A Simple, Rapid, and Inexpensive Color-Based Hemoglobin Assay As a Robust Screening Test for Severe Anemia in Limited Resource Settings

Abstract Severe anemia is common in limited-resource settings (LRS) of sub-Saharan Africa, affecting up to 30% of hospitalized patients and associated with high mortality rates. The World Health Organization (WHO) recommends blood transfusion for patients with hemoglobin (Hb) concentration <4 g/dL in all cases, and for patients with Hb <6 g/dL if there are other clinical complications. In reality, a Hb ≤5 g/dL is roughly used as a threshold for transfusion in many limited-resource settings. The accurate diagnosis of anemia is critical to appropriately utilize the very limited blood supply, and to triage and treat patients in a timely manner to provide life-saving care. Lack of timely transfusions for children with severe anemia has been associated with significant increase in mortality in several studies within Africa. However, accurate diagnosis of anemia is often difficult or impossible in LRS due to lack of equipment, inadequate replenishment of reagents, poor maintenance or calibration of existing equipment, inadequately trained laboratory personnel, or unreliable and inconsistent access to electricity. A recent publication (Opoka RO et al. BMC Health Serv Res2018) examining transfusion practices in Uganda demonstrated that over half of blood transfusions were administered inappropriately, either without a Hb measurement or with Hb values for which transfusion would not be recommended. The WHO Haemoglobin Colour Scale (HCS), a simple, rapid, point-of-care (POC) test requiring a single drop of blood on filter paper, was developed in an effort to improve the accurate diagnosis of anemia in settings where more definitive laboratory testing is not available. There have been many published reports of the HCS with heterogeneous results, including a recent meta-analysis demonstrating significant variation in sensitivity for the detection of anemia and severe anemia, defined as Hb ≤11 g/dL and Hb ≤7 g/dL respectively (36-76%, Marn H. Lancet Glob Health 2016). The lower limit of the HCS is 4 g/dL, and there is very limited data on its accuracy to diagnose severe anemia requiring transfusion (Hb ≤5 g/dL). The AnemoCheckTMis a rapid, inexpensive, color-based POC test initially designed to diagnose anemia in higher-resource settings, and subsequently modified for use in limited-resource settings (Tyburski et al. J Clin Invest 2014). Based on mixed results both in controlled settings within the US and in the field in Tanzania, AnemoCheck was adapted to focus on its ability to detect severe anemia warranting transfusion. The newly modified AnemoCheck-LRS test allows identification of Hb ranging from 2-8 g/dL, with sharp color changes especially differentiable at the clinically relevant 5 g/dL threshold (Figure 1) to allow accurate diagnosis of clinically meaningful severe anemia in settings where this is common. We prepared and tested 200 samples of varying Hb concentration, each of which was evaluated independently by three separate readers, for a total of 1200 evaluations. By standard CBC measurement, the 200 samples had a mean (±SD) Hbof 5.2±1.9 g/dL (range 1.7 to 10.1 g/dL). Of the 570 samples with Hb ≤8 g/dL (upper limit of AnemoCheck), the absolute difference between AnemoCheck and the gold standard CBC Hb was 0.5±0.4 g/dL (actual difference 0.2±0.7 g/dL). The WHO HCS was inaccurate, with Hb readings consistently higher than the CBC Hb, and an absolute and actual difference of 4.9±1.3 g/dL for samples within the detection range of the HCS (4-14 g/dL, n=405). Table 1 summarizes the ability of both tests to diagnose severe anemia (Hb ≤5 g/dL), demonstrating the accuracy of AnemoCheck-LRS. Furthermore, given that most readings that missed the diagnosis of anemia were within 1 g/dL of actual Hb, if 6 g/dL was used as the screening threshold to identify patients who need a more definitive diagnosis, the sensitivity of AnemoCheck increased to 99%. This study demonstrates that the new AnemoCheck-LRS assay is an accurate POC test to diagnosis very severe anemia in a controlled laboratory setting. The widely cited WHO HCS performed poorly, with a stark inability to diagnose very severe anemia in most cases. This study provides important preliminary data to support follow-up field studies that will use AnemoCheck-LRS to diagnose severe anemia, with the goal of the assay serving as a primary screening test for rapid and accurate diagnosis in settings where laboratory capacity and resources are limited. Disclosures Tyburski: Sanguina, LLC: Employment, Equity Ownership. Ware:Bristol Myers Squibb: Research Funding; Nova Laboratories: Consultancy; Biomedomics: Research Funding; Global Blood Therapeutics: Other: advisory board; Addmedica: Research Funding; Agios: Other: advisory board; Novartis: Membership on an entity's Board of Directors or advisory committees.

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AnemoCheck-LRS: an optimized, color-based point-of-care test to identify severe anemia in limited-resource settings

BMC Medicine ◽

10.1186/s12916-020-01793-6 ◽

2020 ◽

Vol 18 (1) ◽

Author(s):

Marina S. Perez-Plazola ◽

Erika A. Tyburski ◽

Luke R. Smart ◽

Thad A. Howard ◽

Amanda Pfeiffer ◽

...

Keyword(s):

Screening Tool ◽

Point Of Care ◽

Low Cost ◽

Limited Resource ◽

Absolute Difference ◽

Severe Anemia ◽

Detection Range ◽

Point Of Care Test ◽

Colour Scale ◽

Life Saving

Abstract Background Severe anemia is common and frequently fatal for hospitalized patients in limited-resource settings. Lack of access to low-cost, accurate, and rapid diagnosis of anemia impedes the delivery of life-saving care and appropriate use of the limited blood supply. The WHO Haemoglobin Colour Scale (HCS) is a simple low-cost test but frequently inaccurate. AnemoCheck-LRS (limited-resource settings) is a rapid, inexpensive, color-based point-of-care (POC) test optimized to diagnose severe anemia. Methods Deidentified whole blood samples were diluted with plasma to create variable hemoglobin (Hb) concentrations, with most in the severe (≤ 7 g/dL) or profound (≤ 5 g/dL) anemia range. Each sample was tested with AnemoCheck-LRS and WHO HCS independently by three readers and compared to Hb measured by an electronic POC test (HemoCue 201+) and commercial hematology analyzer. Results For 570 evaluations within the limits of detection of AnemoCheck-LRS (Hb ≤ 8 g/dL), the average difference between AnemoCheck-LRS and measured Hb was 0.5 ± 0.4 g/dL. In contrast, the WHO HCS overestimated Hb with an absolute difference of 4.9 ± 1.3 g/dL for samples within its detection range (Hb 4–14 g/dL, n = 405). AnemoCheck-LRS was much more sensitive (92%) for the diagnosis of profound anemia than WHO HCS (22%). Conclusions AnemoCheck-LRS is a rapid, inexpensive, and accurate POC test for anemia. AnemoCheck-LRS is more accurate than WHO HCS for detection of low Hb levels, severe anemia that may require blood transfusion. AnemoCheck-LRS should be tested prospectively in limited-resource settings where severe anemia is common, to determine its utility as a screening tool to identify patients who may require transfusion.

