York Blood Center Research Articles

Phase I Trial of CD8-Depleted Human Leukocyte Antigen (HLA) Mismatched Unrelated Donor Lymphocyte Infusion (DLI) to Achieve Remissions in Myelodysplastic Syndrome (MDS) and Secondary Acute Myeloid Leukemia (sAML)

Background Hypomethylating agents (HMAs) are the standard of care in higher risk MDS, yielding a median survival of 12-18 months. After HMA failure or progression to sAML. median survival is only 4-6 months. We developed a novel cellular therapy using HLA mismatched, unrelated, CD8-depleted, CD4+ DLI to induce remission in patients with MDS and sAML who have not previously undergone allogeneic hematopoietic cell transplant (HCT). The DLI is intentionally class II HLA mismatched to activate donor CD4+ T cells which then provide immunologic "help" to reverse recipient immune exhaustion and, thus, promote a potent antitumor response (Symons. BBMT. 2008). Further, HLA mismatched donors are easily identified and allow the potential for an "off the shelf" product. By depleting CD8+ T cells, it is intended that the DLI does not engraft, thus negating the risk of graft-versus-host disease (GVHD). Instead, this therapy is intended to induce remission as a bridge to curative allogeneic HCT. Methods This completed phase I trial enrolled patients with MDS refractory to at least 4 cycles of HMA or sAML at the Moffitt Cancer Center from 2020-2022. Patients who received prior allogeneic HCT were excluded. DLI donors were selected from a pre-existing pool of unrelated donors at the New York Blood Center (NYBC) on the basis of class II HLA mismatch, CMV compatibility, and ABO compatibility. Patients were treated with induction chemotherapy as chosen by their primary physician. In parallel, donors underwent leukapheresis at the NYBC and the cell product was shipped to the Moffitt Cancer Center. The DLI was depleted of CD8+ T cells using the CliniMACS® system with CliniMACS® CD8 reagent in the Moffitt Cell Therapy Laboratory. HLA-mismatched CD4+ DLI was infused fresh within 24-36 hours after completing induction chemotherapy. The trial followed a 3+3 design to determine the recommended phase II dose (RP2D) of DLI where dose level (DL) 1 was 1x106 CD4 cells/kg, DL2 was 1x107 CD4 cells/kg, and DL3 was 5x107 CD4 cells/kg. Dose limiting toxicities (DLTs) were defined as grade 2-4 acute GVHD, grade 3-4 cytokine release syndrome (CRS), grade 2-4 infusion reactions, aplasia beyond 56 days in the presence of detectable donor chimerism, or grade 4 organ toxicity by CTCAE 5.0. Mechanistic studies were pursued to evaluate markers of immune tolerance, cytokine profiles, and confirm the DLI did not engraft. Results Nine patients (8 sAML, 1 MDS) were treated. All patients had progressed through at least one prior line of therapy (Table 1). The median age was 66. All AML patients had adverse risk disease by ELN risk stratification including 4 patients with TP53 mutation and complex cytogenetics. The MDS patient had very high-risk disease by R-IPSS. A suitable donor was identified for all patients despite a donor pool of only 30 donors. Cell collections, shipments, and processing for all patients were successful with all products achieving <3% CD8+ T cells and >70% cell viability. No patients experienced DLTs at any dose level. One patient at DL3 experienced grade 2 CRS that resolved with tocilizumab. There were no cases of grade 3-4 CRS nor GVHD (Table 2). Complete remission (CR) was achieved in 2/3 (66%) patients at DL3, 1/3 (33%) patients at DL2, and 0/3 (0%) patients at DL1. All 3 patients who reached CR proceeded to allogeneic HCT. At the time of marrow recovery post-treatment, donor DNA in the blood and marrow was no longer detectable in any of the patients. Patients who achieved CR (n=3) had significantly higher levels of IL6 on day +1 (p=0.01) and a trend towards higher levels of IL2, IL15, IFN-gamma, and TNF-alpha in the first 7 days after DLI compared to patients who did not achieve CR. Conclusions Induction chemotherapy followed by CD8-depleted HLA mismatched, unrelated donor DLI was feasible and well tolerated with no DLTs, confirming the RP2D of 5x107 CD4 cells/kg. At DL3, 2 of 3 patients achieved CR, including one with TP53 mutation and complex cytogenetics, which is generally resistant to induction chemotherapy and compares favorably to 20-30% historical CR rates with chemotherapy alone in those pts. Mechanistic studies correlated increased post-treatment cytokine levels with depth of remission. Assessment of markers of immune tolerance are pending and will be presented at the conference. Based on these promising results, this novel cellular therapy is being investigated now in a phase II clinical trial at the Moffitt Cancer Center. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Inhibition of human macrophage activation via pregnane neurosteroid interactions with toll-like receptors: Sex differences and structural requirements.

We recently discovered that (3α,5α)3-hydroxypregnan-20-one (allopregnanolone) inhibits pro-inflammatory toll-like receptor (TLR) activation and cytokine/chemokine production in mouse macrophage RAW264.7 cells. The present studies evaluate neurosteroid actions upon TLR activation in human macrophages from male and female healthy donors. Buffy coat leukocytes were obtained from donors at the New York Blood Center (http://nybloodcenter.org/), and peripheral blood mononuclear cells were isolated and cultured to achieve macrophage differentiation. TLR4 and TLR7 were activated by lipopolysaccharide (LPS) or imiquimod in the presence/absence of allopregnanolone or related neurosteroids and pro-inflammatory markers were detected by ELISA or western blotting. Cultured human monocyte-derived-macrophages exhibited typical morphology, a mixed immune profile of both inflammatory and anti-inflammatory markers, with no sex difference at baseline. Allopregnanolone inhibited TLR4 activation in male and female donors, preventing LPS-induced elevations of TNF-α, MCP-1, pCREB and pSTAT1. In contrast, 3α,5α-THDOC and SGE-516 inhibited the TLR4 pathway activation in female, but not male donors. Allopregnanolone completely inhibited TLR7 activation by imiquimod, blocking IL-1-β, IL-6, pSTAT1 and pIRF7 elevations in females only. 3α,5α-THDOC and SGE-516 partially inhibited TLR7 activation, only in female donors. The results indicate that allopregnanolone inhibits TLR4 and TLR7 activation in cultured human macrophages resulting in diminished cytokine/chemokine production. Allopregnanolone inhibition of TLR4 activation was found in males and females, but inhibition of TLR7 signals exhibited specificity for female donors. 3α,5α-THDOC and SGE-516 inhibited TLR4 and TLR7 pathways only in females. These studies demonstrate anti-inflammatory effects of allopregnanolone in human macrophages for the first time and suggest that inhibition of pro-inflammatory cytokines/chemokines may contribute to its therapeutic actions.

