Aleksandar Mijovic

Fludarabine, cytarabine, G‐CSF and idarubicin (FLAG‐IDA) for the treatment of poor‐risk myelodysplastic syndromes and acute myeloid leukaemia

Nineteen patients with high‐risk myelodysplastic syndrome (MDS)/acute myeloid leukaemia (AML) received fludarabine, cytarabine, granulocyte‐colony stimulating factor (G‐CSF), and idarubicin chemotherapy (de novo MDS/MDS‐AML, nine; relapsed/refractory MDS/AML, seven; therapy‐related MDS, three). Median age was 44 years and median disease duration 10 months. 16/19 (84%) patients had abnormal cytogenetics with seven (37%) harbouring abnormalities of chromosome 7. 18/19 (94.7%) patients responded to FLAG‐idarubicin with 12 (63%) achieving complete remission (CR) (<5% blasts and normal cytogenetics). 7/9 (78%) patients with de novo MDS/MDS‐AML achieved CR compared to 5/10 (50%) with alternative diagnoses. Response was associated with age < 50 years, disease duration < 3 months, and cytogenetics other than abnormalities of chromosome 7. Haemopoietic regeneration was rapid in most patients and there were no toxic deaths. Nine patients received a second course of chemotherapy, three have proceeded to allogeneic bone marrow transplant and three to autologous blood stem cell/bone marrow transplantation. Follow‐up is short (median 10 months). 12/19 (63%) patients remain alive and 5/12 (42%) have relapsed at a median 5 months following CR achievement. FLAG‐idarubicin was well tolerated. High rates of morphological and cytogenetic remission, especially in de novo MDS, offer a window of opportunity for assessment of autologous BMT in this group of diseases where no treatment except alloBMT has led to prolongation of survival.

α‐Haemoglobin stabilising protein is a quantitative trait gene that modifies the phenotype of β‐thalassaemia

It has been suggested that altered levels or function of α‐haemoglobin stabilising protein (AHSP), an erythroid‐specific protein that binds specifically to free α‐(haemo)globin, might account for some of the clinical variability in β‐thalassaemia. To assess the variation of AHSP expression, mRNA levels in circulating reticulocytes of 103 healthy individuals were measured by quantitative reverse transcription‐polymerase chain reaction. AHSP expression varied up to threefold, and did not correlate with age or sex. A systematic survey of the AHSP locus identified eight sequence variants, of which six were common. Four common variants, including the longer homopolymer (T18) in the putative promoter, are strongly associated with AHSP expression. Reporter assays in K562 cells showed that the activity of the shorter (T15) reporter was relatively lower than that of the T18 reporter. In a study of nine anaemic patients who were heterozygous for β‐thalassaemia and also heterozygous for the triplicated α‐globin gene (ααα/αα), frequency of the shorter homopolymer was higher than expected. AHSP expression is variable, with cis control accounting for some of its variance. In some families, the subtle altered levels in AHSP related to the AHSP genotype appears to be a relevant contributory factor in the haematological phenotype.

Blood transfusion usage among adults with sickle cell disease - a single institution experience over ten years

Transfusion of red blood cells is a major therapeutic option in sickle cell disease (SCD). There is strong evidence for its efficacy, particularly in primary and secondary stroke prevention in children, however, its use in other areas remains controversial. This study assessed the patterns of transfusion in the adult cohort attending King’s College Hospital over a 10‐year period, from 2000 to 2009. Total blood usage has increased significantly (P = 0·006) during this time, with 78% of the blood received by only 6% of the patients. The increase is explained by increased automated red cell exchange and increased usage for planned and acute transfusions for sickle‐related complications.

