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We follow a patient with Diamond-Blackfan anemia (DBA) mosaic for a pathogenic RPS19 haploinsufficiency mutation with persistent transfusion-dependent anemia. Her anemia remitted on eltrombopag (EPAG), but surprisingly, mosaicism was unchanged, suggesting that both mutant and normal cells responded. When EPAG was withheld, her anemia returned. In addition to expanding hematopoietic stem/progenitor cells, EPAG aggressively chelates iron. Because DBA anemia, at least in part, results from excessive intracellular heme leading to ferroptotic cell death, we hypothesized that the excess heme accumulating in ribosomal protein-deficient erythroid precursors inhibited the growth of adjacent genetically normal precursors, and that the efficacy of EPAG reflected its ability to chelate iron, limit heme synthesis, and thus limit toxicity in both mutant and normal cells. To test this, we studied Rpl11 haploinsufficient (DBA) mice and mice chimeric for the cytoplasmic heme export protein, FLVCR. Flvcr1-deleted mice have severe anemia, resembling DBA. Mice transplanted with ratios of DBA to wild-type marrow cells of 50:50 are anemic, like our DBA patient. In contrast, mice transplanted with Flvcr1-deleted (unable to export heme) and wild-type marrow cells at ratios of 50:50 or 80:20 have normal numbers of red cells. Additional studies suggest that heme exported from DBA erythroid cells might impede the nurse cell function of central macrophages of erythroblastic islands to impair the maturation of genetically normal coadherent erythroid cells. These findings have implications for the gene therapy of DBA and may provide insights into why del(5q) myelodysplastic syndrome patients are anemic despite being mosaic for chromosome 5q deletion and loss of RPS14.

In this report, we present a 29-year-old African American female who was brought to a local emergency department after being found unresponsive by her mother. The etiology of her stroke and severe hemolysis remained unknown, despite her mother reporting the patient’s history of co-inheritance of sickle cell trait and beta-thalassemia trait, and extensive workup during her prolonged hospitalization. She was diagnosed with sickle cell disease (Sβ+ type) two years after discharge when she was referred to a sickle cell specialist for persistent anemia. Here, we also briefly review the challenges to diagnose rarer subtypes of sickle cell disease (SCD), in this case Sβ+ type, as well as the pathophysiology and current management of stroke in SCD.

Objective Biomagnetic liver susceptometry (BLS) is a noninvasive method to quantify liver iron concentration (LIC). Here we report our findings from a prospective study which validates in vivo LIC from a SQUID biosusceptometer by in vitro LIC in fresh tissue and paraffin-embedded biopsies from patients at risk for iron overload.Materials and Methods LIC was measured by BLS and biopsy. LIC by biopsy were measured in 40 dry weight fresh tissue and paraffin-embedded liver biopsy samples. LIC from biopsies and total iron scores from histology were compared to biosusceptometry. In addition, the wet-to-dry weight ratio was determined.Results Liver iron concentrations measured by BLS and in 40 fresh tissue biopsies were related by a factor of 6.0 ± 0.2 (r2 = 0.88). Similar results were obtained from comparisons with deparaffinized biopsies (6.6±0.3, r2=0.87) and histology (6.7±1.3, r2=0.47). In contrast, a mean wet-to-dry weight ratio of 4.1 ± 0.7 was achieved from biopsies immediately weighed after the biopsy procedure.ConclusionLIC derived from two independent measures, the historical biopsy gold standard and biosusceptometry, were highly correlated. When comparing biosusceptometry with wet weight biopsies, the liver tissue sample size is critical.

Sickle cell disease (SCD) is an inherited hemoglobinopathy affecting approximately 100,000 individuals in the United States. Cerebrovascular disease is among the most common and debilitating complications of SCA, with 53% experiencing silent cerebral infarct by age 30 and 3.8% experiencing overt stroke by age 40 years. This review highlights the burden of cerebrovascular disease in SCD, including both stroke and silent cerebral infarct (SCI). We then discuss the pathophysiology of stroke and cerebral fat embolism in the absence of a patent foramen ovale. This review also reveals that options for primary and secondary stroke prevention in SCD are still limited to hydroxyurea and blood transfusion, and that the role of aspirin and anticoagulation in SCD stroke has not been adequately studied. Limited data suggest that the novel disease-modifying agents for SCD management may improve renal dysfunction, leg ulcers, and lower the abnormally high TCD flow velocity. Further research is urgently needed to investigate their role in stroke prevention in SCD, as these novel agents target the main stroke contributors in SCD - hemolysis and vaso-occlusion. This literature review also explores the role of healthcare disparities in slowing progress in SCD management and research in the United States, highlighting the need for more investment in patient and clinician education, SCD management, and research.

Severe cytopenias (anemia, thrombocytopenia, neutropenia or any combination of these) are common causes of ER visits and hospital admissions. In adults, the etiology of cytopenias has a broad differential diagnosis including vitamin and mineral deficiencies, autoimmune conditions, infections, bone marrow failure disorders, or malignancies. We present a case of severe anemia and thrombocytopenia who was initially diagnosed with myelodysplastic syndrome (MDS) based on the results of a bone marrow biopsy. However, subsequent workup revealed that she had B12 deficiency secondary to pernicious anemia. This case highlights how performing a bone marrow biopsy without investigating secondary causes of cytopenia and bone marrow dysplasia can lead to a false diagnosis of MDS. Confirmation of the appropriate diagnosis spared the patient emotional trauma and unnecessary treatment with hypomethylating agents.

Sarcoidosis is a multisystem granulomatous disease of unknown etiology that can present with nonspecific features, often resulting in delayed diagnosis. The diagnosis requires the demonstration of non-caseating granulomas on biopsy. While the prevalence of sarcoidosis in the USA is rare, the disease is rarer yet in Hispanics. It is for this reason that we report herein the case of a Hispanic gentleman with a unique clinical manifestations of sarcoidosis. With what began as a two-month history of joint pain and skin rash, this 55-year-old man was hospitalized with multiple joint pain, weight loss, fatigue and a pruritic rash with leonine facies in the setting of anemia, leukopenia, hypercalcemia, elevated serum creatinine, and urine Bence-Jones proteinuria. CT imaging of the chest was nonspecific, but skin biopsy revealed non-caseating granulomatous disease. After completing an infectious and malignancy evaluation, the patient was diagnosed with sarcoidosis, which was treated successfully with low-dose steroid therapy.

Intravascular large B-cell Lymphoma (IVLBCL) is a rare subtype of extra nodal non-Hodgkin’s lymphoma, which is challenging to diagnose and has a poor prognosis. Here we describe three non-White Hispanic patients newly diagnosed with IVLBCL within 14-month period. All of them presented with persistent fever of unknown origin and symptomatic severe anemia as the initial manifestations. Two out of three cases were successfully diagnosed in a timely manner by fat pad biopsy and have remained disease free up to 34 months after chemotherapy. The third case was diagnosed by bone marrow biopsy and deceased one week later after choosing home hospice care. To date, this is the largest published case series of IVLBCL in non-White Hispanics.

Background Microbial superantigens might initiate or exacerbate autoimmune responses against particular tissues, organs or systems. This study aimed to examine the prevalence of sea, seb, sec, sed, and tsst-1 genes of Staphylococcus aureus in nasal carriage and their association with multiple sclerosis (MS). Methods Nasal swabs were collected from 150 MS patients and 150 healthy individuals (control group) to isolate S. aureus and investigate their superantigen genes (sea, seb, sec, sed and tsst-1) using PCR. Results A total of 300 participants were enrolled in the study, matched for age and gender (150 patients in the MS group and 150 in the control group). The prevalence of S. aureus colonization in MS patients and control groups was 42% and 23.3%, respectively. There was a statistically significant association between S. aureus colonization and MS disease (p

