ALBERT

Description: Sexual hormones are potent regulators of various immune functions. Although androgens are immunosuppressive, estrogens protect against septic challenges in animal model. In human sepsis studies post surgery, post trauma in adults have shown survival advantage for female sex with sepsis. Other reality is that in a developing country like India with a population of 1 billion, sex ratio has been gradually falling in the general population. In year 1901 females per 1000 males were 972 and in 2001 females per 1000 males are 933. Neglect of female child and unwillingness on the part of parents to spend money for treatment of girl child is one of the main reason for less number of girls getting treatment for cancer as compared to males. This study was done to find gender difference in incidence of severe sepsis in children with cancer in a single centre in Delhi, India. It was a retrospective analysis of children with and without cancer admitted to the Pediatric Intensive care Unit (PICU) at Sir Ganga Ram Hospital from January 2003 to January 2006, who met the following criteria: 1) severe sepsis by American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference criteria and 2) receipt of fluid boluses of 〉30 mL/kg or receipt of a dopamine infusion of 〉5 ug/kg/min. Data evaluated were demographic variables, oncologic diagnosis and time from diagnosis to PICU admission, Pediatric Risk of Mortality I (PRISM I) score, neutropenia, use of inotropes, use of mechanical ventilation, culture results, survival to PICU discharge, and 6-month survival. Total admissions in PICU were 1450 out of which 977 were males (M) and 473 females (F) with M:F =2:1.Total number of children admitted with sepsis in PICU were 517 out of which males were 342 and females 175 with M:F= 2:1. Total number of pediatric oncology admissions in hospital (PICU and Ward) were 420 out of which males were 294 and females 126 with M:F = 2.3:1. Total number of pediatric oncology patients admitted in PICU were 60 out of which 44 were males and 16 were females with M:F = 2.8:1. Total number of consecutive pediatric oncology patients admitted to PICU with severe sepsis were 20 out of which 18 were males and 2 females with M:F =9:1. Overall mortality was 40 % at PICU discharge and 50% at 6 months follow up. 6 /18 (33%) males died as compared to 2/2 (100%) deaths in females. Mean PRISM I score was 11.9 among survivors and 19.4 among non-survivors. Mean Prism score for females was 16 as compared to 14.8 in males. We looked at gender distribution of 35 consecutive pediatric oncology patients with febrile neutropenia in the hospital. 28 were males and 7 females (Ratio M:F = 4:1) We looked at 30 consecutive non-oncology patients admitted with severe sepsis in PICU which showed 25 males and 5 females with a ratio of M:F = 5:1.In conclusion, m ale children with cancer have increased incidence of severe sepsis. This small study may reflect a bias of parents not electing to admit female patients with severe sepsis in hospital but as compared to ratio in total admission in PICU and admissions of oncology patients in ward and PICU the ratio is markedly increased to 9:1 which may indicate gender difference due to genetic basis.

Description: Abstract 2081 Poster Board II-58 AZD6244 is an orally bioavailable small molecule inhibitor of the MEK kinase. MEK is downstream of the RAS/RAF pathway, which is activated by mutations occurring in RAS as well as mutations and/or overexpression of upstream receptor tyrosine kinases such as FLT3 and c-KIT in AML. In addition, elevated levels of phosphorylated-ERK (p-ERK), the only known substrate of MEK, have been demonstrated in 〉75% of patients(pts) with AML, and MEK inhibition of primary AML cells in vitro results in growth arrest. AZD6244 was well tolerated in phase I trials in advanced solid tumors and had a favorable pharmacokinetic profile; the recommended phase II dose was 100mg twice daily. We hypothesized that in AML, a MEK inhibitor would lead to inhibition of RAS-mediated signal transduction, with subsequent antiproliferative effects and inhibition of the leukemia clone. We report our experience with the first clinical trial utilizing a MEK inhibitor in advanced AML. Methods: 47 pts were enrolled on a Phase II multicenter study of AZD6244 in relapsed/refractory AML. Median age was 69 years (range, 26-83 yrs) with 57% males. ECOG performance status at baseline was 0, 1 and 2, respectively, in 12, 27 and 8 pts. 14 pts (30%) were previously untreated for AML and 〉60 yrs; 11 of these pts had received prior therapy for an antecedent hematologic disorder (AHD); 1 had therapy-related AML (t-AML) and only 2 pts (4%) had previously untreated de novo AML. 6 pts (13%) had AML in first relapse, 14 (30%) had AML beyond first relapse, and 13 (27%) had primary refractory disease. 4% had good risk cytogenetics, 28% intermediate risk, 49% poor risk, and 19% had other or unknown cytogenetics. Overall, 53% had AML that had evolved from an AHD and/or t-AML. Ten pts had a FLT3 ITD or TKD, 36 had no FLT3 mutation detected, and FLT3 mutational status was unknown in 1. Median number of prior therapies for AML and/or MDS was 2 (range, 0-6). AZD6244 was given at 100mg twice daily without interruption; cycles were repeated every 28 days. Dose modifications and/or delays occurred for grade 3&4 non-hematologic toxicities, or prolonged grade1&2 toxicities. Peripheral blood and/or marrow samples were obtained at baseline for mutational analysis (RAS/c-KIT/FLT3), and at serial time points to measure p-ERK. Results: Daily AZD6244 was tolerable. 