Results of NOPHO ALL2008 treatment for patients aged 1-45 years with acute lymphoblastic leukemia.

Adults with acute lymphoblastic leukemia (ALL) do worse than children. From 7/2008 to 12/2014, Nordic and Baltic centers treated 1509 consecutive patients aged 1-45 years with Philadelphia chromosome-negative ALL according to the NOPHO ALL2008 without cranial irradiation. Overall, 1022 patients were of age 1-9 years (A), 266 were 10-17 years (B) and 221 were 18-45 years (C). Sixteen patients (three adults) died during induction. All others achieved remission after induction or 1-3 intensive blocks. Subsequently, 45 patients (12 adults) died, 122 patients relapsed (32 adults) with a median time to relapse of 1.6 years and 13 (no adult) developed a second malignancy. Median follow-up time was 4.6 years. Among the three age groups, older patients more often had higher risk ALL due to T-ALL (32%/25%/9%, P<0.001), KMT2A rearrangements (6%/5%/3%, P<0.001) and higher day 29 residual leukemia for B-lineage (P<0.001), but not T-ALL (P=0.53). Event-free survival rates (pEFS5y) were 89±1% (A), 80±3% (B) and 74±4% (C) with significant differences only for non-high risk groups. Except for thrombosis, pancreatitis and osteonecrosis, the risk of 19 specified toxicities was not enhanced by age above 10 years. In conclusion, a pediatric-based protocol is tolerable and effective for young adults, despite their increased frequency of higher risk features.

Haemostatic function and biomarkers of endothelial damage before and after platelet transfusion in patients with acute myeloid leukaemia.

OBJECTIVES: The beneficial effect of platelet transfusion on haemostasis is well established, but there is emerging evidence that platelet transfusion induces an inflammatory response in vascular endothelial cells. BACKGROUND: We investigated haemostatic function and endothelial biomarkers before and after platelet transfusion in patients with acute myeloid leukaemia. MATERIALS AND METHODS: Blood was sampled before, 1 and 24 h after platelet transfusion. Primary and secondary haemostasis was evaluated by whole blood aggregometry (Multiplate) and thromboelastography (TEG). Endothelial biomarkers (sICAM-1, syndecan-1, sThrombomodulin, sVE-Cadherin) and platelet activation biomarkers (sCD40L, TGF-beta) were investigated along with haematology/biochemistry analyses. RESULTS: Twenty-two patients were included. Despite continued low platelet counts, platelet transfusion normalised the median values of most TEG parameters and slightly increased platelet aggregation (all P < 0·05). Endothelial biomarkers were not significantly affected by transfusion. The 1 h sCD40L level correlated positively with Syndecan-1 and soluble thrombomodulin delta values, biomarkers of endothelial damage (both P = 0·005). CONCLUSION: Platelet transfusion improved haemostasis, whereas post-transfusion increases in sCD40L were associated with endothelial damage, indicating that transfused platelets and platelet-derived pro-inflammatory mediators may have opposite effects on the endothelium.

Haemostatic function and biomarkers of endothelial damage before and after RBC transfusion in patients with haematologic disease.

BACKGROUND AND OBJECTIVES: Transfusion of red blood cells (RBC) is beneficial for the patient but can also be harmful, as randomized trials have demonstrated increased infection rates, bleeding and mortality. The study aim was to investigate the response of the vascular system (the haemostatic function and the endothelium) to RBC transfusion. MATERIALS AND METHODS: Blood was sampled from patients with various transfusion-dependent haematologic diseases before 1 and 24 h after RBC transfusion. Primary and secondary haemostasis was evaluated by whole-blood impedance aggregometry (Multiplate) and by thromboelastography (TEG). Samples were analysed by ELISA for biomarkers reflecting endothelial activation and damage (sICAM-1, syndecan-1, sThrombomodulin (sTM), sVE-Cadherin), platelet activation (sCD40L) and inflammation (hsCRP). RESULTS: A total of 58 patients were enrolled in the study. Median age was 71 years. Compared to before transfusion, patients had slightly reduced coagulability 1 h after RBC transfusion, assessed by TEG. However, transfusion of older RBC products (>14 days) was associated with increased coagulability (all P < 0·05). The level of syndecan-1 increased slightly 24 h after transfusion (median 12·4 (IQR 9-23) vs. 13·2 (9-25) ng/ml, P < 0·01), indicating increased glycocalyx degradation. CONCLUSION: Overall, RBC transfusion was associated with reduced coagulability and endothelial glycocalyx degradation. Transfusion of older RBCs was however associated with increased coagulability. The changes observed were small to moderate and the clinical relevance of these findings should be investigated in larger studies.