Background: Sickle cell disease (SCD) is an inherited, chronic, and multifaceted condition. Anemia affects most patients with SCD, and low hemoglobin (Hb) levels have been demonstrated to be correlated with end-organ damage (EOD) such as stroke, chronic kidney disease (CKD), end-stage renal disease (ESRD), and pulmonary hypertension (PH). This study sought to estimate the relationship between Hb and risk of EOD based on large-scale, longitudinal analyses of recent data. Methods: Patients with SCD aged 12 years and older and at least 1 Hb level reported from January 2013 to March 2019 in the large, US-representative, provider-centric Symphony Health claims database were included. For each qualifying patient, Hb values were identified and included as separate observations. Onset of new EOD, including stroke, CKD (including ESRD), and PH were ascertained during the 1-year period after the date of each Hb assessment (index date). History of EOD and other comorbid conditions were identified using claims from the database start date (January 1, 2012) or first activity date, whichever was later, up to the index date, to differentiate from newly diagnosed EOD. Patient demographics and clinical characteristics were summarized descriptively. Bivariate analyses of Hb levels and EOD were assessed using generalized estimating equations (GEE) regression with a logistic link function to account for clustering of observations at the patient level. Multivariable GEE regression was employed to evaluate the independent association between Hb and EOD, adjusting for patient demographics and other SCD complications. Results: A total of 16,754 patients with SCD aged 12 years and older were identified (mean age: 34.7 years, 37.7% male), contributing 41,692 observations of Hb levels (mean [SD], 9.8 [2.0] g/dL). In univariate analyses, higher Hb levels were significantly associated with lower odds of new EOD of any type (Figure). In multivariable analyses, after controlling for age, gender, and history of other SCD complications, patients with Hb b %12 g/dL had significantly lower odds of new EOD versus patients with Hb Conclusions: In this large-scale, longitudinal analysis, a significant reduction in the risk of new EOD was observed among SCD patients with higher Hb levels. History of any EOD significantly correlated with presence of new EOD. New SCD treatments that can increase Hb levels can potentially offer clinical and economic value. Disclosures Ershler: Pharmacosmos Therapeutics Inc: Consultancy, Membership on an entity's Board of Directors or advisory committees; Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. De Castro:GlycoMimetics: Membership on an entity's Board of Directors or advisory committees; FORMA Therapeutics: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees. Pakbaz:Amgen: Membership on an entity's Board of Directors or advisory committees; Dova: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Terumo BCT: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Global Blood Therapeutics: Speakers Bureau. Moynahan:Global Blood Therapeutics: Research Funding; Novartis: Research Funding; Policy Analysis Inc.: Current Employment. Weycker:Policy Analysis Inc.: Current Employment, Current equity holder in publicly-traded company; Global Blood Therapeutics: Research Funding; Novartis: Research Funding. Pham:Policy Analysis Inc.: Current Employment; Global Blood Therapeutics: Research Funding; Novartis: Research Funding. Delea:Policy Analysis Inc.: Current Employment, Current equity holder in private company; Global Blood Therapeutics: Research Funding; Novartis: Research Funding. Agodoa:Global Blood Therapeutics: Current Employment, Current equity holder in publicly-traded company. Cong:Global Blood Therapeutics: Current Employment, Current equity holder in publicly-traded company.

Diamond-Blackfan Anemia (DBA) is a rare, inherited bone marrow (BM) failure syndrome characterized by pure red cell aplasia generally presenting within the first year of life. The majority of cases are due to heterozygous mutations in ribosomal genes, either autosomal dominant inherited or sporadicde novoevents. Despite the recognition of the importance of ribosomal biology, the underlying mechanisms are still poorly understood. The only curative treatment is hematopoietic stem cell transplantation, otherwise steroids or transfusions will cause significant long-term morbidity. There is an unmet need for new therapies. We describe the unique clinical course and molecular analyses of a 32-year-old Hispanic woman, provide insights into disease pathophysiology as well as hope for an effective new treatment. She was diagnosed with DBA at the age of one month with isolated severe normochromic anemia. She failed various therapies, including corticosteroids, danazol, growth factors, and additional immunosuppression and developed significant iron overload despite desferal chelation. She was enrolled in a phase II clinical trial investigating the safety and efficiency of the thrombopoietin receptor agonist eltrombopag (EPAG) in patients with moderate aplastic anemia or unilineage cytopenias (NCT01328587). EPAG was administered in an escalating manner reaching 300mg daily. She achieved transfusion-independence by 16 weeks. This dose was continued for an additional 6 months and discontinued for protocol-defined robust response, ie Hb >10g/dL. After discontinuation, her hemoglobin steadily declined over a period of 8 months. EPAG was reinitiated, her Hb again rapidly improved and the EPAG dose was slowly tapered. Seven years since enrollment, the patient has remained on drug, currently at a dose of 25mg daily with normal blood cell counts and no EPAG related toxicity. BM cytogenetics and morphology have remained normal throughout follow up, as has a myeloid somatic mutation panel. Next generation sequencing has revealed a novel, pathogenic mutation in intron 4(c.356+3>C) of theRPS19gene affecting a splice donor site previously implicated in DBA. Testing of both parents was negative, documenting this to be ade novomutation. With digital droplet PCR (ddPCR), we have monitored the variant allele frequency (VAF) in fibroblasts (germline) and different hematopoietic populations (Figure 1). Fibroblasts showed a VAF 50% (heterozygous), while her whole BM and whole blood show a lower VAF between 25% and 37%, both before and on EPAG treatment. Across lineages were analyzed when she was on EPAG, lymphocytes showed the highest VAF (42% to 45%), followed by HSPCs and granulocytes at 24% to 32%. Of note, the erythrocytes progenitors (CD45-CD71+) had the lowest VAF of 8% to 14%. Sequencing of myeloid and erythroid colony forming units (CFU) with both pre and on EPAG BM samples confirmed only heterozygous mutations or wild-type (WT) CFUs in percentages comparable to their respective VAF detected by bulk ddPCR. These results suggest the emergence of WT clones within the BM either through mosaicism or a reversion event. The discrepancy in VAF between peripheral and BM samples is consistent with a proliferative advantage for WT clones, especially in the erythroid and myeloid lineages. Yet despite the presence of WT HSPCs, profound transfusion-dependent anemia persisted in this patient long-term. An imbalance between globin chain and heme production has been documented to result from ribosomal dysfunction in DBA, leading to increased iron-mediated cellular stress and death of erythroid progenitors. We hypothesize the residual mutant cells suppress the growth of WT cells, given the close proximity of large numbers of erythroid cells aggregated by macrophages in erythroid islands, potentially via passage of free iron. These observations have implications for the development of gene addition or gene correction therapies for DBA, suggesting that correcting a fraction of HSPCs will not revert the phenotype. Given the potent intracellular chelation activity of EPAG, and the lack of the EPAG target MPL receptor on erythroid progenitors, we hypothesize that iron chelation is a potential mechanism for improvement of red blood cell production by EPAG in DBA. The results in our patient have encouraged the opening of a prospective clinical trial (NCT04269889) to further explore the potential of EPAG for DBA patients. Figure Disclosures Young: Pharos I&BT Co., Ltd.:Research Funding.Pakbaz:Amgen:Membership on an entity's Board of Directors or advisory committees;Dova:Membership on an entity's Board of Directors or advisory committees;Novartis:Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;Terumo BCT:Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;Global Blood Therapeutics:Speakers Bureau.Dunbar:Novartis:Research Funding.

Background Superantigens can be absorbed trans-mucosal and trans-cutaneous in individuals colonized with superantigen producing Staphylococcus aureus. Ability of superantigens to activate a large numbers of T cells suggests that they may play a role in the course of autoimmune diseases including human multiple sclerosis and experimental autoimmune encephalomyelitis (EAE). In this study we investigated the role of staphylococcal enterotoxin B in immunologic and pathologic changes in experimental animal model of multiple sclerosis. Methods C57BL/6 female mice were treatment with SEB protein prior or post immunization with MOG33-35 peptide. Mice were monitored daily and scored for clinical symptoms following EAE induction. Spleen and spinal cord of mice were removed and used for ELISA and histological studies, respectively. Results Treatment with SEB prior induction of EAE, increased clinical score, the concentration of IL-17A, IFN-γ and histological changes compared to control group. Treatment with SEB after induction of EAE caused these changes, but less severe. Discussion Since SEB causes demyelination of spinal cord and increases the level of pro-inflammatory cytokine response, infiltration of T-lymphocytes and macrophages to CNS, it may exacerbate the clinical signs of EAE in mice and multiple sclerosis in human.

International audience; Erythroferrone (ERFE) is a glycoprotein hormone secreted by erythroblasts in response to stimulation by erythropoietin (EPO). We previously demonstrated that ERFE messenger RNA expression and serum protein concentration increase in mice subjected to hemorrhage or EPO therapy, that ERFE acts on hepatocytes to suppress hepcidin, and that the resulting decrease in hepcidin augments iron delivery for intensified erythropoiesis. We also showed that ERFE contributes to pathological hepcidin suppression and iron overload in mice with non transfused beta-thalassemia. We now report the development and technical validation of a rabbit monoclonal antibody-based sandwich immunoassay for human ERFE. We use this assay to show that blood loss or EPO administration increases serum ERFE concentrations in humans, and that patients with both nontransfused and transfused b-thalassemia have very high serum ERFE levels, which decrease after blood transfusion. The assay should be useful for human studies of normal and disordered erythropoiesis and its effect on iron homeostasis.