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T-MDS Is a Distinct Clinical and Pathological Entity Characterized By Better Survival Compared to t-AML

Blood ◽

10.1182/blood-2021-152380 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 3377-3377

Author(s):

Mithun V. Shah ◽

Rakchha Chhetri ◽

Urshila Durani ◽

Monika Kutyna ◽

Hassan B. Alkhateeb ◽

...

Keyword(s):

Board Of Directors ◽

Research Funding ◽

Advisory Board ◽

World Health ◽

Advisory Committees ◽

Disease Modifying Therapies ◽

The World ◽

Blast Count ◽

Disease Modifying ◽

Health Organization

Abstract Introduction: Therapy-related myeloid neoplasm (t-MN) includes acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), and myelodysplastic/myeloproliferative neoplasms (MDS/MPN) that occur as a complication of DNA-damaging therapies. The World Health Organization recommends considering t-MN as a single entity. Whether t-MDS and t-AML have distinct characteristics and outcomes is not known. The aim of this study was to compare clinicopathological characteristics and outcomes of t-MDS and t-AML. Methods: All patients diagnosed with t-MN based on the World Health Organization criteria were identified. Bone marrow biopsies, cytogenetic, and next-generation sequencing (NGS) were obtained at the treating physician's discretion. Pathogenic/likely pathogenic variants (PV) were called based on the standard criteria. Overall survival (OS) was calculated from the time of t-MN diagnosis until the last follow up using Kaplan-Meier analysis using Wilcoxon test. For survival analysis comparing chemotherapy to best supportive care (BSC) only, patients were censored at the time of allogeneic stem cell transplant (SCT). Multivariate analysis was performed using Cox proportional hazard method and corrected using false discovery rate (FDR). Statistical analysis was performed using JMP (v14.1, SAS Institute) and significance was defined as P<0.05. Results: We identified 554 patients, of which 180 (32.4%), 365 (65.8%), and 9 (1.6%) presented as t-AML, t-MDS, and t-MDS/MPN respectively. t-MDS/MPN patients were excluded from further analysis due to a small number. Clinical and laboratory characteristics of the t-AML and t-MDS cohorts is shown in Table 1. t-AML patients were significantly more anemic and thrombocytopenic at presentation. As expected, t-AML had a higher peripheral blood and BM blast count. There was no difference in proportion of patients with chromosomal abnormalities, though a statistically significantly higher proportion of t-MDS patients had chromosome 5 abnormality, 5q deletion, monosomy 5, chromosome 7 abnormality, monosomy 7 compared to t-AML patients. On other hand, 11q23 (mixed lineage leukemia, MLL) rearrangement was more common in t-AML compared to t-MDS (9.3% vs. 2.8%, P=0.005). A higher proportion of t-MDS patients had PV detected by NGS compared to t-AML (92.9% vs. 85.6%, P=0.038). A higher proportion of t-MDS patients had PV in TP53 (37.6% vs. 21.4%, P=0.004) and ASXL1 (23% vs. 11.7%, P=0.016) genes; whereas a higher proportion of t-AML patients had PV in RAS (18.9% vs. 9.1%, P=0.013) and WT1 (8.1% vs. 2.9%, P=0.05) genes. One hundred twenty-eight (35%) of 365 t-MDS patients progressed to t-AML. The presence of any chromosomal abnormality at t-MDS diagnosis predicted a higher risk of transformation to t-AML (χ 2 3.9, P=0.03). t-AML patients had a significantly shorter OS compared to t-MDS (9.2 vs. 19.7 months, P<0.0001, Figure A). This difference persisted when stratified by no disease modifying therapies (BSC only) 2 vs. 17 months (P<0.0001, Figure B), as well as among those who received at least one line of chemotherapy (14 vs. 24.6 months, P<0.001). Finally, a higher proportion of patients with t-AML underwent SCT and there was a trend towards improved survival for t-AML patients (vs. t-MDS 52.9 vs. 20.7 months, P=0.07) from the time of transplant. Multivariate analysis for OS performed to control for all the variables that were different at presentation (except for blast count), showed that t-MDS (as opposed to t-AML) phenotype at diagnosis, and undergoing SCT were independent predictors of improved survival (Table 2). Conclusion: t-MDS and t-AML have distinct clinical, cytogenetic, and genetic features at presentation. In the absence of disease modifying therapies, t-AML is a more aggressive phenotype, consistently associated with a shorter survival. Even after controlling adverse risk features, t-AML phenotype had a shorter survival compared to t-MDS. Figure 1 Figure 1. Disclosures Litzow: AbbVie: Research Funding; Astellas: Research Funding; Amgen: Research Funding; Actinium: Research Funding; Pluristem: Research Funding; Jazz: Other: Advisory Board; Omeros: Other: Advisory Board; Biosight: Other: Data monitoring committee. Hiwase: Novartis: Membership on an entity's Board of Directors or advisory committees; AbbVie: Membership on an entity's Board of Directors or advisory committees.

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Predictors of Response to Erythropoietin in Autoimmune Hemolytic Anemia

Blood ◽

10.1182/blood-2019-125524 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3516-3516 ◽

Cited By ~ 1

Author(s):

Bruno Fattizzo ◽

Marc Michel ◽

Laetitia Languille ◽

Juri Giannotta ◽

Henrik Frederiksen ◽

...

