Cytokine Levels in Patients with ß-Thalassemia Major and Healthy Individuals: a Systematic Review and Meta-Analysis.

BACKGROUND: Cytokine levels in patients with ß-thalassemia major (ß-TM) have been assessed in several studies. Accordingly, a wide variety of immune disturbances has been shown in patients with thalassemia. Recurrent transfusions cause iron overload, which induces an increase in the production of cytokines. However, no systematic approach or meta-analysis has been done to provide a clear feature of cytokine levels in ß-TM. The present meta-analysis aimed to summarize the existing evidence regarding different levels of cytokines in patients with Β-TM compared to healthy controls. METHODS: This study was performed according to the PRISMA checklist. A systematic search was done in Web of Science (ISI), Scopus, and PubMed databases. The quality of the included studies was assessed based on the New-castle-Ottawa Scale. Meta-analysis was run via STATA 13 software. The standardized mean difference was considered the effect size for comparing the continuous variables. RESULTS: This meta-analysis included 16 studies conducted on 805 ß-TM patients and 624 healthy individuals (with the mean age of 16.10 ± 4.33 and 16.22 ± 3.78, respectively). The results showed significantly higher levels of Tumor Necrosis Factor-alpha (TNF-α), Interleukin-6 (IL-6), and IL-10 in patients with ß-TM compared to the healthy controls. CONCLUSION: The results indicated that the levels of both inflammatory and anti-inflammatory cytokines were higher in patients with ß-TM compared to the healthy population, which could be associated with higher levels of oxidative markers in these patients. Further studies are suggested to evaluate the difference in cytokine levels among different types of thalassemia.

Postpartum Hemorrhage in Heterozygote Factor XIII Deficient Women Compared With Healthy Women. A Cross-Sectional Experience From Iran.

Postpartum hemorrhage (PPH) is a major cause of maternal mortality, which is a common clinical manifestation in women with rare bleeding disorders. In this study, we compare PPH and its complications in heterozygote factor XIII (FXIII) deficient women with healthy women. In this cross sectional case study, 50 women with heterozygote FXIII deficiency and 50 healthy women are evaluated. Data were initially collected by interviewing the women who were receiving FXIII replacement therapy after their childbirths. Data were analysed using SPSS (Version 22) and a P-value of less than .05 was considered statistically significant. The mean age in the patient and control groups were 31.2 and 32.5 years respectively. The occurring rate of PPH in the patient group was significantly higher than the control group (34% vs 2%) (P-value <.0001). None of the confounding variables such as maternal age, gestational age, numbers, and types of delivery in women with PPH showed any significant differences between the control and patient groups. According to the results of this study, the risk of PPH (early and late), miscarriage, and menorrhagia in women who are heterozygous for FXIII deficiency is significantly higher than healthy women. However, the effect of other factors such as maternal age, gestational age, number, and type of delivery require further studies to delineate any confounding factors.

The effect of T helper (Th)/T cytotoxic (Tc) ratio on disease severity in type A hemophilia patients.

BACKGROUND AND OBJECTIVES: The aim of this study was to investigate the T helper (Th) to T cytotoxic (Tc) ratio in children suffering from type A hemophilia disease and to evaluate the correlation of this ratio with disease severity. MATERIAL AND METHOD: Two mls of EDTA anti coagulated whole blood was collected. Immunophenotyping of lymphocytes count was carried out by FACS analysis using a double CD4 and CD8 kit. The mean ± SD of absolute numbers of CD4 and CD8 lymphocytes/ml was calculated and the ratio of CD4/CD8 was evaluated by statistical method. RESULTS: Among 80 type A hemophilia patients, 66 (82.5%) were male. The mean age was 15 ± 3.51 years. 12 (15%) of them were suffering from mild disease and 68 (85%) had sever disease. The CD4 /CD8 ratio was obtained between 0.45 and 1.44 with mean1.79 ± 0.78. The correlation between this ration and disease severity was 0.019. CONCLUSION: The results showed that CD4/CD8 ratio has correlation with disease severity in type A hemophilia patients, however there was no association between this ratio and gender.

Association of HFE Gene Mutations With Serum Ferritin Level and Heart and Liver Iron Overload in Patients With Transfusion-dependent Beta-Thalassemia.

