLL) and multiple myeloma (MM) received SNS-032 as a loading dose followed by 6-hour infusion weekly for 3 weeks of each 4-week course. There were 19 patients with CLL and 18 with MM treated. Tumor lysis syndrome was the dose-limiting toxicity (DLT) for CLL, the maximum-tolerated dose (MTD) was 75 mg/m(2), and the most frequent grade 3 to 4 toxicity was myelosuppression. One patient with CLL had more than 50% reduction in measurable disease without improvement in hematologic parameters. Another patient with low tumor burden had stable disease for four courses. For patients with MM, no DLT was observed and MTD was not identified at up to 75 mg/m(2), owing to early study closure. Two patients with MM had stable disease and one had normalization of spleen size with treatment. Biomarker analyses demonstrated mechanism-based PD activity with inhibition of Cdk7 and Cdk9, decreases in Mcl-1 and XIAP expression level, and associated CLL cell apoptosis. SNS-032 demonstrated mechanism-based target modulation and limited clinical activity in heavily pretreated patients with CLL and MM. Further single-agent, PD-based, dose and schedule modification is warranted to maximize clinical efficacy.

Doxycycline for haematopoietic stem cell transplantation-related thrombotic microangiopathy.

Transplantation-associated thrombotic microangiopathy (TA-TMA) is a devastating consequence of allogeneic haematopoietic stem cell transplantation (HSCT) with a mortality rate of 60–90%. None of the interventions used, as used up till now in idiopathic thrombotic thrombocytopaenic purpura (TTP) (fresh frozen plasma transfusion, plasma exchange and steroids), were effective to treat TA-TMA [1,2]. We report a dramatic improvement of TA-TMA in two HSCT patients [conditioning, cyclophosphamide, total body irradiation, graft-versus-host disease (GVHD) prophylaxis] using doxycycline. A 36-year-old woman with Hodgkin's lymphoma received an allogeneic HSCT in December 2002. Twelve months later, she developed a biopsy-proven TMA (proteinuria, 3 g/day, microscopic haematuria, oliguric acute renal failure with creatinine level at 680 µmol/L; haemoglobin Hb, 6.3 g/dL; schistocytes; platelet count, 35 × 109/L; LDH, 1754 IU/L). The serum complement proteins were at normal levels, no mutations of the membrane cofactor protein were found and a plasma ADAMTS13 activity was found at 40%. Steroids, plasma exchange, fresh frozen plasma transfusion, vincristine and haemodialysis were tried with a partial response (haemoglobin, 7.3 g/dL, platelet 70 000/mm3 both after treatment). Doxycycline 200 mg daily was added for a suspected gastrointestinal Bartonella infection. Within two months, haemoglobin and platelet count rose without transfusion to 10.8 g/dL and 234 000/mm3, respectively. Despite improvement of haematological parameters, the patient remained dialysis-dependent. The second patient had a similar haematologic disease and course under doxycycline prescribed for a bartholinitis. Five patients with TTP and Bartonella-like erythrocyte inclusions, successfully treated with doxycycline, experienced recurrence of their TTP following cessation of treatment [3]. TA-TMA has a multi-factorial aetiology of endothelial damage. Doxycycline targeting the adherens junction on endothelial cells prevents vascular hyperpermeability [4]. Doxycycline as a potential treatment of TA-TMA warrants further studies. Conflict of interest statement. None declared.

Hydroxyurea therapy requires HbF induction for clinical benefit in a sickle cell mouse model

Hydroxyurea has proven clinical efficacy in patients with sickle cell disease. Potential mechanisms for the beneficial effects include fetal hemoglobin induction and the reduction of cell adhesive properties, inflammation and hypercoagulability. Using a murine model of sickle cell disease in which fetal hemoglobin induction does not occur, we evaluated whether hydroxyurea administration would still yield improvements in hematologic parameters and reduce end-organ damage. Animals given a maximally tolerated dose of hydroxyurea that resulted in significant reductions in the neutrophil and platelet counts showed no improvement in hemolytic anemia and end-organ damage compared to control mice. In contrast, animals having high levels of fetal hemoglobin due to gene transfer with a gamma-globin lentiviral vector showed correction of anemia and organ damage. These data suggest that induction of fetal hemoglobin by hydroxyurea is an essential mechanism for its clinical benefits.

