Peripheral Blood Platelet Counts Research Articles

Phase II Study of a JAK1/2 Inhibitor Ruxolitinib for Systemic Chronic Active Epstein-Barr Virus Disease: An Investigator-Initiated Trial

Background: Systemic chronic active Epstein-Barr virus disease (sCAEBV) is a rare EBV-positive T- or NK-lymphoproliferative disease. Although the only curative treatment for sCAEBV available now is allogeneic hematopoietic stem cell transplantation (allo-HSCT), the presence of disease activity, persistent inflammation, at the time of allo-HSCT is associated with poor outcomes (Am J Hem.2022, 97, p780). STAT3 is constitutively activated contributing to cytokine production and cell survival of EBV-infected cells in sCAEBV (Oncotarget. 2019, 9, p31077). Thus, STAT3 inhibition by ruxolitinib, a JAK1/2 inhibitor, may be effective against disease activity of sCAEBV. Methods: We conducted an investigator-initiated trial of open-label, phase 2, prospective and multicenter to assess the efficacy and safety of ruxolitinib in sCAEBV patients with disease activity. The diagnostic criteria were as follows: elevated EBV-DNA load in the peripheral blood (PB) (>102.5 copies/µg DNA); EBV infected T or NK cells detected in affected tissues or PB; systemic inflammatory symptoms persisting for more than three months; exclusion of other possible diagnoses, such as immune deficiencies, autoimmune diseases, or lymphoma (Blood adv. 2021, 4, p2918). sCAEBV patients ≥13 y.o. with fever (≥ 37.5 ºC), and/or liver dysfunction (ALT ≥ 2.0 × ULN) were enrolled. Anti-VCA-IgM-positive patients were excluded. The initiation dose of ruxolitinib was 5-20 mg twice a day determined by the platelet count in PB. The treatment effects were classified as complete response (CR), partial response (PR), progressive disease (PD), and stable disease (SD). CR was defined as the disappearance of all the elements of disease activity such as fever, liver dysfunction, uveitis, progressive skin lesions, and vasculitis. PR was defined as the disappearance of at least one of the elements listed above. PD was defined as the conversion to active disease, exacerbation of active disease, or the development of overt T- or NK-cell lymphoma. SD was defined as presenting no progression. Ruxolitinib was administered for eight weeks. If CR was observed and allo-HSCT was scheduled, ruxolitinib was terminated early even if these events had occurred within less than eight weeks after initiating investigational drug administration. The primary endpoint of efficacy assessments was CR rate at eight weeks after the initiation of drug administration or at the time of early termination. Safety was assessed based on the frequency of adverse events defined by Common Terminology Criteria for Adverse Events, version 4.0. Results: Nine patients were enrolled between January 2019 and August 2021; five males and four females aged 13-64 y.o.; median age of 40 y.o. The types of EBV-infected cells were as follows: four were CD4, one was CD8, and four were CD56. Seven patients completed the study. Five among them received ruxolitinib for eight weeks and were treated as outpatients. Two patients fulfilled the criteria of early termination and each was treated for 35 and 12 days. The responses are shown in the figure. CR rate and OR rate after eight weeks or at early termination, the primary and the secondary endpoints were 28.6% (2/7) and 42.9% (3/7), respectively. No one showed progressive disease. One patient developed a grade 4 adverse event of oral bleeding during the treatment and resulted in discontinuing the administration of ruxolitinib on day 13. Seven patients received allo-HSCT. Five patients achieved undetectable level of EBV-DNA PB after allo-HSCT. Conclusion: The results indicate that ruxolitinib has demonstrated encouraging effects and is a potent therapeutic reagent against sCAEBV with active disease. Further analysis shall complete its assessment. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Outcomes of Older Patients with Aplastic Anemia Treated with Frontline Anti-Thymocyte Globulin (ATG)-Based Immunosuppressive Therapy