Editorial introductions.

Editorial introductions.

Anna Frajlich's New York City

Abstract Anna Frajlich was exiled from her homeland in 1969 and arrived in the United States a year later. This article traces through her poetry and prose the arc of Frajlich's residence in New York, from wary foreigner, residing in windswept Brooklyn, up to her present status as retired Columbia University faculty member who has made her home on Manhattan's Upper East Side. In other words, from her earliest poem about Brooklyn in 1973 to poems in which she describes events from her apartment on the Upper East Side, published in early 2021. In the essay the author draws on his first-hand experience as participant in her 2017 reading at the Cornelia Street Café; translator of Frajlich's volume of short fiction, Laboratorium [The laboratory, 2018], and editor of Frajlich's Ghost of Shakespeare: Collected Essays (2020). While the poetry is the main object of study, the article looks at the short story “Laboratorium,” filling in the realia about the New York Blood Center behind the fiction, including the biography of the head researcher, Dr. Wolf Szmuness, an internationally recognized expert who came to the United States from Poland, after spending time in Stalin's Gulag. And lastly, the piece examines two poems published in 2021: “Morza i rzeki” [Seas and rivers], which brilliantly sums up Frajlich's interest in bodies of water, for example, “Brooklyn Canzone” (1973), and the poem “Z marginesu pandemii” [From the margins of the pandemic], where the poet sees hope for the end of the pandemic and the unnatural isolation experienced by so many in the previous year and a half.

Introduction

Introduction

The Safety and Efficacy of Granulocyte Transfusions in Pediatric Recipients with Severe Neutropenia

Background:Pediatric oncology and stem cell transplant patients are at high risk for severe bacterial and fungal infections due to the myelosuppressive effects of chemotherapy and conditioning, respectively. Febrile neutropenia is one of the most concerning complications of chemotherapy. Even with the rapid initiation of empiric antibiotics, morbidity and mortality in this patient population occur frequently. Prognosis is worse in patients with proven bacteremia, with mortality rates of 18% and 5% reported in patients with gram‐negative and gram‐positive bacteremia, respectively (de Naurois et al. Annals of Oncology, 2010). Although gram positive organisms are known to be the most common cause of bacteremia in neutropenic patients (Kibbler et al. Curr Opin in Infect Dis, 1999), recent studies within the last 5 years have reported gram-negative organisms as the most common cause of bacteremia in this patient population (Mert et al. J Infect Dev Ctries, 2019, Islas-Muñoz et al. Int J Infect Dis, 2018, Sierra et al. Medicina, 2020, Cattaneo et al. Ann Hematol, 2018, Parodi et al. PloS one, 2019).Granulocytes harvested from healthy donors can temporarily raise the functional neutrophil counts in transfusion recipients. Data in the adult population show that while these transfusions are safe, they may be of limited efficacy, with patients receiving more than 6 x10 8 having better outcomes (Price et al. Blood, 2015). However, there is a paucity of data in the pediatric population (Atallah et al. Curr Opin in Hematol, 2006, Price et al. Semin Hematol, 2007, Estcourt et al. Cochrane Database Syst Rev, 2015).Objective:To determine the safety of granulocyte transfusions in pediatric recipients with severe neutropenia.Methods:Following IRB approval, we completed a retrospective cohort study of neutropenic pediatric recipients with various infections who received granulocyte transfusions. We reviewed the records of 74 pediatric recipients at the Maria Fareri Children's Hospital at Westchester Medical Center who received granulocyte transfusions from 2011-2019. The medical record was reviewed for patient age, underlying medical condition, indication for granulocyte transfusion, duration of fever, time to resolution of infection, mortality, and adverse reactions to the granulocyte transfusion. Mobilized granulocytes (dexamethasone) were collected from healthy donors at the New York Blood Center, as we have previously reported (Sulis/Cairo et al, Blood 2002, Price et al, Blood 2015).Results:The average age was 11 years (<1-20) with 38 male patients and 36 female patients. The majority of patients were either stem cell transplant recipients, patients with hematologic malignancies, or both. The most common indication for granulocyte transfusion was a documented bacterial infection (56.7%). Fifty-two percent had gram negative infection and 45.2% had gram positive infection. Nine percent were staph infections. Patients received granulocytes for a median of 7.5 days. 54% of the patients cleared their infection with antibiotics prior to receiving the granulocytes. In the remaining patients, infection resolved in 32.4% while receiving granulocyte transfusions in addition to antimicrobial therapy. In this subset of patients, 63.6% had bacterial infection with 71.4% having gram positive infection, all of which were staph infections. The infection cleared after a median of 4 days of granulocyte transfusions. Patients in this subset were on antibiotics for a median of 5 days prior to starting granulocytes. Adverse events related to the granulocyte infusion occurred in 6 patients, with 3 patients having a fever during the transfusion (CTCAE 1), 1 with hypothermia (CTCAE 2), and 1 with joint pain (CTCAE 1). 3 patients died during the period when they were receiving granulocytes. 2 due to infection complication and one due to seizure. 30 day survival was 86.5% and 100 day survival was 85.1%.Conclusions:Granulocyte transfusions can be safely administered to pediatric patients with severe neutropenia. 32.4% cleared the infection with granulocyte transfusion. 100 day survival is 85.1%. Adverse events had CTCAE scores of 1-2. A majority of patients had gram negative infections, but the majority of patients that had resolution of infection with granulocytes had staph infections. It is possible that granulocytes may have greater efficacy against staph infections than other types of infection. [Display omitted] DisclosuresLiu: Incyte: Honoraria; Pharmacyclics: Honoraria, Speakers Bureau; Astellas: Honoraria, Speakers Bureau; Pfizer: Research Funding; Beigene: Honoraria, Speakers Bureau; Celgene: Research Funding. Cairo: Jazz Pharmaceutical: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Amgen: Speakers Bureau; Sanofi: Speakers Bureau; Servier: Speakers Bureau; Sobi: Speakers Bureau; Omeros: Membership on an entity's Board of Directors or advisory committees; Nektar: Membership on an entity's Board of Directors or advisory committees.

