Gihan M. Kamal

Tissue Factor, Tissue Factor Pathway Inhibitor and Factor VII activity in Cardiovascular Complicated Type 2 Diabetes Mellitus

OBJECTIVES Tissue factor (TF) is the main initiator of the extrinsic coagulation pathway through factor VII (FVII) activation, which is physiologically inhibited by tissue factor pathway inhibitor (TFPI). Alteration of this pathway has been described in Type 2 diabetes mellitus (T2DM). The aim of this study is to assess TF and TFPI plasma levels and FVII coagulant activity (FVIIa) in T2DM in relation to cardiothrombotic disease and their correlation to metabolic and clinical behavior of the patients. METHODS The study was conducted on 80 T2DM patients divided to accordingly; groupI: 40 patients without a history or clinically detected heart disease, and groupII: 40 patients with a history of myocardial infarction compared to 30 controls. The patients were recruited from Ain Shams University diabetes clinic from September 2007 to February 2009 after informed consent was obtained. Peripheral blood samples were taken for measurement of plasma TF and TFPI levels using ELISA technique and quantitative FVIIa using FVII deficient plasma. RESULTS Plasma levels of TF, TFPI and FVIIa were significantly higher in T2DM patients compared to the controls (p<0.001). TF (236.50±79.23)and TFPI (242.33±85.84)were significantly higher in group II, compared to group I (150.33±81.16), (152.8± 82.46), (p<0.001). TF and TFPI were significantly correlated to body mass index and glycemic control. Also, TF and TFPI were significantly higher in hypertensives (p=0.001) and dyslipidemics (p=0.006) but not in smokers (p=0.64), (p=0.11) respectively. CONCLUSION There was a correlation between high TF, TFPI plasma levels, FVIIa activity and cardiothrombotic complications in T2DM especially in the presence of high risk factors such as poor glycemic control, dyslipidemia and obesity. Future target therapy against TF may be beneficial for T2DM patients.

Detection of 14q32 rearrangements in multiple myeloma, using simultaneous FISH analysis combined with immunofluorescence

BACKGROUND 14q32 rearrangement has been identified as a recurrent hotspot of translocations in multiple myeloma (MM). The Fluorescence Immunophenotyping and Interphase Cytogenetics as a tool for the Investigation of Neoplasms (known as FICTION technique) for evaluation of chromosomal changes in MM. The aim of this work is to detect 14q32 rearrangement, using FICTION technique, on archival bone marrow (BM) slides of MM patients, and to study its prognostic value. METHOD This study was conducted at Ain Shams University Hospital. The FICTION technique, which uses CD138 and dual color, and the break-apart 14q32 rearrangement probe, was performed on archived smears of BM slides for 50 MM patients at the time of diagnosis. RESULTS A significantly higher percentage of cases were positive for 14q32 rearrangement by FICTION (32%) compared to fluorescence in situ hybridization (FISH) (12%) (p=0.04). Cases positive by FICTION for the rearrangement were designated as Group A, while negative cases were designated as Group B. Significantly lower Hb and CRP levels were found among Group B when compared to Group A patients (p=0.001 and 0.01, respectively). Serum albumin level and Bence Jones protein (BJP) significantly affect overall survival (OS) (p=0.01, 0.007, respectively). However, a statistically non-significant shorter mean survival time was found in positive cases through FICTION versus negative cases. CONCLUSION FICTION technique provides a sensitive tool for establishing clonal plasma cells (PC) infiltration of BM aspirates, and is amenable for use on archived as well as fresh smears.

Blood indices to differentiate between β-thalassemia trait and iron deficiency anemia in adult healthy Egyptian blood donors

Background β-Thalassemia trait (BTT) often shows microcytosis, a normal or an increased red blood cell (RBC) count, and an elevated level of HbA 2 , which provide the basis for laboratory screening. BTT is an important differential diagnosis of iron deficiency anemia (IDA). Donors with BTT have hemoglobin values comparable with normal; hence, they are accepted for donation and they usually escape diagnosis. Aim The aim of this work was to differentiate BTT from IDA through blood indices performed in routine complete blood count. Patients and methods A total of 200 samples were obtained from apparently healthy adult Egyptian blood donors randomly. Complete blood count and mean corpuscular volume (MCV) were performed to all individuals. Hemoglobin electrophoresis and/or serum ferritin was performed to samples with MCV less than 78 fl. Results Prevalence of BTT in this study was 6%, whereas IDA represented 4.5% of total 200 samples investigated. The cutoff value of MCV 73 fl was 91.7% sensitive and 100% specific in differentiating BTT from IDA. Red blood cell distribution width at level 14.5% or below can differentiate BTT from IDA with 83.3% sensitivity and 100% specificity. RBCs count at value above 5.47 million/mm 3 can differentiate BTT from IDA with 100% sensitivity and 100% specificity. Conclusion The cutoff values of MCV 73 fl or less, RBC count above 5 × 10 6 /mm 3 , and red blood cell distribution width 14.5% or less were suggested to be associated with a high probability of BTT.