42 pts are evaluable for efficacy and safety. Median number of cycles administered was 1 (range, 1-9). 19 pts (40%) received ≥2 cycles. 4 pts required dose reduction. The most common drug-related toxicities were grade 1&2 diarrhea, nausea, fatigue and vomiting, occurring in 43%, 36%, 31% and 24%, respectively. Grade 3&4 adverse events possibly related to AZD6244 included fatigue, nausea and dehydration, occurring in 7%, 5% and 5%, respectively. 4 pts had a minor response (defined as 〉50% decline in peripheral blood and/or marrow blasts lasting 4 weeks). 2 additional patients also had 〉50% decline in marrow blasts but did not have a follow up confirmatory biopsy. In 1 of these pts, the decline in blasts was associated with sustained improvement in platelets (〉100K/uL) lasting 4 months. 6 additional pts had evidence of disease stabilization, lasting a median of 34 days (range, 21-222+ days). Analysis of p-ERK by flow cytometry has just been intiated, and in the first 3 pts analyzed, baseline p-ERK levels were low, and none of these pts responded. In contrast, p-mTOR levels (downstream of the PI3 Kinase pathway) were significantly elevated in these same pts. Conclusions: Administration of the oral MEK inhibitor AZD6244 is feasible in AML. Modest evidence of antileukemic activity has been observed, consistent with the predicted cytostatic activity of this class of drugs. Analysis of the effect of AZD6244 on p-ERK and signaling intermediates of the PI3 Kinase pathway such as p-mTOR is ongoing. Given its modest toxicity profile, AZD6244 should be investigated further in combination with drugs that target other critical signaling pathways and/or dysregulated transcriptional pathways in AML. Sponsored by NCI grant NO1-CM-62201 Disclosures: No relevant conflicts of interest to declare.

Description: Recombinant factor VIIa (rFVIIa; NovoSeven) has been successfully used in the management of hemophilia patients with inhibitors for many years. Recombinant activated factor VIIa is being increasingly used to secure haemostasis in difficult clinical situations. rFVIIa is a novel hemostatic agent that shows promise in non-hemophiliac patents of a significant therapeutic role in variety of coagulopathic and hemorrhagic conditions in clinical situations ranging from thrombocytopenia, disseminated intravascular coagulation and transfusion-related coagulopathy, as well as in patients experiencing massive blood loss undergoing orthotopic liver transplantation, cardiac, orthopedic and genitourinary surgery. This review will explore its use in the control of platelet function disorder associated haemorrhage in patients without pre-existing coagulopathy/Dengue hemorrhagic shock/post surgery bleed/post procedural uncontrolled bleeding etc, and will highlight the growing realization that rFVIIa may have a major role not only as a treatment for hemophilia, but also as a universal hemostatic agent. The mechanism of action suggests that its enhancing effects in haemostasis are limited to the site of injury and that systemic activation of the coagulation cascade does not occur. In contrast to rising experience obtained by ongoing clinical trials in adults, poor data exists for the use of rFVIIa in acquired coagulopathies in childhood. We report on four children, 1 year to 14 years old, with severe bleeding episodes treated by recombinant factor VIIa. One patient of Dengue hemorrhagic shock (Grade IV Dengue Hemorrhagic fever) with DIC, one of Glanzmann thrombosthenia with massive upper gastrointestinal bleed, one of hemorrhagic shock with bleeding from hypopharynx 48 hr post-surgery (even after surgical correction of bleeding points), and one of gross hematuria for more than 24 hrs post renal biopsy. Manifestation of bleeding included mucosal/gastrointestinal bleeding, intra-abdominal bleeding, hematuria. Recombinant factor VIIa was used as bolus therapy. Dose regimen was calculated individually with dose of 90-μg/kg/dose. Repeat dose was used in one patient with Glanzmann thrombosthenia in view of partial response after 1st dose and restart of bleeding after 2 hours. Prior to factor VIIa administration patients were given trial of FFP, cryoprecipitate and platelets as appropriate. We monitored the response to the therapy by maintenance of blood pressure, an estimation of blood loss and by coagulation tests. In all patients, bleeding symptoms could be markedly reduced or stopped by application of rFVIIa. No adverse effects were observed, especially no thrombembolic complications. Nevertheless one of the four patients died - 13-year-old female child with Dengue hemorrhagic shock with DIC died after 35 days of hospital stay due to resistant pseudomonas sepsis. The use of recombinant factor VIIa may be a valuable therapeutic option in children with severe acquired coagulopathies/uncontrolled bleeding post procedure since it provides a good hemostatic efficacy and probably few adverse side-effects.