Delayed haemolytic transfusion reaction in adults with sickle cell disease: a 5‐year experience

Delayed haemolytic transfusion reactions (DHTR) are potentially life‐threatening complications in patients with sickle cell disease (SCD). Between 1 August 2008 and 31 December 2013, 220 of 637 adult patients in our centre had at least one red blood cell (RBC) transfusion in 2158 separate transfusion episodes. Twenty‐three DHTR events occurred in 17 patients (13 female) including 15 HbSS, one HbSC and one HbSβ0 thalassaemia, equating to a DHTR rate of 7·7% of patients transfused. Mean interval from RBC transfusion to DHTR event was 10·1 ± 5·4 d, and typical presenting features were fever, pain and haemoglobinuria. Twenty of the 23 (87·0%) DHTR episodes occurred following transfusion in the acute setting. Notably, 11/23 (47·8%) of DHTRs were not diagnosed at the time of the event, most were misdiagnosed as a vaso‐occlusive crisis. 16/23 DHTRs had ‘relative reticulocytopenia’, which was more common in older patients. Seven of 23 episodes resulted in alloantibody formation, and three caused autoantibody formation. DHTRs are a severe but uncommon complication of RBC transfusion in SCD and remain poorly recognized, possibly because they mimic an acute painful crisis. Most of the DHTRs are triggered by RBC transfusion in the acute setting when patients are in an inflammatory state.

Allogeneic haematopoietic SCT for chronic myelomonocytic leukaemia: a single-centre experience.

Haematopoietic SCT (HSCT) offers the only potentially curative option in chronic myelomonocytic leukaemia (CMML). In this study, we report on single-centre results of 18 patients with CMML who have undergone allogeneic HSCT. The median age of patients was 54 years. Seven patients had AML, which had transformed from CMML. Overall, 11 patients received stem cells from an unrelated donor. A total of 15 patients received a T-cell-depleted fludarabine/BU-based reduced-intensity conditioning HSCT. The actuarial 3-year OS, non-relapse mortality (NRM) and relapse incidence for the cohort was 31±11%, 31±14% and 47±13%, respectively. Patients with favourable cytogenetics had a 3-year disease-free survival of 65±17%, whereas none of the seven patients with intermediate or poor risk cytogenetics survived beyond 2 years (P<0.01). No patients with favourable risk cytogenetics died from NRM causes, while the 2-year NRM for the intermediate/poor risk cytogenetics subgroup was 71±22% (P<0.02). In terms of disease status at transplantation, patients who had <5% BM blasts had a 3-year disease-free survival of 46.9±19% compared with those with >5% blasts at the time of transplantation (that is, 20.0±13%). Recipient age, type of conditioning regimen or stem cell dose did not have a significant impact on overall outcomes. Our data support existing evidence that allogeneic HSCT is a feasible therapeutic option for CMML, with the ability to attain long-term remission among patient subgroups.

Red blood cell alloimmunization in sickle cell disease—prevalence and trends: a single‐center cross‐sectional study from United Kingdom

