Bronwyn Williams

Pregabalin in severe burn injury pain: A double-blind, randomised placebo-controlled trial

&NA; This randomised, double‐blind, placebo‐controlled trial assessed the efficacy and tolerability of pregabalin to alleviate the neuropathic component of moderate to severe burn pain. Patients aged 18 to 65 years admitted to a burns unit with a 5% or greater total body surface area burn injury were screened to participate in the trial. Using the Neuropathic Pain Scale (NPS), patients scoring 4 or higher on ‘hot’ pain or ‘sharp’ pain were invited to participate. Consenting patients were randomly assigned to receive pregabalin or placebo for 28 days with individual dose titration commencing at 75 mg twice daily to a maximum pregabalin dose of 300 mg twice daily. The primary outcome measure was the patients’ daily response to the sharp and hot pain of the NPS. Secondary outcome measures included the remaining elements of the NPS, daily opioid requirement, length of hospital stay, pain at 6 months, and side effects of nausea, vomiting, drowsiness and giddiness. For patients administered pregabalin, the primary outcome measures hot (P = .01) and sharp (P = .04) pain were significantly reduced compared with those in patients administered placebo. Secondary outcome measures of itch, unpleasantness, surface pain, and procedural pain were significantly lower (P < .05) in the pregabalin group. Adverse effects were uncommon, with no difference between the treatment groups. There was no significant difference between the pregabalin and placebo treatment groups with respect to opioid consumption, duration of hospital stay, or pain at 6 months. Pregabalin was efficacious and well tolerated in patients after severe burn injury and whose pain was characterised by features of acute neuropathic pain. In this study, pregabalin was well tolerated and significantly reduced several elements of the neuropathic pain scale including hot pain, unpleasantness of the pain, surface pain, and itch, and also significantly reduced procedural pain.

KLF1 Null Neonates Display Hydrops Fetalis and a Deranged Erythroid Transcriptome

We describe a case of severe neonatal anemia with kernicterus caused by compound heterozygosity for null mutations in KLF1, each inherited from asymptomatic parents. One of the mutations is novel. This is the first described case of a KLF1-null human. The phenotype of severe nonspherocytic hemolytic anemia, jaundice, hepatosplenomegaly, and marked erythroblastosis is more severe than that present in congenital dyserythropoietic anemia type IV as a result of dominant mutations in the second zinc-finger of KLF1. There was a very high level of HbF expression into childhood (>70%), consistent with a key role for KLF1 in human hemoglobin switching. We performed RNA-seq on circulating erythroblasts and found that human KLF1 acts like mouse Klf1 to coordinate expression of many genes required to build a red cell including those encoding globins, cytoskeletal components, AHSP, heme synthesis enzymes, cell-cycle regulators, and blood group antigens. We identify novel KLF1 target genes including KIF23 and KIF11 which are required for proper cytokinesis. We also identify new roles for KLF1 in autophagy, global transcriptional control, and RNA splicing. We suggest loss of KLF1 should be considered in otherwise unexplained cases of severe neonatal NSHA or hydrops fetalis.

Fatal immune dysregulation due to a gain of glycosylation mutation in lymphocyte perforin

Mutations in the perforin gene (PRF1) are a common cause of the fatal immune dysregulation disorder, familial hemophagocytic lymphohistiocytosis (type 2 FHL, FHL2). Here we report a female infant born with biallelic PRF1 mutations: a novel substitution, D49N, and a previously identified in-frame deletion, K285del. We assessed the effects of each mutation on the cytotoxicity of human NK cells in which the expression of endogenous perforin was ablated with miR30-based short hairpin (sh) RNAs. Both mutations were detrimental for function, thereby explaining the clinically severe presentation and rapidly fatal outcome. We demonstrate that D49N exerts its deleterious effect by generating an additional (third) N-linked glycosylation site, resulting in protein misfolding and degradation in the killer cell. Our data provide a rationale for treating some cases of type 2 familial hemophagocytic lymphohistiocytosis, based on the pharmacologic inhibition or modification of glycosylation.