Microbial superantigens might initiate or exacerbate autoimmune responses against particular tissues, organs or systems. This study aimed to examine the prevalence ofNasal swabs were collected from 150 MS patients and 150 healthy individuals (control group) to isolateA total of 300 participants were enrolled in the study, matched for age and gender (150 patients in the MS group and 150 in the control group). The prevalence ofThe rate of

BACKGROUND: Life expectancy for individuals with sickle cell disease (SCD) is shorter in California than in other states with multiple contributing factors. These include a shortage of adult hematologists expert in SCD management, lack of resources for the provision of comprehensive care, and limited options for disease modifying therapies. Adults with SCD are vulnerable to negative social determinants of health including low income, challenges with attaining adequate education and employment, and racial disparities. Adults with SCD may not be well educated about health maintenance and treatment options. We piloted an adult sickle cell clinic under the direction of an adult hematologist with expertise in SCD management in California's Inland Empire. The program was instituted in January of 2017 at an academic medical center. Here we report on an interim analysis of the impact of the clinic on patients' decision-making regarding treatment options, including opioids and healthcare utilization (annual inpatient and emergency department (ED)visits). METHODS: Data was collected from electronic medical records (EMR) for 65 consecutive adults with SCD who were seen by the adult sickle cell hematologist at least once either in the clinic or as an inpatient consult between January 2017- July 2019. For patients seen as outpatient, expectations were outlined as monthly clinic visits for 30 minutes each, including 10 - 15 minutes of education about SCD and available treatments. Individualized care plans aimed at decreasing the frequency of pain episodes were implemented and discussed at each visit. Care plans generally involved recommendations for disease modifying therapies not previously available to them. Cayenne Wellness Center, a community based organization partner, provided additional education and psychosocial economic assessment to offer resources including transportation to patients in need. Patients were grouped as adherent, non-adherent or inpatient consult and followed over time. They were assigned to the non-adherent group if they met 2 out of the 3 following criteria: clinic no-shows of >50%, appointment interval >3 months, and patients' choice to not comply with the agreed upon disease modifying therapy or to only stay on opioids. We reviewed annual admissions, ED visits, and opioid use from the EMR. For adults who joined the clinic in 2019 or relocated, only opioid use was included in this report. RESULTS: Thirty-three percent (N= 22) of adults with SCD in the current sample chose not to follow up with the hematology clinic after their first inpatient consultation. For the remaining 43 patients, the median age was 34 years (range 19 to 59); 60% were female and 20% were diagnosed with Hgb SC. Forty nine percent (N=21) were classified as adherent. Twenty three percent (N=10) of patients had joined the clinic in 2019 or relocated. In the adherent group, 43% of patients had a 79% decrease in their annual admission rates and 37% had a 100% decrease in the average number of ED visits. At their first clinic visit, 72% (N=31) of patients were noted to be using opioids at home. Over time, 53% of the adherent group had a decrease in opioid use, while 36% of the non-adherent group had an increase in opioid use. CONCLUSION: This pilot clinic showed that regular adult hematology sickle cell clinic follow up to individualize and optimize therapies and provide education can improve patient outcomes. Individuals who were adherent to disease modifying treatment regimens and had regular hematology outpatient follow up showed a decrease in ED visits, admissions, and opioid use. Disclosures Vichinsky: GBT: Consultancy, Research Funding; Agios: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; bluebird bio: Consultancy, Research Funding. Pakbaz:Novartis: Honoraria, Speakers Bureau.

Introduction: Despite convincing evidence toward causal role of Lipoprotein(a) in occlusive arterial disease, the data is conflicting when it comes to venous thromboembolism (VTE) and pulmonary embolism (PE). Also it is not known if intervention to normalize Lipoprotein(a) will decrease risk of recurrent VTE and PE eliminating the need for life long anticoagulation. To our knowledge this isfirst data set report focusing on evaluating association between Lipoprotein(a) and VTE in patients younger than 50 years old. Methods: Inthis retrospective study, chart review was completed for twenty-six consecutive patients referred to hematology clinic with diagnosis of deep vein thrombosis (DVT) or PE in year 2017-2018 . Four patients older than 50 years old at the time of acute events were excluded. Lipoprotein(a) had only been measured in patients who had negative hypercoagulable work up with normal lipid panel but had obesity . Protein C, S and anti-thrombin were not measured if patients were already on anticoagulation. Serum level of Lipoprotein(a) greater than 75 nmol/L was considered to be elevated. Results: Total of 22 patients (18 females) were included in the data analysis. Nine patients had DVT, 5 patients had PE, and 8 patients had both DVT and PE. Median age was 34 (12-47). Lipoprotein(a) level was not checked on eight patients who had SLE (n=1), surgery (n=1), Factor V Leiden mutation (n=1), protein S deficiency (n=1), anti-phospholipid syndrome (n=2), prothrombin gene mutation (n=1), and one patient who had lost follow up. The median Lipoprotein(a) level was 107 (8-276). Serum Lipoprotein(a) was elevated in 8 out of the 14 screened patients (57%) with the median of 135 (107-276). Out of 8 patients with elevated Lipoprotein(a), only 1 patient had additional clinical risk factors for thrombosis (history of smoking, alcohol abuse, hypertriglyceridemia and elevated LDL). In an attempt to normalize Lipoprotein(a) level, 3 patients were started on niacin but only one tolerated maximum 1000 mg niacin daily which resulted in decrease in level but did not achieve normalization. Conclusion: This data suggests that elevated serum Lipoprotein(a) in females younger than 50 years old is associated with DVT/PE events. Further investigation is required to confirm this finding. At this time it is not known if attempt to normalize Lipoprotein(a) will prevent recurrent PE/DVT and eliminate need for long life anticoagulation in patients with unprovoked VTE who have elevated lipoprotein(a). Disclosures Pakbaz: Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

Advances in the management of thalassemia have resulted in increased life expectancy and new challenges. We conducted the first survey of education and employment status of people with thalassemia in North America.A total of 633 patients (349 adults and 284 school age children) enrolled in the Thalassemia Clinical Research Network (TCRN) registry in Canada and the U.S. were included in the data analysis. Predictors considered for analysis were age, gender, race/ethnicity, site of treatment (Canada vs. United States), transfusion and chelation status, serum ferritin, and clinical complications.Seventy percent of adults were employed of which 67% reported working full-time. Sixty percent had a college degree and 14% had achieved some post-college education. Eighty-two percent of school age children were at expected grade level. In a multivariate analysis for adults, Whites (OR = 2.76, 95% CI: 1.50-5.06) were more likely to be employed compared to Asians. Higher education in adults was associated with older age (OR = 1.67, 95% CI: 1.29-2.15), female gender (OR = 2.08, 95% CI: 1.32-3.23) and absence of lung disease (OR = 14.3, 95% CI: 2.04-100). Younger children (OR = 5.7 for 10-year increments, 95% CI: 2.0-16.7) and Canadian patients (OR = 5.6, 95% CI: 1.5-20) were more likely to be at the expected education level. Neither transfusion nor chelation was associated with lower employment or educational achievement.Individuals with thalassemia in North America can achieve higher education; however, full-time employment remains a problem. Transfusion and chelation do not affect employment or education status of this patient population.

Background/Aims: There is increasing evidence demonstrating the value of transfusions in sickle cell disease (SCD). However, resultant iron overload can be life threatening if untreated. Chelation therapy with deferoxamine requires parenteral infusions that can negatively impact quality of life and adherence to treatment. Methods: As part of a phase II trial, SCD patient-reported outcomes were evaluated. One hundred and ninety-five patients were randomized (2:1) to receive oral deferasirox (5–30 mg/kg/day) or deferoxamine (20–50 mg/kg, 5 days per week); 121 had previously received deferoxamine. Results: At each time point, significantly more patients who had previously received deferoxamine were ‘satisfied/very satisfied’ with deferasirox, or found treatment to be ‘convenient/very convenient’ compared with deferoxamine (p < 0.001). In these patients, fewer hours were lost from daily activities with deferasirox than deferoxamine treatment. Most patients (77%) preferred deferasirox, and more were willing to continue taking deferasirox than deferoxamine at end-of-study (84 vs. 11%, respectively). Conclusions: Patients with SCD are therefore more satisfied with deferasirox, which has a lower impact on daily activities than deferoxamine. Given the high levels of satisfaction, it is likely that quality of life will be improved. These results also suggest that treatment adherence with deferasirox may be better than with deferoxamine, which should lead to improved long-term outcomes.

Accurate measurement of liver storage iron is important for the management of iron overload from regular red blood cell transfusion therapy. In clinical trials testing iron chelator efficacy in iron overloaded patients, with different centers involved, it is mandatory to standardize the procedures of liver iron concentration (LIC) measurements. The agreement (precision and bias) of the SQUID biosusceptometer in Oakland/USA (CHO) and Torino/Italy (TOR) was evaluated in comparison to the validated System in Hamburg/Germany (UKE). In a blinded round-robin test, liver iron concentrations were quantified within 1 month by the 3 SQUID biosusceptometer systems, in 20 patients with thalassemia, sickle cell disease or CDA type-1 and in 10 normal subjects. Mean LIC values were determined from 5 vertical scans at each of two, different positions. Prediction of LIC at CHO and TOR in comparison with UKE was excellent, with coefficients of determination between sites of R 2 = 0.97, resulting in inter-site standard deviations of 276 and 315 μg/g liver, respectively. A significant proportional underestimation of 27% was noted for the TOR system. A systematically lower skin–liver distance of 1.0 mm at the TOR site could only account for 10% of the underestimated LIC. Intra-site precision was within an acceptable range for repeated measurements in the majority of iron overloaded subjects.