Miller and colleagues reported red blood cell (RBC) alloimmunization prevalence (AIP) of 14.4% (34/237) in sickle cell disease (SCD) patients recruited into a randomized trial across 31 US centers. Trial protocol allowed exclusion of 27 already alloimmunized patients; had these patients been taken into account, true AIP would have reached 16.1% (61/378). We analyzed AIP in adult (>16 years) SCD patients cared by our hospital, located in an ethnically mixed area of South London (surrounding boroughs of Lambeth and Southwark have, respectively, 25.9 and 26.8% Black race population, i.e., approx. 155,000 people). A total of 659 SCD patients (55% female) attended our hospital over a 10-year period (2000-2009). During this period, 314 of 659 (47.6%) patients received at least 1 RBC unit at our hospital (median, 10 units [range, 1-876 units]; median age of transfused patients was 35 [range, 16-82] years; 197 were women [62.7%]). RBC alloantibodies were detected in 39 patients (12.4%). A total of 64 alloantibodies were identified (1-8; median, one per patient): 26 (40.6%) were directed against Rh and Kell system antigens (excluding antibodies that do not require prophylactic matching, e.g., C or Kp). Overall, 21 of 39 alloimmunized patients (53.8%) had Rh and/or K antibodies, either alone or with other antibodies. AIP in women was 14.2%, compared with 9.4% in men (NS; p = 0.28, Fisher’s exact test). Of note, of 12 patients with multiple (≥2) alloantibodies, 11 were female. Of 40 patients on regular automated RBC exchanges, eight (20%) developed antibodies: two anti-C and one each anti-E, -f, -C, -Kn, and -Kp. One patient developed anti-K and -Kp. Most of these antibodies ceased being detectable after a short time. None led to discontinuation of transfusion program. Matching for C, c, E, e, and K antigens in SCD patients was deemed “desirable” by the British Committee for Standards in Haematology in 1996; it was instituted in our hospital around 1997, shortly after the National Blood Service began issuing RBC units with full Rh and Kell phenotype printed on the label. Sixteen years later, the proportion of Rh/Kell alloantibodies in our study group is still high (40.6%), although it compares favorably with an earlier UK study that reported 17.6% alloimmunization rate, with 66% antibodies being within the Rh/Kell systems. Whereas a proportion of patients may have become alloimmunized before 1997, an unexpectedly high prevalence of Rh/K antibodies may be accounted for by less stringent antigen matching in emergencies, errors in blood selection, or transfusions received in centers with less experience with SCD patients. The presence of variant Rh genes, as suggested by the finding of anti-D in an individual with a “partial D” and an alloanti-e in an e+ patient, may also compound this problem. AIP increased with the number of RBC units received, but appeared to plateau after transfusion of 11 to 25 units. Patients who had received more than 100 RBC units had AIP of 22.2%, compared to 19.6% in those who had received 11 to 25 units and 12.9% in recipients of 6 to 10 units. These rates are very similar to those reported by Miller and colleagues, possibly reflecting the proportion of “antibody makers” in SCD population. In an attempt to gauge the clinical impact of RBC alloimmunization, we defined a group of patients who would be impossible to support on a regular basis; these included patients with: 1) alloantibodies against highfrequency antigens, for example, anti-hr; and 2) multiple antibodies that would reduce the theoretical availability of RBCs to less than 1%. Four of 39 (10.2%) alloimmunized patients fulfilled the above criteria. Thus, the impact of alloimmunization on blood availability appears limited to a minority of patients. Intriguingly, the ratio of alloimmunized to nonalloimmunized patients varied among age groups: 16 to 25 years, 0.08; 26 to 35 years, 0.16; 36 to 45 years, 0.17; 46 to 55 years, 0.12; and more than 56 years, 0.10. Decline after the age of 36 to 45 years suggests that mortality may be higher in alloimmunized subjects. Alternatively, evanescence of alloantibodies in the absence of exposure to cognate antigens may have contributed to this decline. Prevalence of alloimmunization in patients with SCD in our center is similar to that reported by Miller and colleagues. AIP appears to have declined in comparison with historical data, despite increased blood usage, presumably due to matching for Rh/K antigens. However, rates of Rh and Kell alloimmunization still remain relatively high. Impact of alloimmunization on survival in SCD merits further investigations.

Optimizing outcomes in clozapine rechallenge following neutropenia: a cohort analysis

OBJECTIVE Certain patients with treatment-refractory schizophrenia may be rechallenged with clozapine following previous neutropenia. Evidence guiding patient selection and the effectiveness of lithium and granulocyte-colony stimulating factor (G-CSF) in rechallenge is limited, and factors associated with successful outcomes are unclear. METHOD Outcomes were studied in patients rechallenged with clozapine at a tertiary referral center between January 2007 and December 2013, following 1 or more previous trials terminated due to neutropenia, defined as an absolute neutrophil count (ANC) < 1.5 × 10(9)/L. Demographic characteristics, details of each clozapine trial including ANC, and coprescribed medication were extracted, and factors associated with rechallenge outcomes were examined. RESULTS Nineteen patients underwent clozapine rechallenge following previous neutropenia; 4 (21%) experienced further neutropenia, 2 of which developed agranulocytosis. Compared to successfully rechallenged patients, unsuccessfully rechallenged patients were significantly older (t = 2.10, P = .05), experienced onset of neutropenia sooner (W = 10.0, P = .03), and were more commonly coprescribed valproate. In addition to 5 patients with benign ethnic neutropenia (BEN), 8 patients not of an ethnicity associated with BEN also had idiopathic low neutrophil counts at baseline; lithium and G-CSF coprescription facilitated successful rechallenge in these patients. CONCLUSIONS In this selected population, the initial neutropenia was unlikely to be related to clozapine in a substantial proportion of cases. This group was successfully rechallenged following careful consideration of the risks and benefits, and lithium and G-CSF contributed to allowing continued clozapine therapy. In addition to black patients, other ethnic groups can have persistently low ANC unrelated to clozapine.