Prevalence of maternal red cell alloimmunisation: a population study from Queensland, Australia

Summary The aim of this study was to determine the current prevalence of red cell antigen alloimmunisation in Australia. Blood group (ABO and RhD) and red cell antibody screen results of pregnant women who presented at public hospitals in Queensland between the period of January 2011 and June 2013 were evaluated retrospectively. Antibody prevalence in pregnancy was compared to other published studies. A total of 482 positive antibody screens from 66,354 samples (0.73%) were identified. The prevalence of antibodies was: anti-E 27.6%; anti-D 10.4%; anti-Kell 9.5%; anti-c 8.7%; anti-Duffy 3.1%, including Fya and Fyb; anti-MNS 7.9%, including M, N, S and s; anti-Lewis 6%, including Lea and Leb; and multiple antibodies (16%, including anti-D). Compared to other studies, including one from Australia in 1977, the anti-D alloimmunisation rate had dropped significantly, with little change in anti-c and some increase in anti-E and anti-Kell cases. Continued vigilance is required to ensure eligible RhD negative women receive prophylaxis according to the current RhD immunoprophylaxis guidelines, especially those who have a fetomaternal haemorrhage (FMH). RhD positive women that are at risk of developing an antibody during pregnancy should have their pregnancy monitored according to published guidelines. Once antibodies are identified, consideration should be given to paternal antigen status in an attempt to identify the pregnancy that will be at risk of alloimmunisation.

Contemporary management of neonatal alloimmune thrombocytopenia: good outcomes in the intravenous immunoglobulin era: results from the Australian neonatal alloimmune thrombocytopenia registry

Abstract Objective: To describe the natural history, antenatal and postnatal therapy, and clinical outcomes of Australian patients with fetomaternal/neonatal alloimmune thrombocytopenia (NAIT) recorded in the Australian NAIT registry. Methods: Analysis of registry data of Australian mothers treated antenatally for NAIT and any fetus/newborn with thrombocytopenia (TCP) and maternal human platelet antigen (HPA) antibodies. Results: Ninety four potential cases (91 pregnancies; three twin pregnancies) were registered between December 2004 and September 2015 with 76 confirmed or treated as NAIT. NAIT was frequently unanticipated (44 cases, 58%), whilst 32 cases (42%) were anticipated due to personal or family history. In 70/76 cases, the diagnosis of NAIT was made based on HPA antibody results; anti-HPA-1a was most commonly detected (58/70, 82%), followed by anti-HPA-5b (5/70, 7%). Intracranial haemorrhage (ICH) was detected in seven cases (9%). Maternal antenatal therapy resulted in improved clinical outcomes. For antenatally treated cases, whilst 10/29 (34%) neonates had severe TCP, only one ICH was detected. Conclusions: This study provides data on contemporary “real world” management of Australian mothers and babies with NAIT. Antenatal IVIG therapy was associated with better neonatal outcomes. Maternal side-effects and treatment costs were substantial.

Acute myeloid leukemia with myelodysplasia‐related changes showing basophilic differentiation