Partial splenic embolization and peg-IFN plus RBV in liver transplanted patients with hepatitis C recurrence: safety, efficacy and long-term outcome

There is limited information on the long-term outcome in liver transplant (LT) subjects undergoing partial splenic embolization (PSE) prior to full dose pegylated interferon/ribavirin (peg-IFN/RBV). Retrospective review of eight LT subjects after PSE and antiviral therapy. Baseline platelets and neutrophils were <50 000 cells/mL and <1000 cells/mL in 75% and 50%. Mean splenic infarction volume was 85 +/- 13%. PSE produced major complications in three (37.5%): recurrent sterile netrophilic ascites and renal insufficiency (n = 2), and splenic abscess (n = 1). Full-dose peg-IFN/RBV was started in seven (87.5%), with two early withdrawals (28.6%) despite early virological response (toxicity and infection); both subjects died. Anemia led to RBV dose-adjustment in six (86%), with human recombinant erythropoietin (EPO) use in four (57%). No peg-IFN adjustments or granulocyte-colonies stimulating factor were needed. Two patients reached sustained virological response (SVR) (28.6%). Two non-responders maintained prolonged therapy with biochemical/histological improvement. After a median follow-up of 151 wk, we observed significant improvements in hematological parameters, aspartate aminotransferase, alanine aminotransferase, international normalized ratio, and prothrombin activity. Extensive PSE after LT produced significant morbidity (37.5%). Peg-IFN/RBV was completed in five out of seven (71%), with SVR in two (28.6%). RBV adjustement due to anemia was high despite EPO use. Only patients able to complete or maintain antiviral therapy survived, with long-term significant benefits in hematological parameters and liver function tests.

Safety, therapeutic effectiveness, and cost of parenteral iron therapy

Patients have to discontinue the use of oral iron therapy due to the development of side effects and lack of long-term adherence to medication for iron deficiency anemia. This study aimed to evaluate the therapeutic effectiveness, safety, and cost of intravenous iron sucrose therapy. The computerized database and medical records of 453 patients diagnosed with iron deficiency anemia who received intravenous iron sucrose therapy for iron deficiency anemia between 2004 and 2008 were reviewed. The improvement of hematologic parameters and cost of therapy were evaluated 4 weeks after therapy. 453 patients (443 females, 10 males; age: 44.2 +/- 12.3 years) received iron sucrose therapy. Mean hemoglobin, hematocrit, and mean corpuscular volume values were 8.2 +/- 1.4 g/dL, 26.9 +/- 3.8%, and 66.1 +/- 7.8 fL, respectively, before therapy and 11.5 +/- 1.0 g/dL, 35.8 +/- 2.5%, 76.5 +/- 6.1 fL, respectively, after therapy (P < 0.001). A mean ferritin level of 3.4 +/- 2.4 ng/mL before therapy increased to 65.9 +/- 40.6 ng/mL after therapy (P < 0.001). All patients responded to intravenous iron therapy (transferrin saturation values of the patients were >50%). The mean cost of therapy was 143.07 +/- 29.13 US dollars. The therapy was well tolerated. Although the cost of intravenous iron sucrose therapy may seem high, a lack of adherence to therapy and side effects including gastrointestinal irritation during oral iron therapy were not experienced during intravenous therapy.

Failure of a non-authorized copy product to maintain response achieved with imatinib in a patient with chronic phase chronic myeloid leukemia: a case report

IntroductionDue to high rates of response and durable remissions, imatinib (Glivec®, or Gleevec® in the USA; Novartis Pharma AG) is the standard of care in patients with chronic myeloid leukemia. Recently, a non-authorized product which claims comparability to imatinib has become available.Case presentationThis report describes the loss of response in a 36-year-old male patient with chronic-phase chronic myeloid leukemia who had previously been in full hematologic and cytogenetic remission and partial molecular remission for three years, under treatment with brand-name imatinib of 400 mg per day. Before the initiation of treatment with a copy product, imatib (CIPLA-India), the patient had negative BCR-ABL status. Within three months of initiation of treatment with the copy product, the patient's BCR-ABL status became positive, with substantial decreases noted in white blood cell counts, red blood cell counts and platelet counts. Conversion of the BCR-ABL status to negative and improvements in hematologic parameters were achieved when the brand medication, imatinib, was resumed at a dose of 600 mg per day.ConclusionIn our patient, the substitution of a copy product for imatinib resulted in the rapid loss of a previously stable response, with the risk of progression to life-threatening accelerated phase or blast crisis phase of the disease. Without supportive clinical evidence of efficacy and safety of imatib (or any other copy product) caution should be used when substituting imatinib in the treatment of any patient with chronic myeloid leukemia.