Keyword(s):

Bone Marrow ◽

Hemolytic Anemia ◽

Autoimmune Hemolytic Anemia ◽

Research Funding ◽

Specific Treatment ◽

Advisory Board ◽

Recombinant Erythropoietin ◽

Severe Anemia ◽

Predictors Of Response ◽

Small Series

BACKGROUND AND AIM Bone marrow compensation in autoimmune hemolytic anemia (AIHA) is an emerging predictor of clinical outcome. It is measured by reticulocytosis that may be inadequate in a proportion of cases, particularly in chronic refractory ones. Moreover, reticulocytosis may be masked by constant destruction, particularly in cold forms. Recombinant erythropoietin (EPO), has been anecdotally used off-label in AIHA to improve anemia, but only case reports and small series have been described. Here we evaluate EPO efficacy and predictors of response in a multicentric cohort of primary and secondary AIHA patients. METHODS Hematological data, hemolytic markers (LDH, reticulocytes), and concomitant treatments were retrospectively and prospectively collected. Efficacy was evaluated at 15 and 30 days, and then at 3,6 and 12 months after EPO start. Response was considered as partial (PR, >2 g/dL Hb increase or >10 g/dL) or complete (CR, >12g/dL and normalization of hemolytic markers). Forty-six AIHA cases followed from June 2007 to June 2019 at 9 centers in Italy, France, Norway, Austria, Denmark, and UK were included. RESULTS Table 1 shows patients characteristics: all AIHA types (warm, cold, mixed, and DAT negative) were present, and 5 cases were secondary to a lymphoproliferative disorder (not active and without specific treatment at the time of EPO start). Bone marrow evaluation pre-EPO (N=24) showed hypercellularity in 14 cases, dyserythropoiesis in 11, and reticulin fibrosis in 3; a lymphoid infiltrate was found in 19 patients (T-cell in 6, B-cell in 10, mixed in 3), greater than 10% in the 5 secondary cases only. Forty-one cases (89%) had been previously treated, with a mean of 1.8+1 lines of therapy including steroids, rituximab, splenectomy, immunosuppressors and sutimlimab (1 case, where the drug completely abolished hemolysis). The majority (67%) started EPO due to non-response to ongoing treatment (18 steroids, 6 immunosuppressors, 1 sutimlimab) or within 3 months from rituximab course (7). At EPO initiation, 30% of cases displayed severe anemia, 71% had inadequate reticulocytosis (bone marrow responsiveness index<121), and 73% showed inappropriately low endogenous EPO levels. Of note, 2 patients had concomitant renal impairment, possibly contributing to this finding. Most cases received epoetin alpha 40,000 UI/week (45%), followed by darbopoetin alpha (34% of cases, median dose 102 mcg/week) and epoetin zeta (14% of cases, 30,000 UI/week). EPO was administered for a median of 6 months and responses were observed in 68% and 70% of cases at month+1 and +3. Comparable response rates were recorded at month+6 (70%, 13 CR and 1 PR, N=20) and +12 (72%, 8 CR and 5 PR, N=18), although evaluable cases were fewer. Median Hb increase from baseline was 2.5 g/dL (0.2-7.6) at month+1 (p<0.001), and 3.1 g/dL (0-9.4) at month+3 (p<0.001). Consistently, reticulocytes increased by 23 x109/L (0-217) at month+1, and 33 x109/L (0-353) at month+3. No EPO-related adverse events occurred (particularly no thrombosis). At last follow up, 23 cases had discontinued EPO: 13 for long lasting CR and 10 because of NR. Considering predictors of response, a better efficacy was observed in primary versus secondary AIHA (71 vs 40%) and in patients with shorter time from diagnosis to EPO treatment (52% of responders started EPO within 1 year from diagnosis vs 8% of NR, p=0.01). Moreover, responders had received a lower number of previous treatments (p=0.04), particularly rituximab (p=0.05) and immunosuppressors (p=0.08). Remarkably, responders more frequently showed severe anemia (86% vs 62%) and lower endogenous EPO (91% vs 50% with a cut-off of <60 UI/L, p=0.05) at baseline. CONCLUSIONS EPO is effective in roughly 70% of chronic refractory AIHA cases, independently from antibody thermal characteristics/isotype and underlying disease. Concomitant treatments may partially affect response evaluation, although EPO treatment has been introduced because of their partial or complete inefficacy. Further limitations are the retrospective nature of the study and a possible selection bias (i.e. most of patients had inadequate reticulocytosis). Predictors of response were severe anemia and low levels of endogenous EPO, as well as, shorter disease duration and a lower burden of previous treatments. These data suggest an early use of EPO in this setting in order to overcome inadequate bone marrow compensatory ability. Table Disclosures Fattizzo: Apellis: Consultancy. Michel:Novartis: Consultancy; Amgen: Consultancy; Rigel: Consultancy. Frederiksen:Novartis: Research Funding; Janssen Pharmaceuticals: Research Funding; Abbvie: Research Funding; Alexion: Research Funding; Gilead: Research Funding. Mauro:Gilead: Consultancy, Research Funding; Shire: Consultancy, Research Funding; Abbvie: Consultancy, Research Funding; Jannsen: Consultancy, Research Funding; Roche: Consultancy, Research Funding. Jilma:TrueNorth a Bioverativ company, a Sanofi company: Consultancy, Research Funding. Hill:Regeneron: Honoraria; Roche: Honoraria; Ra Pharma: Honoraria; Bioverativ: Honoraria; Novartis: Honoraria; Akari: Honoraria; Alexion: Honoraria; Apellis: Honoraria. Berentsen:Mundipharma: Research Funding; Apellis, Bioverativ (a Sanofi company), Momenta Pharmaceuticals, and True North Therapeutics: Consultancy; Alexion, Apellis, and Janssen-Cilag: Honoraria. Barcellini:Agios: Other: Advisory board; Bioverativ: Other: Advisory board; Alexion: Other: Invited Speaker, Research Funding; Novartis: Other: Invited Speaker, Research Funding; Incyte: Other: Advisory board. OffLabel Disclosure: Erythropoietin (EPO) is not yet indicated for the use in autoimmune hemolytic anemia. Here we report retrospective data on a large cohort of cases treated with EPO as a support to bone marrow compensation.