OBJECTIVE: This study was performed on patients with transfusion-dependent beta-thalassemia (TDT) to investigate the effect of HFE gene mutations of iron overload in a large group of patients with TDT major and its relationship with heart and liver T2* magnetic resonance imaging (MRI) level. MATERIALS AND METHODS: In a cross-sectional study, a total of 253 patients with TDT who had regular blood transfusion were included in this study. HFE gene mutations including H63D and C282Y were evaluated in all patients through molecular assay. Heart and liver T2* MRI results, types, duration of iron therapy, and the demographic data including age, gender, serum ferritin level, blood transfusion, and splenectomy history of the included participants were also collected, using a questionnaire. RESULTS: Homozygous and heterozygous H63D mutation was found in 39.5% of the patients and C282Y mutation was found only in 1 patient. Ferritin level was significantly higher in patients with H63D mutation in comparison with patients without this mutation (P=0.036). Although heart T2* MRI and also the liver T2* MRI in the patients with H63D was slightly higher, the difference was not statistically significant. No significant correlation was observed between serum ferritin level and heart and liver T2* MRI, and iron chelation regimen. DISCUSSION: Heart and liver iron overload was not significantly different between patients with and without H63D mutation. As for serum ferritin, it was significantly higher among patients with H63D mutation compared with patients without this mutation. Hence, it is recommended to consider HFE gene mutations among patients with thalassemia to reach a better iron overload evaluation and management.

Effects of three months of treatment with vitamin E and N-acetyl cysteine on the oxidative balance in patients with transfusion-dependent ß-thalassemia.

Oxidative stress is a major mechanism contributing to the progression of ß-thalassemia. To assess the effect of vitamin E and N-acetyl cysteine (NAC) as antioxidant agents on total oxidative stress (TOS) status and total antioxidant capacity (TAC) in patients with transfusion-dependent ß-thalassemia (TDT). In this open-label randomized controlled trial, from May to August 2019, 78 eligible patients with TDT over the age of 18 were enrolled. All patients were registered at the Thalassemia Clinic of Shiraz University of Medical Sciences in Southern Iran. Patients were randomly allocated to the NAC group (10 mg/kg/day, orally), vitamin E group (10 U/kg/day, orally), and control group. The duration of the study was 3 months. The mean age of the participants was 28.5 ± 5.1 (range: 18-41) years. At the end of the study, TOS significantly decreased only in the vitamin E group (mean difference (MD), 95% confidence interval (CI): 0.27 (0.03-0.50), P = 0.026). TAC significantly decreased in both supplemented groups at the 3rd month of treatment (NAC group: MD (95% CI): 0.11 (0.04-0.18), P = 0.002 and vitamin E group: 0.09 (0.01-0.16), P = 0.022 respectively). Hemoglobin did not significantly change at the end of the study in each group (P > 0.05). Mild transient adverse events occurred in 4 patients of the NAC group and 5 patients of the vitamin E group with no need to discontinue the treatment. Vitamin E can be a safe and effective supplement in improving oxidative stress in patients with TDT. Moreover, it seems that a longer duration of using antioxidant supplements needs to make clinical hematologic improvement in TDT patients.

Hb S (HBB: c.20A>T) and α- and ß-Thalassemia Coinheritance in Iranian Patients.

Hb S (HBB: c.20A>T) and α- and/or ß-thalassemia (α- and/or ß-thal) coinheritance is a common genetic disorder in regions with a high prevalence of thalassemia and sickle cell disease. The clinical manifestations of this coinheritance vary from mild to severe complications. Iran is a country with a high incidence of thalassemia and sickle cell disease. This study aimed to evaluate the coinheritance of sickle cell disease with α- and/or ß-thal in Iranian patients. In this cross-sectional study from 2018-2019, a total of 47 participants with the Hb S abnormality, who were referred to the Zafar Thalassemia Clinic (Tehran, Iran), were selected as a study group. Molecular analysis for the evaluation of α and ß gene mutations was performed in all participants. Hb SS, Hb S/ß-thal and Hb S/Hb D-Punjab (also known as Hb D-Los Angeles, Hb D-Chicago, Hb D-North Carolina, Hb D-Portugal and Hb Oak Ridge) (HBB: c.364G>C) were detected in 21 (44.7%), 23 (48.9%) and three (6.4%) patients, respectively. α Gene mutations were also detected in five patients with Hb S/ß-thal, four patients with sickle cell disease and one patient with Hb S/Hb D-Punjab. In the current study, -α3.7/αα with ß gene abnormalities was the most common genotype. Our study showed that the coinheritance of sickle cell disease with α- and ß-thal is common and evaluation of these disorders, especially in pre marriage screening is important for diagnosis and management strategies.