Effect of vitamin E on cadmium toxicity in common carp (Cyprinus carpio L

The sublethal median concentration of cadmium chloride was used at concentration 1mg/L for 7 days ,with 0.2mg/1g body weight of vitamin E for 3 days which was used as an antioxidant there was no improvement in hematological parameters, but there was significant reduction in the serum alanine aminotransferase and creatine phosphokinase activity. Treatment with vitamin E and cadmium chloride could not repair the tissues damage result from cadmium which included grossly congestion of gills , hitopathological lesions revealed hyperplasia of epithelial cells with hyperatrophy of piler cells and inflammatory cells infiltration which lead to adhesion of the secondary lamellae of gills, In liver and kidney which appeared congested with presence of pale areas, histopathological lesions include infiltration of inflammatory cells specially melanomacrophage and mononuclear cells in hepatic tissue with thickening of the bile duct wall, haemmorrhage and necrosis in hepatic tissue, while in kidney there was congestion of blood vessels, deposition of hyaline casts in the renal tubule.

Correction of Sickle Cell Anemia with γ-Globin Gene Delivered by Lentivirus Vector in the Setting of Myeloablative or Reduced Intensity Conditioning, and Establishing Critical Determinants for Successful Gene Therapy for Sickle Cell Disease.

While genetic delivery of recombinant anti-sickling β-globin genes have been shown to correct murine sickle cell anemia (SCA), correction of SCA by delivery of a natural hemoglobin, fetal hemoglobin (HbF), the proportion of genetically modified hematopoietic stem cells (HSC), or amount of HbF necessary to correct the disease is unknown. We designed a lentivirus vector carrying γ-globin exons with β-globin regulatory elements and non-coding sequences, GbG. First, GbG or mock transduced Berkeley sickle HSC were transplanted using a myeloablative (lethal irradiation) transplant model, to acheive full donor chimerism. GbG mice showed high HbF expression (HbF 41 ± 5% measured by HPLC) that was sustained in primary (6 mo) and secondary (7.5 mo) transplant recipients, and resulted in effective correction of hematological and functional RBC parameters, and reduction of inflammation that results from sickle cell disease. We found significantly reduced irreversibly sickled cells (2.3 ± 0.7% in GbG versus 10.2 ± 0.3% in mock mice; p<0.001), minimal sickling of RBC when exposed to graded hypoxia using tonometry, improved RBC deformability (performed by ektacytometry), and a four-fold increase in RBC half-life (by in vivo biotin labeling) in the GbG group of mice. There was correction of anemia, and reduction in hemolysis (measured by LDH levels), reticulocytes, and leukocytosis (Table 1). This was accompanied by a dramatic improvement in chronic organ damage that is seen in untransplanted Berkeley/mock group of mice: there was a significant reduction in spleen weights and normalization of splenic follicular architecture, correction in bone marrow myeloid:erythroid ratios, and a notable absence of kidney infarction and atrophy, and liver infarction and extramedullary hematopoiesis that was observed in mock mice. Untransplanted Berkeley and mock mice showed shortened survival consistent with a severe SCA phenotype. Genetic correction with GbG improved survival to 100% compared to a 20% survival in the mock transplanted. Notably, in our proof-of principle studies, comparable functional sickle RBC correction was also seen in the Townes knock-in sickle mice (Wu et al, Blood 2006) transduced with GbG. Myeloablative conditioning in this setting allowed non-competitive repopulation of donor genetically modified HSC, resulting in high HbF and correction of disease. However, myeloablation in SCA is associated with peri-transplant mortality and long-term effects, and may not be necessary for achieving correction of phenotype. To address this, we used a unique reduced-intensity conditioning transplant model. We transplanted GbG-modified Berkeley HSC into sub-lethally irradiated Berkeley mice. In this model, when HbF was <10%, there was a small and variable improvement in hematological and functional sickle RBC parameters. However, when HbF was γ10%, there was consistent long-term correction in RBC sickling, deformability, RBC survival, and improvement in hematological parameters for 10–11 months (Table 1). Impressively, when HbF was γ10%, there was a significant reduction in splenomegaly, absence of liver and kidney pathology, and a dramatically improved overall survival of the mice, comparable to that seen in the myeloablative model. Comparison of the proportion of F-cells (HbF containing RBC) and HbF/F-cell to the assays showing correction of SCA revealed that >30% HbF/F-cell and >60% F-cells consistently corrected SCA. The mean HSC transduction (assessed by secondary HbF+ CFU-S at 6 months post transplant) was 50% and 30% in the myeloablative and reduced intensity transplant models, respectively, with 1–3 GbG copies/ cell. Furthermore, three GbG mice showed correction of SCA with 20% HSC transduction, a clinically achievable goal. Taken together, this study is the first demonstration of correction of SCA with gene therapy using γ-globin, and defines critical determinants for effective gene therapy of this disease.MouseModelHb (g/dl)RBC 106/ul)Reticulocyte (%)WBC (K/ul)MockMyeloablative7.6±0.75.8±0.440.0±3.029.7±1.4GbGMyeloablative10±0.8*9.4±0.8**15.8±3.2**10.6±3.1**GbG, HbF ≥ 10%Reduced intensity9.3±0.6*8.1±0.5**21.2±1.9**13.4±1.1***p<0.05; ** p<0.001