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Clinical, Hematological, and Biologic Characteristics in Chronic Myelomonocytic Leukemia Patients with a JAK2 V617F Mutation

Blood ◽

10.1182/blood.v128.22.3189.3189 ◽

2016 ◽

Vol 128 (22) ◽

pp. 3189-3189

Author(s):

Klaus Geissler ◽

Agnes Barna ◽

Eva Jäger ◽

Temeida Alendar ◽

Elmir Ljubuncic ◽

...

Keyword(s):

Research Funding ◽

Real Life ◽

Jak2 V617f ◽

Advisory Board ◽

Chronic Myelomonocytic Leukemia ◽

World Health ◽

Jak2 V617f Mutation ◽

V617f Mutation ◽

Myelomonocytic Leukemia

Abstract Background:Chronic myelomonocytic leukemia (CMML) is a hematopoietic malignancy of the elderly with a heterogenous molecular pathophysiology. Whereas mutations in components of the RAS pathways are among the most common somatic mutations in CMML the JAK2 V617F mutation which is a typical finding in polycythemia vera and around 50% of patients with essential thrombocythemia and primary myelofibrosis, respectively, is by far less frequently detected in CMML but can be consistently found in a subgroup of patients in larger series. Due to the fact that JAK2 V617F-positive CMML is a rare disease the clinical, hematological and in vitro growth characteristics of this entity are poorly investigated. In the "Austrian Biodatabase for Chronic Myelomonocytic Leukemia (ABCMML)" we retrospectively and prospectively collect clinical, biologic, and molecular information of patients with CMML from different centers in a real life setting. Aims:Our aim was to characterize the clinical, hematological, molecular and biologic features of CMML patients harboring a JAK2 V617F mutation. Methods:The diagnosis of CMML was established according to diagnostic criteria of the World Health Organization (WHO) classification of 2008 (Vardiman et al, Blood 2009). Clinical and hematological data were obtained from patients records. For molecular characterization we used next-generation sequencing with amplicon-based target enrichment of 39 CMML associated genes. Only mutations with an allele burden of >10% were considered positive in this analysis. Autonomous colony-forming units granulocyte/macrophage (CFU-GM) growth in the absence of exogenous cytokines was assessed using semisolid cultures as previously described (Geissler et al, J Exp Med 1996). Results:Up to now targeted NGS data are available in 116 patients and in vitro culture data in 75 patients respectively. We identified 13 CMML patients who had a JAK2 V617F mutation with an allele frequency >10%. Clinical, hematological, and biologic characteristics in these patients were compared with 103 patients who had NGS sequencing and were negative for the JAK2 V617F mutation. As shown in Table 1 JAK2 V617F-positive CMML patients had significantly higher WBC counts, higher hemoglobin values, higher platelet counts and more pronounced splenomegaly as compared to JAK2 V617F-negative patients. On the other hand the percentage on monocytes in peripheral blood and the numbers of CFU-GM growing in vitro without addition of exogenous growth factors were lower in CMML patients with the JAK2 V617F mutation as compared to patients without this mutation. The majority of JAK2 V617F-positive patients had additional mutations that can be also found in JAK2 V617F-negative patients, in particular mutations in genes of epigenetic regulation and RNA-splicing, respectively. As shown in Figure 1 there was a trend towards a better survival of patients with the JAK2 V617F mutation as compared to JAK2 V617F-negative patients (p=0.05). In a JAK2 V617F-positive CMML patient with splenomegaly, who was treated with the JAK1/2 inhibitor ruxolitinib off label, we were able to demonstrate the disappearance of constitutional symptoms and a durable spleen response lasting for over 56 months (Fig. 2). Conclusion:Out data show that CMML patients with the JAK2 V617F mutation have hematological, biologic and clinical characteristics different from JAK2 V617F-negative CMML patients. These findings suggest that JAK2 V617F-positive CMML patients should be regarded as a distinct subgroup which may benefit from specific targeted treatments. Disclosures Geissler: Novartis: Honoraria. Pfeilstöcker:Novartis: Consultancy, Speakers Bureau. Burgstaller:Novartis: Consultancy, Honoraria. Zach:Novartis: Other: Honoraria for Advisory Board. Hörmann:Novartis: Other: Honoraria for Advisory Board. Jäger:Roche: Other: Personal fees, Research Funding. Sperr:Amgen: Honoraria, Research Funding; Novartis: Honoraria. Kusec:Novartis: Other: Honoraria for lectures. Valent:Novartis: Honoraria, Research Funding; Amgen: Honoraria; Celegene: Honoraria, Research Funding.

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Prevalence of anemia among pregnant women in rural Koppal: a study from teaching hospital, Koppal, India

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20173605 ◽

2017 ◽

Vol 6 (9) ◽

pp. 3792 ◽

Cited By ~ 1

Author(s):

Seema B. N.

Keyword(s):

Pregnant Women ◽

Public Health Problem ◽

Peripheral Blood Smear ◽

Poverty Line ◽

World Health ◽

Major Public Health Problem ◽

Severe Anemia ◽

Mild Anemia ◽

High Prevalence ◽

Prevalence Of Anemia

Background: Anemia is the nutritional deficiency disorder and 56% of all women living in developing countries are anaemic according to World Health Organization. India has the highest prevalence of anaemia and 20% of total maternal deaths are due to anemia. To determine the prevalence of anemia and factors influencing its causation among pregnant women. Methods: This is the study of 1769 pregnant women which was conducted in a rural population of Koppal district, Karnataka, India, from June 2016 to November 2016 i.e. a period of 6 months. This longitudinal prospective observational study was conducted in the district hospital of Koppal. Anemia was classified as per the Indian Council of Medical Research (ICMR) criteria. The diagnosis of anemia was undertaken by peripheral blood smear examination and standard hemoglobin estimation by shale’s method.Results: The average age of pregnant women was 23.5 years, ranging between 18 and 40 years. Most of the women belonged to below poverty line (BPL) families (84.6%) and Hindu religion (98%). Regarding education, 28.9% were illiterates. The mean haemoglobin level was found to be 8.95. Prevalence of anemia was 96.5% among the pregnant females in this region of rural Koppal. Out of these 22.47% had mild anemia, 56.30% had moderate anemia, 14.98% had severe anemia and 2.73% very severe anemia according to ICMR classification of anemia.Conclusions: High prevalence of anemia among pregnant women indicates anemia to be a major public health problem in the rural community and indicates strict implementation of National Nutrition Anemia prophylaxis programme. Factors such as socioeconomic status, education, birth interval, and gravida contribute to this high prevalence.