Correlation of bleeding score with frequency and severity of bleeding symptoms in FXIII deficiency assessing by the ISTH Bleeding Assessment Tool.

OBJECTIVES: The ISTH bleeding assessment tool (ISTH-BAT) is developed for standardization of bleeding symptoms in bleeding disorders. The aim of this study is to apply this bleeding score for FXIII deficient patients and its relation to the frequency and severity of symptoms. METHODS: In this cross-sectional study, 63 patients with severe FXIII deficiency were evaluated for the assessment of bleeding score according to the standard ISTH-BAT questionnaire. All patients were registered at two major thrombosis and hemostasis centers in Iran affiliated to Zahedan University of medical sciences (50 patients) and Shiraz University of medical sciences (13 patients). RESULTS: Significant correlations between the bleeding score and number of symptoms (r = 0.668, P < 0.001) and with a number of severe symptoms (r = 0.938, P < 0.001) were detected. There was no significant relationship between the mean bleeding score and CNS bleeding (P = 0.390). CONCLUSION: The ISTH-BAT score is an acceptable bleeding assessment tool for standardization and evaluation of patients with FXIII deficiency.

A retrospective study on clinical manifestations of neonates with FXIII-A deficiency.

We assessed clinical presentations and the rate of central nervous system (CNS) bleeding in neonates with FXIIID who exhibited bleeding diathesis in the early days of their lives. A total of 27 neonates presented bleeding or abnormal clinical symptoms, diagnosed with FXIII deficiency were evaluated. Factor XIII concentrate was initiated as the first-line of treatment, and prophylactic therapy was given to all patients. Umbilical cord bleeding, delayed detachment of umbilical stunt, seizure, hematoma, and ecchymosis were concurrent complications in 27 (100%), 5 (18.5%), 5 (18.5%), 3 (11.1%), and 1 (3.7%) of the patients, respectively. History of having CNS bleeding was detected in 13 (48.1%) patients. There was no significant association between CNS bleeding and gender, familial history of FXIIID, or other clinical presentations. Also, there was no significant difference in the mean age of the patients who had CNS bleeding (3.4 ±â€¯0.9 days) and without CNS bleeding (2.9 ±â€¯0.7 days). However, a near significant threshold difference between the patients with and without CNS bleeding was found regarding the mean number of suspicious FXIIID death in their family (1.8 ±â€¯0.5 and 0.7 ±â€¯0.1, respectively, P = 0.05). Therefore, a suggested diagnostic algorithm based on prenatal diagnosis could be useful for timely detection of FXIII deficiency in neonates.

The Zinc and Copper Levels in Thalassemia Major Patients, Receiving Iron Chelation Therapy.

Essential trace elements deficiency including zinc and copper are frequently reported in the literature, but the results are controversial. The aim of this study was to evaluate zinc and copper levels in thalassemia major (TM) patients who were on regular transfusion and iron chelation therapy. In a case-control cross-sectional study 43 TM patients and 43 age-matched and sex-matched healthy controls were examined. Patients were selected by convenience sampling method from TM patients who were registered in Thalassemia Clinic during 6 months. Serum zinc and copper levels were evaluated in all subjects. Zinc and copper dietary intake were also assessed. The median zinc level in the participants was significantly lower than the control group (35 [6.3 to 298] vs. 173 [3.1 to 584] µg/dL; P<0.05), but the mean copper level was significantly higher in the patients in comparison with the control group (260±118 vs. 201±69 µg/dL; P<0.05). In contrast, the mean zinc and copper dietary intake in the patient's group were significantly lower than the control group. The mean serum zinc and copper levels in the patient's group were not different according to iron chelation therapy type. Also, zinc and copper levels in the patient's group were not statistically significant based on ferritin level, age, and duration of therapy. Essential trace elements level change and deficiency might occur in TM patients. Hence, routine assessment of these elements is recommended for better management.

Prevalence and Prognostic Impact of Wilms' Tumor 1 (WT1) Gene, Including SNP rs16754 in Cytogenetically Normal Acute Myeloblastic Leukemia (CN-AML): An Iranian Experience.