Characteristics of coronavirus disease 19 convalescent plasma donors and donations in the New York metropolitan area

BackgroundConvalescent plasma (CP) is an important initial treatment in pandemics and the New York (NY) metropolitan area is likely to remain a hotspot for collection and distribution of such units. This study reports characteristics of coronavirus disease 19 CP (CCP) donors and their donations to the New York Blood Center (NYBC).Study design and methodsAll CCP data from our first day of collection on March 26th through July 7th, 2020 are included in this retrospective analysis. Donor and donation data were extracted from NYBC electronic databases. SARS‐CoV‐2 antibody testing was initially performed by the NY State Department of Health, and later by NYBC using Ortho and Abbott platforms.ResultsCCP donor age and ABO distributions were consistent with reported lower COVID‐19 susceptibility in O blood types. CCP versus whole blood donors had similar on‐site deferrals, but higher post‐donation deferral rates. CCP versus routine plasmapheresis donations had higher vasovagal reactions but similar product rejection rates. Changes in antibody (Ab) test platforms resulted in significant changes in the percent of donors regarded as antibody positive. Donor correlates with higher anti‐spike total Ig S/CO ratios were Hispanic ethnicity, overweight body mass index, and longer symptom duration; and with higher anti‐nucleocapsid IgG S/CO ratios were male gender, older age, Hispanic ethnicity, and fewer days between symptom onset and first donation.DiscussionWe identify donor characteristics not previously reported to correlate with Ab titer. Our analysis should assist with donor outreach strategies, blood center operating logistics, and recruitment of high titer donors.

Administration of high titer convalescent anti-SARS-CoV-2 plasma: From donor selection to monitoring recipient outcomes

Early in the SARS-CoV-2 pandemic, convalescent plasma (CP) therapy was proposed as a treatment for severely ill patients. We conducted a CP treatment protocol under the Mayo Clinic Extended Access Program at University Hospital Brooklyn (UHB). Potential donors were screened with a lateral flow assay (LFA) for IgM and IgG antibodies against the SARS-CoV-2 S1 receptor-binding domain (RBD). Volunteers that were LFA positive were tested with an ELISA to measure IgG titers against the RBD. Subjects with titers of at least 1:1024 were selected to donate. Most donors with positive LFA had acceptable titers and were eligible to donate. Out of 171 volunteers, only 65 tested positive in the LFA (38.0%), and 55 (32.2%) had titers of at least 1:1024. Before our donation program started, 31 CP units were procured from the New York Blood Center (NYBC). Among the 31 CP units that were obtained from the NYBC, 25 units (80.6%) were positive in the LFA but only 12 units (38.7%) had titers of at least 1:1024. CP was administered to 28 hospitalized COVID-19 patients. Patients who received low titer CP, high titer CP and patients who did not receive CP were followed for 45 days after presentation. Severe adverse events were not associated with CP transfusion. Death was a less frequent outcome for patients that received high titer CP (>1:1024) 38.6% mortality, than patients that received low titer CP (≤1:1024) 77.8% mortality.

Affinity of Anti-Spike Antibodies in SARS-CoV-2 Patient Plasma and Its Effect on COVID-19 Antibody Assays

Background: Measuring anti-spike protein antibodies in human plasma or serum is commonly used to determine prior exposure to SARS-CoV-2 infection and to assess the anti-viral protection capacity. According to the mass-action law, a lesser concentration of tightly binding antibody can produce the same quantity of antibody-antigen complexes as higher concentrations of lower affinity antibody. Thus, measurements of antibody levels reflect both affinity and concentration. These two fundamental parameters cannot be disentangled in clinical immunoassays, and so produce a bias which depends on the assay format. Methods: To determine the apparent affinity of anti-spike protein antibodies, a small number of antigen-coated magnetic microparticles were imaged by fluorescence microscopy after probing antigen-antibody equilibria directly in patient plasma. Direct and indirect anti-SARS-CoV-2 immunoassays were used to measure antibody levels in the blood of infected and immunized individuals. Findings: We observed affinity maturation of antibodies in convalescent and vaccinated individuals, showing that higher affinities are achieved much faster by vaccination. We demonstrate that direct and indirect immunoassays for measuring anti-spike protein antibodies depend differently on antibody affinity which, in turn, affects accurate interpretation of the results. Interpretation: Direct immunoassays show substantial antibody affinity dependence. This makes them useful for identifying past SARS-CoV-2 exposure. Indirect immunoassays provide more accurate quantifications of anti-viral antibody levels. Funding: No external funding sources were used in this study.Declaration of Interest: All authors are employed by Abbott LabsEthical Approval: Patient plasma/serum samples used for this study were purchased from New York Biologics (Southampton, NY), Access Biologicals, LLC (Vista, CA) and New York Blood Center (New York, NY). The samples purchased from Access Biologicals LLC were collected under an IRB protocol approved by Ballad Health System IRB. The samples purchased from New York Biologics were collected under an IRB approved by Ethical and Independent Review Services (E&I). The patient plasma samples purchased from New York Blood Center (New York, NY), were collected from volunteer blood donors who consented to the use of their samples for research purposes at the time of collection.