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Prediction of response to erythropoietin treatment in chronic anemia of cancer [see comments]

Blood ◽

10.1182/blood.v84.4.1056.1056 ◽

1994 ◽

Vol 84 (4) ◽

pp. 1056-1063 ◽

Cited By ~ 134

Author(s):

H Ludwig ◽

E Fritz ◽

C Leitgeb ◽

M Pecherstorfer ◽

H Samonigg ◽

...

Keyword(s):

Predictive Power ◽

Financial Burden ◽

Ferritin Level ◽

Performance Status ◽

Serum Levels ◽

Medical Intervention ◽

World Health ◽

Chronic Anemia ◽

Factor C ◽

Hb Concentration

Abstract Chronic anemia of cancer can be corrected in approximately 50% of the cases by treatment with recombinant human erythropoietin (rHuEPO). Early prediction of responsiveness would avoid the emotional and financial burden of ineffective medical intervention. Eighty patients with chronic anemia of cancer undergoing treatment with rHuEPO (150 U/kg, 3 times per week by subcutaneous injection; after 6 weeks without response, 300 U/kg) participated in this study. Response was defined as a gain of at least 2 g/dL hemoglobin (Hb) within 12 weeks. Multivariate discriminant analysis and logistic regression analysis of response were performed on routine blood tests; serum levels of EPO, iron, ferritin, transferrin, and its receptor; World Health Organization (WHO) performance status; various cytokines; neopterin; stem cell factor; C- reactive protein; and alpha 1-antitrypsin. At baseline, none of these factors showed sufficient prognostic power. The following predictive algorithm was developed: (1) If after 2 weeks of therapy both the serum EPO level is > or = 100 mU/mL and Hb concentration has not increased by at least 0.5 g/dL, unresponsiveness of the patient is very likely (predictive power, 93%); otherwise, response may be predicted with an accuracy of 80%. (2) If both the serum level of EPO is less than 100 mU/mL and Hb concentration has increased by > or = 0.5 g/dL, response is highly probable (predictive power, 95%). (3) Alternatively, a serum ferritin level of > or = 400 ng/mL after 2 weeks of rHuEPO therapy strongly indicates unresponsiveness (predictive power, 88%), whereas a level less than 400 ng/mL suggests response in 3 of 4 patients.

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Quality of selected anti-retroviral medicines: Tanzania Mainland market as a case study

BMC Pharmacology and Toxicology ◽

10.1186/s40360-021-00514-w ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Sophia Mziray ◽

Betty A. Maganda ◽

Kissa Mwamwitwa ◽

Adam M. Fimbo ◽

Seth Kisenge ◽

...

Keyword(s):

Quality Control ◽

Screening Test ◽

Product Information ◽

Healthcare Delivery ◽

Antiretroviral Drugs ◽

World Health ◽

Fixed Dose ◽

People Living With Hiv ◽

Quality Control Testing

Abstract Background Antiretroviral drugs (ARVs) have significantly reduced morbidity, mortality and improved the quality of life of people living with HIV infection. Poor quality ARVs may result in harmful consequences such as adverse drug reactions, treatment failure and development of drug resistant strains and sometimes death, which in turn may undermine the healthcare delivery system. To ensure optimal treatment outcomes, medicines quality control must be undertaken regularly. This study was aimed at evaluating the quality of ARVs circulating on the Tanzania Mainland market. Methods This was a survey study. ARVs samples were collected in 20 regions of Tanzania Mainland, between 2012 and 2018. All sampled ARVs were subjected to screening testing using the Global Pharma Health Fund® Mini-Lab kits. Sampled ARV’s that failed screening test or yielded doubtful results and 10 % (10 %) of all that complied with the screening test requirements were selected for full quality control testing. Quality control testing was conducted at the Tanzania Medicines and Medical Devices Authority (TMDA) laboratory a World Health Organisation prequalified. Samples collected from the medicine distribution outlets were also, subjected to product information review. Results A total of 2,630 samples were collected, of which 83.7 % (2200/2630) were from port of entry (POEs). All sampled ARVs were screened and conformed to the specifications, except of the fixed dose combination (FDC) lopinavir/ritonavir 0.27 % (7/2630) and lamivudine/zidovudine/nevirapine 0.27 % (7/2630) that failed the disintegration test. Out of the 100 samples selected for full quality control testing, 3 % of them failed to comply with the specifications, of which FDC stavudine/lamivudine/nevirapine failed disintegration and assay tests 2 % (2/100) and 1 % (1/100), respectively. Samples failing the assay test had low content of stavudine (86.6 %) versus specification limits (90 -110 %). Out of the 430 samples which were subjected to product information review, 25.6 % (110/430) failed to comply with the TMDA packaging and labelling requirements. Conclusions The quality of majority of ARVs circulating on the Tanzania Mainland market was good, even so, significant deficiencies on labelling and packaging were observed. These results call for continuous monitoring of quality of medicines circulating on the Tanzania Mainland market.

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Myelodysplastic Syndrome with Excess Blasts and Secondary Acute Myeloid Leukemia: Same Disease with Different Blast Count

Blood ◽

10.1182/blood-2019-124977 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 2692-2692

Author(s):

Xueyan Chen ◽

Megan Othus ◽

Brent L Wood ◽

Roland B. Walter ◽

Pamela S. Becker ◽

...