BACKGROUND: The aim of this study was to evaluate the effect of Wilms' tumor 1 (WT1) gene mutations in adult cytogenetically normal acute myeloblastic leukemia (CN-AML) patients on survival and clinical outcome. PATIENTS AND METHODS: A total of 88 untreated Iranian adult patients with CN-AML were selected as a study group. Exons 7 (including the SNP rs16754), 8, and 9 as a WT1 gene hotspot region were evaluated by polymerase chain reaction and direct sequencing for detection of mutations. Response to treatment and clinical outcome including overall survival (OS) and disease-free survival (DFS) were evaluated according to WT1 gene mutational status. RESULTS: WT1 gene mutations were found in 12.5% of patients, most of which were found in exon 7. Complete remission was lower and relapse was higher in patients with WT1 gene mutation compared with WT1 gene wild type patients. OS and DFS was significantly lower in patients with WT1 gene mutation compared with patients with WT1 gene wild type (P < .001). Also, we did not find any significant effects of SNP rs16754 in exon 7 on clinical outcome and survival in patients with CN-AML. CONCLUSION: WT1 gene mutations are a predictor indicator of a poor prognosis factor in CN-AML patients. It is recommended that WT1 gene mutations be included in the molecular testing panel in order to better diagnose and confirm their prognostic significance for better management and treatment strategy.

Hydroxyurea as a first-line treatment of extramedullary hematopoiesis in patients with beta thalassemia: Four case reports.

OBJECTIVE AND IMPORTANCE: Extramedullary hematopoiesis (EMH) is evidenced by erythropoietic masses, which occurs as a compensatory mechanism to overcome hypoxia during chronic anemia. EMH masses in spinal cord could lead to cord compression and neurological symptoms. Besides transfusion, radiotherapy, and surgery, hydroxyurea (HU) is also a treatment strategy in EMH. CLINICAL PRESENTATION: We described four cases of beta thalassemia with EMH who were treated with HU as a monotherapy. INTERVENTION (AND TECHNIQUE): HU therapy was done in all patients without any transfusion during therapy. CONCLUSION: HU is a good treatment option for patients with EMH and it could be a substitute for radiotherapy and invasive surgery or regular blood transfusion.

Guidelines for diagnosis and management of Beta-thalassemia intermedia.

Beta-thalassemia intermedia (ß-TI) is a genetic variant of beta-thalassemias with a clinical disorder whose severity falls between thalassemia minor and thalassemia major. Different genetic defects are involved in this disorder and, based on severity of disease, clinical complications like skeletal deformities and growth retardation, splenomegaly, extramedullary hematopoiesis, heart failure, and endocrine disorders may be present in untreated patients. Precise diagnosis and management are essential in these patients for prevention of later clinical complications. Diagnosis of TI is based on clinical and laboratory data. There are some treatment strategies like modulation of gamma-globulin chain production with hydroxyurea or other drugs, transfusion, splenectomy, and stem cell transplantation. Iron chelation therapy is also needed in many of these patients even if they are not transfused. The aim of this manuscript is to review the clinical manifestations, complications, genetic defects, and unmet treatments needs in TI.

Changes in platelet count and mean platelet volume during infectious and inflammatory disease and their correlation with ESR and CRP.

BACKGROUND: The measurements of platelet count and mean platelet volume (MPV) are routinely available nowadays. The aim of this study was to evaluate the platelet count and MPV trend in infectious and inflammatory processes. We also investigated whether these parameters were associated with the known markers of disease activity, erythrocyte sedimentation rate (ESR) and C- reactive protein (CRP). METHODS: This cross-sectional study was conducted on 100 children with diagnosis of infectious and inflammatory diseases. Platelet count, MPV, ESR, and CRP were measured at the time of hospitalization and thereafter in the recovery phase. RESULTS: Mean platelet count increased in the patients at the time of admission in the hospital compared to the recovery and discharge time (mean 430,820 ± 134,643/µl vs. 350,970 ± 99,374/µl, P < 0.001). However, MPV decreased significantly during the same period (8.2 ± 1.1 fl vs. 8.7 ± 0.9, P < 0.001). Platelet count was directly correlated with CRP (mean 6.4 ± 0.3 mg/l), (r = 0.49, P < 0.001) and ESR (mean 10.9 ± 1.1 mm/hr), (r = 0.32, P = 0.003). On the other hand, MPV was inversely correlated with CRP (r = 0.39, P < 0.001) and ESR (r = -0.24, P = 0.034). CONCLUSIONS: This study demonstrated a higher level of platelet count and lower MPV in the patients with active disease compared to the recovered patients. These parameters were well correlated with the known disease activity markers. We propose that platelet parameters can be considered as reliable markers for assessment of disease activity and response to treatment.