It's time to phase out "serologic weak D phenotype" and resolve D types with RHD genotyping including weak D type 4.

CDS, JTQ, LMK, SGS and WAF have disclosed no conflicts of interest. CMW has received speaker honorarium from Grifols and Immucor and consulting honorarium from Quotient, Cerus, and ArchOncology with renumeration to New York Blood Center. GAD and MAK are on the Grifols Speakers Bureau. MD has received speaker honorarium from Grifols. RV receives financial support from bioMérieux, Cerus, Fresenius-Kabi, Hemanext, and Hemastrat. STJ receives speaker honorarium from Grifols and Immucor.

Editorial introductions

Current Opinion in Hematology was launched in 1994. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of hematology is divided into nine sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Editor and the Section Editor for this issue. EDITOR IN CHIEF Narla MohandasNarla MohandasDr Narla Mohandas is Vice President for Research at New York Blood Center, New York, USA. He received his doctoral degree from Washington University, St. Louis, USA in Chemical Engineering. After completing post-doctoral training in hematology research with Dr Marcel Bessis, Institute of Cellular Pathology in Paris, France, he joined the Faculty of Laboratory Medicine at University of California, San Francisco where he spent 13 years. In 1989, he moved to Lawrence Berkeley National Laboratory, University of California to head the Hematopoiesis group. During his 12-year tenure at the Berkeley Laboratory he also served as Interim Director of Human Genome Project for three years. In 2001, he moved to the New York Blood Center. Dr Mohandas’ scientific interests during his 45-year research career have focused on red cell physiology and pathology. In particular, his efforts have contributed to improved understanding of the molecular and structural basis for red cell membrane disorders, developing detailed mechanistic insights into pathophysiology of thalassemias and sickle cell disease, characterizing structural and functional changes induced in red cells by the malarial parasite, plasmodium falciparum. His research efforts during last ten years are focused on molecular understanding of normal and disordered human erythropoiesis including Diamond-Blackfan anemia and Myelodysplasia. Dr Mohandas served as a member of the National Institutes of Health Hematology study section for 18 years and is currently member of the NHLBI Advisory Council. He has been a member of numerous committees including the Executive committee of American Society of Hematology. He served as Associate Editor of Blood from 2003–2012 and is currently Editor-in-Chief of Blood Cells, Molecules and Disease and of Current Opinion in Hematology. SECTION EDITOR David C. DaleDavid C. DaleDr David C. Dale is Professor of Medicine and former Dean of the School of Medicine at the University of Washington. He is a native of Knoxville, Tennessee, and a graduate of the Harvard Medical School. He received post-graduate training at Massachusetts General Hospital, the National Institutes of Health and the University of Washington. He has career-long interests in medical education, medical history and basic and clinical research focused on inflammation, neutrophils, and the clinical problem of neutropenia. Dr Dale has served as President of the American College of Physicians, the Society of General Internal Medicine, the Western Association of Physicians, the Medical Honor Society-Alpha Omega Alpha, and the American Clinical and Climatological Association. He is Editor-in-Chief Emeritus for the Scientific American Medicine the medicine text also known as ACP Medicine. He is the Founder and Co-Director of the Severe Chronic Neutropenia International Registry and Co-President (with Rose Marie Dale) of the Friends of the University of Washington School of Medicine. Dr Dale is actively involved in teaching, research and patient care at the University of Washington and a member of the Council for the Washington Chapter of ACP.

Circulating Levels of ATP Is a Biomarker of HIV Cognitive Impairment

Background: In developed countries, Human Immunodeficiency Virus type-1 (HIV-1) infection has become a chronic disease despite the positive effects of anti-retroviral therapies (ART) but still at least half of the HIV infected population shown signs of cognitive impairment. Therefore, biomarkers of HIV cognitive decline are urgently needed. Methods: We analyze the opening of one of the larger channels expressed by humans, pannexin-1 channels, in the uninfected and HIV infected population (n=175). Upon opening several intracellular second messengers are released into the extracellular space including PGE2 and ATP in serum/plasma. We correlated the cognitive status of the patients with circulating levels of both factors upon a visit to the clinic. Findings: Here, we demonstrate that pannexin channels on fresh PBMCs from uninfected individuals are closed. In contrast, all HIV-infected individuals analyzed, even the ones under effective ART, had a spontaneous opening of pannexin-1 channels and increased circulating levels of PGE2 and ATP. These results suggest that even low or undetectable levels of HIV result in chronic inflammation and opening of pannexin-1 channels. Furthermore, we found that circulating levels of ATP, but not PGE2, correlated with the cognitive status of people living with HIV. Interpretation: We propose that circulating levels of ATP could predict CNS compromise and lead to the breakthroughs necessary to detect and prevent brain compromise in the HIV-infected population. Funding Statement: This work was funded by The National Institute of Mental Health grant, MH096625, the National Institute of Neurological Disorders and Stroke, NS105584, and UTMB internal funding (to E.A.E). Research in the Geiger (J.D.G.) laboratory was supported by the National Institute of General Medical Sciences under award numbers P30GM100329 and U54GM115458, the National Institute of Mental Health under award numbers R01MH100972 and R01MH105329, the National Institute of Neurological Diseases and Stroke under award number R01NS065957, and the National Institute of Drug Abuse under award number 2R01DA032444. The NNTC is made possible through funding from the NIMH and NINDS by the following grants: Manhattan HIV Brain Bank (MHBB): U24MH100931; Texas NeuroAIDS Research Center (TNRC): U24MH100930; National Neurological AIDS Bank (NNAB): U24MH100929; California NeuroAIDS Tissue Network (CNTN): U24MH100928; and Data Coordinating Center (DCC): U24MH100925. The authors also acknowledge the New Jersey and New York Blood Center, the Alfred P. Sloan Foundation Minority fellowship (to S.V.) and Mount Sinai NeuroAIDS Disparities Summer Institute, R25 MH080663 (to S.V. trainee). Declaration of Interests: The authors stated: None. Ethics Approval Statement: Patients gave written, informed consent for the provision of blood for the purposes of HIV research before inclusion in the current CHARTER pilot study. The protocol for blood collection and analysis was approved by the Mount Sinai, Rutgers University and University of Texas Medical Branch Institutional Review Board (Protocol Numbers, Pro20140000794, Pro2012001303, 18-0136, 18-0135, 18-0134).