Impact of serum soluble programed death ligand 1 on end of treatment metabolic response of diffuse large B cell lymphoma patients

AbstractProgrammed death ligand-1 (PD-L1) plays an important role in the immune evasion of cancer cells and, in turn, can influence the outcome of many malignancies. The serum soluble PD-L1 (sPD-L1) levels were measured in diffuse large B cell lymphoma (DLBCL) patients at diagnosis and at end of treatment. Their impact on end of treatment metabolic response was analyzed. Serum sPD-L1 level was significantly elevated in DLBCL patients at diagnosis than in controls (P < 0.001). Also, serum sPD-L1 level at diagnosis was significantly higher than that at end of treatment (P < 0.001). Patients who achieved partial response (PR) had significantly higher serum sPD-L1 level at end of treatment than controls (P < 0.001). In contrast, all patients especially those who achieved complete response (CR) had insignificantly different serum sPD-L1 level at end of treatment than controls (P = 0.354 and P = 0.090, respectively). There was a significant difference between serum sPD-L1 level at diagnosis and that at end of treatment in patients who achieved PR and CR (P = 0.023 and P < 0.001, respectively). On univariate analysis, presence of comorbidities, Ann Arbor stage IV, high serum sPD-L1 level at diagnosis and high serum sPD-L1 level at end of treatment were significantly associated with achievement of PR (P = 0.018 and P = 0.043, P = 0.045 and P < 0.001, respectively). On multivariate analysis, serum sPD-L1 levels at diagnosis and at end of treatment were still influencing metabolic response significantly (P = 0.014 and P = 0.007, respectively). Serum sPD-L1 is a predictor for metabolic response to immunochemotherapy in DLBCL patients.

CXCR4 (CD184) expression on stem cell harvest and CD34+ cells post-transplant

OBJECTIVES/BACKGROUND CXCR4 is a receptor for stromal-derived factor-1 (SDF-1), a molecule that has a chemotactic activity for lymphocytes and is important in homing of hematopoietic stem cells to their adult marrow. We evaluated the CXCR4 (CD184) expression in the harvest cells and in the post-transplant bone marrow (BM) and its relation to engraftment, as determined by the consensus criteria and chimerism. METHODS This is a prospective study which included 30 patients undergoing hematopoietic stem cell transplantation; 15 patients received autograft and 15 patients received allograft on dates between January 2012 and May 2014. We assessed CD184 (CXCR4) using flow cytometry in the harvest cells together with post-transplant BM assessment on Day 28 and Day 90 for complete morphologic, molecular studies, and detection of CD184 expression on CD34+ cells with chimerism studies on total peripheral blood mononuclear cells. RESULTS Diagnoses of the enrolled patients were as follows: seven (24.1%) with acute myeloid leukemia, eight (27.6%) with multiple myeloma, four (13.8%) with acute lymphoblastic leukemia, three (10.3%) with non-Hodgkin lymphoma, two (6.9%) with myelodysplastic syndromes, two (6.9%) with aplastic anemia, two (6.9%) with chronic myeloid leukemia, one (3.4%) with Hodgkin lymphoma, and one (3.4%) with plasmacytomas. One patient died and was excluded from the study because there were not enough data about engraftment. There was no statistical significance between the level of CD184 in stem cell harvest and the prediction of successful engraftment (p>0.05) as well as in Day 28 BM sample (p>0.05), whereas there was a statistical significance between the level of CD184 in Day 90 BM sample and the occurrence of successful engraftment (p=0.002). CONCLUSION SDF-1/CXCR4 axis plays a crucial role in engraftment; however, more studies are warranted to assess their expression post-transplant. Evaluating the ligand (chemokine, SDF-1) or its receptor (CXCR4) may serve as potential surrogate markers for assessment of engraftment.

Effect of comorbidities on hematopoietic stem cell transplantation outcome in adult patients with different hematologic diseases: a single-center experience in Egypt

Background Hematopoietic stem cell transplantation (HSCT) is a procedure that can restore marrow function in patients who have had severe marrow injury. It is either autologous or allogeneic. It has become increasingly important to optimize pretransplant risk assessment to improve hematopoietic cell transplantation (HCT) decision making. Single-organ comorbidity involving the liver, lung, heart, or kidney before HCT has been traditionally found to cause organ toxicity after HCT. The HCT-comorbidity index (HCT-CI) has provided better prediction of HCT-related morbidity and mortality compared with other non-HCT-specific indexes. Aim The aim of this study was to investigate the impact of various pretransplant comorbidities on the outcome of patients who had undergone either allogeneic or autologous HSCT in relation to treatment-related mortality, disease-related mortality, and overall survival. Patients and methods A retrospective study was conducted at the Bone Marrow Transplantation Unit, Ain Shams University, on 119 patients who were transplanted either using autologous or allogeneic HSCT. All of them were older than 18 years and had different types of hematologic diseases. The most frequent hematologic disease was acute myeloid leukemia (34.4%), followed by multiple myeloma (17.6%), acute lymphoblastic leukemia (16.8%), and lymphoma (10.9%), whereas aplastic anemia, myelodysplastic syndrome, chronic myeloid leukemia, and biphenotypic leukemia collectively represented 20.1%. They were either incomplete or partial remission. They were categorized on the basis of the HCT-CI as follows: mild score (0), 43 (36.2%) patients; moderate score (1-2), 60 (50.4%) patients; and severe score (΃3), 16 (13.4%) patients. The study data were collected from medical notes, pathology reports, and laboratory data. Results There was a statistically significant relation between the HCT-CI and overall survival (P = 0.012), disease-free survival (P = 0.007), mortality (P = 0.047), and the incidence of graft failure (P = 0.034). Conclusion We concluded that the HCT-CI is a better predictor for detecting the influence of comorbidity in patients with hematologic disorders on mortality, overall survival, and disease-free survival after HCT.