Background: Advances in the treatment of aplastic anemia (AA), such as the addition of eltrombopag (EPaG) to immunosuppressive therapy (IST) and the expanded use of unrelated and haploidentical stem cell transplant (SCT) have steadily improved outcomes. However, little is known about the characteristics and outcomes of patients (pts) ≥ 60 years (yrs) of age with newly diagnosed AA who have been treated with an ATG-based regimen. Presumed low bone marrow (BM) reserves, higher frequency of underlying clonal hematopoiesis, intolerance to therapy, comorbidities, and challenges in proceeding to salvage SCT have led to the speculation that response and survival of these pts to IST may be inferior than their younger counterparts. Methods: We retrospectively analyzed the characteristics and outcomes of pts ≥ 60 yrs of age (OLDER) at the time of diagnosis of AA treated with frontline (F/L) ATG based therapy at our center and compared them to pts < 60 yrs of age (YOUNG) treated with F/L ATG over the same time period. We captured their clinical characteristics, cytogenetic abnormalities, mutations in DNMT3A (D), ASXL1 (A) and TET2 (T), exposure to EPaG, response, time to response (TTR) and survival. Overall response included complete and partial response per the standard definitions. Relapse free survival (RFS) was tabulated from the time of best response to loss of response, 2nd ATG infusion, salvage SCT or death (whichever was earlier) and overall survival was tabulated from the time of response to death from any cause. Results: From Jan 2011-May 2012, 43 OLDER pts were treated as F/L for AA of whom 41 (95%) received ATG based therapy; 68 YOUNG pts were treated as F/L for AA over the same time period of whom 62 (91%) received ATG based regimen. Four YOUNG pts vs. no pts in the OLDER group received upfront SCT, and 2 pts in each group were treated with non ATG based therapy: single agent CSA, EPaG, or alemtuzumab. Comparative baseline characteristics are depicted in Table 1. There were no differences in the baseline WBC, peripheral blood lymphocyte percentage and platelet counts between the ATG treated OLDER and YOUNG groups. Both groups had similar frequencies of cytogenetic abnormalities and PNH clones, though OLDER pts had mutations in D-A-T genes compared to the YOUNG group (62% vs. 38%, p=0.05). Both groups had equal concurrent exposure to EPaG with ATG. Cumulatively 23/41 (56%) pts in the OLDER group had an overall response (OR) compared to 43/62 (70%) pts in the YOUNG group (p=0.1); 11/23 (48%) and 23/43 (53%) responders in each group attained CR respectively. There were no differences in OR rates in both groups based on concurrent EPaG exposure: 61% vs. 46% with and without EPaG, respectively, in the OLDER group (p=0.5) and 74% vs 60%, respectively, (p=0.38) in the YOUNG group. On logistic regression analysis using baseline platelet counts, PB lymphocyte (%), D-A-T mutations, karyotype, and EPaG use as covariates, none affected the odds of OR in the 2 groups. The median TTR was 111 days (range, 10-323 days) and 177 days (51-410) in YOUNG AND OLDER groups, respectively; and this was not affected by EPaG use in either group. At a median follow of 38 months (mos) from ATG initiation (53 mos for the OLDER group and 32 mos for the YOUNG group), the median RFS was 49 mos and 39 mos (p=0.6) and median OS 55 vs. not reached (NR) (p <0.0001) in OLDER and YOUNG groups respectively (Fig.1). Significantly more pts in the YOUNG group underwent a subsequent SCT (19% vs. 5%) due to loss of response/ no response, possibly accounting for the higher OS rates. Rates of transformation to MDS or AML was 5% in both groups. Conclusion: Frontline ATG based IST in older pts with AA is a feasible and safe treatment option with promising response rates of 56% and median RFS more than 4 years; figures which are comparable to younger pts with AA treated with IST. The overall risks of transformation to MDS/AML on long term follow-up remain low (≈5%). Further studies assessing the response of the ATG+EPaG combination in these pts and the possibilities of clonal evolution with time needs to be conducted. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Low Pre-ChemoradiotherapyPan-Immune-Inflammation Value (PIV) Measures Predict Better Survival Outcomes in Locally Advanced Pancreatic Adenocarcinomas.

ObjectiveThis study sought to determine whether pretreatment pan-immune-inflammation value (PIV) could be used to predict prognosis in patients with locally advanced pancreatic adenocarcinoma (LA-PAC) following definitive concurrent chemoradiotherapy (C-CRT).MethodsThe outcomes of 178 LA-PAC patients who received definitive C-CRT were analyzed retrospectively. For all patients, the PIV was calculated using the peripheral blood platelet (P), monocyte (M), neutrophil (N), and lymphocyte (L) counts obtained on the first day of C-CRT: PIV=P×M×N÷L. The optimum cutoff values for PIV connected to progression-free (PFS) and overall survival (OS) results were sought using receiver operating characteristic (ROC) curve analysis. The OS and PFS differences between the PIV groups constituted the primary and secondary endpoints, respectively.ResultsROC curve analysis indicated that the ideal PIV cutoff was 464 (AUC: 75.9%, sensitivity: 74.1%, specificity: 71.9%), which categorized patients into two groups based on PFS and OS results: low PIV (L-PIV; N = 69) and high PIV (H-PIV; N = 109). According to comparative survival analyses, patients in the L-PIV group had significantly longer median PFS (14.3 vs 7.3 months; HR: 3.04; P<0.001) and OS (25.9 vs 13.3 months; HR: 2.86; P<0.001) than those in the H-PIV group. Although none of the H-PIV patients could survive beyond 5 years, the estimated 5-year OS rate was 29.7% in the L-PIV cohort. In multivariate analyses, besides the L-PIV, N0 nodal stage, and CA 19–9 ≤ 90 U/mL appeared to be the independent predictors of better PFS (P < 0.05 for each) and OS (P < 0.05 for each) results.ConclusionThe present results indicated that pre-C-CRT L-PIV measures were associated with favorable median and long-term PFS and OS results in LA-PAC patients, suggesting that the PIV is a potent and independent novel prognostic biomarker.

Зміни деяких показників тромбоутворення та активності запалення як маркерів тяжкості перебігу та прогнозу захворювання у пацієнтів з COVID-19 та коморбідною есенціальною гіпертензією

The purpose of the study was to determine the features of thrombosis (D-dimer) and inflammation (procalcitonin) in patients with COVID-19 with acute respiratory syndrome in combination with essential hypertension and to determine their role as markers of severity and prognosis of comorbid pathology. Materials and methods. A retrospective study of the medical records of 232 patients with confirmed COVID-19 disease with acute respiratory syndrome was performed. Patients were divided into two groups: with comorbid essential hypertension (main group) and without essential hypertension (comparison group), which amounted to 149 and 83 persons, respectively. The information obtained from the medical records included demographic data, symptoms and course of the disease, complications, instrumental and laboratory results (including peripheral blood platelet count, international normalized ratio, D-dimer and procalcitonin levels), and data of patients’ treatment. Results. According to the results of the study, the number of patients hospitalized in the intensive care unit with respiratory viral disease COVID-19 and comorbid hypertension, both in absolute and relative terms, was significantly higher (p = 0.005). The number of patients in this group who required non-invasive lung ventilation was also significantly higher (39% versus 17%), indicating a more severe and rapid course of the disease. In terms of hospitalization, both groups of patients had no significant differences, but the mortality rate in the group with comorbid essential hypertension was significantly higher (p = 0.005). In our study, level of D-dimer in patients of both study groups exceeded the reference values, but it was significantly higher in patients of the main group, compared with patients in the comparison group (p = 0.005). According to the platelet counts and international normalized ratio in patients of both groups no significant differences were found (p = 0.10 and p = 0.32, respectively), there was only a slight increase in peripheral blood leukocytes at the time of hospitalization in patients of the main group (p = 0.083). In addition, in patients with combined pathology, the mortality rate was higher and, at the same time, it was in these patients that direct correlations of strong density were found between D-dimer and procalcitonin with mortality (r = 0.77, and r = 0.72, respectively, p = 0.001 and p = 0.003). Conclusion. In patients with COVID-19 with acute respiratory syndrome, there is a significant increase in markers of thrombosis (D-dimer) and inflammatory activity (procalcitonin), while the severity of their changes is significantly greater in patients with comorbid essential hypertension. Patients with COVID-19 with acute respiratory syndrome in combination with essential hypertension have a more severe course of the disease and a significantly higher mortality rate, which is associated with a tendency to develop thrombocytopenia and is associated with changes in markers of thrombosis and inflammation. Determination of D-dimer and procalcitonin levels are reliable markers for both severity and prognosis in patients with COVID-19 with severe acute respiratory syndrome, and especially in conditions of comorbidity with essential hypertension, which may have a significant impact on strategy selection and tactics of treatment of such patients