Phase I Study Demonstrates Activity and Tolerability of Diphtheria Toxin Interleukin-3 Fusion Protein in Patients with AML and MDS.

Interleukin-3 receptor (IL-3R) proteins are over-expressed on blasts and cancer stem cells of multiple hematologic malignancies. The recombinant diphtheria toxin fusion protein, DT388IL3, specifically targets IL-3R and is composed of the catalytic and translocation domains of diphtheria toxin (DT388) fused to human interleukin-3 (IL3). DT388IL3 demonstrated selective toxicity to acute myeloid leukemia (AML) stem cells both in vitro and in vivo, and was prepared for a Phase I clinical study in AML and myelodysplasia (MDS) patients. FDA approval (BB IND#11314) and IRB approvals were obtained. 80 AML and MDS patients were screened and 38 AML and 3 MDS patients were treated. The median age of treated patients was 62 years (range, 25–81 years). There were 22 males and 19 females. AML disease was de novo in 5, 1st relapse in 12, 2nd relapse in 8, and refractory in 12. MDS disease was high-grade in one and intermediate-grade in 2. Five AML patients had a history of MDS, and one had a history of secondary AML. One patient each had previously received an autologous or allogeneic stem cell transplant. AML cytogenetics was unfavorable in 15, intermediate in 21, and not done in 2. Seven patients were treated with 4 ug/kg, eight patients with 5.3 ug/kg, thirteen patients with 7.1 ug/kg, seven with 9.4 ug/kg, and six with 12.5 ug/kg DT388IL3 for up to six treatments (one cycle). Of note, patients have not yet received a second cycle. Drug-related toxicities were mild to moderate and transient including fever, chills, hypotension, transaminasemia, hypoxemia, and hypoalbuminemia. Pretreatment anti-DT antibody levels ranged from 0 – 9.6ug/mL (mean = 2.3ug/mL); day 15 post-treatment antibody levels were 0 – 600ug/mL (mean = 92ug/mL); day 30 antibody levels were 1.1 – 306ug/mL (mean = 82ug/mL). Day 1 Cmax ranged from 0 – 350 ng/mL and correlated with dose; Day 12 Cmax ranged from 0 – 179 ng/mL and correlated with Day 12 anti-DT antibody levels. Development of anti-DT antibody levels at Day 15 and 30 did not interfere with response. Consistent with an absence of toxicity to normal hematopoietic progenitors, responses occurred in the absence of prolonged myelosuppression. Among 38 evaluable AML patients, we have observed one CR of 8 months duration, 2 partial remissions (PRs) lasting one and three months, and 3 minimal responses with clearance of peripheral blasts and marrow blast cytoreductions of 89%, 90%, and 90% lasting one to two months. In one evaluable MDS patient, we achieved a PR lasting four months with improvement in hematologic parameters and conversion to transfusion independence. Patient accrual is proceeding with correlative IL3R content of blasts and cancer stem cells. These results of activity and tolerability are encouraging and suggest that DT388IL3 may achieve a role in the management of patients with myeloid malignancies.