Description: In a prospective study started in 2001 echocardiography (ECHO) was used to screen 195 unselected adult sickle cell patients for pulmonary hypertension (PHTN). The prevalence of PHTN [tricuspid regurgitant jet velocity (TRV) of 2.5 m/sec or higher, corresponding to a pulmonary artery systolic pressure (PAs) of at least 35 mm Hg] was 32 %. Markers of hemolysis (low Hb, and high reticulocytes and LDH) were associated with PHTN risk. Although the pulmonary pressures in sickle-related PHTN were not as high as in other forms of PHTN, they were predictive of short survival (NEJM2004;350:886). We now report the TRV results in 113 patients who had repeat ECHO exams at 2.1 years (range 1.2–4.1 y) after study enrollment. Their mean age was 36.2 ± 10.3 y and 59 % were female. Their hemoglobin types were: SS, 77.7 %; SC, 14.3 %; Sickle-thal.+, 6.3 %; and Sickle-thal.0, 1.8 %. At baseline, 40 patients had PHTN (mean TRV 2.75 m/sec) and their mean TRV at the 2 y follow up was 2.71 m/sec (p=0.45). In 6 subjects the TRV decreased to normal values from baselines of 2.5 – 3 m/sec. Nevertheless, the mortality of the patients diagnosed with PHTN at baseline currently stands at 40% at 40 months of follow-up. Seventy-three patients did not have PHTN at enrollment (mean TRV 2.0 m/sec) and as a group their TRV at the 2 y follow up had not changed significantly (mean 2.1, p=0.1). However, 11 of the 73 patients (15.1%) with initially normal TRV developed PHTN at 2 years (mean TRV 2.70, range 2.5–3.5 m/sec). The table shows that age, sex, Hb type, Hb F %, and hydroxyurea treatment of the patients who developed PHTN at the 2 y follow up were not significantly different from those who did not. However, patients who developed PHTN were significantly more anemic, had higher reticulocyte counts, and higher serum ferritin values. A trend toward an increased bilirubin and LDH was observed. Hence, hemolysis probably played a pathogenetic role in these patients’ increased pulmonary pressures, as is also postulated for sickle patients who had PHTN at baseline. These preliminary results suggest that the incidence of PHTN in adult sickle patients could be as high as 7 % per year and that ECHO screening of these patients every two years is probably indicated. No PHTN PHTN P value N 62 11 Mean age, y (±SD) 34.1 ± 8.9 34.6 ± 13.4 0.85 Sex (% female) 56 64 0.75 Non-SS (%) 27 18 0.5 On hydroxyurea (%) 41 25 0.5 Hb (g/dl, mean±SD) 9.98 ± 1.74 8.68 ± 1.91 0.04 Hb F (%,mean±SD) 7.9 ± 6.8 7.5 ± 7.4 0.869 Abs. Retics (x1000/mm3, mean±SD) 205 ± 107 288 ± 151 0.045 LDH (U/L, mean±SD) 286 ± 107 359 ± 179 0.09 Bilirubin (mg/dl, mean±SD) 2.5 ± 1.88 3.7 ± 2.58 0.10 Ferritin (mg/L, mean±SD) 632 ± 925 1439 ± 1849 0.046 Creatinine (mg/dl, mean±SD) 0.76 ± 0.23 0.69 ± 0.25 0.36

Description: Abstract 2583 Poster Board II-560 Background: Leg ulceration is a common, debilitating complication of sickle cell disease (SCD), affecting 8 to 50% of patients, and recently found to be associated with the hemolytic phenotype. We evaluated the relationship of leg ulceration history with estimated pulmonary artery systolic pressure, hemolytic rate and other clinical characteristics in a cohort of 396 adults with SCD. Materials and methods: All SCD patients were enrolled in a NHLBI-approved protocol and were screened for pulmonary hypertension with echocardiography at steady state. We collected a detailed past medical history, as well as a comprehensive set of laboratory tests. Comparisons between patients with and without a history of leg ulcers were made using Wilcoxon rank sum tests to compare medians of continuous variables. Associations between categorical variables and leg ulcer history in two groups were tested using the chi-square test of independence. Results: Eighteen % of all subjects had a history of leg ulceration. Patients affected were older, predominantly had homozygous SCD, and had markers of significantly more severe hemolysis, including low hemoglobin and high reticulocyte counts, LDH and AST. They also had a significantly higher