Measuring the impact of a restrictive transfusion guideline in patients with acute myeloid leukaemia.

Interventions to change physician transfusion behavior are often evaluated by examining the amount of red blood cell (RBC) units transfused or the proportion of patients transfused before and after the intervention. The pre-transfusion haemoglobin concentration is a sensitive measure of transfusion practice, but has not been used to evaluate behavioral interventions. We examined the effect of a Danish National Board of Health December 2007 transfusion guideline on the behavior of clinicians treating acute myeloid leukaemia (AML). We compared the effect of the guideline on pre-transfusion haemoglobin concentrations with other measures of transfusion behavior, including use of RBC units and proportion of patients transfused. No change in transfusion behavior could be demonstrated by examining amount of RBC units transfused and proportion of patients transfused. Conversely, the pre-transfusion haemoglobin concentration fell significantly. Pre-transfusion haemoglobin determination is a sensitive measure of the effect of an intervention to change physician transfusion behaviour.

Haemoglobinopathies and glucose-6-phosphate dehydrogenase deficiency in a Scandinavian perspective.

Haemoglobinopathies (mainly thalassaemia and sickle-cell anaemia syndromes) and glucose-6-phosphate dehydrogenase deficiency (G6PD) are globally among the most prevalent single-genomic diseases. About 3% of the world's population are heterozygotic for beta-thalassaemia and about 1-2% for sickle-cell anaemia, and it is estimated that more than 400 million people are affected by G6PD deficiency worldwide. The disorders are most prevalent in the Mediterranean area, in Asia and Africa. The Scandinavian countries, among others, have seen a boom in immigration during the past 20 years, and therefore migration makes haemoglobinopathies as well as G6PD deficiency increasingly more important from a differential diagnostic perspective in most countries. The purpose of the present special issue of the Journal is to summarize current epidemiological data and elucidate trends and practices in the laboratory diagnosis of these disorders.

Epidemiology of haemoglobin disorders in Europe: an overview.

OBJECTIVE: As a result of global population movements, haemoglobin disorders (thalassaemias and sickle cell disorders) are increasingly common in the formerly non-indigenous countries of Northern and Western Europe and in the indigenous countries of Southern Europe. This article presents an overview of the changing picture and a method for assessing service needs. METHOD: Data on country of birth or ethnic origin of residents are adjusted to obtain the estimated proportions of residents and births in non-indigenous groups at risk for haemoglobin disorders in European countries. The results are combined with prevalence data in each country of origin to obtain country prevalence estimates. Service indicators (annual tests or other interventions required to ensure equitable delivery of treatment and prevention) are then derived by country. RESULTS: Haemoglobin disorders now occur at comparable frequency throughout Northern, Western and Southern Europe. Annually, there are more affected conceptions in Northern and Western than in Southern Europe, and sickle cell disorders are more common than thalassaemias. There is growing need for health policy-makers to support motivated professionals working to develop optimal patient care, carrier diagnosis, genetic counselling and access to prenatal diagnosis throughout the Region. CONCLUSION: There is a strong case for pan-European collaboration on haemoglobin disorders to share policies, standards and the instruments required to support them. These include methods for needs assessment, service standards, education and information strategies and materials, and methods for evaluating service delivery.

Phenotypic presentation and underlying mutations in carriers of beta-thalassaemia and alpha-thalassaemia in the Danish immigrant population.

OBJECTIVE: The thalassaemia syndromes are the most common hereditary diseases in the world and now appear with relatively high frequency in non-endemic regions. Guidelines recommend the use of mean corpuscular haemoglobin (MCH) alone or in combination with mean corpuscular volume (MCV) in screening for alpha- and beta-thalassaemia. This article deals with the viability of MCV<78 fL alone as screening parameter for thalassaemia in non-endemic regions. MATERIAL AND METHODS: Data from the Center for Haemoglobinopathies, Herlev University Hospital, consist of MCV measurements from 438 patients with alpha-thalassaemia and 450 patients with beta-thalassaemia referred between 1996 and 2005, and simultaneously measured MCV and MCH measurements in 86 patients referred between November 2004 and November 2005. RESULTS: In 450 beta-thalassaemia patients and 117 alpha0-thalassaemia patients diagnosed between 1996 and 2005, only two beta-thalassaemia patients had MCV>or=78 fL. All alpha0-thalassaemia patients had MCV<78 fL. In contrast, 38% of patients with alpha+-thalassaemia had MCV>78 fL. When MCV and MCH were measured simultaneously, one patient with beta-thalassaemia was missed if MCV was used as a screening tool and one patient was missed if MCH was used. Forty-four different beta-thalassaemic mutations were found. CONCLUSIONS: Our data support the notion that the use of MCV<78 fL instead of MCH<27 pg is acceptable as a screening criterion in a non-endemic population. Only 0.5% of the beta-thalassaemia patients were missed and all the patients with alpha0-thalassaemia were diagnosed. Since the racial heterogeneity of the immigrant population in non-endemic regions creates a scenario with a broad spectrum of mutations and haemoglobinopathy, laboratories should be equipped to detect a large variety of mutations.