Outcome of enzyme replacement therapy in patients with Gaucher disease type I. The Romanian experience

This study reports the first evaluation of therapeutic response in Romanian patients with Gaucher disease type I, after therapy with Cerezyme recently became available in our country. 24 patients (11-50 years) received Cerezyme 20-60 U/kg every two weeks for at least 18 months. Haemoglobin, platelet count, volume of the liver and spleen, plasma chitotriosidase and the severity score were assessed every 6 months; skeletal radiography and osteodensitometry were also monitored. Eleven patients were splenectomized before start of therapy. Eight patients had anaemia (mean haemoglobin 9.4 g/dl) and 14 patients, of whom 13 were without splenectomy, had thrombocytopenia (mean 65,692/mm3). Haemoglobin values normalized after 6 months and the platelet count increased to 147,818/mm3 after 18 months of treatment. Splenomegaly improved (mean 13.8x to 5.6x normal), hepatomegaly improved (mean 1.4x to 1.06x normal), the severity score decreased (mean 15.9 to 8.4), plasma chitotriosidase levels showed a reduction from 40,956 to 11,266 nmol/h per ml plasma. Bone disease improved clinically in all patients; bone radiography and osteodensitometry showed no further disease progress. We observed a mean weight gain of 4.3 kg, an improvement in quality of life, and the absence of therapeutic adverse events. Enzyme replacement therapy administered for 18 months in Romanian patients with Gaucher disease type I led to a marked improvement in haematological parameters and hepato- and splenomegaly. In the majority of patients we observed no further progress of bone disease; for an improvement in skeletal disease, a longer treatment period is required.

Lack of BCL-2 confers interferon-alpha sensitivity to B-cell lymphomas

Hairy cell leukemia (HCL) is a chronic B-cell lymphoproliferative disorder with pathological manifestations usually including splenomegaly and panctopenia. Interferons (IFNs), specifically of the α subtypes have shown a significant anti-tumor effect in HCL patients, with improvement of hematological parameters within the first few months of treatment. However, the therapeutic effect of IFN-α is still rather limited. The mechanisms responsible for the beneficial action of IFN-α in HCL patients are unclear. A continuous line of cells (Eskol) from a patient diagnosed with HCL was established and shown to have several properties of HCL. Even though, Eskol cells are very resistant to anti-proliferative activity of IFN-α, Daudi cells, another human B-cell-derived cell line, are very sensitive to anti-proliferative activity of IFN-α and are commonly used as a model cell to test anti-proliferative effect of IFN-α. To understand the molecular reason(s) behind the observed obvious differences to IFN sensitivity of above cells, we have analyzed the expression levels of BCL2, caspase-1, Laminin and PARP in these cells. We found that Daudi cells do not express BCL2 at all, and probably because of that, these cells have constantly cleaved, and probably activated form of caspase-1. However, when we overexpresed BCL2 in these cells, they lost processed form of caspase-1 and became resistant to anti-proliferative activity of IFN-α. These results let us to suggest that IFN-α sensitivity of B-cell lymphomas, once again, depends on the presence or absence of BCL2.