prevalence of elevated tricuspid regurgitation velocities (TRV≥2.5 m/sec, 56% vs. 40%, p=0.02; TRV≥3 m/sec, 22% vs. 12%, p=0.006). High serum uric acid and lower serum albumin were significantly associated with a history of leg ulcers. A self-reported history of hepatitis also was associated with leg ulceration. None of the other parameters evaluated were significantly associated with leg ulceration, including history of pain, acute chest syndrome, stroke or priapism. Significantly, patients with a history of leg ulcers were more likely to have died by the time of data analysis (21% vs. 9%, P=0.02). Discussion: These data in SCD patients with a history of leg ulcers provide the first demonstration of an association with elevated serum uric acid and confirmation of published associations with elevated pulmonary pressures and markers of hemolytic severity. The uric acid association is more significant than that for serum creatinine or urea nitrogen, suggesting that uric acid is more than simply a marker of renal dysfunction. In patients without SCD, there is a growing literature implicating uric acid as a possible cause of hypertension and a marker of risk for cardiovascular disease, pulmonary hypertension, and early mortality. This is particularly interesting, in view of the epidemiological relationship between leg ulcers and pulmonary hypertension demonstrated here and previously by others. The results continue to support linkage of leg ulcers and pulmonary hypertension to a hyperhemolytic -vasculopathy subphenotype of SCD. Disclosures: No relevant conflicts of interest to declare.

Description: Background. Pulmonary hypertension, defined by an elevated pulmonary artery systolic pressure measured by Doppler-echocardiogram, has been identified as the major predictor of death in the adult sickle cell disease population. While diastolic dysfunction is also observed in this population, the prevalence in unselected patients, the association with high pulmonary artery systolic pressure, and the attributable mortality remain unknown. Methods. Diastolic function parameters, pulmonary artery systolic pressures and right and left ventricular size and function were measured prospectively in 215 subjects with sickle cell disease. Associations between these parameters, lab and echocardiographic variables and prospective mortality were determined. Results. Diastolic dysfunction, measured by conventional and tissue-Doppler echocardiography, was present in 19% of patients with sickle cell disease. Diastolic dysfunction and pulmonary hypertension were both present in approximately 11% of patients and diastolic dysfunction accounted for approximately 10–20% of the variability in tricuspid regurgitant jet velocity. Importantly, Cox Proportional Hazards analysis revealed that diastolic dysfunction, as reflected by low E/A ratio, was associated with prospective mortality with a risk ratio of 1.9 (95%CI 1.0 to 3.7; p=0.028), even after adjustment for tricuspid regurgitant jet velocity. While pulmonary hypertension remained the dominant determinant of mortality risk, even after adjustment for measures of diastolic function (adjusted rate ratio of 5.3; 95% CI= 1.9 to15.0; p

Description: Patients with sickle cell disease have decreased nitric oxide bioavailability, and studies from several groups have confirmed a blunted response to various NO donors in humans and mice with sickle cell disease. Recently published studies show that nitrite induces vasodilation in humans, apparently mediated by conversion of nitrite to NO. This study is designed to determine the potential therapeutic effect of intra-arterial nitrite infusion to restore nitric oxide dependent blood flow in the forearms of patients with sickle cell disease. Venous occlusion strain gauge plethysmography is used to measure the change of forearm blood flow in patients with sickle cell disease, before and after sequential brachial artery infusions of increasing doses of sodium nitrite. In addition, NO responsiveness before and after nitrite infusion is measured by