Editorial introductions

Editorial introductions

Implications of the US Food and Drug Administration draft guidance for mitigating septic reactions from platelet transfusions.

In March 2016, the US Food and Drug Administration (FDA) issued the second draft guidance entitled “Bacterial Risk Control Strategies for Blood Collection Establishments and Transfusion Services to Enhance the Safety and Availability of Platelets for Transfusion.”1 This draft guideline addresses the residual risk of bacterial contamination of platelet products, which may result in septic transfusion reactions. Among blood products, platelet products are most frequently associated with septic transfusion reactions, as they are stored at room temperature. Since 2004, multiple steps have been implemented to decrease the risk of contamination. These include skin cleansing, diversion pouch, and bacterial screening. These steps have decreased the rate of septic reactions from a reported range of 10 to 400 to 7 to 25 per 1 000 000, and the rate of fatal septic reactions from a reported range of 2 to 63 to 2 to12 per 1 000 000 apheresis platelet products transfused.2 Thus, the overall risk has decreased by approximately two thirds. In the last couple of years, additional steps to decrease risk of septic reactions have been FDA approved, including pathogen-reduction technologies (PRT) and point-of-issue (POI) (also known as point-of-release) testing capabilities. At the New York Blood Center (NYBC), the residual risk as reported from hospitals is septic reaction rate of 1 per 250 065.3 Recent data using prospective testing report 20 per 51 400 (1/2570) platelet products contaminated resulting in 4 per 51 400 (1/12 800) reactions (1 being fatal [1/51 400]).4 PRT decreases most bacteria load by >4 logs. Hemovigilance data have not reported septic transfusion cases with pathogen-reduced (PR) platelets.5 Prospective screening of apheresis platelets using the Pan Genera Detection (PGD) test (Verax Biomedical, Marlborough, MA), a POI test, demonstrated a residual bacterial contamination risk of 1 per 2302 (75% detected with PGD) apheresis platelets. The PGD has a false positive rate of 0.51% and a false negative rate of 1 in 9206.6 The FDA-reported fatality rates due to bacteria contamination of platelets (both pooled and apheresis) range from 1 to 4 per year from 2011 to 2015 in ∼2.1 million annual platelets transfused.7,8 Staphylococcus aureus was the contaminant in the majority of contaminated apheresis platelets. The FDA draft guidance asks for implementation of PRT, POI testing, or a second bacterial culture, or to shorten the shelf life of the platelet product from 5 to 3 days. Each of these methods has considerable logistical and clinical issues. In June 2016, during the open comment period, the NYBC, as well as other blood centers, including AABB (formerly known as the American Association of Blood Banks) and ABC (America’s Blood Centers), expressed their opinions regarding the impact of implementing the draft guidance as written (https://www.regulations.gov/docket?D=FDA-2014-D-1814). We have recently submitted additional comments and have urged the FDA to reopen the comment period to encourage a broader community to remark. Options for meeting these new guidelines based upon days from collection are shown in Table 1. Once the guidance is finalized, there is a proposed 1-year implementation date. Table 1. Platelet product shelf-life and draft guidance options

Editorial introductions

Current Opinion in Hematology was launched in 1994. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of hematology is divided into nine sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Mohandas NarlaMohandas NarlaDr Mohandas Narla is Vice President for Research and Director of the Lindsley F. Kimball Research Institute of New York Blood Center, USA. He received his doctoral degree from Washington University in St. Louis, USA, in Chemical Engineering. After completing post-doctoral training in hematology research with Dr Marcel Bessis, Institute of Cellular Pathology in Paris, France, he joined the faculty of the Department of Laboratory Medicine at University of California, USA, where he spent 13 years. In 1989, he moved to Lawrence Berkeley National Laboratory, University of California to head the Hematopoiesis group. During his 12 year tenure at the Berkeley Laboratory he also served as Interim Director of the Human Genome Project for three years. In 2001, he moved to the New York Blood Center, USA. Dr Mohandas’ scientific interests have long focused on red cell physiology and pathology. In particular, his efforts have contributed to improved understanding of the molecular and structural basis for red cell membrane disorders, developing detailed mechanistic insights into pathophysiology of thalassemias and sickle cell anemia, characterizing structural and functional changes induced in red cells by the malarial parasite, plasmodium falciparum. More recently his research efforts are focused on molecular understanding of normal and disordered erythropoiesis including Diamond-Blackfan Anemia and Myelodysplasia. Dr Mohandas served as a member of the National Institute of Health Hematology study section for 13 years and has been a member of numerous committees including the Executive committee of the American Society of Hematology. He served as Associate Editor of Blood from 2003–2012. He is currently Editor-in-Chief of Blood Cells, Molecules and Diseases and is on the Editorial Board of Journal of Biological Chemistry and Biochemistry. Edward F. PlowEdward F. PlowDr Plow received his PhD in Biochemistry in 1970. He joined The Scripps Research Institute, USA, as a postdoctoral fellow and remained at Scripps for 22 years, ultimately becoming a Full Member and Head of the Committee on Vascular Biology. In 1992, he relocated to the Cleveland Clinic, USA, to become Head of Research of the Joseph J. Jacobs Center for Thrombosis and Vascular Biology. He continues to hold this position and is Chair of the Department of Molecular Cardiology in the Lerner Research Institute of the Cleveland Clinic since 1994. Throughout his career, Dr Plow has performed research related to thrombosis, hemostasis and vascular biology. A primary area of his research interests has been platelets and the mechanisms of their adhesive and aggregation responses. This research has led him to investigate integrin structure and function on blood and vascular cells. A primary emphasis of his current research is the molecules and mechanisms governing integrin activation, where he has been instrumental in showing that the kindlin family is critical for integrin function in model cells, mice and humans. At the same time, Dr Plow has had a longstanding interest in the plasminogen system, with a particular emphasis on plasminogen and plasminogen receptors. The role of these molecules in cell adhesion, migration and inflammation has been emphasized. Recent studies by Dr Plow's group have touched into the areas of matrix biology and the roles of micro-RNAs in the pathogenesis of cardiovascular and neoplastic diseases. Dr Plow was an Established Investigator of the American Heart Association and the recipient of the Distinguished Career award of the ISTH and of the Platelet Colloquium. He has chaired two Gordon Research Conferences and organized the ATVB Meeting of the AHA. He has chaired the Council of the ISTH and the ATVB Council of the AHA. He has received an honorary degree from the Medical University of Lodz, Poland; a ZiQiang Professorship of Shanghai University, China, and was elected a Fellow of the American Association of the Advancement of Science. Dr Plow is the 2014 recipient of the International Society of Fibrinolysis and Proteolysis Prize.

