Roberto Calabrese

High nontransferrin bound iron levels and heart disease in thalassemia major

Although the presence of nontransferrin bound plasma iron (NTBI) in transfusional iron overload is well documented, knowledge about its clinical significance is limited. We assessed NTBI levels in a large and homogeneous series of thalassemia patients on regular transfusion and chelation and explored the hypothesis that NTBI levels may be associated with relevant clinical outcomes: in particular, heart disease. Among 174 patients with thalassemia major and intermedia, we showed the presence NTBI in 145 of 174 or 83.3% of cases. NTBI levels correlated with transferrin saturation, age, and ALT, and not with serum ferritin or liver iron concentrations. At a multiple regression analysis, transferrin saturation and heart disease but not age was independent predictors of NTBI. Patients with heart disease had NTBI levels significantly higher than those without. All patients with heart disease had transferrin saturation above 70%, and all were NTBI positive. Conversely, none of the patients without NTBI and/or with transferrin saturation less than 70% had preclinical or clinical heart disease. To our knowledge, this is the first documentation of a link between the presence of NTBI in thalassemic patients with transfusional iron overload and heart disease. Further investigation from these preliminary findings may clarify whether NTBI assessment may have a role in evaluating the risks and optimizing treatment for transfusion‐dependent patients. Am. J. Hematol., 2009.

Diamond-Blackfan anemia: genotype-phenotype correlations in Italian patients with RPL5 and RPL11 mutations

Background Diamond-Blackfan anemia is a rare, pure red blood cell aplasia of childhood due to an intrinsic defect in erythropoietic progenitors. About 40% of patients display various malformations. Anemia is corrected by steroid treatment in more than 50% of cases; non-responders need chronic transfusions or stem cell transplantation. Defects in the RPS19 gene, encoding the ribosomal protein S19, are the main known cause of Diamond-Blackfan anemia and account for more than 25% of cases. Mutations in RPS24, RPS17, and RPL35A described in a minority of patients show that Diamond-Blackfan anemia is a disorder of ribosome biogenesis. Two new genes (RPL5, RPL11), encoding for ribosomal proteins of the large subunit, have been reported to be involved in a considerable percentage of patients. Design and Methods In this genotype-phenotype analysis we screened the coding sequence and intron-exon boundaries of RPS14, RPS16, RPS24, RPL5, RPL11, and RPL35A in 92 Italian patients with Diamond-Blackfan anemia who were negative for RPS19 mutations. Results About 20% of the patients screened had mutations in RPL5 or RPL11, and only 1.6% in RPS24. All but three mutations that we report here are new mutations. No mutations were found in RPS14, RPS16, or RPL35A. Remarkably, we observed a higher percentage of somatic malformations in patients with RPL5 and RPL11 mutations. A close association was evident between RPL5 mutations and craniofacial malformations, and between hand malformations and RPL11 mutations. Conclusions Mutations in four ribosomal proteins account for around 50% of all cases of Diamond-Blackfan anemia in Italian patients. Genotype-phenotype data suggest that mutation screening should begin with RPL5 and RPL11 in patients with Diamond-Blackfan anemia with malformations.

Iron overload in patients receiving allogeneic hematopoietic stem cell transplantation: quantification of iron burden by a superconducting quantum interference device (SQUID) and therapeutic effectiveness of phlebotomy.