Serum ferritin (SF) and liver iron concentration (LIC), as measured by SQUID biosusceptometry, were assessed in a convenience sample of transfusion independent thalassemia patients (nTx-Thal, n=26), regularly transfused thalassemia (Tx-Thal, n=89), or sickle cell patients (SCD, n=45) to investigate the severity of iron overload and the relationship between SF and LIC in nTx-Thal compared to SCD and Tx-Thal. SF correlated with LIC (RS=0.53, P

Purpose We evaluated bone mineral density (BMD) and risk factors for poor bone mineralization in children with sickle cell anemia (SCA). Patients and Methods Twenty-five children with severe manifestations of SCA (frequent hospitalizations, growth delay, or need for chronic red cell transfusions) were enrolled. Bone density was assessed at lumbar spine and proximal femur with dual-energy X-ray absorptiometry (DXA), and Z-scores were calculated by comparison with age, sex, and ethnicity-specific reference data. Results The median age of the study population was 12.8 years (10.2–19.8 years). Calcium intake was inadequate in 60%, and serum 25-hydroxy vitamin D (25-OHD) level

Adherence to deferoxamine (DFO) is vital for the long-term survival of patients with thalassemia; however, currently no measure exists to quantify adherence directly. In this study, 90 patients with thalassemia major underwent liver iron concentration (LIC) assessment by SQUID biosusceptometer, were asked to rate their adherence to DFO using a Numerical Likert Scale (NLS), and were educated about complications of iron overload. Of 38% (n= 28) of patients who rated themselves as very compliant, 19 had elevated LIC related to inadequate dosing of DFO and nine reported nonadherence in the past. Adherence improved after counseling and LIC decreased by 25% (7-60%) in eight previously noncompliant patients who returned for subsequent LIC over 15 months. In conclusion, the NLS seems to be a simple but reliable tool to assess patients' adherence to DFO. Education and frequent noninvasive LIC assessments can improve adherence and iron burden. Elevated LIC does not necessarily reflect concurrent noncompliance; however, it can be an indication of nonadherence in the past.

The impact of thalassemia major and thalassemia intermedia and their associated complications on quality of life (QOL) is largely unknown. Determining the degree of health impairment as perceived by the patient is essential information needed to recommend suitable therapy. The objective of this study was to evaluate QOL in transfusion-independent patients with thalassemia (non-Tx) compared with that in transfused patients (Tx) and to identify the factors that affect QOL in thalassemia. A convenient sample of 48 thalassemia patients (29 Tx and 19 non-Tx) with mean age of 14.6 years (SD = 7.5 years) were selected during a comprehensive visit to complete a Dartmouth Primary Care Cooperative Information Chart System (COOP) questionnaire. Patients rated QOL from excellent (1) to poor (5) on five dimensions of health status. Scores of 4 or 5 represent major limitations. These results were augmented by a brief medical history and chart review. Forty-one percent of Tx patients and 47% of non-Tx patients reported severe impairments in 1-6 and 1-2 domains, respectively. The most commonly reported affected domains were feelings such as anxiety, depression, and concern of overall health status or indications of recent deterioration in health. In contrast with previous beliefs, transfusion-independent thalassemia patients also suffer serious impairment in QOL. Presented data suggest that all patients with thalassemia undergo QOL assessment so that interventions focused on affected domains can be implemented.

Treatment of hepatitis C virus (HCV) in the general population has improved over the last decade. Patients treated with peginterferon alfa (PegIFN) and ribavirin (RBV) combination therapy demonstrate overall 50-55% sustained viral response (SVR) with rates as high as 80% in patients with genotypes 2 and 3. Because RBV induces hemolysis and subsequently increases blood transfusion requirements, combination therapy has been considered contraindicated for hemoglobinopathies. This report reviews the response to interferon alfa and RBV (IFN/RBV) and PegIFN/RBV combination therapies in patients treated in the Northern California Comprehensive Thalassemia Center. A total of six thalassemia major patients were treated with IFN/RBV (n = 5; age: 4-38 years) or with PegIFN/RBV (n = 1; age: 26 years). Quantitative HCV RNA polymerase chain reaction and liver iron level assessment were completed. Transfusion volumes were obtained from patients' medical records. On IFN/RBV combination, four of five patients demonstrated SVR. The one patient on PegIFN/RBV showed end-treatment viral response after 6 months of therapy (genotype 3), but subsequently relapsed. Liver iron pretreatment level ranged from 0.2 to 22 mg/g dry weight, with a mean +/- SD of 7.9 +/- 7.7. Transfusion requirement increased by a median of 43.5% (range: 32-137%). Five of the six patients had liver iron measurements within 1 year following completion of treatment, with quantitative liver iron increasing in two patients by 2.5 mg/g dry weight, decreasing in two patients by 3 and 14 mg/g dry weight, and remaining unchanged in one patient. All patients were able to complete combination therapy, although dose reductions were required. Patients with thalassemia and high iron overload can obtain SVR after combination therapy with rates similar to those in the general population and without significant complications. Although transfusion requirements increased in most patients, iron burden was not necessarily increased.

Although the pathogenesis of sickle cell disease lies in disordered hemoglobin structure and function, downstream effects of sickle hemoglobin include changes in hemostatic system that overall result in a pro-thrombotic phenotype. These changes include thrombin activation, decreased levels of anticoagulants, impaired fibrinolysis and platelet activation. Limited studies to date suggest that biomarkers of activation can be affected by currently available anti-thrombotic drugs, and provocative data from pilot studies indicate there may be improvement in clinically important outcomes. Therefore, clinical trials with antithrombotic therapies, are justified with both SCD related complications (VOC, pain) and thrombotic complications as outcome events of interest.

Background: The importance of sialic acid binding adhesin (sabA) as a new outer membrane protein in gastroduodenal diseases has been recognized. The prevalence rate of sabA gene varies in different geographic areas. Objectives: The aim of this study was to determine the frequency of sabA gene in Helicobacter pylori (H. pylori) strains isolated from different clinical outcomes in Tehran, Iran. Patients and Methods: The study included 120 patients with dyspeptic symptoms admitted to the endoscopy suite of gastroenterology section of Firouzgar University Hospital, Tehran, Iran from March to August 2011. Gastric biopsy specimens were evaluated for the presence of H. pylori using standard microbiological method and polymerase chain reaction (PCR) assay. The sabA genopositive was determined by PCR in H. pylori strains. Results: H. pylori isolates were recovered from 82 patients with duodenal ulcer (DU; n = 17), gastric ulcer (GU; n = 15), gastric cancer (GC; n = 13), and gastritis (G; n = 37). The frequency of sabA gene in H. pylori strains was 100% in gastric cancer, 86.7% in gastric ulcer, and 83.3% in both gastritis and duodenal ulcer. Conclusions: This is a report on the prevalence of sabA gene in H. pylori isolated from different gastric patients in Iran. The results showed a high prevalence of sabA in our clinical H. pylori isolates.

Haemoglobin E-beta thalassaemia (Hb E/β-thalassaemia) is the genotype responsible for approximately one-half of all severe beta-thalassaemia worldwide. The disorder is characterized by marked clinical variability, ranging from a mild and asymptomatic anaemia to a life-threatening disorder requiring transfusions from infancy. The phenotypic variability of Hb E/β-thalassaemia and the paucity of long-term clinical data, present challenges in providing definitive recommendations for the optimal management of patients. Genetic factors influencing the severity of this disorder include the type of beta-thalassaemia mutation, the co-inheritance of alpha-thalassaemia, and polymorphisms associated with increased production of foetal haemoglobin. Other factors, including a variable increase in serum erythropoietin in response to anaemia, previous or ongoing infection with malaria, previous splenectomy and other environmental influences, may be involved. The remarkable variation, and the instability, of the clinical phenotype of Hb E beta-thalassaemia suggests that careful tailoring of treatment is required for each patient, and that therapeutic approaches should be re-assessed over-time.

The Thalassemia Clinical Research Network collected adherence information from 79 patients on deferoxamine and 186 on deferasirox from 2007 to 2009. Chelation adherence was defined as percent of doses administered in the last 4 weeks (patient report) out of those prescribed (chart review). Chelation history since 2002 was available for 97 patients currently on deferoxamine and 217 on deferasirox, with crude estimates of adherence from chart review. Self-reported adherence to both deferoxamine and deferasirox were quite high, with slightly higher adherence to the oral chelator (97 vs. 92%). Ninety percent of patients on deferasirox reported at least 90% adherence, compared with 75% of patients on deferoxamine. Adherence to both chelators was highest in children, followed by adolescents and older adults. Predictors of lower deferoxamine adherence were smoking in the past year, problems sticking themselves (adults only), problems wearing their pump, and fewer transfusions in the past year. Predictors of lower deferasirox adherence were bodily pain and depression. Switching chelators resulted in increased adherence, regardless of the direction of the switch, although switching from deferoxamine to deferasirox was far more common. As adherence to deferoxamine is higher than previously reported, it appears beneficial for patients to have a choice in chelators.