Active dendritic cell immunotherapy for glioblastoma: Current status and challenges

Abstract Dendritic cell (DC) immunotherapy is developing as a promising treatment modality for patients with glioblastoma multiforme (GBM). The aim of this article is to review the data from clinical trials and prospective studies evaluating the safety and efficacy of DC vaccines for newly diagnosed (ND)- and recurrent (Rec)-GBM and for other high-grade gliomas (HGGs). By searching all major databases we identified and reviewed twenty-two (n = 22) such studies, twenty (n = 20) of which were phase I and II trials, one was a pilot study towards a phase I/II trial and one was a prospective study. GBM patients were exclusively recruited in 12/22 studies, while 10/22 studies enrolled patients with any diagnosis of a HGG. In 7/22 studies GBM was newly diagnosed. In the vast majority of studies the vaccine was injected subcutaneously or intradermally and consisted of mature DCs pulsed with tumour lysate or peptides. Median overall survival ranged between 16.0 and 38.4 months for ND-GBM and between 9.6 and 35.9 months for Rec-GBM. Vaccine-related side effects were in general mild (grade I and II), with serious adverse events (grade III, IV and V) reported only rarely. DC immunotherapy therefore appears to have the potential to increase the overall survival in patients with HGG, with an acceptable side effect profile. The findings will require confirmation by the ongoing and future phase III trials.

Effects on erythropoiesis of alemtuzumab‐containing reduced intensity and standard conditioning regimens

Haemopoietic cell transplantation (HCT) with reduced‐intensity conditioning (RIC) has been associated with delayed disappearance of host anti‐A and anti‐B isohaemaglutinins and hindrance of donor erythropoiesis in major ABO mismatched transplants. Erythroid recovery, disappearance of recipient type and appearance of donor‐type isohaemaglutinins was compared in 84 patients undergoing RIC and 50 patients with standard‐conditioning (SCo) HCT. All patients received alemtuzumab as part of their conditioning. The incidence of immune‐mediated anaemia and red cell transfusion usage were also compared. Immune factors affecting post‐transplant erythroid kinetics showed little variance between different conditioning regimens. Disappearance of recipient isohaemaglutinins and emergence of donor red cells proceeded at similar rates in RIC and SCo transplants; the effects of ABO mismatch were marginal. Pure red cell aplasia, alloimmune haemolysis and autoimmune haemolytic anaemia were not more common in RIC transplants. We believe that alemtuzumab played a critical role in dampening immune reactions of both the host and the donor. Patients in both conditioning groups had similar post‐transplant erythroid burst‐forming unit (BFU‐E) counts; BFU‐E chimaerism analysis showed that 90–100% progenitors were of donor origin. However, transfusion requirements were significantly higher in the SCo group, due at least partly to earlier onset of bone marrow hypoplasia.

Granulocyte colony stimulating factor (G-CSF) can allow treatment with clozapine in a patient with severe benign ethnic neutropaenia (BEN): a case report.

Clozapine is the treatment of choice for treatment-resistant schizophrenia, but it is associated with a risk of neutropaenia and agranulocytosis. Clozapine use is regulated by mandatory blood monitoring in the UK, requiring cessation of treatment should the absolute neutrophil count (ANC) drop below specified values. Benign reductions in the ANC in non-white populations are common, and this can preclude a patient from receiving treatment with clozapine. A diagnosis of benign ethnic neutropaenia can reduce these treatment restrictions (UK specific), but the degree of neutropaenia can be significant enough to still prevent treatment. In this report, we show that response to granulocyte colony stimulating factor (G-CSF) may be quite variable and difficult to predict, but with careful monitoring it can be used to increase the ANC count and allow continued treatment with clozapine.