Bombay blood phenotype: Laboratory detection and transfusions recommendations

Four main blood types routinely identified today are A, B, AB, and O. Universal donors have type "O" blood, and have no "A" or "B" antigens. In turn, no blood reactions will occur in recipients. Conversely, universal recipients having type "AB" blood will have no antibodies to the "A" or "B" antigens. Bombay phenotype has no "A" or "B" antigens, classifying it as "O" blood type. Furthermore, Bombay phenotype lacks expression of the H antigen, which is present on every blood cell. When mixed with any type of blood other than Bombay blood, hemolytic reactions occur. A 55-year-old male had his blood typed and screened after trauma activation for an eye injury. On forward grouping, the patient was identified as blood type "O". On reverse grouping, agglutination occurred. Laboratory procedures were evaluated and an expanded antigen panel was performed which confirmed this agglutination, which led to the suspicion of a rare blood type. The patient did not require blood transfusion and was further evaluated by New York Blood Center where the diagnosis of Bombay Phenotype was confirmed. This case emphasizes the importance of proper laboratory investigations for rare blood types, preventative strategies, as well as management of Bombay blood type.

Age-Adjusted Co-Morbidity Score - but Not Revised Disease Risk Index - Is Associated with Progression-Free Survival after Intermediate Intensity Double Unit CBT in Adults with Hematologic Malignancies

Introduction: CB transplantation (CBT) after intermediate intensity conditioning is a less toxic alternative to CBT after high dose myeloablation. However, determinants of progression-free survival (PFS) and the impact of the pre-transplant revised Disease Risk Index (rDRI) and age-adjusted Hematopoietic Cell Transplant Co-morbidity Index (aaHCT-CI) are not established.Methods: We evaluated 2-year PFS in double-unit CBT (dCBT) recipients with hematologic malignancies who were conditioned with a myeloablative but intermediate intensity regimen of cyclophosphamide 50 mg/kg, fludarabine 150 mg/m2, thiotepa 5-10 mg/kg, 400 cGy of TBI with cyclosporine-A/mycophenolate mofetil and no ATG. Eligible patients for this analysis included first allograft recipients aged < 70 years with acute leukemia, MDS, MPD (all < 10% blasts pre-transplant), B-cell NHL or HL. Patients were scored by the rDRI (with FLT-3 positivity categorized as high risk) and aaHCT-CI. PFS was estimated using the Kaplan-Meier method, while Cox proportional hazards regression models were used to assess the association between patient and graft characteristics and PFS.Results: Patients [n = 100, median age 51 years (range 19-70) and median weight 78 kg (32-139) had AML (38 CR1,17 CR2, 1 refractory), ALL (13 CR1, 2 CR2, 1 CR3), MDS (10, blasts ranging 1-10%), MPD (5), B-cell NHL (11 DLBCL or indolent) or HL (2). The rDRI distribution was 6 (6%) low, 55 (55%) intermediate, 34 (34%) high, and 5 (5%) very high whereas the median aaHCT-CI was 3 (range 0-9). The median infused CD34+ cell doses of the larger and smaller units were 1.17 (range 0.35-3.72) and 0.68 (range 0.17-2.18) x 105/kg, respectively, whereas the median 8 allele HLA-match was 5/8 (range 2-8/8). In 42/100 (42%) patients the dCBT grafts were supplemented by CD34+ cell selected haplo-identical peripheral blood stem cells. The cumulative incidence of day 45 neutrophil engraftment was 97% whereas day 100 grade II-IV and III-IV aGVHD were 69% and 15%, respectively, and 1-year chronic GVHD was 6%. Day 180 TRM was 17% and 2-year relapse incidence was 11%. With a median survivor follow-up of 27 months (range 5-91), the 2-year PFS was 66% (95%CI: 56-75). Kaplan-Meier estimates and univariate and multivariate analyses of 2-year PFS by relevant patient and graft variables are shown (Table and Figures). Dividing patients into low-intermediate vs high-very-high rDRI and aaHCT-CI 0-2, 3 and > 4 revealed high aaHCT-CI was associated with worse PFS whereas older age alone and high-very high rDRI were not. The adverse effect of high aaHCT-CI was mediated by an increased risk of TRM early post-transplant.Conclusions: dCBT with intermediate intensity conditioning (Cy/Flu/Thio/TBI 400) is effective in adult patients with high-risk malignancies. Notably, pre-transplant rDRI was not associated with PFS suggesting this therapy is associated with a robust graft-versus-malignancy effect. High aaHCT-CI, however, adversely impacted PFS. These findings support the use of intermediate intensity dCBT in patients with high risk disease without concurrent high aaHCT-CI, and, as with adult donor allografts, new treatment strategies are required for patients with a significant co-morbidity burden. [Display omitted] [Display omitted] [Display omitted] DisclosuresGiralt:JAZZ: Consultancy, Honoraria, Research Funding, Speakers Bureau; TAKEDA: Consultancy, Honoraria, Research Funding; CELGENE: Consultancy, Honoraria, Research Funding; AMGEN: Consultancy, Research Funding; SANOFI: Consultancy, Honoraria, Research Funding. Scaradavou:National Cord Blood Program- New York Blood Center: Employment.