Keyword(s):

Acute Myeloid Leukemia ◽

Myeloid Leukemia ◽

Research Funding ◽

Mutational Analysis ◽

World Health ◽

Secondary Aml ◽

Data Safety ◽

Monitoring Committee ◽

Mutational Hotspots ◽

Acute Myeloid

Introduction: The World Health Organization (WHO) diagnoses acute myeloid leukemia (AML) if ≥20% myeloid blasts are present in peripheral blood or bone marrow. Consequently a patient with even 19% blasts is often ineligible for an "AML study". A less arbitrary means to define "AML" and myelodysplastic syndromes ("MDS") emphasizes biologic features. Here, focusing on patients with WHO-defined MDS with excess (5-19%) blasts (MDS-EB) or AML with myelodysplasia-related changes (AML-MRC) or therapy-related (t-AML) (WHO defined secondary AML), we compared morphologic blast percentage (MBP) with the frequency of mutations in genes belonging to different functional groups, and with the variant allele frequency (VAF) for individually mutated genes. Methods: 328 adults with WHO-defined AML (de novo and secondary; n=149) or MDS (n=179) and with mutational analysis by next-generation sequencing (NGS) performed at the University of Washington Hematopathology Laboratory between 2015-2017 were included. Of these, 86 had MDS-EB and 49 had secondary AML. Mutational analysis was performed using a customized, amplicon-based assay, TruSeq Custom Amplicon (Illumina, San Diego, CA). Custom oligonucleotide probes targeted specific mutational hotspots in ASXL1, CBL, CEBPA, CSF3R, EZH2, FBXW7, FGFR1, FLT3, GATA1, GATA2, HRAS, IDH1, IDH2, JAK2, KIT, KMT2A, KRAS, MAP2K1, MPL, NOTCH1, NPM1, NRAS, PDGFRA, PHF6, PTEN, RB1, RUNX1, SF3B1, SRSF2, STAG2, STAT3, TET2, TP53, U2AF1, WT1, and ZRSR2. VAF ≥5% was required to identify point mutations. Spearman's correlation coefficient was used to examine the relation between VAF of individually mutated genes and MBP. The Mann Whitney test served to compare the distribution of VAF in AML (≥20% blasts) vs. MDS (<20% blasts), before and after exclusion of subgroups as described below. Fisher's exact test was used to compare incidence of mutations. Results: 96% of cases had ≥one mutation in the 36 genes tested using NGS. Considering all 328 patients, mutations in tumor suppressor and cohesin complex genes were similarly frequent in MDS and AML, whereas spliceosomal genes, in particular SF3B1 and SRSF2, were more frequently mutated in MDS than in AML (46% vs. 26%, p<0.001). Mutations in epigenetic modifiers were more common in AML than MDS (54% vs. 42%, p= 0.035) as were transcription factor mutations (52% vs. 28%, p<0.001). However comparisons limited to MDS-EB vs. AML-MRC/t-AML, indicated the differences observed when comparing all MDS and all AML were less apparent, both statistically and more perhaps importantly with respect to observed frequencies. For example, spliceosomal gene mutations were found in 35% in MDS-EB and 27% in AML-MRC/t-AML (p=0.34) vs. 46% and 26% in all MDS and all AML. NPM1 mutations were detected in only 8% of AML-MRC/t-AML vs. 3% in MDS-EB but 29% for all AML. Results were analogous with FLT3 ITD, FLT3 TKD, and JAK2 mutations. Examining 20 individually mutated genes detected in ≥ 10 patients only with SRSF2 (p=0.04), did distribution of VAF differ statistically according to whether blast percentage was <20% versus ≥20%. Conclusions: The similar prevalence of mutations in different functional categories in MDS-EB and AML-MRC/t-AML suggests these entities are two manifestations of the same disease. We believe it appropriate to combine these WHO entities allowing patients in each to be eligible for both AML and MDS trials. Disclosures Othus: Glycomimetics: Other: Data Safety and Monitoring Committee; Celgene: Other: Data Safety and Monitoring Committee. Walter:Amgen: Consultancy; Boston Biomedical: Consultancy; Agios: Consultancy; Argenx BVBA: Consultancy; Astellas: Consultancy; BioLineRx: Consultancy; BiVictriX: Consultancy; Covagen: Consultancy; Daiichi Sankyo: Consultancy; Jazz Pharmaceuticals: Consultancy; Kite Pharma: Consultancy; New Link Genetics: Consultancy; Pfizer: Consultancy, Research Funding; Race Oncology: Consultancy; Seattle Genetics: Research Funding; Amphivena Therapeutics: Consultancy, Equity Ownership; Boehringer Ingelheim: Consultancy; Aptevo Therapeutics: Consultancy, Research Funding. Becker:Accordant Health Services/Caremark: Consultancy; AbbVie, Amgen, Bristol-Myers Squibb, Glycomimetics, Invivoscribe, JW Pharmaceuticals, Novartis, Trovagene: Research Funding; The France Foundation: Honoraria.

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Perioperative Anticoagulant Use for Surgery Evaluation (PAUSE) Study: A Perioperative Management Plan for Patients with Atrial Fibrillation Who Are Receiving a Direct Oral Anticoagulant

Blood ◽

10.1182/blood-2018-120770 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. LBA-5-LBA-5 ◽

Cited By ~ 2

Author(s):

James Douketis ◽

Alex C. Spyropoulos ◽

Joanne M Duncan ◽

Marc Carrier ◽

Gregoire Le Gal ◽

...

Keyword(s):

