An antithrombin replacement strategy during asparaginase therapy for acute lymphoblastic leukemia is associated with a reduction in thrombotic events.

Thrombosis is a well-recognized complication of asparaginase therapy for acute lymphoblastic leukemia (ALL), associated with the depletion of antithrombin (AT). Following a high incidence of thrombotic episodes during induction therapy for ALL in our tertiary referral center, we prospectively instituted a protocol of AT replacement. Forty-five consecutive adolescents and adults with ALL treated with asparaginase-containing phase I induction protocols were included in this observational study. Fifteen received standard therapy with no replacement; the subsequent 30 were managed with the protocol described. One or more low AT levels (<70 iu/dl) were recorded in 76% of patients in the cohort managed using the protocol, resulting them in receiving an AT replacement. There was a significant reduction in the incidence of thrombosis with this strategy (0/30 vs. 5/15, p < 0.001). We suggest that such a strategy should be studied in a prospective randomized sub-study within the context of a national ALL trial.

Homo- and heteroleptic alkoxycarbene f-element complexes and their reactivity towards acidic N-H and C-H bonds.

The reactivity of a series of organometallic rare earth and actinide complexes with hemilabile NHC-ligands towards substrates with acidic C-H and N-H bonds is described. The synthesis, characterisation and X-ray structures of the new heteroleptic mono- and bis(NHC) cyclopentadienyl complexes LnCp2(L) 1 (Ln = Sc, Y, Ce; L = alkoxy-tethered carbene [OCMe2CH2(1-C{NCHCHN(i)Pr})]), LnCp(L)2 (Ln = Y) , and the homoleptic tetrakis(NHC) complex Th(L)4 4 are described. The reactivity of these complexes, and of the homoleptic complexes Ln(L)3 (Ln = Sc 3, Ce), with E-H substrates is described, where EH = pyrrole C4H4NH, indole C8H6NH, diphenylacetone Ph2CC(O)Me, terminal alkynes RC≡CH (R = Me3Si, Ph), and cyclopentadiene C5H6. Complex 1-Y heterolytically cleaves and adds pyrrole and indole N-H across the metal carbene bond, whereas 1-Ce does not, although 3 and 4 form H-bonded adducts. Complexes 1-Y and 1-Sc form adducts with CpH without cleaving the acidic C-H bond, 1-Ce cleaves the Cp-H bond, but 2 reacts to form the very rare H(+)-[C5H5](-)-H(+) motif. Complex 1-Ce cleaves alkyne C-H bonds but the products rearrange upon formation, while complex 1-Y cleaves the C-H bond in diphenylacetone forming a product which rearranges to the Y-O bonded enolate product.

The management of pregnancy in paroxysmal nocturnal haemoglobinuria on long term eculizumab.

In Paroxysmal nocturnal haemoglobinuria (PNH), pregnancy is associated with increased maternal and foetal complications to such an extent that the condition has been considered relatively contra-indicated in PNH. Eculizumab has revolutionized the treatment of PNH. We evaluate its use in pregnancy to date. We report on seven patients exposed to eculizumab at different stages of pregnancy including the first two patients to receive the drug from conception to delivery. There was no evidence of complement blockade from cord blood samples taken at delivery. Eculizumab appears safe to use in this setting and is likely to prevent many of the complications usually observed.

Antithrombin-α for the prophylaxis of venous thrombosis in congenital antithrombin deficiency.

ATryn(®) is a transgenically produced recombinant antithrombin (AT) concentrate licensed in Europe and the USA for the thromboprophylaxis of hereditary AT-deficient patients undergoing surgical procedures who are at a high risk of venous thromboembolism. It is also licensed, in the USA only, for prevention the of venous thromboembolism in association with delivery and the immediate post-partum period. ATryn is administered as a continuous intravenous infusion, with weight-adjusted loading and maintenance dosing regimens. Recombinant AT has an identical amino acid structure with minor glycosylation differences to endogenous AT. ATryn has a shorter half-life but an equivalent efficacy to that of plasma-derived AT concentrates in the prevention of venous thromboembolism in this rare distinct group with a high thrombotic risk. In addition, this recombinant product should be free from the risk of human viral or prion transmission.