Iron overload (IO) is a known adverse prognostic factor in patients who undergo allogeneic hematopoietic stem cell transplantation (HSCT) for thalassemia and appears to play a similar role in patients with other hematologic disorders. The estimation of IO is based primarily on serum ferritin level; however, many confounding factors can result in ferritin overestimation, especially in HSCT recipients. The aim of the present study was to quantify IO after HSCT using a superconducting quantum interference device (SQUID), and to evaluate the impact of IO on hepatic function and infections. In addition, the feasibility of iron depletion was investigated. A total of 102 consecutive allogeneic HSCT recipients admitted to our outpatient department between December 2005, and December 2007, were analyzed. Primary diagnosis included acute leukemia/myelodysplastic syndrome in 61% of cases. Assessment of IO after HSCT included serum ferritin; in those with hyperferritinemia (ferritin>1000 ng/mL), liver iron concentration (LIC) was evaluated by SQUID magnetic susceptometry. Iron removal therapy was offered to patients with moderate IO (LIC 1000-2000 microg Fe/g wet weight [ww]) or severe IO (LIC >2,000 microg Fe/g ww). Fifty-seven patients had a ferritin level <1000 ng/mL: the median time between HSCT and assessment of ferritin level was 1006 days (range, 93-5239 days), significantly different from the median time of 183 days (range, 78-2957 days) in the 45 patients with a ferritin level >1000 ng/mL. Out of 42 patients evaluated by SQUID, 29 had moderate to severe IO (median LIC value, 1493 microg Fe/g ww [range, 1030-3253]). In a multivariate analysis, a significant correlation was found between a ferritin level >1000 ng/mL and the presence of at least one abnormal liver function test (LFT) ORo=6.8; 95% CI=2.2-20.6). In addition, the rate of proven/probable invasive fungal disease was significantly higher in the patients with hyperferritinemia (13% vs 0%; P=.006). Nineteen of the 24 patients considered eligible for iron-depletion therapy underwent regular phlebotomy; 13 completed the program in a median of 287 days (range, 92-779 days), reaching the target of a ferritin level<500 ng/mL; LIC was significantly reduced (median, 1419 microg Fe/g ww to 625 microg Fe/g ww; P < .001) in 8 of the 9 patients who were revaluated by SQUID at the end of the iron-depletion program. In conclusion, the measurement of LIC obtained by SQUID documented the presence of moderate/severe IO in 69% of the patients with a high ferritin level. Our data showed that in HSCT recipients, high ferritin level is an independent risk factor for abnormal LFTs, and IO may be considered a potential risk factor for fungal infections. A phlebotomy program may be feasible in two-thirds of the patients who might benefit from iron depletion.

Long‐term follow‐up analysis after rituximab therapy in children with refractory symptomatic ITP: identification of factors predictive of a sustained response

We report the long‐term follow‐up (median 39·5 months) of 49 paediatric patients (33 females and 16 males) with refractory symptomatic immune thrombocytopenic purpura (ITP) treated with rituximab. The overall response rate was 69% (34/49 patients). Twenty‐one responders had a platelet count >50 × 109/l at a median 20·2 months from treatment. Kaplan–Meier analysis showed a probability of relapse‐free survival (RFS) of 60% at 36 months from the first rituximab infusion. The number of infusions and a previous splenectomy did not influence overall response rate. Patients who achieved complete response were significantly older at diagnosis and first rituximab infusion than partial responders (P = 0·027). Older children displayed a significantly greater probability of sustained response (RFS) at 36 months than younger children (88·9% vs. 56·7%, P = 0·037). Earlier responses (within 20 d from treatment) were significantly associated with both complete (P = 0·004) and sustained response (P = 0·002). Only mild and transient side‐effects were observed in 9/49 children; no major infections nor delayed toxicities were recorded during the follow‐up.

Perfusion index variations in clinically and hemodynamically stable preterm newborns in the first week of life

BackgroundThe perfusion index, derived from the pulse oximeter signal, seems to be an accurate predictor for high illness severity in newborns. The aim of this study was to determine the perfusion index values of clinically and hemodynamically stable preterm newborns in the first week of life.MethodsPerfusion index recordings were performed on the first, third and seventh day of life on 30 preterm newborns. Their state of health was assessed according to clinical and behaviour evaluation and to the Score for Neonatal Acute Physiology.ResultsThe median(interquartile range) perfusion index values were 0.9(0.6) on the first, 1.2(1.0) on the third, and 1.3(0.9) on the seventh day, with a significant increase between the first and the third day.ConclusionsPerfusion index proved to be an easily applicable, non-invasive method for monitoring early postnatal changes in peripheral perfusion. Its trend during the first week of life suggests that its clinical application should take age into account. Further studies are needed to obtain reference perfusion index values from a larger sample of preterm newborns, to identify specific gestational age-related cut-off values for illness and to test the role of perfusion index in monitoring critically ill neonates.

Looking for a relation between serum leptin concentration and body composition parameters in healthy term infants in the first 6 months of life.

We carried out a cross-sectional study of 115 healthy infants, younger than 6 months old, exclusively breast-fed or formula-fed, to investigate correlations between circulating leptin concentrations and body composition measurements. Serum leptin was evaluated with radioimmunoassay, and body composition with bioelectrical impedance analysis. Multiple regression analysis showed a relationship between serum leptin and body mass index in the entire study population (P = 0.042). There was a significant negative relationship between serum leptin and phase angle (P = 0.006) in formula-fed infants. Serum leptin was positively related to subscapular skinfold thickness (P = 0.055) and negatively to reactance (P = 0.057) only in formula-fed infants, although the differences were just below significance. Serum leptin concentration was higher in breast-fed infants (P = 0.002), and was not correlated with body composition parameters. This study indicates that there is a relation between leptin and infant body composition in the first months of life, although the link needs to be explored further.