Poster 104: The Role of Patient Demographic Factors in the Composition of Bone Marrow Aspirate Concentrate: A Flow Cytometry Analysis

Objectives:Bone marrow aspirate concentrate (BMAC) is one type of orthobiologic that has gained increased popularity over the last decade for a variety of orthopedic procedures. Multiple factors have been demonstrated to influence the MSCs concentration and chondrogenic potential in BMA and thus BMAC, ranging from aspiration location to amount extracted to peripheral blood platelet count. Some studies have suggested that age may affect chondrogenic potential of BMAC derived MSCs but may not affect initial MSC concentration. Therefore, the purpose of this study was to 1) investigate the concentration value and variance BMAC content and 2) investigate the effects of donor age, sex, and other demographic factors on the amount of MSCs as measured by flow cytometry in bone marrow aspirate concentrate (BMAC).Methods:A review of patients who underwent BMAC treatment as part of a clinical trial were enrolled and complete BMAC flow cytometry data were included in analysis. Chart review was performed to identify patient demographic factors to determine their relationship to flow cytometry cell count. Flow cytometry was performed on both patient bone marrow aspirate (BMA) and BMAC samples to identify multipotent MSC phenotype defined as cell-surface co-expression of the antigens CD105, CD73, and CD90 (≥95% positive) and the absence of hematopoietic lineage markers CD45, CD34, CD14 or CD11b, CD79a or CD19, and HLA-DR (≤2% positive). The ratio of cells in BMA: BMAC samples was calculated, and Spearman correlations and Kruskall-Wallis tests were used to determine the relationship of cell concentration to demographic factors.Results:A total of 80 patients were included in analysis (49% male, mean age: 49.93±12.17 years). Mean concentration of BMA and BMAC was 2,048.13±2,004.14 MSCs/mL and 5618.87±7568.54 MSC/mL, respectively, with a mean BMAC:BMA ratio of 4.35 ± 2.09 (Figure 1). A significantly higher MSC concentration was observed in the BMAC samples (P=0.005). No patient demographic factors (age, sex, height, weight, BMI, smoking status) significantly impacted MSC concentration in the BMAC samples.Conclusions:This study validates that BMAC concentrates and increases MSCs from BMA approximately four-fold. In addition, in opposition to our hypothesis, no demographic factors affected the final number of MSCs observed with flow cytometry analysis. These preliminary results suggest that BMAC successfully concentrates BMA and provides a higher number of MSCs. Baseline patient characteristics likely have minimal effects on the number and concentration of MSCs in BMAC, and therefore may not limit patient selection for BMAC for clinical use.Figure 1.Distribution of the ratio of BMAC to BMA

Immune Thrombocytopenic Purpura: A Case Report

Immune Thrombocytopenic Purpura also known as Idiopathic Thrombocytopenic Purpura or ITP, is an autoimmune disorder characterised by accelerated destruction and suboptimal platelet production that leads to reduced peripheral blood platelet counts. ..

Peripheral Blood Inflammatory Markers Can Predict Benign and Malignant Thyroid Nodules.

Objective Inflammation is related to the occurrence and development of various cancers. This study was designed to explore the role of peripheral blood platelet count, neutrophil-lymphocyte ratio (NLR), platelet count-lymphocyte count ratio (PLR), systemic inflammation index (SII), and other inflammatory markers in predicting benign and malignant Thyroid Imaging Reporting and Data System (TI-RADS) grade 3 thyroid nodules. Methods In this retrospective study, 514 patients with TI-RADS grade 3 thyroid nodules were enrolled. According to the pathological results, the patients were divided into the benign and malignant nodule groups. We compared the clinical characteristics between the two groups and analysed the influencing factors for malignant thyroid nodules by univariate and stepwise multivariate logistic regression analyses and then analysed the cutoff value of each influencing factor according to the receiver operating characteristic curve. Results The leukocyte count, neutrophil count, platelet count, NLR, PLR, and SII of the malignant nodule group were significantly higher than those of the benign nodule group (P < 0.05), the age and the diameter of nodule of the malignant nodule group were significantly smaller than those of the benign nodule group (P < 0.05). After excluding the influence of confounding factors, SII (odds ratio (OR) = 1.006; 95% confidence interval (CI) = 1.003–1.008; P < 0.001), PLR (odds ratio (OR) = 0.981; 95% confidence interval (CI) = 0.981–0.992; P < 0.05), leukocyte count (odds ratio (OR) = 0.654; 95% confidence interval (CI) = 0.466–0.892; P < 0.05), and age (OR = 0.969; 95% CI = 0.954–0.985; P < 0.001) were independent risk factors for malignant thyroid nodules, and the cutoff value of SII and PLR in predicting benign and malignant thyroid nodules were 545.63 × 109/L and 138.63. Conclusion This study showed that peripheral blood SII, PLR, leukocyte count and age were independent risk factors for malignant thyroid nodules, and the combination of these can better predict benign and malignant thyroid nodules, which can further guide the diagnosis and treatment of TI-RADS grade 3 thyroid nodules.