Hemoglobin E thalassemia accounts for about one-half of all cases of severe beta thalassemia. There is marked variability in its clinical severity ranging from an asymptomatic to a transfusion-dependent phenotype. The phenotypic variability and inadequate longitudinal data present challenges in determining the optimal management of patients. This article summarizes findings on the natural history of Hemoglobin E thalassemia and some factors responsible for its clinical heterogeneity. Major genetic factors include the type of beta thalassemia mutation, the co-inheritance of alpha thalassemia, and polymorphisms associated with increased synthesis of fetal hemoglobin. Other factors, including response to anemia, and the influence of infection with malaria and other environmental influences, may be important. The remarkable variation and instability of clinical phenotypes in Hemoglobin E thalassemia require individual management plans for each patient, which should be reassessed over time.

There is increasing evidence demonstrating the value of transfusions in sickle cell disease (SCD). However, resultant iron overload can be life threatening if untreated. Chelation therapy with deferoxamine requires parenteral infusions that can negatively impact quality of life and adherence to treatment.As part of a phase II trial, SCD patient-reported outcomes were evaluated. One hundred and ninety-five patients were randomized (2:1) to receive oral deferasirox (5-30 mg/kg/day) or deferoxamine (20-50 mg/kg, 5 days per week); 121 had previously received deferoxamine.At each time point, significantly more patients who had previously received deferoxamine were 'satisfied/very satisfied' with deferasirox, or found treatment to be 'convenient/very convenient' compared with deferoxamine (p0.001). In these patients, fewer hours were lost from daily activities with deferasirox than deferoxamine treatment. Most patients (77%) preferred deferasirox, and more were willing to continue taking deferasirox than deferoxamine at end-of-study (84 vs. 11%, respectively).Patients with SCD are therefore more satisfied with deferasirox, which has a lower impact on daily activities than deferoxamine. Given the high levels of satisfaction, it is likely that quality of life will be improved. These results also suggest that treatment adherence with deferasirox may be better than with deferoxamine, which should lead to improved long-term outcomes.

Background While it is appropriate to treat transfusional iron overload to limit end-organ injury after bone marrow transplantation (BMT) for β-thalassemia major (TM), this approach after BMT for sickle cell disease (SCD) and hematological malignancies has not been studied. Procedure Fifteen children with SCD (n = 4), TM (n = 6), or acute myelogenous leukemia (AML, n = 5) underwent HLA-identical sibling BMT between 2000 and 2003. Prospective evaluations of iron biomarkers were performed and the three groups were compared. Results The pre-BMT duration and volume of RBC transfusions varied among the three groups, but baseline ferritin and liver iron concentration (LIC) were similar. In contrast, liver histology differed. Liver inflammation was present in four TM patients and portal fibrosis was observed in five TM and one SCD patient. Hepatic veno-occlusive disease (VOD) developed in 5 of 15 patients. VOD was not associated with age, ferritin, ALT, or transfusions, but an association with liver inflammation and elevated LIC was suggested. Phlebotomy was performed in five patients after BMT. Changes in LIC were minimal in non-phlebotomized patients (P = 0.02). Conclusion Iron biomarkers demonstrated significant iron overload before BMT in patients with malignant and non-malignant disorders. However, iron overload was associated with liver inflammation and VOD primarily in TM patients. The clinical significance of iron overload in patients after BMT remains uncertain, but this is the first study to suggest that VOD may be associated with transfusional iron burden. Pediatr Blood Cancer 2008;50:319–324. © 2007 Wiley-Liss, Inc.

Abstract 2126 Introduction: Serum ferritin (SF), the most convenient marker of iron burden in sickle cell anemia (SCA), is potentially confounded by effects of inflammation in SCA. Serum transferrin (STF) has been described as one of the independent predictors of elevated tricuspid regurgitant velocity (TRV) in SCA. Therefore in this report we investigate the potential predictive role of STF in morbidity and mortality of individuals with SCA. Methods: Patients with sickle cell disease documented by high-pressure liquid chromatography were eligible for the study. Four hundred and sixty SCA patients were recruited in this study from the community through multimedia advertisements, community outreach, and regional clinics. All evaluated patients were screened by history taking, physical examination, laboratory studies, and transthoracic echocardiography. All patients provided written informed consent. The advertisements and protocol were approved by the institutional review boards of the National Heart, Lung, and Blood Institute and Howard University. Only outpatients in stable condition were included; patients who had had a vaso-occlusive crisis within the previous two weeks or an episode of acute chest syndrome within the previous four weeks were excluded. Results: Two hundred and sixty two participants with HbSS were included in the data analysis. Forty-seven percent were male. Median age was 32 years old. Median TRV in this cohort was 2.4 m/s. Forty nine percent of participants had TRV≥2.5 m/s and 19% had TRV≥3 m/s. Patients with lower STF (0.05), but all-cause death rate was higher (22% vs. 6%, p=0.0001). Hemoglobin, CRP, alkaline phosphatase, uric acid, placenta growth factor ( Among age, gender, BNP, TRV,GFR,WBC, STF, systolic blood pressure and fetal hemoglobin, the Cox proportional analysis of mortality found TRV, GFR and STF the independent significant predictors of mortality in this cohort. Kaplan-Meier survival curve showed that patients with transferrin Conclusion: In this cohort of adults with sickle cells anemia, STF is found to be an independent predictor of endothelial dysfunction, high TRV and mortality. It may be a more sensitive predictor than serum ferritin. We propose that iron overload may induce a state of endothelial dysfunction that is a risk factor for clinical vasculopathy and death. Disclosures: No relevant conflicts of interest to declare.

Abstract 257 Background. Advances in treatment of thalassemia have led to increased life expectancy for patients making outcomes such as health related quality of life (HRQOL) an important consideration of therapy. Little has been published about the HRQOL of pediatric patients with thalassemia. There are limited reports on how this illness impacts the family. Because the familial situation is the starting point for how patients learn to live with their condition, it is important to document this effect and how it changes over time. This report looks at changes in parental reported HRQOL from baseline (BL) to year 1 (Y1) in the Thalassemia Clinical Research Networks (TCRN) Thalassemia Longitudinal Cohort (TLC) study. Patients and Methods. The TCRN is a NIH-sponsored network of 16 major thalassemia centers in the US, Canada and London. We report here on the results from 77 patients under the age of 14 who completed BL and assessments at Y1. Overall the patients were 47% male with a mean age of 9 years (range 5–13). 94% were chronically transfused, and 69% had β-thalassemia, and 12% were E-β thalassemia patients. 57% used an oral chelator, while 29% were on desferoxamine (DFO). HRQOL was measured by self-report with the Children Health Questionnaire (CHQ), 28-item Parental Form (PF28). The 28 items derive 12 subscales that assess physical and psychosocial health. 2 summary scales assess overall physical health and psychosocial health. We defined a clinically significant change as a difference of at least 2 points on any subscale. Results. Clinical Changes: 45% saw a reduced number of transfusions from BL to year 1 (32% showed no change). 73% did not change chelator, while 18% changed from DFO to oral (2.6% other way). 5% began a chelation regimen. Only one percent of patients developed new secondary complications. 63% showed no change in their general adherence rate; 25% showed a decrease. HRQOL changes: As a population, mean HRQOL remained stable over the 1 year study period. Age appears to be significant for CHQ assessment of child's self esteem and behavior (and overall psychosocial assessment), but gender, country and ethnicity do not appear to be significant. The average number of scales with significant changes was eight. Only one CHQ assessment does not show any significant changes on any CHQ scale, while three reports showed changes on all 14 scales. The psychosocial scales showed more significant changes than physical health assessments. Figure 1 illustrates the reported changes by scale. Measures of overall general health, parental emotions and child behavior showed the most changes. Assessment of the child's physical and psychosocial roles and family cohesion showed the least change. The physical health assessments of function and pain showed lower significant changes than the psychosocial health assessments. More psychological health measures show a significant drop than familial assessments. When we examine scale changes by age groups, the youngest age group (5-7) showed modestly better physical and psychosocial scale changes. The 8–10 age group saw more than twice the number of parents seeing a decline in a physical or psychosocial health scale. The oldest age group (11-14) showed the fewest changes, with mainly higher physical health scale changes, but lower scores on the psychosocial scales. Clinical Associations: Changes in number of transfusions and adherence do not appear to impact CHQ assessment. However, changes in chelator appear to be significant for parental time (P=0.048) and the psychosocial summary scale (p=0.04). Changes in secondary complication appear to be associated with changes in the CHQ assessment of the child's behavior (p=.04). Conclusions. The dearth of clinical changes suggests that patients enrolled in TCRN are receiving optimized health care. The lack of changes on the CHQ's physical health scales is to be expected given the low number of clinical changes, and the reported changes in CHQ do not appear to be related to clinical changes. At this stage of data analysis, CHQ assessment in thalassemia appears to be associated with the normal effects a growing child has on the family. This would be the desired result of effective clinical intervention in thalassemia. Further analyses of changes are needed to understand the relationship between changes in HRQOL and specific changes in clinical measures. Disclosures: Neufeld: Novartis, Inc: Research Funding; Ferrokin, Inc: Research Funding.