Board Of Directors ◽

Major Bleeding ◽

Research Funding ◽

Perioperative Management ◽

Elective Surgery ◽

Bleeding Risk ◽

Advisory Board ◽

Advisory Committees ◽

Arterial Thromboembolism ◽

High Bleeding Risk

Abstract Introduction: The perioperative management of patients who are taking a direct oral anticoagulant (DOAC) for atrial fibrillation (AF) and require an elective surgery/procedure is uncertain. No studies have addressed the timing of perioperative DOAC interruption and resumption, and if perioperative heparin bridging and coagulation function testing are needed. The Perioperative Anticoagulant Use for Surgery Evaluation (PAUSE) Study hypothesized that a simple, standardized perioperative management strategy, based on DOAC-specific interruption and resumption intervals, that foregoes perioperative heparin bridging and coagulation function testing, is safe for patient care, with associated low rates of major bleeding (1%) and arterial thromboembolism (0.5%). We postulated that this management yields a high proportion of patients (>90%) with a minimal to no DOAC level at surgery/procedure. Methods: PAUSE is a prospective study with 3 parallel DOAC cohorts of patients with AF taking apixaban, dabigatran or rivaroxaban and requiring anticoagulant interruption for an elective surgery/procedure. Patients were managed using a standardized protocol based on DOAC pharmacokinetic properties, procedure-associated bleeding risk (Appendix 1) and creatinine clearance (CrCl). DOACs were interrupted for 1 day before and after surgery for a low bleed risk surgery and 2 days before and after a high bleed surgery; longer interruption was done in patients on dabigatran with a CrCl<50 mL/min (Figure 1). A blood sample was obtained just before the procedure to measure residual DOAC levels (Appendix 2). Heparin bridging and preoperative coagulation testing were not used to manage patients. Patient follow-up occurred weekly for 30 days post-procedure for the primary clinical outcomes of major bleeding and arterial thromboembolism (Appendix 3). The incidence (95% confidence interval [CI]) of clinical outcomes was determined for each DOAC cohort using an intention-to-treat (ITT) analysis (interrupted at least 1 DOAC dose) and per-protocol analysis (adhering to DOAC interruption and resumption protocol). Results: We enrolled 3007 patients from 23 sites in Canada, the U.S. and Europe (Appendix 4). The patient characteristics were (Figure 2): mean age 72.5 years; 66.1% male; 33.5% high bleeding risk surgery/procedure, with 1257 patients in the apixaban cohort, 668 in the dabigatran cohort and 1082 in the rivaroxaban cohort (Table 1). DOAC interruption and resumption intervals are shown in Table 2. The 30-day postoperative rate (95% CI) of major bleeding was 1.35% (0-2.00) in the apixaban cohort, 0.90% (0-1.73) in the dabigatran cohort and 1.85% (0-2.65) in the rivaroxaban cohort; the rate (95% CI) of arterial thromboembolism was 0.16% (0-0.48) in the apixaban cohort, 0.6% (0-1.33) in the dabigatran cohort and 0.37% (0-0.82) in the rivaroxaban cohort (Table 3). There were 2541 (84.5%) patients with preoperative DOAC levels measured: a level <50 ng/ml occurred in 90.5% of patients in the apixaban cohort, in 95.1% of the dabigatran cohort and in 96.8% of the rivaroxaban cohort. Of 1007 patients having a high bleeding risk procedure, 832 (82.6%) had DOAC levels measured: 98.8% had a level <50 ng/mL (Table 4). Rates of major bleeding and arterial thromboembolism in the per protocol analysis were comparable to those of the ITT analysis (Table 5). Conclusions: In patients with AF who were taking a DOAC (apixaban, dabigatran, rivaroxaban) and required anticoagulant interruption for an elective surgery/procedure, using a standardized DOAC-specific perioperative management strategy was safe for patient care, with associated low rates of perioperative MB (<2%) and ATE (<1%). Further, a high proportion of patients (>90% overall; 98.8% at high bleeding risk) had a minimal or no residual DOAC level at the time of the surgery/procedure. PAUSE is the largest study, to date, that addresses how to manage the common problem of perioperative DOAC management. It is likely to have a practice-changing impact and will inform future practice guidelines in perioperative care. Study Funding: CIHR (313156) and the H&S Foundation of Canada (G-14-0006136). Aniara-Hyphen Biomed (assays). Acknowledgments: We thank Drs. Walter Ageno, David Garcia, Lehana Thabane, Wendt Lim, Lori Linkins, William Ristevski, and Demetrios J. Sahlas. Also, Kayla Lucier, Grace Wang, Tara McDougall, and HRLMP and CRLB. Supported by CanVector and REDCap. Disclosures Douketis: Bayer: Other: Advisory Board; Janssen: Consultancy; BMS: Other: Advisory Board; Biotie: Other: Advisory Board; Daiichi-Sankyo: Other: Advisory Board; Boehringer-Ingelheim: Consultancy, Other: Advisory Board, Research Funding; The Medicines Company: Other: Advisory Board; Sanofi: Consultancy, Other: Advisory Board; Astra-Zeneca: Other: Advisory Board; Portola: Other: Advisory Board; Pfizer: Other: Advisory Board. Spyropoulos:Janssen Scientific Affairs, LLC: Consultancy. Carrier:Bayer: Honoraria; Leo Pharma: Research Funding; Pfizer: Honoraria; BMS: Honoraria, Research Funding. Vanassche:Bayer: Consultancy; Boehringer Ingelheim: Consultancy; BMS/Pfizer: Consultancy. Verhamme:Bayer: Honoraria, Research Funding; Medtronic: Honoraria; Portola: Honoraria; Boehringer Ingelheim: Honoraria; Leo Pharma: Honoraria, Research Funding; BMS: Honoraria, Research Funding; Daiichi-Sankyo: Honoraria, Research Funding; Pfizer: Honoraria, Research Funding. Shivakumar:Pfizer: Honoraria; Servier: Honoraria; Bayer: Honoraria; LEO Pharma: Honoraria. Gross:Pfizer: Honoraria; Bayer: Honoraria; LEO Pharma: Honoraria; Servier: Honoraria. Lee:Pfizer: Consultancy, Research Funding; BMS: Research Funding; Servier: Honoraria; LEO Pharma: Consultancy, Research Funding; Bayer: Consultancy, Honoraria. Le Templier:BMS-pfizer: Honoraria. Wu:Leo Pharma: Honoraria; Pfizer: Honoraria; BMS-Pfizer: Honoraria. Coppens:Bayer: Honoraria, Other: Non-financial support, Research Funding; CSL Behring: Honoraria, Other: non-financial support, Research Funding; Uniqure BV: Research Funding. Arnold:Bristol Myers Squibb: Research Funding; UCB: Consultancy; Amgen: Consultancy, Research Funding; UCB: Consultancy; Amgen: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Bristol Myers Squibb: Research Funding; Novartis: Consultancy, Research Funding. Caprini:Alexion Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Recovery Force: Consultancy; BMS: Membership on an entity's Board of Directors or advisory committees; Pfizor: Membership on an entity's Board of Directors or advisory committees; Janssen R&D: Membership on an entity's Board of Directors or advisory committees. Summer:Octapharma: Honoraria. Schulman:Daiichi-Sankyo: Honoraria; Bayer: Honoraria; Sanofi: Honoraria; Boehringer-Ingelheim: Honoraria, Research Funding.