Cryptococcus neoformans var neoformans resistant to fluconazole in an HIV-negative patient with chronic lymphocytic leukemia.

Cases of fluconazole-resistant Cryptococcus neoformans have been reported in AIDS patients previously treated with fluconazole. We report a case of fluconazole-resistant cryptococcal meningitis in an HIV-negative patient not previously exposed to fluconazole. The patient experienced a clinical relapse after discontinuation of therapy with amphotericin B and subsequent initiation of fluconazole therapy. In vitro resistance was initially verified by Etest and tablet diffusion and later confirmed by NCCLS broth microdilution.

Prevalence of hereditary haemochromatosis in late-onset type 1 diabetes mellitus: a retrospective study.

BACKGROUND: Although genotyping studies suggest that hereditary haemochromatosis is one of the most common genetic disorders in white people, it is still thought of as an uncommon disease. Our aim was to test the hypothesis that hereditary haemochromatosis is a disease often overlooked in patients with late-onset type 1 diabetes mellitus, a late manifestation of untreated iron overload. METHODS: We did a retrospective study in which we genotyped for the C282Y and H63D mutations in the haemochromatosis gene in 716 unselected Danish patients who developed type 1 diabetes mellitus after age 30 years and 9174 controls from the general Danish population. We also screened for hereditary haemochromatosis by assessment of transferrin saturation. FINDINGS: More patients with diabetes (n=9, relative frequency 1.26%, 95% CI 0.58-2.37) than controls (23, 0.25%, 0.16-0.38) were homozygous for C282Y (odds ratio 4.6, 2.0-10.1, p=0.0001). These patients had unrecognised signs of haemochromatosis. Transferrin saturation and ferritin concentrations ranged from 57% to 102% and 17 microg/L to 8125 microg/L, respectively. Frequency of compound heterozygosity (C282Y/H63D) did not differ between patients with diabetes (eight) and controls (131) (odds ratio 0.8, 95% CI 0.4-1.7). Positive and negative predictive values of transferrin saturation greater than 50%, in identification of C282Y homozygosity, were 0.26 and 1.00, respectively. A saturation of less than 50% therefore excluded C282Y homozygosity, whereas a saturation of more than 50% suggested C282Y homozygosity. INTERPRETATION: Measurement of transferrin saturation followed by genetic testing could prevent liver and heart problems and improve life expectancy in patients with diabetes. Population screening before the onset of diabetes might improve the outlook of patients even further, but will be less cost effective.

[Screening for hemoglobinopathies at a knowledge center in Copenhagen. Resources should be allocated to solve a growing health problem in the Nordic countries]. / Hemoglobinopatiscreening vid kunskapscentrum i Köpenhamn. Resurser bör avsättas för att lösa växande hälsoproblem i Norden.

Increased immigration to the nordic countries of people from areas in which hemoglobinopathies are common diseases has resulted in an increased frequency of individuals heterozygous for serious hemoglobin disorders such as beta-thalassemia and sickle cell disease. Thus, in Copenhagen County, about 4 per cent of the immigrants from these countries are carriers of one of these diseases. A center for hemoglobinopathies has been established in Copenhagen County, dealing with diagnostics, screening procedures, genetic counseling, prenatal diagnosis, education and treatment of various hemoglobin disorders. In collaboration with Rigshospitalet and the laboratory serving general practitioners, a screening program for pregnant women of relevant ethnic origin has been established, capable of servicing the entire Copenhagen area.

A phosphoglycerate kinase mutant (PGK Herlev; D285V) in a Danish patient with isolated chronic hemolytic anemia: mechanism of mutation and structure-function relationships.