An 84-year-old woman presented to the Accident and Emergency department because of a general deterioration in her health. A full blood count showed white cell count 23.4 3 10/l, hemoglobin concentration 52 g/l, MCV 89 fl, and platelet count 9 3 10/l. The differential count showed neutrophils 1.6 3 10/l, lymphocytes 1.3 3 10/l, and blast cells 20.9 3 10/l. Approximately half of the blast cells had basophilic granules and some were vacuolated (images). No mature basophils were seen. The neutrophils were almost all dysplastic (images), showing nuclear hypolobation and other abnormalities of nuclear shape, hypogranularity, and occasional detached nuclear fragments. A bone marrow aspirate showed 12% blast cells and two months later this had risen to 22% blast cells. Granulopoiesis was dysplastic and more than 50% of megakaryocytes were hypolobulated, including micromegakaryocytes. Cytogenetic analysis showed 41–42,XX,-3,add(5)(p13),add(6)(q?25),-7,-10,111,-15,-17[cp10]/44– 45,idem,13,-4,1mar[5]/46XX[5]. According to the 2008 World Health Organization classification of Tumours of Haematopoietic and Lymphoid Tissues[1], a diagnosis of acute myeloid leukemia (AML) could be made at presentation on the basis of the peripheral blood blast count (90%) despite bone marrow blast cells being only 12%. The leukemia could be further categorised as AML with myelodysplasia-related changes on the basis both of the dysplasia (more than 50% of cells in two lineages) and the complex karyotype. Despite the prominent basophilic differentiation, the diagnosis is not acute basophilic leukemia since, in the hierarchical WHO classification, the myelodysplasia-related changes take precedence. Basophilic differentiation can be clinically relevant since occasional patients have features of histamine excess – urticaria and peptic ulceration[2] – and an anaphylactoid reaction following chemotherapy has been reported[3].

Performance monitoring and transfusion QAP performance levels

This presentation will endeavour to provide an understanding of Performance Monitoring in Quality Assurance of Transfusion as measured by a project undertaken by the Royal College of Pathologists of Australasia (RCPA) Quality Assurance Program (QAP) in 2012. In 2001 the Commonwealth Department of Health and Ageing (DoHA) sought proposals to undertake an evaluation of Australian pathology laboratory accreditation arrangements. Recommendations from the report were that (1) the DoHA and the Health Insurance Commission seek the cooperation of the RCPA QAP to establish explicit external quality assurance performance criteria and a mechanism for the RCPA QAP to identify relatively poorly performing laboratories; (2) RCPA QAP and other external quality assurance providers regularly submit to the National Association of Testing Authorities (NATA) reports identifying laboratories that are poorly performing according to these agreed performance criteria. The review process included establishment of a methodology/scoring system; a retrospective data analysis; establishment of criteria for acceptable performance based on the retrospective data analysis and reasonable expectations for completing a corrective action. Information and results from QAP surveys was used to assess individual participant data against established criteria to provide laboratories of an objective measure of their performance relative to their peers whilst meeting the needs of the performance review process.

Pathology queensland’s experience with leukaemia/lymphoma associated immunophenotype in B lymphoblastic leukaemia

Aim: The identification of leukaemia/lymphoma associated immunophenotype (LAIP) in diagnostic cases of B lymphoblastic leukaemia/lymphoma (B-ALL) is an important prerequisite in the assessment of minimum residual disease (MRD) in follow-up specimens. Using an 8-colour protocol on the BDFACS Canto II flow cytometer, we describe our initial experience in the identification of LAIP in B-ALL. Method: A novel combination of markers was obtained from a literature analysis. The 8-colour fluorochrome panel consisted of three tubes. Data were analysed using Kaluza flow cytometry analysis software. B-ALL and control specimens were examined from July 2012 onwards. Results: The immunophenotype of 23 B-ALL cases were compared with normal precursor B-cells. Preliminary data demonstrate that classic markers for B-ALL such as CD10 (strong), CD58 (positive), CD81 (weak) and CD38 (weak) were less useful as LAIP, as the fluorescence intensity was difficult to distinguish from normal precursor B-cells. In comparison, CD19/CD66c, CD19/CD123, CD34/CD20 and CD34/CD22 LAIP were more distinct in B-ALL cases compared to controls. However CD34/CD21, CD19/CD15, CD19/CD65, CD19/NG2, and CD19/CD49f LAIP were uncommon in our cohort of patients. Conclusion: CD19/CD66c, CD19/CD123, CD34/CD20 and CD34/CD22 appear to be more useful LAIP in our initial cohort to distinguish B-ALL from normal precursor B-cells.