Role of the Systemic Immune-Inflammation Index in Patients with Metastatic Renal Cell Carcinoma Treated with First-Line Ipilimumab plus Nivolumab.

Simple SummaryThe aim of this study was to evaluate the predictive and prognostic value of the systemic immune-inflammation index (SII), which is based on peripheral blood platelet, neutrophil, and lymphocyte counts, in patients with metastatic renal cell carcinoma (mRCC) treated with ipilimumab plus nivolumab in the first-line setting. High SII score was an independent prognostic factor for worse progression-free survival and overall survival. The clinical benefit rate was higher for patients with a low SII index if compared to a high SII index. An increase in SII of >20% from baseline after 12 weeks of therapy was significantly associated with tumor progression at first imaging. The SII index is both prognostic and predictive and could refine decision making in patients treated with ipilimumab plus nivolumab.Background: The aim of this study was to evaluate the predictive and prognostic value of the systemic immune-inflammation index (SII) in patients with metastatic renal cell carcinoma (mRCC) treated with first-line ipilimumab plus nivolumab. Methods: This retrospective study included forty-nine mRCC patients treated with first-line ipilimumab plus nivolumab at the Department of Urology of the University of Tuebingen, Germany. SII was assessed before starting ipilimumab plus nivolumab therapy at the time of first imaging and at tumor progression. Optimal SII cut-off was stratified by ROC-analysis. Univariable and multivariable Cox regression analyses were used to evaluate the predictive and prognostic value of SII. Results: Optimal SII cut-off was 788. Twenty-nine/forty-nine patients had high SII (≥788) before initiation of ipilimumab plus nivolumab. High SII was an independent prognostic factor for worse progression-free (HR 2.70, p = 0.014) and overall survival (HR 10.53, p = 0.025). The clinical benefit rate was higher for patients with low SII if compared to high SII (80% vs. 32.1%). An increase in SII > 20% from baseline after twelve weeks of therapy was associated with progression at first imaging (p = 0.003). Conclusions: SII is both prognostic and predictive and could refine decision making in patients with unclear imaging on therapy with ipilimumab plus nivolumab.

Neutrophil extracellular traps enriched with IL-1β and IL-17A participate in the hepatic inflammatory process of patients with non-alcoholic steatohepatitis.

Neutrophil extracellular traps (NETs) are implicated in the pathogenesis of various non-infectious inflammatory and thrombotic diseases. We investigated the presence and possible associations of NETs with various histopathologic parameters in patients with non-alcoholic steatohepatitis (NASH). We retrospectively assessed 20 liver biopsy specimens from patients with non-alcoholic fatty liver disease (NAFLD), including 17 specimens with NASH, and 14 control specimens. NETs were identified with confocal microscopy as extracellular structures with co-localization of neutrophil elastase (NE) and citrullinated histone-3. Interleukin-1β (IL-1β) and IL-17A were assessed with the same methodology. Histologic features of NAFLD were semi-quantitatively evaluated, and correlated with presence of NETs, neutrophil density, and platelet density/aggregates (assessed by immunohistochemistry for NE and CD42b, respectively). NETs were identified in 94.1% (16/17) of the NASH biopsy specimens; they were absent from all other NAFLD and control specimens. The presence of NETs was strongly correlated with steatosis (p = 0.003), ballooning degeneration (p < 0.001), lobular inflammation (p < 0.001), portal inflammation (p < 0.001), NAS score (p = 0.001), stage (p = 0.001), and diagnosis of NASH (p < 0.001). NETs were decorated with IL-1β and IL-17A. Platelet aggregates were much larger in NASH specimens, as compared to controls. In conclusion, NETs are implicated in the pathogenesis of NASH. Their associations with inflammation, ballooning degeneration (a hallmark of NASH), and stage emphasize their role in the disease process. In this setting, NETs provide a vehicle for IL-1β and IL-17A. In addition, platelet aggregation in hepatic sinusoids implies a role for thromboinflammation in NASH, and may explain the low peripheral blood platelet counts reported in patients with NASH.

Regulation of Thrombopoiesis by the Inhibitor of MyoD Family A (I-mfa)

Abstract The differentiation of megakaryocytes (Mk) from hematopoietic stem and progenitor cells (HSPC) is crucial to homeostasis and requires tight regulation. Cell-intrinsic factors skew HSPCs towards the Mk lineage and promote terminal differentiation, but this regulatory network is not yet well understood. The Inhibitor of MyoD Family A (I-mfa) is a protein which interacts with multiple pathways, including β-catenin/TCF/LEF and JNK which have known roles in HSPC differentiation. This led us to examine the role of I-mfa in hematopoiesis, hypothesizing that it promotes Mk differentiation by regulating cellular signaling events. Mice which completely lack I-mfa expression (I-mfa KO) had reduced percentages of Mk/Erythroid Progenitors (MEPs) in the bone marrow compared to WT animals by flow cytometry, as well as reduced platelet counts in peripheral blood. To examine the potential role for I-mfa in thrombopoiesis, K562 cells (which show PMA-induced Mk differentiation) were transfected with a vector for doxycycline-induced overexpression of I-mfa, and differentiation was assessed by flow cytometry for Mk surface markers. Cells overexpressing I-mfa showed increased differentiation with a higher proportion of CD61+, CD71− cells compared to parent. The mechanism underlying this effect is being examined by analyzing cellular signaling after PMA stimulation and identifying I-mfa binding partners over time. This work demonstrates a role for I-mfa in the regulatory control of hematopoiesis and lineage commitment through its regulation of thrombopoiesis. These results may also suggest that I-mfa could be an important cellular regulator in hematopoietic disorders including anemia, bone marrow failure, or hematological malignancies. Supported by NIH T32 Immunology Training Grant AI00763316A1