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Secreted Factors Determine Resistance to Idelalisib in Marginal Zone Lymphoma Models of Resistance

Blood ◽

10.1182/blood-2019-124299 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 2569-2569

Author(s):

Alberto J Arribas ◽

Sara Napoli ◽

Eugenio Gaudio ◽

Luciano Cascione ◽

Alessandra Di Veroli ◽

...

Keyword(s):

B Cell ◽

Cell Lines ◽

Research Funding ◽

Advisory Board ◽

Institutional Research ◽

Rna Seq ◽

Scientific Advisory Board ◽

Scientific Advisory ◽

Erbb Signaling ◽

Travel Grant

Background . PI3Kδ is expressed in B-cells and has a central role in the B-cell receptor signaling in B-cell derived malignancies. Idelalisib was the first-in-class PI3Kδ inhibitors and several second-generation compounds are undergoing clinical investigation as single agents and in combinations. To identify modalities to overcome the resistance that develops to this class of agents, we have developed two idelalisib-resistant models derived from splenic marginal zone lymphoma (SMZL) cell lines. Materials and Methods. Cells were kept under idelalisib (IC90) until acquisition of resistance (RES) or with no drug (parental, PAR). Stable resistance was confirmed by MTT assay after 2-weeks of drug-free culture. Multi-drug resistance phenotype was ruled out. Cells underwent transcriptome and miRNA profiling by RNA-Seq, whole exome sequencing (WES), lipidomics profiling, pharmacological screening (348 compounds), and FACS analysis. Cytokines and growth factor secretion was performed by ELISA. Results. Two RES models were obtained from VL51 and Karpas1718 with 7-10 fold times higher IC50s than PAR counterparts. In both models, conditioned media from RES cells transferred the resistance in the PAR cells. While WES did not identify somatic mutations associated with resistance, RNA-Seq and lipidomics analyses showed that the two cell lines had developed resistance activating different modalities. The VL51 RES model showed an enrichment in BCR-TLR-NFkB (TLR4, CD19, SYK), IL6-STAT3 (IL6, CD44), chemokines (CXCL10, CXCR4, CXCR3) and PDGFR (PDGFRA, PRKCE) signatures, paired with increased p-AKT and p-BTK levels, decreased cardiolipins and sphingomyelins levels, and increased levels of specific triacylglycerols and glycerophosphocholines. In particular, there was an over-expression of surface expression of PDGFRA and secretion of IL6 in the medium. Silencing of both IL6and PDGFRA by siRNAs reverted the resistance, while the silencing of the individual genes had only a partial effect. These data were paired with the acquired sensitivity to the PDGFR inhibitor masitinib, identified in the pharmacologic screening. In the Karpas1718 model, we observed an increased p-AKT activity with an enrichment for B-cell activation signatures (RAG1, RAG2, TCL1A), proliferation (E2F2, MKI67), ERBB signaling (HBEGF, NRG2, ERRB4), increased levels of some triacylglycerols and repressed levels for specific glycerophosphocholines. HBEGF secretion was confirmed by ELISA. The addition of recombinant HBEGF to the medium induced resistance in the PAR cells. Combination with the pan ERBB inhibitor lapatinib was beneficial in the K1718 RES. Recombinant HBEGF also induced resistance to the BTK inhibitor ibrutinib in the PAR cells and in the mantle cell lymphoma SP-53 cell line. Specific members of the let-7 family of miRNAs were repressed in the RES lines derived from both cell lines, indicating the involvement of miRNA deregulation in the mechanism of resistance. Indeed, let-7 members are known to directly target IL6-STAT3 and cytokine signaling cascade, as well PI3K-AKT network. In solid tumors, let-7 members are also expressed at low levels in tumors with constitutive active ERBB signaling, in accordance with the activation of ERBB pathway and p-AKT we observed in our Karpas1718model. Experiments with a LIN28B inhibitor are now on-going. Finally, we validated the findings across a panel of 34 B-cell lymphoma cell lines, in which IL6, PDGFRA, HBEGF and LIN28 expression levels were negatively correlated with idelalisib sensitivity, while the latter was positively correlated with let-7 levels (P <0.05). Conclusions. We developed two distinct models derived from MZL of secondary resistance to the PI3Kδ inhibitor idelalisib. We identified treatments that might overcome resistance to idelalisib and are worth of further investigations. The two models, driven by different biologic processes, will allow the evaluation of further alternative therapeutic approaches. Disclosures Stathis: PharmaMar: Other: Renumeration; ADC Therapeutics: Other: Institutional research funding; Abbvie: Other: Renumeration; Bayer: Other: Institutional research funding; Novartis: Other: Institutional research funding; MEI-Pharma: Other: Institutional research funding; Roche: Other: Institutional research funding; Pfizer: Other: Institutional research funding; Merck: Other: Institutional research funding. Stuessi:Gilead: Speakers Bureau. Zucca:Gilead: Honoraria, Other: travel grant. Rossi:Gilead: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Abbvie: Honoraria, Other: Scientific advisory board; Janseen: Honoraria, Other: Scientific advisory board; Roche: Honoraria, Other: Scientific advisory board; Astra Zeneca: Honoraria, Other: Scientific advisory board. Bertoni:Nordic Nanovector ASA: Research Funding; Acerta: Research Funding; Jazz Pharmaceuticals: Other: travel grants; ADC Therapeutics: Research Funding; Bayer AG: Research Funding; Cellestia: Research Funding; CTI Life Sciences: Research Funding; EMD Serono: Research Funding; Helsinn: Consultancy, Research Funding; ImmunoGen: Research Funding; Menarini Ricerche: Consultancy, Research Funding; NEOMED Therapeutics 1: Research Funding; Oncology Therapeutic Development: Research Funding; PIQUR Therapeutics AG: Other: travel grant, Research Funding; HTG: Other: Expert Statements ; Amgen: Other: travel grants; Astra Zeneca: Other: travel grants.

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