Association of Activated Circulating Endothelial Cells with Vascular Complications in Egyptian Beta-Thalassemic Patients

Background: There is evidence of an association between circulating endothelial cells (CECs) and vascular complications in thalassemic patients. Objectives: To quantify CECs and its activated fraction (AECs) in Egyptian s-thalassemic patients and to investigate their association with incidence of vascular complications. Subjects and Methods: Eighty pediatric patients and 30 healthy pediatric volunteers were studied for the proportion of CECs and AECs using cellular expression of endothelial adhesion receptors: CD146 and CD106 by flow cytometry. Results: CECs, AECs were higher in patients’ group than control group (p=0.001). AECs, serum ferritin, total leucocyte count (TLC), platelet (PLT) count were higher in patients with vascular complications and splenectomized patients (p=0.001for all). Percent of AECs was positively correlated to each of serum iron (p=0.001) and serum ferritin (p=0.001). No correlation was found between AECs (percent/absolute count) or MFI of CD106 and serum ferritin neither in group with vascular complications nor in splenectomized group (p>0.05). Also, no correlation was found between red blood cell (RBC) and PLT counts neither in group with vascular complication and who underwent splenectomy, nor in those without vascular complications and did not undergo splenectomy or those who underwent splenectomy but has no vascular complications (p=0.05). Size of the AEC compartment, intensity of CD106 expression were positively correlated to each of TLC, PLT count (p=0.001 for all). Risk of vascular complications was identified if percent of ACEs was ≥58.3% of CECs, absolute count of AECs was ≥0.059 x 103 /µl, MFI of CD106 was ≥7.9, with an effectiveness of 95%, 91.3%, 95% respectively. Conclusion: Measurement of AECs presents an effective quantitative method for assessment of risk of vascular complications in thalassemia.

Value of CD11a and CD18 in flow cytometric immunophenotypic diagnosis of acute promyelocytic leukemia

As acute promyelocytic leukemia (APL) has the highest curability among different acute amyeloid leukemia (AML) subtypes and requires a unique form of treatment, it is important to quickly establish or exclude the diagnosis of this subtype of leukemia. Furthermore, accurate and rapid diagnosis of APL is critical due to its association with disseminated intravascular coagulation. Patients and methods: This study was conducted on 100 newly diagnosed AML M0-M3 patients and a comprehensive flow cytometric immunophenotypic (FCM IPT) analysis of their peripheral blood (PB) and/or bone marrow samples with the inclusion of CD18 and CD11a monoclonal antibodies was done. Results: Cases of AML-M3 did not express human leukocyte antigen (HLA)-DR, CD11a and CD18, a highly significant different finding compared to non M3 cases (P Conclusion: Testing for CD18 and CD11a in conjunction with routine diagnostic FCM IPT panel will append extra diagnostic power to FCM IPT in the differentiation of difficult cases of AML-M3 from AML-(M0-M2).

Measurement of the serum B-cell-activating factor of the tumor necrosis factor family (BAFF) in patients with idiopathic thrombocytopenic purpura and its correlation with immunosuppressive therapy

Background The B-cell-activating factor of the tumor necrosis factor family (BAFF) is a homotrimeric type 2 transmembrane protein that also exists in a soluble form. It belongs to the family of tumor necrosis factor ligands and is expressed at the surfaces of myeloid cells and antigen-presenting cells and induces B-lymphocyte proliferation and immunoglobulin secretion. Aim of the study The aim of this study was to assess the serum BAFF level in patients with idiopathic thrombocytopenic purpura (ITP) and to determine the correlation of its level with response to immunosuppressive therapy (corticosteroids). Participants and methods The study included 60 participants: 40 patients with newly diagnosed ITP who were followed up for 3 months after immunosuppressive therapy (steroids), divided into responders and nonresponders, and 20 healthy control individuals. Results The serum BAFF level was lower in the controls (mean±SD 3.4±2.2 ng/ml) than the ITP patients (responders and nonresponders) before treatment (mean±SD 19.8±2.9 and 20.5±8.8 ng/ml, respectively) with a statistically highly significant difference ( P P Conclusion The serum BAFF level increases in patients with ITP and reverts to normal after treatment in responders but remains high in nonresponders. We recommend further randomized-controlled clinical trials exploring the role of drugs acting on BAFF in the treatment of autoimmune disorders.