CRLF3 plays a key role in the final stage of platelet genesis and is a potential therapeutic target for thrombocythemia

AbstractThe process of platelet production has so far been understood to be a 2-stage process: megakaryocyte maturation from hematopoietic stem cells followed by proplatelet formation, with each phase regulating the peripheral blood platelet count. Proplatelet formation releases into the bloodstream beads-on-a-string preplatelets, which undergo fission into mature platelets. For the first time, we show that preplatelet maturation is a third, tightly regulated, critical process akin to cytokinesis that regulates platelet count. We show that deficiency in cytokine receptor-like factor 3 (CRLF3) in mice leads to an isolated and sustained 25% to 48% reduction in the platelet count without any effect on other blood cell lineages. We show that Crlf3−/− preplatelets have increased microtubule stability, possibly because of increased microtubule glutamylation via the interaction of CRLF3 with key members of the Hippo pathway. Using a mouse model of JAK2 V617F essential thrombocythemia, we show that a lack of CRLF3 leads to long-term lineage-specific normalization of the platelet count. We thereby postulate that targeting CRLF3 has therapeutic potential for treatment of thrombocythemia.

Perioperative platelet count in peripheral blood is associated with the early stage of PND after major orthopedic surgery: a prospective observational study

BackgroundPerioperative neurocognitive disorders (PND) are common complications of major surgery among elderly patients, remarkably decreasing patients’ life quality. Platelet count has been proved to be an essential factor in inflammation. However, as far as we know, the relationship between platelet count and PND is not clear yet in the orthopedic area. PND could be a long-term disease, which sometimes lasts for several years, and it is meaningful to find a biomarker of PND at the early stage. Thus, we designed this study to find out the association between perioperative platelet count and occurrence of PND, and determine whether preoperative platelet count could be a biomarker of the early stage of PND.MethodsA prospective observational study was performed on the patients who would take total knee arthroplasty or total hip arthroplasty. Their peripheral platelets were counted by blood routine examination 1 day before and 3 days after the surgery. And we assessed their neurocognitive functions 1 day before and 3 days after the surgery. These data were recorded and analyzed to find out the relationship between platelet count and the occurrence of PND.ResultsEventually, 70 patients finished the whole process, and 14 of them developed PND. The median preoperative platelet count in the PND group was significantly higher than that in the non-PND group (239 vs 168 × 10^9/L, p = 0.009). Preoperative platelet count was an independent risk factor for PND (odds ratio = 1.014, 95% confidence interval [CI] 1.000–1.027, P = 0.043) in the logistic multivariable regression, while the area under the curve of the receiver operating characteristic curve of the prediction model was 0.796 (95% CI 0.676–0.916).ConclusionsThe higher preoperative and postoperative level of platelet count in the peripheral blood were associated with the early stage of PND, and preoperative platelet count could be a potential predictor of the early stage of PND in patients undergoing major orthopedic surgeries.Trial registrationChinese Clinical Trial Registry: ChiCTR2000033001, registration date: 17 May 2020.

Recent advances in the mechanisms and treatment of immune thrombocytopenia.

SummaryPrimary immune thrombocytopenia is an autoimmune disease associated with a reduced peripheral blood platelet count. The phenotype is variable with some patients suffering no bleeding whilst others have severe bleeding which may be fatal. Variability in clinical behaviour and treatment responses reflects its complex underlying pathophysiology. Historically the management has relied heavily on immune suppression. Recent studies have shown that the older empirical immune suppressants fail to alter the natural history of the disease and are associated with a poor quality of life for patients. Newer treatments, such as the thrombopoietin receptor agonists, have transformed ITP care. They have high efficacy, are well tolerated and improve patients’ quality of life. A greater understanding of the underlying pathophysiology of this disorder has helped develop a number of new targeted therapies. These include inhibitors of the neonatal Fc receptor inhibitors, Bruton tyrosine kinase and complement pathway. Here we discuss the mechanisms underlying ITP and the new approach to ITP care.

The Pan-Immune-Inflammation Value predicts the survival of patients with anaplastic lymphoma kinase-positive non-small cell lung cancer treated with first-line ALK inhibitor

BackgroundAnaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs) have significantly improved the clinical outcomes of patients with ALK-positive non-small cell lung cancer (NSCLC). However, reliable biomarkers to predict the prognostic role of this treatment are lacking. The Pan-Immune-Inflammation Value (PIV) has recently been demonstrated as a novel comprehensive biomarker to predict survival of patients with solid tumors. Our study aimed to evaluate the prognostic power of PIV in this group of patients. Patients and methods94 patients with advanced ALK-positive NSCLC who received first-line ALK inhibitors were enrolled in this study. PIV was calculated as the product of peripheral blood neutrophil, monocyte, and platelet counts divided by lymphocyte count. Kaplan-Meier method and Cox hazard regression models were used for survival analyses. ResultsThe 1-year progression-free survival (PFS) was 63.5%, and the 5-year overall survival (OS) rate was 55.1%. Patients with higher PIV, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune inflammation index (SII) had worse PFS in univariate analysis, but only the PIV (hazard ratio [HR] = 2.90, 95% confidence interval [CI]: 1.79–4.70, p < 0.001) was an independent prognostic factor in multivariate analysis. Similarly, patients with higher PIV, NLR, PLR, and SII had a worse OS in the univariate analysis, but only the PIV (HR = 4.70, 95% CI: 2.00–11.02, p < 0.001) was significantly associated with worse OS in multivariate analysis. ConclusionPIV is a comprehensive and convenient predictor of both PFS and OS in patients with ALK-positive advanced NSCLC who received first-line ALK TKIs. Prospective clinical trials are required to validate the value of this new parameter.

Radiomitigation by Melatonin in C57BL/6 Mice: Possible Implications as Adjuvant in Radiotherapy and Chemotherapy.