Abstract 1371 Poster Board I-393 The study examines the quality of life (QOL) of pediatric thalassemia patients and their families enrolled in the Thalassemia Longitudinal Cohort (TLC) study of the NHLBI-sponsored Thalassemia Clinical Research Network, which comprises 17 centers in the US, Canada, and London, UK. The study evaluates 99 baseline responses to the Children's Health Questionnaire (CHQ) PF28, a self-administered survey filled out by the parent or guardian of patients age 5 y and older. The CHQ utilizes 12 scales that can be grouped into parental assessments of the child's physical well-being; mental, emotional and behavioral health; and the familial context. We previously showed that compared to the US population, the thalassemia population is significantly different on 7 of the 12 scales. Here we evaluate these data by patient gender, race, age, and chelator type. The mean age of the population was 9.7 y (range 5.0-13.8 y), with 48% male, and 65% non-white. While parents assessed males to have a lower QOL than females, the only significant difference was in their assessment of the child's emotional role/behavior (school or friends). When comparing white to non-white (predominantly Asian) patients, with the exception of bodily pain, non-white thalassemia patients reported poorer PF28 scores. However, only the reported impact on parental time and emotion are significant. These variances appear to mirror the US population. Figure 1 shows PF28 summary scores by age in thalassemia compared to the general US population. Parents evaluate their child with thalassemia with lower physical health than US norms (p Finally, when CHQ PF28 assessments are compared by chelator type (subcutaneous deferoxamine vs. oral deferasirox), parents report that children receiving deferoxamine have generally lower QOL than the rating for those receiving Deferasirox. However, the only significant differences are with perceived physical function, impact on family activities, and the overall physical summary scale. The CHQ PF28 data provides important insight into the impact the child with thalassemia has on the family. Although psychosocial QOL is similar, children, and especially adolescents, with thalassemia have lower physical QOL, especially those on chelation with Deferoxamine. Because PF28 takes the parents' point of view, it can't be determined from these data alone whether the reported difference between parenteral and oral chelator would hold true for direct patient assessments. The gender of the child also appears to affect parental expectation of the child's QOL. These data validate the observational evidence that a child with thalassemia has a significant impact on the family. Figure 1 TLC CHQ PF28 Summary Scales compared to US norms Figure 1. TLC CHQ PF28 Summary Scales compared to US norms Disclosures: Odame: Novartis: Consultancy, Speakers Bureau. Thompson: Novartis: Research Funding. Neufeld: Novartis: Research Funding.

Liver biopsy, which is the gold standard for liver iron assessment in patients with hemosiderosis, is painful, associated with risk of infection or bleeding, and may be affected by uneven iron distribution and variation in analytical methods. Monitoring iron overload by serum ferritin is still a routine practice although its limitations are well known. Therefore, using non-invasive liver iron assessment by quantitative MRI or by liver susceptometry with a SQUID biomagnetometer (BLS) would be the better alternatives. This report explores the accuracy of liver iron concentration (LIC) measured by BLS at CHRCO compared to liver biopsy, in patients with thalassemia and sickle cell disease. A total of 33 patients with chronically transfused thalassemia (n=16) or sickle cell disease (n= 17) were prospectively assessed for LIC measured by BLS and liver biopsy within 2 month of each other. LIC was measured by a low temperature SQUID biosusceptometer system (Ferritometer®) under the standardized Hamburg-Torino-Oakland protocol. Iron in fresh tissue liver biopsy samples (with a dry weight larger than 1 mg) was measured at Mayo clinics by Inductively Coupled Plasma Mass Spectrometer (ICP-MS). Median value for the wet to dry weight of the tissue samples was 3.8 (3.1–6.2). Subjects ranged in age from 7 to 40 years (median: 18 y). Median LIC (wet weight) measured by SQUID was 1915 (415–4826) [mg/g wet weight ], median LIC by biopsy (dry weight) was 12681(1854–32864) [mg/g dry weight]. Serum ferritin ranged from 405 to 9843 (median: 1831). The Spearman rank correlation between wet weight LIC assessed by BLS and dry weight LIC from fresh tissue sample measured by ICP-MS was highly significant (RS=0.93, p Fig1. LInear regression LIC (BLS)=(0.165 ± 0.008) *LIC (biopsy) weighted by the uncertainties to the two methods (R2 = 0.92, reduced chi-square χ2= 0.5). Fig1. LInear regression LIC (BLS)=(0.165 ± 0.008) *LIC (biopsy) weighted by the uncertainties to the two methods (R2 = 0.92, reduced chi-square χ2= 0.5).

Low bone mineral density (BMD) is commonly seen in regularly transfused thalassemia patients; however, there have been few reports for bone mineral density assessment in transfusion independent thalassemia patients. The present report includes the results of BMD assessments in patients with transfusion independent thalassemia who were referred to the bone density clinic through 2002–2006. BMD was evaluated by dual energy x-ray absorptiometry (DXA, Hologic Delphi A). A convenience sample of 24 patients (Females=15) with transfusion independent thalassemia were measured with a mean age of 22.1 ± 13.8 years. Subjects younger than 10 yrs old (n = 7) underwent scans for Lumbar spine (LS; L1-L4) and whole body (WB), patients ages 10–20 (n = 5) were assessed for LS, WB, and non-dominant hip, and for patients older than 20 (n = 12), LS and hip scans were completed. Z-scores specific for age and gender were generated using Zemel BS et al.(J. Bone Min Res 2004) database. Z-scores less than −2.0 were considered as low bone density. Calcium intake was assessed by a brief food frequency questionnaire. Past medical history, medications, history of fractures, and family history of osteoporosis were obtained by chart review and patient interview. Data is presented as Mean ± SD. T-test was used to assess differences in continuous variables. The mean LS Z-score (n = 24) was −1.5 ± 1.0 and the mean hip Z-score (n = 17) was −0.5 ± 1.1. Mean WB Z-score (n = 10) was −2.0 ± 1.2. There was a significant (p

Children with acute leukemias typically receive RBC transfusions during the course of their treatment. However, the severity and significance of transfusional iron overload is not known in this patient population. Earlier, we reported elevated serum ferritin (SF) in 5 patients with AML who received HLA-identical sibling bone marrow transplantation (BMT). However, SF has a wide predictive interval for liver iron concentration (LIC) in thalassemia and sickle cell disease and the current recommendation is to measure LIC to estimate total body iron burden. Further exploration of the SF-to-LIC ratio (SF/LIC) to investigate the relationship between SF and LIC has shown ratio differences by specific disease (SCD, thalassemia, genetic hemochromatosis), transfusion status and use of chelation. The reasons for these differences are not presently known. In this study LIC was measured within 2 weeks of serum ferritin (SF), in 8 AML patients after transplantation, to explore the significance of the elevated SF and to determine the range and character of the SF/LIC ratio after BMT for AML. LIC was measured (1–4 year after BMT) by a low temperature SQUID biosusceptometer system (Ferritometer®) under the standardized Hamburg-Torino-Oakland protocol. The range for LIC in healthy individuals measured by SQUID is 90–340 mg/g wet weight. The median serum ferritin was 1227 (582–1723) μg/l and the median LIC was 1284 (751–1612) mg/g wet weight or approximately 4 times greater than the upper limit of normal. ALT was measured in 4 patients of which 2 were mildly elevated. Neither LIC nor SF changed over the interval of follow-up extending to 3 years in 2 patients (aged 11.5y and 14.5 y) who returned annually for LIC measurements. The ratio of SF/LIC ranged from 0.5 to 1.4 (median: 0.9) in the patients with AML. This compares to ratios of 1.2 (0.6–2.6) in regularly transfused sickle cell disease patients (n=45), 0.87 (0.23–2.7) in transfusion dependent thalassemia patients and 0.32 (0.05–0.57) in transfusion independent thalassemia patients. These preliminary observations suggest that children with acute leukemias who undergo bone marrow transplantation develop significant transfusion related iron accumulation. Additional investigation should be undertaken to determine if AML patients would benefit from iron reduction therapy by phlebotomy after BMT.