Long-Term Follow up of Pediatric Patients with Hodgkin Lymphoma Treated with High Dose Therapy and Autologous Stem Cell Transplantation

Introduction: Despite improved outcomes for children with Hodgkin lymphoma (HL), relapsed and refractory disease remain a challenge for a subset of patients. High dose therapy followed by autologous stem cell transplantation (ASCT) is the standard of care for relapsed disease, largely based on data from studies in adults. As new therapies emerge for HL, risk stratification of pediatric patients with relapsed disease will be essential to determine which patients are likely to benefit from ASCT and which patients should be selected for alternative therapy. In this study we report the long-term outcome of 34 pediatric patients with HL who underwent ASCT at a single institution.Methods: We conducted a retrospective analysis of 34 consecutive pediatric patients with HL who underwent ASCT at Memorial Sloan Kettering Cancer Center from 1989-2013. Data collected included age, histology, treatment prior to ASCT, disease status at the time of transplant, conditioning regimen, and outcome after ASCT. Given recent data supporting a Childhood Hodgkin International Prognostic Score (CHIPS) for risk stratification in first-line therapy(Schwartz et al, ASH Abstract #3649, 2011), this score was calculated at the time of relapse to evaluate its prognostic relevance in the relapse setting. One point was awarded for each of the following: stage IV disease, bulky mediastinal adenopathy, albumin <3.5, and fever. Kaplan-Meier survival analysis was used to estimate the probability of overall survival (OS) and disease-free survival (DFS).Patient Characteristics: Pathologic classification included nodular sclerosis (n=30), mixed cellularity (n=1), lymphocyte predominant (n=2), or subtype unspecified (n=1). The median age was 17.9 yrs (range 9.7-21) and 47% of patients were male. Thirty-three patients had relapsed disease; one patient had primary refractory disease. The median time from diagnosis to first relapse was 13 months (range 5-60). Twenty-five patients (73.5%) had chemotherapy responsive disease at the time of transplant (CR or PR). Others had stable disease (n=6), mixed response (n=2) or progressive disease (n=1). Thirty-one of 34 patients received radiation therapy either during initial treatment or as part of a salvage regimen. Four patients received brentuximab vedotin at the time of relapse. ASCT preparative regimen consisted of cyclophosphamide-etoposide + total lymphoid irradiation (n=14) or + carmustine (n=16), while 4 patients received the BEAM regimen. All but two patients treated after 1997 received chemotherapy-only preparative regimens.Results: The median follow up for the cohort was 70.5 months (range 2.5-144). The 12-year OS and DFS were 65.1% and 63.6% respectively. The cause of death included HL (n=7), sepsis (n=1) and end stage renal disease (n=1). Patient age, stage at diagnosis, and time from diagnosis to relapse were not associated with differences in DFS. Patients who received an ASCT after 1997 had a better outcome than those who received an ASCT before 1997 (DFS 44.9% vs. 81.8%, p=0.012). Patients with chemotherapy sensitive disease at the time of transplant had a superior DFS (74.5% vs. 33.3%, p=0.005). Although not statistically significant, there was a trend toward improved outcome among patients with early stage disease at relapse (stage I/II) compared to advanced stage (III/IV) (DFS 81.3% vs. 54.2%, p=0.098). Among 21 patients with data available to calculate CHIPS at time of relapse, there was a superior OS among those with a lower CHIPS with OS of 100%, 70%, 50%, and 0% for patients with a CHIPS of 0, 1, 2, and 3 respectively (p=0.021). There were no patients with a CHIPS of 4. There was a trend toward improved DFS among patients with a low CHIPS, however this was not statistically significant (DFS of 100%, 70%, 66.7%, and 0% in patients with a CHIPS of 0, 1, 2, and 3 respectively, p=0.176).Conclusions: ASCT offers the prospect of durable, disease free survival for a significant proportion of pediatric patients with relapsed HL. The outcome among patients who received an ASCT in recent years (1997-2013) was high (DFS 81.8%). Chemotherapy sensitive disease at the time of transplant was associated with superior DFS. To our knowledge this is the first report evaluating the potential utility of CHIPS in the relapse setting. Despite the small sample size (n=21) CHIPS was predictive of OS, suggesting that this measure should be studied further as a potential prognostic marker in relapsed HL. DisclosuresTrippett:Seattle Genetics, Inc.: Research Funding; OSI Pharmaceuticals: Research Funding. Kernan:Gentium S.p.A.: Research Funding. Prockop:Atara Biotherapeutics: Other: I have no financial disclosures, but Atara Biotherapeutics has exercised a licensing agreement with Memorial Sloan Kettering Cancer Center and MSKCC and some investigators at MSKCC have a financial interest in Atara.. Scaradavou:National Cord Blood Program- New York Blood Center: Employment. Moskowitz:Celgene: Membership on an entity's Board of Directors or advisory committees; Seattle Genetics: Honoraria, Research Funding; Merck: Membership on an entity's Board of Directors or advisory committees, Research Funding; Genentech: Membership on an entity's Board of Directors or advisory committees; Pharmacyclics: Research Funding.