Phosphoglycerate kinase (PGK) is a X-linked enzyme that plays a key role in the glycolytic pathway. Twelve different variants have already been reported. We describe a new PGK variant, PGK Herlev (Asp 285-->Val), in a 69-year-old Danish patient with isolated chronic hemolysis but who had no neurological or muscular disorders. The description of the mutation is based upon PCR amplification of specific regions of the PGK gene, followed by direct sequencing. Although observed in a male patient, this mutated X-linked gene is expressed partially, i.e., both normal and substituted nucleotides are present at the same position in a ratio of approximately 1:9. The most likely explanation for this observation is based on the occurrence of a somatic mutation of the PGK gene. The relationship of structure to function in PGK Herlev, as well as in all known variants, was examined by the use of a computer model based on the known spatial structure of the yeast and horse enzymes. Such an approach can be generalized to any other protein that has been crystallized and for which x-ray diffraction data are available in a species closely related to man.

[Localized diffuse pulmonary AL-amyloidosis]. / Lokaliseret diffus pulmonal AL-amyloidose.

A 56 year-old woman was admitted due to exertional dyspnoea. Her chest x-ray and CT scanning showed widespread diffuse infiltrative changes in both lungs, associated with a pronounced decrease in diffusion capacity. Transbronchial biopsies showed primary (AL) amyloidosis. Systemic AL-amyloidosis was excluded and diagnosis of localised diffuse parenchymal pulmonary amyloidosis was established. Treatment with prednisolone and melphalan for one year has stabilised the condition. Lung transplantation will be considered in case of deterioration.

[Hemoglobinopathy in the county of Copenhagen]. / Haemoglobinopati i Københavns Amt.

In Copenhagen County, haemoglobinopathy was centralized to the Department of Haematology L, Herlev University Hospital from January 1995. All pregnant women of relevant ethnic origin admitted to the obstetric departments of the Country in 1995, were examined by haemoglobin electrophoresis. furthermore, we performed haemoglobin electrophoresis on immigrants admitted on suspicion of haemoglobinopathy. 24 (4.8%) of 505 examinations in pregnant women were abnormal. 12 reflected a carrier condition for either beta-thalassaemia or sickle cell disease; 53 of 82 examinations in non-pregnant patients were abnormal; 29 had beta-thalassaemia minor and the rest included the haemoglobin variants C, D, E, H and S, mostly in a heterozygous from. The genetic lesions, all of which were mutations, were characterized by molecular genetic analysis in 13 cases with demonstrated beta-gene disorder. The gene frequency of haemoglobinopathies among immigrants to Denmark is common. The Danish health care system must therefore be prepared to address this problem including the clinical aspects, screening and molecular biological examinations, prenatal diagnosis and genetic counselling.

In B-cell chronic lymphocytic leukaemia chromosome 17 abnormalities and not trisomy 12 are the single most important cytogenetic abnormalities for the prognosis: a cytogenetic and immunophenotypic study of 480 unselected newly diagnosed patients.

Of 560 consecutive, newly diagnosed untreated patients with B CLL submitted for chromosome study, G-banded karyotypes could be obtained in 480 cases (86%). Of these, 345 (72%) had normal karyotypes and 135 (28%) had clonal chromosome abnormalities: trisomy 12 (+12) was found in 40 cases, 20 as +12 alone (+12single), 20 as +12 with additional abnormalities (+12complex). Other frequent findings included abnormalities of 14q, chromosome 17, 13q and 6q. The immunophenotype was typical for CLL in 358 patients (CD5+, Slg(weak), mainly FMC7-) and atypical for CLL in 122 patients (25%) (CD5-, or Slg(strong) or FMC7+). Chromosome abnormalities were found significantly more often in patients with atypical (48%) than in patients with typical CLL phenotype (22%) (P < 0.00005). Also +12complex, 14q+, del6q, and abnormalities of chromosome 17 were significantly more frequent in patients with atypical CLL phenotype, whereas +12single was found equally often in patients with typical and atypical CLL phenotype. The cytomorphology of most of the +12 patients was that of classical CLL irrespective of phenotype. In univariate survival analysis the following cytogenetic findings were significantly correlated to a poor prognosis: chromosome 17 abnormalities, 14q+, an abnormal karyotype, +12complex, more than one cytogenetic event, and the relative number of abnormal mitoses. In multivariate survival analysis chromosome 17 abnormalities were the only cytogenetic findings with independent prognostic value irrespective of immunophenotype. We conclude that in patients with typical CLL immunophenotype, chromosome abnormalities are somewhat less frequent at the time of diagnosis than hitherto believed. +12single is compatible with classical CLL, and has no prognostic influence whereas chromosome 17 abnormalities signify a poor prognosis. In patients with an atypical CLL immunophenotype, chromosome abnormalities including +12complex, 14q+, del 6q and chromosome 17 are found in about 50% of the patients, and in particular chromosome 17 abnormalities suggest a poor prognosis.