Oxidative stress in stable cystic fibrosis patients: Do we need higher antioxidant plasma levels?

UNLABELLED Oxidative stress plays an important role in cystic fibrosis (CF). However, there is a lack of validated biomarkers of oxidative damage that correlate with the antioxidant needs of patients with CF. OBJECTIVE To investigate oxidative stress in stable pediatric CF patients and evaluate if vitamin supplementation may be tailored to individual needs and oxidative status. RESULTS Lipid-adducts 4-hydroxynonenal (HNE-L) and malonaldehyde (MDA-L) (chromolipids) were elevated in the majority of patients despite normal plasma vitamin E, A and C. HNE-L and MDA-L increased with age, while plasma vitamins decreased. The most relevant correlation was identified between vitamin C and chromolipids. Patients with pancreatic insufficiency (PI) showed significantly higher plasma chromolipids despite no differences in plasma vitamins. CONCLUSIONS The majority of patients showed elevated plasma chromolipids that increased with age. Antioxidant vitamin reference ranges provide incomplete information on the redox status. CF patients with PI showed excessive oxidative stress damage.

Effectiveness of bibliographic searches performed by paediatric residents and interns assisted by librarians. A randomised controlled trial.

BACKGROUND Considerable barriers still prevent paediatricians from successfully using information retrieval technology. OBJECTIVES To verify whether the assistance of biomedical librarians significantly improves the outcomes of searches performed by paediatricians in biomedical databases using real-life clinical scenarios. METHODS In a controlled trial at a paediatric teaching hospital, nine residents and interns were randomly allocated to an assisted search group and nine to a non-assisted (control) group. Each participant searched PubMed and other online sources, performing pre-determined tasks including the formulation of a clinical question, retrieval and selection of bibliographic records. In the assisted group, participants were supported by a librarian with ≥5 years of experience. The primary outcome was the success of search sessions, scored against a specific assessment tool. RESULTS The median score of the assisted group was 73.6 points interquartile range (IQR = 13.4) vs. 50.4 (IQR = 17.1) of the control group. The difference between median values in the results was 23.2 points (95% CI 4.8-33.2), in favour of the assisted group (P-value, Mann-Whitney U test: 0.013). CONCLUSIONS The study has found quantitative evidence of a significant difference in search performance between paediatric residents or interns assisted by a librarian and those searching the literature alone.

Psychometric validation of the Italian version of the I-QoL questionnaire: clinical and urodynamic findings

Introduction and hypothesisThe aim was to validate the Italian version of the Incontinence-Quality of Life questionnaire (I-QoL) in women with clinical and urodynamic urinary incontinence (UI). A secondary end point was to compare the results of women with reported UI, but negative urodynamic findings.MethodsThe Italian translation of the I-QoL was administered to 267 Italian women with pelvic organ prolapse < stage III, and who had undergone previous surgical or medical therapy for UI. Cronbach’s alpha was calculated to assess internal consistency of the I-QoL items. Reproducibility was assessed using the intraclass correlation coefficient (ICC). Convergent validity involved comparison of I-QoL scores and the Short Form-36 Health questionnaire.ResultsOne hundred and sixty-seven patients were considered for the primary end point: 47 had a negative history of UI and a normal urodynamic test, 120 complained of UI confirmed by a urodynamic test, 59 had a positive history for UI and a urodynamic test negative for UI, and 35 patients not reporting UI had a positive urodynamic test. The I-QoL score revealed that the QoL was lower in patients with reported UI, irrespective of urodynamic findings. The overall I-QoL summary score and subscales showed high internal consistency (alpha ranges from 0.88 to 0.96). ICC ranged from 0.98 to 0.99, demonstrating the stability of the scores. The physical domain of the I-QoL showed a 0.27 correlation with the physical functioning subscale of the SF-36. No significant difference in I-QoL scores was found among various types of UI.ConclusionThe Italian translated version of the I-QoL is reliable, consistent and a valid instrument for assessing impact on quality of life in Italian speaking women with UI.