Comparative evaluation of parasitology and serological tests in the diagnosis of visceral leishmaniasis in India: a phase III diagnostic accuracy study

In this phase III trial for diagnostics for visceral leishmaniasis (VL) in India, we compared parasitological diagnosis with several serological tests: direct agglutination test (freeze dried; DAT-FD), rK-39 strip test, rK-26 strip test and a latex agglutination test for antigen detection in urine (KAtex) in 452 subjects from the endemic regions of Bihar, India. The subjects were segregated into four categories: 230 confirmed patients, 52 probable cases, 70 non-cases and 100 healthy endemic controls. The first two groups were used for estimating sensitivity, the latter two for specificity. Sensitivity of DAT-FD was 98.9%, rK-39: 98.9%, KAtex: 67.0% and rK-26: 21.3%. Sensitivity of DAT-FD on blood taken on filter paper (DAT-FDF) was 99.3%, which was comparable with that using serum. Specificity of serological tests was comparable and high (DAT-FD and DAT-FDF: 94%, rK-39 strip test: 97%, KAtex: 99% and rK-26 strip test: 100%). The classical 'gold standard' parasitological demonstration in splenic smear performed poorly as it missed 18.4% of cases that benefited from VL treatment. Reproducibility of the serological tests between field and central laboratories was excellent (kappa = 1.0, 0.99, 0.96 and 0.94 respectively for microscopy, DAT-FD, rK-39 strip test and rK-26 strip test). A high degree of agreement was observed between DAT-FD and rK-39 strip test (kappa = 0.986). Although DAT-FD and rK-39 strip test were highly sensitive with excellent specificity, the ease of use of the latter makes it most suitable for the diagnosis of VL in the field conditions.

The Increasing Relevance of Copper Deficiency in Hematological Practice.

Background: Copper deficiency is an established cause of hematological abnormalities, traditionally described in malnourished infants and persons with malabsorption or short bowel syndromes, particularly those requiring long-term parenteral nutrition. With the recent increase in bariatric (weight reduction) surgery, acquired copper deficiency may be increasing in incidence but the diagnosis is frequently delayed.Methods: To outline the natural history of copper deficiency we searched the Mayo Clinic database and our heavy metals laboratory for patients diagnosed with low serum copper during the years 1974–2005. Copper deficiency was defined as a serum level < 0.75 μg/ml.Results: We identified 123 patients with a low serum copper. 77 patients were excluded as the the hypocupremia was either transient or due to other factors such as Wilson's disease. The remaining 46 patients were all symptomatic. 25 patients had hematological abnormalities, 20 of these patients also had neurological involvement. 5 had isolated hematological manifestations and 21 patients had isolated neurological findings, most commonly myeloneuropathy. 13 presented with anemia and leukopenia, 5 with pancytopenia, 6 with anemia and 1 with isolated neutropenia. In 10 of the 25 cases, a secondary contributing cause for the hematological findings was identified. These included possible anemia of chronic disease (4), renal insufficiency (2), iron deficiency (1), B12 deficiency (1), GI hemorrhage (1), and splenomegaly (1) while copper deficiency was the only identifiable cause in the remaining 15 patients. Hematological parameters at diagnosis are outlined in the table.15 of the 25 patients with hematological manifestations had a history of GI surgery, including 6 patients who had bariatric surgery. The median time from surgery to diagnosis was 11.5 years (range 8 months - 45 years) and was shorter for bariatric surgery (10 years, range: 8 months - 25 years) than for non-bariatric surgery (18 years, range: 2–45 years). 1 patient had a history of excessive zinc ingestion, 1 had malabsorption secondary to chronic pancreatitis and 1 patient had celiac disease. In 7 cases, no explanation was found. 24 of 25 patients received treatment with oral or intravenous copper, 5 were lost to follow up. In 16 patients the hematologic parameters either improved significantly or normalized, while in the remaining 3 patients there was no improvement. Factors that may explain the lack of response in these patients included splenomegaly (1), renal insufficiency (1) and multiorgan illness (1).Conclusion: Copper deficiency is an increasingly frequent cause of hematological abnormalities, and can manifest with refractory cytopenias with or without associated neurological symptoms. Thrombocytopenia is relatively rare. Previous GI surgery, especially bariatric surgery, appears to be a major causative factor. Most patients will have an improvement in hematological parameters after copper supplementation. Recognition of copper deficiency is therefore assuming greater importance in view of the increasing frequency of bariatric surgery, ease of treatment and potential for irreversible neurological damage if diagnosis is delayed.Hematologic parameters at diagnosisHgB (g/dL)MCV (fL)WBC (x109/L)ANC(x109/L)Plts(x109/L)Median10.6993.01.25215Range7.9-13.683.9-114.11-5.60.18-4.054-554