Melatonin (N-acetyl-5-methoxytryptamine), a chief secretory molecule of the pineal gland, has multiple properties, and numerous clinical investigations regarding its actions are in progress. This study investigated the radiomitigative role of melatonin in C57BL/6 mice. Melatonin (100 mg/kg) was orally administered once daily starting at 1 h on day 1 and subsequently every 24 h until day 7 after whole-body irradiation (WBI) and survival was monitored for 30 days. The bone marrow, spleen, and intestine were studied to evaluate the mitigative potential of melatonin after radiation-induced damage. Melatonin significantly improved the survival upto 60% and 90% after 9 Gy (lethal) and 7.5 Gy (sub-lethal) WBI, respectively. Melatonin alleviated WBI-induced myelosuppression and pancytopenia, and increased white blood cell, red blood cell, platelet, and lymphocyte (CD4+ and CD8+) counts in peripheral blood. Bone marrow and spleen cellularity were restored through enhanced haematopoiesis. Melatonin ameliorated the damage in the small intestine, and promoted recovery of villi length, crypts number, and goblet cell count. Melatonin mitigates the radiation-induced injury in the gastrointestinal and haematopoietic systems. The observed radiomitigative properties of melatonin can also be useful in the context of adjuvant therapy for cancer and radiotherapy.

Prognostic Value of Pretreatment Lymphocyte-to-Monocyte Ratio and Development of a Nomogram in Breast Cancer Patients.

PurposeThe objective of this study was to explore the prognostic significance of pretreatment hematologic parameters in predicting disease-free survival (DFS) of breast cancer patients.Materials and MethodsThe medical records of 440 breast cancer patients in Shandong Cancer Hospital and Institute from 2003 to 2013 were analyzed retrospectively. Through the results of blood routine before treatment, the absolute lymphocyte count (ALC), absolute neutrophil count (ANC), absolute monocyte count (AMC), and absolute platelet count (APC) in peripheral blood were collected. The lymphocyte-to-monocyte ratio (LMR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and neutrophil-to-monocyte ratio (NMR) were calculated. Cox proportional hazard model was used for univariate and multivariate analysis. The DFS was compared using Kaplan–Meier method. The prognostic nomogram of patients with breast cancer was developed.ResultsThe median DFS for all patients was 64.10 months. Univariate analysis showed that the DFS was associated with surgical approach, TNM stage, molecular subtype, neoadjuvant chemotherapy, radiotherapy, and LMR (p < 0.05). TNM stage, molecular subtype, and LMR were independent prognostic factors of breast cancer in multivariate analysis (p < 0.05). According to the Kaplan–Meier survival curve analysis, patients with higher LMR (≥4.85) were associated with longer median DFS (median DFS, 85.83 vs. 60.90, p < 0.001). The proposed nomogram that incorporated LMR, TNM stage, and molecular subtype got a concordance index (c-index) of 0.69 in predicting 5-year DFS.ConclusionIn breast cancer patients, higher LMR was associated with longer median DFS and the nomogram including LMR, TNM stage, and molecular subtype could accurately predict the prolonged 5-year DFS of breast cancer patients.

Essential thrombocythemia in children and adolescents — analysis of 31 cases

Introduction. Essential thrombocythemia is an extremely rare disorder in childhood. This disease is characterized by a persistent increase in the peripheral blood platelet count, associated with a proliferation of atypical megakaryocytes in the bone marrow.Aim — to analyze the clinical features of the course of essential thrombocythemia (ET) and the response to therapy in pediatric and adolescent patientsMaterials and methods. Thirty-one patients with ET under the age of 21 years were analyzed. All patients were diagnosed with ET in accordance with WHO criteria on the basis of an examination, including assessment of clinical data, laboratory tests (general clinical tests; morphological, genetic, and histological examinations of bone marrow), instrumental studies, and an assessment of response to treatment.Results. The average age of disease onset was 9 years 9 months, with a median of 9 years 6 months. Organomegaly was recorded in 16 (52 %) patients, of whom 6 (37.5 %) had isolated splenomegaly and 6 (37.5 %) had hepatosplenomegaly. Bleeding was noted in 6 (19.4 %) patients with a deep decrease in vWF:RCo (no more than 15 %) and an extreme increase in platelets (PLT) (more than 2000 × 109 /L). Twelve (38.7 %) patients suffered from microcirculation disorders (headaches, dizziness, melalgia), half of them had a platelet count of 1000–2000 × 109 /L, which is comparable to asymptomatic patients. No thrombosis was registered in our group. The JAK2V617F mutation was detected in 3 (9.7 %) patients, a mutation in the CALR gene was found in 9 (29.0 %) of patients, there was a mutation in the MPL gene in one (3.2 %) patient, and in the remaining cases (18 (58.1 %) patients), there was no damage to typical driver genes. Translocation t(12;12) was revealed in 1 (3.2 %) patient. The response to one-component cytoreductive therapy (CR+PR) was found to be quite high in young patients and constituted about 70–80 %. The complete response rate (CR) was as follows, respectively: 42.9 % (3) — to anagrelide therapy (ANA), 47.4 % (9) — to interferon therapy (INF), and 0 % — to hydroxycarbamide (HU). However, HU was not used in the fi rst line of therapy for the children in our group.Conclusion. In the pediatric population, ET patients are dominated by the group of “triple-negative” disease, which somewhat complicates the differential diagnosis with secondary thrombocytosis. Compared to the adult population, the risk of bleeding is higher for pediatric patients, which is associated with the large number of patients with extremely high levels of platelets. In the case of hemorrhagic syndrome development or microcirculatory disorders that cannot be stopped by taking antiplatelet agents, we recommend giving preference to INF and HU as fi rst-line therapy, due to the peculiarities of pharmacokinetics and the potential risk of progression of myelofi brosis during ANA therapy.