Introduction Assessment of QOL is important for clinicians, as it will allow them to provide the patients with better care. The objective of this study is to assess the QOL in SCD patients. Methods A convenience sample of 34 patients with SCD (50% female) with a mean age of 21 years (SD= 9.4 y), completed a Dartmouth Care Cooperative Chart System (COOP) questionnaire (Table 1) during a comprehensive clinic visit at Children's Hospital & Research Center in Oakland. High scores (patient ratings of 4 or 5) represent unfavorable levels of health or major limitations. A score of 3 represents moderate impairment while scores of 1 or 2 indicate no impairment. A brief chart review was completed to obtain medical history. Results 60% of the transfused patients (Tx) had severe impairment in at least one domain and this was the case in 71% of non-transfused patients (Non-Tx). As shown in table 2, the most affected domains were different between the two groups of Tx and non-Tx. In non-Tx patients the most affected domains were those of pain, overall health, and social support. In Tx patients, the most affected domains were pain, daily activities, and change in health. Although both groups had a similar amount of pain (non-Tx=42% and Tx=50%), Tx patients reported a better overall QOL (question 9). The most common complications that non-Tx patients suffered from were AVN (71%), vaso-occlusive episodes (46%), acute chest syndrome (46%), pneumonia (17%), reactive airways disease (17%), chest pain (13%), headaches (13%), and sepsis episodes (13%). Data showed that 30% of the Tx patients suffered from strokes previous to start of transfusion. The most common complications found in these patients were acute chest syndrome (30%), reactive airways disease (50%), urinary tract infections (20%), and depression (20%). Conclusions Both transfused and non-transfused SCD patients suffer from serious impairments in QOL. We recommend all SCD patients undergo QOL assessments and intervention which focuses on affected domains. Studies are needed to determine the impact of complications on QOL. Table 1 . COOP Questionnaire Q1 Physical Fitness Q2 Feelings Q3 Daily Activities Q4 Social Activities Q5 Pain Q6 Change in Health Q7 Overall Health Q8 Social Support Q9 Quality of Life Table 2 . Frequency of moderate to severe impairment of domains Non-Tx Tx Score 3 (%) Score 4/5 (%) Score 3 (%) Score 4/5 (%) Q1 13 25 10 10 Q2 33 25 11 11 Q3 27 1 22 22 Q4 1 1 0 20 Q5 21 42 10 50 Q6 21 17 38 25 Q7 29 33 10 30 Q8 26 30 13 13 Q9 33 17 20 0

Assessing iron chelator efficacy in clinical trials requires standardization of liver iron concentration measurements. In a blinded round-robin test, liver iron concentration (LIC) was measured within 1 month in 18 patients with thalassemia or sickle cell disease and in 10 normal subjects at the 3 SQUID biosusceptometer systems located in Hamburg (UKE), Torino (TOR), and Oakland (CHO). Mean LIC values (range: normal up to 8000 μg/g-liver) were determined from 5 separate vertical scans. The observed intrasite precision (SD of Altman-Bland differences from duplicate measurements with repositioning) was found in the expected range of ±130 (UKE), ±200 (TOR), and 220 μg/g-liver (with 3 operators involved at CHO). Prediction of LIC at TOR and CHO in comparison with UKE was very good, with coefficients of determination between sites of R2 = 0.97, resulting in intersite standard deviations (SD) of 247 and 326 μg/g-liver, respectively. Differences of 24, 20, and 5% were noted for the comparisons UKE-TOR, CHO-TOR, and UKE-CHO, respectively (see Fig. 1). This suggests the need for further standardization of analysis methods. In conclusion, we found that intra-site precision was within an acceptable range for repeat measurements in the majority of iron overloaded subjects. Prediction of liver iron concentration at the three centers was highly correlated. Figure 1. Agreement (Passing-Bablok regression) between liver iron measurements (mean LIC from 2 positions) by the SQUID biosusceptometer system in Hamburg (LIC-UKE) and the systems in Torino (LIC-TOR) and Oakland (LIC-CHO). Figure 1. Agreement (Passing-Bablok regression) between liver iron measurements (mean LIC from 2 positions) by the SQUID biosusceptometer system in Hamburg (LIC-UKE) and the systems in Torino (LIC-TOR) and Oakland (LIC-CHO).

Introduction: Frequently transfused patients with SCD develop hemosiderosis, which, if untreated, results in multi-organ damage and early death. DFO is the only iron chelator (IC) approved by the FDA and is injected subcutaneously over 8–12 hours/day, 5–7 days/week. However, adherence to this therapy is difficult for patients. This report summarises patient satisfaction with deferasirox (DSX), an oral IC in development, compared to DFO in an open-label Phase II trial. Methods: A total of 195 patients with SCD were randomized and treated with DSX (n=132) or DFO (n=63). Seventy-four patients had not received IC at baseline, of whom 25 were randomized to DFO and 49 to DSX. DSX was taken orally once/day while DFO was infused via a portable pump over 8–12 hours/day, 5–7 days/week. Patient reported outcome data were documented, including satisfaction and convenience with treatment, and number of hours lost/month for taking IC. Patients with previous experiences of DFO reported preferences for DSX, DFO, or neither. At end-of-study (EOS), patients reported their willingness to continue taking the drug they were on. Results: At baseline, only 21% of patients previously treated with DFO reported that they were ‘very satisfied’ or ‘satisfied’ with DFO taken prior to the study, and only 16.5% reported that DFO was ‘very convenient’ or ‘convenient’. Further, 77.1% of them preferred DSX. Reasons included: more convenient to take (38.6%), less disruptive to their day (18.1%), less sore (15.7%) and less disruptive to sleep (6.0%). Table 1 indicates the greater satisfaction and convenience experienced by those on DSX versus DFO regardless of chelation status at baseline. At EOS, significantly more patients on DSX (84.3%) indicated they would be willing to continue DSX, compared to 10.5% of patients on DFO. Similarly, patients reported that time lost due to taking DSX ranged from 0.2–2.9 hours/month, while time lost due to taking DFO ranged from 3.2–37.4 hours/month. Table 1. Satisfaction and Convenience in Patients Previously Treated with DFO versus Treatment Naïve Patients DSX DFO Previous DFO Treatment naïve Previous DFO Treatment naïve Very Satisfied or Satisfied, % Wk 2 85.5 73.5 23.7 24.0 Wk 12 89.2 63.3 42.1 36.0 Wk 24 86.7 69.4 39.8 32.0 EOS 84.3 59.2 23.7 24.0 Very Convenient or Convenient, % Wk 2 79.5 73.5 15.8 32.0 Wk 12 83.1 71.4 36.8 24.0 Wk 24 79.5 71.4 34.2 24.0 EOS 79.5 63.3 18.4 20.0 Conclusions: Results suggest satisfaction and convenience scores are significantly higher, and the impact on daily activities is less, for patients on DSX than those on DFO. Further studies are needed to explore whether higher satisfaction and convenience will lead to better adherence to DSX. As adherence to chelation therapy impacts on survival in transfusion-dependent patients with SCD, these data indicate that DSX may significantly improve the care of transfusion-dependent patients.

Introduction: Compliance with Desferrioxamine is the most important factor determining morbidity and mortality in transfusion dependent thalassemia patients. Clinical and laboratory methods to assess compliance are essential in modifying patient treatment and determining efficacy of therapy. Simple screening tools for patient compliance assessment needs to be developed and must be correlated with reliable measurement of iron stores. Objective: The purpose of this study is to assess a simple compliance tool and compare it with quantitative iron stores. Methods and Patients: A Likert Numerical Scale assessed Adherence to a chelation program. This scale rated adherence to compliance from 1 (poor) to 5 (excellent). 90 transfusion dependent thalassemia patients underwent a brief interview, followed by the administration of the Likert Numerical scale to both the patient and their corresponding physician. This was followed by quantitation of their Serum Ferritin (SF) and liver iron concentration (LIC) utilizing the LTc- SQUID biosusceptometer (Ferritometer ®, Model 5700, Tristan Technologies, San Diego, USA). A subset of patients was followed serially to determine if compliance and liver iron changed as a result of the initial testing. Results: LIC was assessed in a total of 90 transfusion-dependent patients with a mean age of 17 years (4 – 48 y). The average duration of transfusion and chelation therapy was 14.6 y (range: 1 – 42) and 12.1 y (1 – 40 yrs), respectively. The median value for LIC was 2307 μg/g-liver (range: 364 – 7570). 78 % of patients rated themselves as very compliant (4 or 5) yet 40% of these patients had elevated LIC > 2500μg/g-liver. 92% of the patients received an identical rating from their physician (Spearman rank RS = 0.9). 19/28 patients with high compliance ratings had elevated LIC (> 2500 μg/g) secondary to recent onset of chelation therapy or inadequate Desferrioxamine dosing when compared to their PRBC cc/kg/y requirements. In 9 compliant patients, no apparent explanation for their elevated liver iron could be found. A subgroup of 16 patients with a mean age of 17 years (3 – 44y) underwent serial LIC and SF measurements. The median interval between first and last measurements was 10 month (range: 4–15). At the time of first SQUID measurement, the median values for LIC and SF were1202 μg/g-liv (893–6167) and 1502 μg/l (660–4496) respectively. Following counseling concerning the liver iron results, DFO dose changes occurred and compliance rose from 1 (poorest) to 5 (excellent) in 7/8 patients studied. The LIC decreased by 25% (7–60%) as the compliance rate improved. In contrast, the SF fluctuated, but at the time of study testing, 10 patients had a significant increase in serum ferritin despite a lower LIC. Conclusion: Patient compliance can be adequately assessed and result in improved iron balance. However, SF may underestimate compliance and result in inadequate management. We recommend all patients undergo serial assessment of compliance accompanied with LIC and necessary counseling containing their iron stores.