test doses of the NO donor sodium nitroprusside (SNP). Six patients have completed the study and enrollment is continuing. These data indicate that nitrite promotes regional blood flow in patients with sickle cell disease, albeit with a blunted response compared to our healthy control subjects, in whom we previously have found increased blood flow up to 187% with comparable dosing. The significant but blunted response is consistent with the state of nitric oxide resistance to NO donors that has been seen by several groups in patients and mice with SCD. Additionally, we find in these patients that nitrite partially restores SNP responsiveness, with baseline maximal SNP responses more than doubling on average following nitrite infusion, although this finding is preliminary. No adverse effects of nitrite were seen in these six patients. Our early results support a role for nitrite as an NO donor effective in restoring NO-dependent blood flow in patients with sickle cell disease. Additional translational studies are warranted to evaluate the therapeutic effects of systemic nitrite dosing. Table 1. Forearm Blood Flow Response to Nitrite Infusion Nitrite Dose (micromole/min) Sickle Cell Disease Historical Controls P〈 .0001 (ANOVA) 0.4 5 +/−7.2% N=6 22 +/−3.2% N=10 4 15 +/− 11% N=6 Not infused 40 49 +/− 8.9% N=6 187 +/− 16%N=18 Table 2. Nitrite Effect on Nitroprusside Responsiveness SNP Dose (micrograms/min) Pre-Nitrite Post-Nitrite P= .02 (RM-ANOVA) N=6 0.8 +21 +/− 5.6% +33 +/− 8.3% 1.6 +15 +/− 5.9% +62 +/− 15.1% 3.2 +29 +/− 6.3% +67 +/− 11.5%

Description: Pulmonary hypertension has a prevalence of 30% in patients with sickle cell disease (SCD) in the United States with mortality rates of 40% at 40 months after diagnosis. The global burden of SCD is highest in sub-Saharan Africa where more than 200,000 children are born with the disease annually. The prevalence of pulmonary hypertension among individuals with SCD in Africa has not been previously reported. We performed Doppler echocardiographic assessments of pulmonary-artery systolic pressure in 206 consecutive hydroxyurea sickle cell patients at steady state in Nigeria, West Africa (101 males and 105 females; age range 10–52, mean [+/−SD] age, 21.5 +/− 7.7 years; 196 homozygous sickle cell and 10 compound heterozygotes SC). A control group consisted of 93 healthy Nigerians. Hemoglobin gentotype was determined by electrophoresis and DNA sequencing. Pulmonary hypertension was defined prospectively as a tricuspid regurgitant jet velocity (TRV) of at least 2.5 m per second. We collected clinical data on the patients and controls, and blood specimens for clinical laboratory measurements. Doppler-defined pulmonary hypertension occurred in 25% of sickle cell patients (21% with TRV 2.5 – 2.9 m/sec, 4% with TRV ≥ 3 m/sec). The presence of pulmonary hypertension was inversly associated with age (p=0.04) and hemoglobin (p=0.0016), and positively associated with reticulocyte count, serum levels of lactose dehydrogenase (p=0.03), creatine kinase, and blood urea nitrogen and systolic (p=0.03) and diastolic blood pressure (p=0.002) in bivariate analyses. In a multivariate linear regression model age, diastolic blood pressure and blood urea nitrogen had significant independent associations with pulmonary hypertension. There were no significant associations of HIV/AIDS, hepatitis B and C co infections and malarial parasitemia rate with pulmonary hypertension. Our findings suggest that pulmonary hypertension is common among sickle cell patients in Africa and it appears to be a complication of chronic hemolysis and vasculopathy. The prevalence of pulmonary hypertension decreases with age in Nigerian SCD patients, in sharp contrast to U.S. SCD patients, who demonstrate increasing prevalence with age. The public health implications of this finding are significant considering the potential number of individuals at risk for this complication. Large prospective cohort studies to determine the outcome of pulmonary hypertension in sickle cell patients in Africa are needed.