Efficiency and Safety of Eltrombopag for Multi-Line Failed Chinese Patients with Immune Thrombocytopenia: Cases with Decreased Megakaryocyte Response Well from Single Center Experience

Immune thrombocytopenia (ITP) is an autoimmune disease characterized by decreased platelet (PLT) count in peripheral blood and marrow megakaryocyte dysfunction, which was induced by antiplatelet antibodies or cytotoxic T cells. Many ITP patient were previously full response to first-line treatment such as corticoids (CIS) or immunoglobulin (IVIG), but were intolerant or relapse during the maintenance treatment, and turn to receive recombinant human thrombopoietin (rhTPO), rituximab (RTX), splenectomy as well as immunosuppressive therapy (IST). Unfortunately, there still some patients failed to multiple treatments are faced with high bleeding risk.Eltrombopag, the first oral non-peptide thrombopoietin receptor agonist (TPO-RA) that approved by US FDA in 2008, is the second-line treatment option for chronic ITP based on guideline recommendation. As reported, the effective rate of eltrombopag in ITP ranges from 59% to 89.7%, and limited predictive factors were available to assess the efficiency for individual. The characteristic of marrow megakaryocyte (MK) in ITP was reported as normal or hyper megakaryocytosis on the initiation (before treatment), however there are also ITP patients with decreased marrow MK, and the response of eltrombopag to these patients have not been fully reported. Bone marrow aspiration is a routine examination in China for the diagnosis of ITP with severe thrombocytopenia. Therefore, we conducted a research tried to assess the efficiency of eltrombopag to patients with multi-line failed ITP, and analyzing the possible factors may contribute to the differences based on personal characteristic.Thirty-five multi-line failed ITP patients with PLT count bellow 30× 10 9/L who received eltrombopag treatment were enrolled, and divided into three groups, the hyper-MK (MK count>35, n=17), normal-MK (8-35, n=10) and hypo-MK (≤7, n=8) groups. The average PLT count was 10.63±6.30×10 9/L before eltrombopag treatment, and it increased significantly to 12 (2-65)×10 9/L, 39 (2-212)×10 9/L, 68 (2-453)×10 9/L, 60 (3-358)×10 9/L, and 75 (3-308)×10 9/L in the 1st, 2nd, 4th, 6th , and 8th weeks after treatment (all P=0.000, except 1st week). The median intervals time required for platelet to reach 30×10 9/L and 100×10 9/L for the first time were 11 (4-40) and 21 (10-65) days, respectively (Fig. A-C). We found the overall, complete (PLT count ≥100×10 9/L) and partial response (PLT count ≥30×10 9/L or at least twice the baseline value) rates were 54.3% (n=19), 48.6% (n=17), and 5.7% (n=2) respectively to eltrombopag in our center. The overall response rate of patient with decreased MK was 75%, which was unexpectedly higher than the patient with increased or normal MK count (52.9% and 40%, respectively) (Fig. D). To explain the underling mechanism, we detected the peripheral T lymphocyte, B lymphocytes and NK cells before eltrombopag. Results showed that the patient with decreased MK were characteristic with higher T helper (Th) cells (39.62±2.01%) and regulatory T (Tregs) cells (7.93±1.63%) when compared to the hyper-MK (30.44±10.95%, 4.23±1.67%) and normal-MK group (25.67±5.72%, 4.81±2.12%). For patient with poorer eltrombopag response group, more percentage and absolute number of NK cells (15.48±7.12%, 234.4±91.80×10 6/L) were found in peripheral blood (Fig. E-F). We also discovered that previous first-line (CIS or IVIG) treatment, rhTPO effectiveness, RTX splenectomy and IST had no influence on eltrombopag response (Fig. G). As for safety, nine eltrombopag related adverse events were reported, and most commonly were upper respiratory tract infection (8.6%), elevated ALT (5.7%), and venous thrombosis (5.7%). All the side effect was cured by symptomatic treatment, eltrombopag dose reduction or discontinue.In summary, ITP patients with decreased megakaryocyte respond well to eltrombopag, and the abnormality of NK cells may play a role in patients exert a poor response. In further clinical practice, we should considering the megakaryocytes count as well as peripheral NK population to better predicting eltrombopag response in ITP patients. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Inhibition of MDM2 Improves the Therapeutic Effect of Hypomethylating Agents in Myelodysplastic Syndromes (MDS) and Chronic Myelomonocytic Leukemia (CMML)