Prospective Evaluation of Cord Blood (CB) & Haplo-Identical Donor Availability Reveals Compromised Donor Access for Both Graft Types in Minorities and High Rates of Failure to Clear Haplo Donors in Adult Patients

Background: Many patients in need of hematopoietic allografts without matched siblings do not have any 8/8 HLA-matched unrelated volunteer donors (URD). This is especially true in patients of non-European & mixed ancestries & this applies to 50% of patients undergoing URD searches at our center. While unrelated donor CB & haploidentical (haplo) related donors offer alternative graft sources their availability in all patient populations is not established.Methods: We prospectively evaluated the availability of CB & haplo grafts 9/2012 - 7/2015 in a phase II clinical trial of double unit CBT (dCBT) supplemented by haplo CD34+ cells in patients with hematologic malignancies lacking an 8/8 HLA-matched URD. CB units required a cryopreserved TNC dose ≥ 1.5 x 107 /kg/unit, were ≥ 4/6 HLA-A,-B antigen, -DRB1 allele matched, & high resolution 8 HLA-allele match & CD34+ cell dose were also considered. Standard criteria were used to define donor eligibility for haplo PBSC collection. Reasons for failure of haplo donor clearance were classified as either medical ineligibility or psychosocial (including financial inability to relocate to our transplant center, international donors unable to come to the US, donor refusal or withdrawal of consent during workup, donor imprisonment, or patient refusal to approach the donor for collection).Results: 89 patients [median age 50 years (range 15-68)] were evaluated. Diagnoses included 58 acute leukemias, 10 MDS/ myeloproliferative disorders, & 21 NHL/ Hodgkins lymphomas. Evaluation of CB graft &/or haplo donor availability revealed 3 patient groups. Group 1 (59/89, 66% of the total) had both suitable CB grafts & haplo donors and underwent dCBT-haplo CD34+ transplants. 33% were non-European & their median weight was 78 kg (range 33-133). The CB grafts had a median infused TNC of 2.4 (larger unit) & 1.9 (smaller unit) x 107/kg with a median 5/8 (range 2-7/8) donor-recipient HLA-match whereas the 59 haplos (median age 36 years, range 15-71) included 17 siblings, 9 parents, 27 children, & 6 extended family. In Group 1, the first haplo chosen was cleared for donation in 52/59 (88%) patients whereas 6/59 (10%) required work-up of 2-4 haplos/ patient for a total of 16 donors who failed clearance for medical or psychosocial reasons. The remaining patient had pan-donor specific HLA antibodies to 5 haplos & subsequently a 7/8 HLA-matched nephew was secured. Group 2 (17/89, 19% of the total) received only dCB grafts due to failure to identify a suitable haplo donor. Group 2 patients were more likely to be non-European (65%) but had a similar weight (median 78 kg, range 55-118) as Group 1. The CB grafts were also similar to Group 1 (median infused TNC 2.2 & 1.5 x 107/kg & median donor-recipient HLA-match 5/8, range 3-8/8). Of these 17 dCBT only patients, 6 had no eligible haplos identified within their extended family whereas in 8 patients 1-4 haplos/ patient failed to clear for medical reasons, combinations of medical & psychosocial reasons, or pursuit of haplos failed due to a combination of medical failure & subsequent transplant urgency. Of the remaining patients, 2 had haplos who failed for purely psychosocial reasons, & in 1 the transplant was too urgent to delay to complete donor clearance. In this group a total of 19 haplos failed to clear. Finally, Group 3 (13/89, 15% of the total) had no dCB grafts + no haplo grafts. They were nearly all (85%) non-European including 7 patients of African ancestry & they had a higher weight (median 95 kg, range 52-143). One of these patients received a haplo transplant, 3 had no haplos identified, & in 9 patients clearance of potential haplos was not determined to date, or they pursued alternative therapy, were lost to follow-up, or their disease progressed.Conclusions: In this study, 15% of patients had no CB grafts & these patients were predominantly non-European with a high weight. Additionally, over 20% of patients had no haplo grafts & compromised haplo donor availability was common especially in minority patients. This data demonstrates that even in patients with identified haplos, donor clearance cannot be assumed & the need for workup of multiple haplos/ patient can delay admission & substantially add to transplant costs. These observations support continued investment in public CB inventories to provide a readily available graft especially for minority patients who are at increased risk for inability to identify a CB &/or haplo donor. DisclosuresPerales:National Marrow Donor Program: Membership on an entity's Board of Directors or advisory committees; Merck: Honoraria; Amgen: Honoraria; Incyte: Honoraria; Seattle Genetics: Honoraria. Giralt:TAKEDA: Consultancy, Honoraria, Research Funding; JAZZ: Consultancy, Honoraria, Research Funding, Speakers Bureau; AMGEN: Consultancy, Research Funding; SANOFI: Consultancy, Honoraria, Research Funding; CELGENE: Consultancy, Honoraria, Research Funding. Scaradavou:National Cord Blood Program- New York Blood Center: Employment.

Detection of bacterial contamination in apheresis platelets: is apheresis technology a factor?

Apheresis platelet (AP) contamination may be influenced by manufacturing methods because bacteria are subject to the same forces that permit separation of blood cells. This study assesses whether apheresis technology influences in-process detection of bacterial contamination. Blood Systems, Inc. (BSI) and New York Blood Center (NYBC) use Amicus and Trima devices to collect APs. Manufacturing (arm disinfection and in-line diversion) was consistent for both devices in the study period. Detection was performed using BacT/ALERT. True-positive (TP) rates were calculated and significance testing was performed using chi-square tests separately for BSI and NYBC. For BSI, multivariable logistic regression analysis was also performed to identify factors associated with TP results. For BSI, there were 49 TPs in 354,946 donations (1.4/10,000): 2.5 per 10,000 for Amicus and 1.0 per 10,000 for Trima (p < 0.05). Multivariable logistic regression analysis showed significant association between TP and devices (odds ratio, 2.8; 95% confidence interval [CI], 1.01-8.0) and for one collection region. For NYBC, there were 18 TPs in 161,840 donations (1.1/10,000): 2.1 per 10,000 for Amicus and 0.4 per 10,000 for Trima (p < 0.05). The TP rate was significantly higher in Amicus collections than in Trima collections at NYBC and BSI. These results do not allow for conclusions regarding the relative clinical risk of PLTs collected by Amicus and Trima. Future evaluations of component quality and clinical outcomes should consider different collection technologies.