The association of glutathione S-transferase gene mutations (including GSTT1 and GSTM1) with the prognostic factors and relapse in acute lymphoblastic leukemia.

Acute lymphoblastic leukemia (ALL) is the most common malignancy in children. It accounts for one fourth of all childhood cancers and approximately 75% of all childhood leukemias. Some prognostic factors determine the outcome of therapy [e.g. age, sex, initial white blood cell count (WBC), etc.]; however, it is believed that other mechanisms such as glutathione S-transferase (GST) gene mutation, the expression of lung resistance protein (LRP), and multidrug resistance-associated protein (MRP) also plays a role in treatment failure. In this study, GST gene mutations including GSTM1 and GSTT1 were evaluated in patients with leukemia. Thirty newly diagnosed ALL patients younger than 15 years of age participated in the present study. Bone marrow aspiration and biopsy were evaluated for immune phenotyping and DNA was extracted for GST genotyping. All data plus sex, age, initial WBC count, central nervous system (CNS) or testicular involvement, immune phenotype, and outcome (relapse or not) were analyzed statistically. Genotyping showed that 46% were double null, 50% were M1 null and 93.3% were T1 null for GST mutations. There was no statistically significant relationship between GSTT1 and GSTM1 mutations, or between double null status, prognostic factors and relapse (P > .05). So, although the results of GST mutations were consistent, it seems that these mutations are not statistically significant.

Management of Bleeding in Post-liver Disease, Surgery and Biopsy in Patients With High Uncorrected International Normalized Ratio With Prothrombin Complex Concentrate: An Iranian Experience.

BACKGROUND: To evaluate the efficacy of prothrombin complex concentrate (PCC) in the management of bleeding in patients with liver disease and patients undergoing surgery or biopsy who had a high uncorrected international normalized ratio (INR). OBJECTIVES: In this study, we examined an Iranian sample and investigated the efficacy of PCC to manage bleeding in patients with liver disease and also patients with high uncorrected INR who were scheduled for surgery or biopsy. MATERIALS AND METHODS: A total of 25 patients including 16 patients with post-liver disease bleeding (group 1) and 9 patients with high uncorrected INR who were scheduled for surgery or biopsy (group 2) were enrolled. All patients were treated with 25 IU/kg PCC, and efficacy was defined as any reduction in or cessation of bleeding episodes and correction of INR before surgery or biopsy. The patients were also evaluated for any adverse effects. RESULTS: INR decreased significantly in both groups of patients, with no bleeding episodes during or after the study in group 1 and during or after surgery/biopsy in group 2. All patients tolerated the therapy well without any significant adverse effects. CONCLUSIONS: The efficacy of PCC therapy was satisfactory in this study. PCC therapy in patients with liver disease and patients undergoing surgery or biopsy seems to be effective and safe, and may be a good treatment strategy for these patients, if fresh frozen plasma or vitamin K are not effective.

The evaluation of cisplatin effect on tubular function in children on chemotherapy.

The dose limiting side effect of cisplatin is nephrotoxicity. The aim of this study was to investigate tubular function in children who have received cisplatin and forced diuresis. We performed a cohort study on 20 children under 15 years of age with various type of malignancy on cisplatin-based chemotherapy. Twenty-four-hour urine was collected in three periods: before the first, third, and fifth doses of cisplatin administration to check urine for sodium (Na), magnesium (Mg), uric acid, creatinine (Cr), phosphorus (P), calcium (Ca), beta-2 microglobulin, and N-acetyl-beta-D-glucosaminidase (NAG) levels. At the same time, blood samples were taken to check serum Cr, Na, Mg, Ca, P, and uric acid levels. Then, we compared the mean of glomerular filtration rate (GFR); fraction excretions (FE,%) of Na, Mg, and uric acid; tubular phosphorous reabsorption (TPR,%), 24-hour urine Ca (mg); urine beta-2 microglobulin (mcg/mL); and NAG (IU/L) in three periods of cisplatin administration. The FE of Na, Mg, and urine beta-2 microglobulin increased after administration of cisplatin but TPR, FE, uric acid, and NAG decreased in the 2nd and 3rd period compared to 1st period. GFR revealed a little change that was not significant. Urine calcium was decreased significantly in the second and third periods of cisplatin administration. Since the patients were hydrated for forced diuresis and received magnesium sulfate to prevent nephrotoxicity, we did not see significant tubular dysfunction. But we saw that urine calcium excretion decreased after cisplatin injection without any change in serum calcium in spite of preventive measures.