Hypomethylating agents (HMA) are the current standard care for MDS and CMML. However, a large proportion of patients experience HMA treatment failure that is associated with poor prognosis. Novel treatments are urgently needed for these diseases. We performed next generation sequencing (NGS) based mutation profiling that targeted the 81 most frequently mutated genes in baseline bone marrow (BM) mononuclear cells (MNCs) from patients with MDS and CMML (N=83) prior to HMA treatment. Analysis of impact of the mutations on outcomes of HMA treatment indicated that patients with TP53 mutations (N=22) had significantly worse overall survival (HR = 3.29; P < 0.05; q < 0.05). This result is consistent with previous reports and suggests that strengthening the activity of wild type (WT) TP53, through strategies such as inhibition of TP53 negative regulator MDM2, may improve therapeutic efficacy of HMAs in patients with MDS and CMML.To test this hypothesis, we evaluated in vitro the effects of the combination of the MDM2 inhibitor DS-3032b and azacytidine (AZA). Due to the dearth of MDS or CMML cell lines, initial analysis was performed in the TP53 WT AML cell line MOLM13. Results indicated that DS-3032b and AZA combination induced a synergistic decrease in cell survival (coefficient of drug interaction=0.65), accompanied with increased apoptosis and CDKN1A1 (P21) RNA expression. No combination survival effect was observed in the TP53 mutant AML cell lines SKM1 or TF1.We next evaluated in vivo combination therapeutic effects of the MDM2 inhibitor DS-5272 and AZA in a Tet2-knockout (KO) (Tet2flox/flox/Vav-Cre) mouse model. Prior work indicated that Tet2-KO mice had an MDS/CMML-like phenotype and a persistent long-term (LT) BM repopulating activity that was resistant to AZA. DS-5272 and AZA were administered to mice sequentially: DS-5272 (50 mg/kg) was administered orally for 5 days, followed by daily AZA (2.5 mg/kg, i.p.) for a 7 days. DS-5272 was also administered on the 1st and 3rd days during AZA treatment. After a 2-week gap, the treatment cycle was repeated once. Following the combination treatment, Tet2-KO mice showed significantly reduced monocytosis (P<0.05) and increased platelet counts (P<0.001) in peripheral blood (PB), and significant reductions in Gr1+/CD11b1+ myeloid cells (P<0.001), common myeloid progenitors (CMPs) (P<0.005), and Lin-/Sca1+/c-Kit1+ cells (LSKs) (P<0.01) in BM. Next, we evaluated the impact of treatment on LT BM repopulation activity. CD45.2+ BM cells isolated from drug-treated Tet2-KO mice were mixed with BM cells from CD45.1 WT mice and then transplanted into lethally irradiated CD45.1 WT recipient mice. Significantly lower (P<0.05) CD45.2 chimerism was observed in PB of the recipients transplanted by BM cells from DS-5272 and AZA combination treated Tet2-KO mice compared to recipients that received cells from vehicle control and mono-agent treated Tet2-KO mice, starting from 4 months post-transplantation (Fig.1A). Lower CD45.2 chimerism was also observed in the BM LSK population (P<0.001) of the same recipients at the endpoint of 6 months post-transplantation.To study the molecular mechanisms underlying the combinational therapeutic effects of the MDM2 inhibitor and AZA observed in the Tet2-KO mice, we performed RNA-seq on BM LSK cells isolated from drug-treated mice. Compared to LSKs from vehicle control mice, over 800 genes with significantly altered RNA expression (>1.5 fold; FDR<0.05) were identified in the LSKs from DS-5272 and AZA combination treated Tet2-KO mice, whereas 110 and 476 genes with altered RNA expression were identified in the LSKs of DS-5272 or AZA treated Tet2-KO mice respectively. REACTOME pathway analysis identified 263 pathways that were significantly (FDR<0.25) and uniquely activated in the BM LSKs from mice treated with DS-5272 and AZA combination. Many of these pathways were associated with TP53 stability, TP53 activity, and TP53 regulated apoptosis and cell cycle (Fig.1B), suggesting a coordination between MDM2 inhibition and HMA treatment to activate TP53 in BM HSPCs.In conclusion, our work provides proof-of-concept evidence that combining an MDM2 inhibitor with AZA can improve the therapeutic efficacy of AZA in MDS and CMML, through mechanisms including synergistic activation of TP53 in BM HSPCs and inhibition of LT BM repopulating activity. This concept should be further evaluated through pre-clinical studies and clinical trials. [Display omitted] DisclosuresWei: Daiichi Sanko: Research Funding. Daver: Amgen: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Bristol Myers Squibb: Consultancy, Research Funding; Hanmi: Research Funding; Trillium: Consultancy, Research Funding; Glycomimetics: Research Funding; Genentech: Consultancy, Research Funding; Sevier: Consultancy, Research Funding; Novimmune: Research Funding; FATE Therapeutics: Research Funding; Trovagene: Consultancy, Research Funding; Abbvie: Consultancy, Research Funding; Astellas: Consultancy, Research Funding; Gilead Sciences, Inc.: Consultancy, Research Funding; Daiichi Sankyo: Consultancy, Research Funding; ImmunoGen: Consultancy, Research Funding; Novartis: Consultancy; Jazz Pharmaceuticals: Consultancy, Other: Data Monitoring Committee member; Dava Oncology (Arog): Consultancy; Celgene: Consultancy; Syndax: Consultancy; Shattuck Labs: Consultancy; Agios: Consultancy; Kite Pharmaceuticals: Consultancy; SOBI: Consultancy; STAR Therapeutics: Consultancy; Karyopharm: Research Funding; Newave: Research Funding.

The hematological diversity of human parvovirus B19 infection after allo-hematopoietic stem cell transplantation in pediatric patients

目的探讨异基因造血干细胞移植（allo-HSCT）患儿造血重建后人类细小病毒B19（HPV-B19）感染的血液学表现。方法对9例allo-HSCT后合并HPV-B19感染的患儿进行回顾性分析。结果9例患儿占同期接受allo-HSCT患儿的8.04％（9/112），男8例，女1例，中位年龄9（3～13）岁，均采取清髓性预处理方案。HPV-B19感染中位时间为移植后61（36～114）d。allo-HSCT并发HPV-B19感染患儿血液学表现具有异质性，9例患儿以血红蛋白伴网织红细胞下降为主要特点，7 d内网织红细胞比例、绝对值下降幅度中位数分别为90.4％（24.7％～98.7％）、90.7％（18.6％～99.0％）。除常见红系造血停滞表现外，allo-HSCT后合并HPV-B19感染的患儿还具有非红系的血象及骨髓变化：5例患儿外周血出现中性粒细胞下降，但骨髓涂片未见粒系增生受抑；6例患儿骨髓涂片查见巨核系增生减低，其中5例患儿外周血血小板下降。同时，allo-HSCT造血重建后合并HPV-B19感染的患儿骨髓红系受抑并非必要表现，9例患儿虽然均出现血红蛋白下降，但仅5例患儿骨髓红系增生减低。结论血液病患儿allo-HSCT造血重建后合并HPV-B19感染的血液学表现具有异质性，血红蛋白伴网织红细胞下降对HPV-B19感染早期诊断可能具有重要意义。