Introduction: Thalassemia patients have experienced a dramatic increase in lifespan secondary to improved and more complicated therapy. The impact of the disease and its treatment on quality of life is largely unknown. Determining the degree of health impairment as perceived by the patient is essential information needed to recommend suitable therapy. Factors that affect the quality of life of thalassemia major patients may differ from thalassemia intermedia patients. Identifying the specific causes for negative patient assessment of overall health status can result in successful intervention. The objective of this study is to determine the factors that affect quality of life in both transfused and non-transfused thalassemia patients. Methods: The Dartmouth Care Cooperative Chart System (COOP) questionnaire is a standardized, validated, visual screening tool that screens the major domains affecting quality of life. Patients rate quality of life from excellent (1) to poor (5). Scores of 1 and 2 are normal. A Score of 3 are mild to moderate impairment, and 4 and 5 are severe abnormalities. 50 patients were randomly selected during a comprehensive visit to complete a COOP questionnaire. These results were augmented by a brief medical history and chart review. Results: Forty-eight thalassemia patients, including 25 transfusion dependent (Tx) and 23 non-transfused (Non-Tx) patients (50% female) were randomly selected and completed the COOP questionnaire. The mean age of the total population was 19 years (0.9–37.9 yrs) and was similar in both groups. Half of both groups had scores of 3 or less indicating no severe impairment. However, 56% of patients had ratings of 3 indicating mild to moderate impairment of major domains. Four patients (2 Tx, 2 Non-Tx) had repeated 4–5 ratings in multiple domains indicating severe impairment of quality of life. The most commonly reported affected domains were feelings, such as anxiety, depression, and concern of overall health status or indications of recent deterioration in health. Conclusion: At least 50% of transfusion and non-transfusion dependent thalassemia patients demonstrate some impairment in quality of life. Forty-four percent of the population had a severe impairment in at least one domain. In particular, mental health issues are widespread. In contrast to previous beliefs, non-transfusion dependent patients also suffer serious impairment in quality of life. This data suggests all patients should undergo quality of life assessments and intervention, which focuses on affected domains. Studies to determine if quality of life affects patients’ adherence to chelation therapy are needed.

Introduction: Monitoring iron overload by serum ferritin in patients with hemosiderosis is still a routine practice although its limitations are widely studied and well known. Using non-invasive liver iron assessment by quantitative MRI or by biomagnetic liver susceptometry (BLS) with SQUID biomagnetometers would be the better alternative, however, these methods are available at only a few centers worldwide. Objective: To determine the relationship between serum ferritin (SF) and liver iron concentration (LIC), measured by BLS at CHRCO, in patients with different types of hemosiderosis. Methods and Patients: A total of 97 patients with thalassemia (TM: 3 to 52 y, 54% females) and 39 patients with sickle cell disease (SCD: 5 to 49 y, 60% female) were prospectively assessed for LIC and SF. Both tests were performed within 2 weeks of each other. Most patients with TM and SCD were chronically transfused, while 10 b-thalassemia intermedia (TI), 5 HbE/β-thalassemia (HbE), and 5 SCD patients were not on transfusion programs. LIC was measured by LTc SQUID biosusceptometer system (Ferritometer®, Model 5700, Tristan Technologies, San Diego, USA) under the standardized Hamburg-Torino-Oakland protocol. A non-parametric test (U-test) was utilized to analyze differences between SF and LIC data. Results: In chronically transfused TM and SCD patients, the median SF and LIC were very similar (Table I). In TI&HbE patients, ferritin results were disproportionately low with respect to LIC. In order to improve prediction of iron stores by SF, the SF/LIC ratio was calculated. There was a significant difference between the median ratios of the two groups of transfused and non- transfused thalassemia patients, 0.82 vs. 0.32 [μg/l]/[μg/gliver], respectively (p < 0.01). In SCD patients the ratio is significantly (p < 0.01) higher. Conclusion: Present data confirm ferritin to be a poor predictor of liver iron stores both in sickle cell disease and thalassemia. Relying only on ferritin to monitor iron overload in patients with hemosiderosis can be misleading, especially, in sickle cell disease and non-transfused thalassemia patients. Taking into account disease specific ferritin-LIC relations, could improve the prediction of iron stores. However, assessment of liver iron stores is the ultimate method to initiate and adjust chelation treatment in order to avoid progressive organ injury. Table I. Median values and ranges ( − ) of serum ferritin (SF) and liver iron concentration (LIC) in transfused (Tx) and non-transfused (non-Tx) hemosiderosis patients. Patient group n SF μg/l] LIC [mg/gliver ] SF:LIC Thalassemia Tx 82 1721 (209–8867) 3424 (364–7570) 0.82 (0.3–1.8) TI &HbE non-Tx 15 766 (52–2681) 2174 (226–5498) 0.32 (0.1–1.4) SCD Tx 34 2757 (400–9138) 1941 (518–6670) 1.2 (0.6–3.3)

The “Optimal Liver Iron” range in iron overloaded patients with thalassemia has been established by Olivieri and Brittenham (Blood, 1997) as 1–2.2 mg/g wet weight liver using direct measurement or calculated as 3.2 to 7 mg/g dry liver weight based on a 3.33 correction factor for body water. This report describes the relationship between liver iron concentration (LIC) measured by SQUID biosusceptometry (BLS, wet weight) compared to liver biopsy (dry weight), in patients with thalassemia (THAL) or sickle cell disease (SCD). A total of 38 chronically transfused patients (THAL n=19, SCD n=19) were prospectively assessed for LIC measured by BLS and liver biopsy within 2 month of each other. Most BLS results were submitted to data repository before receiving iron concentration from liver biopsy. LIC was measured by a low temperature SQUID biosusceptometer system (Ferritometer®) under the standardized Hamburg-Torino-Oakland protocol. Iron in fresh tissue and paraffin embedded liver biopsy samples was measured at Mayo clinics by Inductively Coupled Plasma Mass Spectrometer (ICP-MS). Subjects ranged in age from 5 to 40 years (median: 18 y). Median LIC (n=38) measured by SQUID was 1777 (365–4883) [mg/g wet weight], median LIC by biopsy (fresh tissue) was 10861(1854–32864) [mg/g dry weight]. After excluding the subjects with BMI>30 kg/m2 (n=5), the Spearman rank correlation between wet weight LIC assessed by BLS and dry weight LIC from fresh tissue sample measured by ICP-MS was highly significant (RS=0.90, p

Despite its limitations, serum ferritin (SF) is commonly used to monitor chelation therapy in primary and secondary hemochromatosis. To better predict liver iron concentration (LIC), we prospectively investigated the relationship between SF and LIC in a total of 421 patients with primary (HFE-1 associated, n=241) or secondary hemochromatosis (n=180), consisting of chronically transfused thalassemia (Tx-Thal: n=89) or sickle cell disease patients (Tx-SCD: n=45) and transfusion independent thalassemia patients (nTx-Thal: n=26). In all patients, LIC was measured by SQUID biosusceptometry. SF correlated with LIC (RS = 0.51–0.83, p < 0.001) but was a poor predictor for LIC. SF was significantly lower (p < 0.001) in nTx-Thal and HFE-1 patients despite similar LIC (421 – 5524 μg/g-liver) and it was higher in Tx-SCD compared to Tx-Thal (p = 0.03). In order to improve the value of SF, we calculated the SF/LIC ratio for each group. SF/LIC remained stable over time in patients whose therapy did not change. In iron loaded patients without blood transfusion therapy (nTx-Thal and HFE-1), the median SF/LIC ratio was significant lower (0.32 and 0.43) as compared to transfused patients (Tx-Thal: 0.87, HCV-Thal: 0.99, Tx-SCD: 1.2), probably, indicating differences in the secretion of ferritin into plasma. We conclude that SF alone can mislead the iron unloading therapy as it underestimates LIC in nTx-Thal patients and overestimates LIC in Tx-SCD patients. Once the initial LIC value is obtained and the individual SF/LIC ratio is determined in a patient, the ratio together with SF may be more useful than SF alone to monitor iron overload and predict LIC.