ALBERT

Beschreibung: The introduction of disease specific therapy for patients with type 1 Gaucher disease (GD) was a revolution in the management of patients, but not without significant cost to the patient and to society. The management of mildly effected patients is still debated, and reviews about GD as well as chapters in textbooks fail to emphasize the fact that some patients may remain untreated for many years without any GD-related complications. Patient reported outcome measures (PROMs) were developed as a way to ascertain patients' views of their symptoms, their functional status, and their health-related quality-of-life (HRQoL). In this study, we evaluated the responses to a GD -specific PROM of untreated patients with GD1 and compared them to patients on GD-specific therapy. Methods: A PROM survey was developed for GD including 15 questions; six Point Verbal Response Scale regarding the last month and nine Visual Analogue Scales (VAS) from 0-10 regarding the last week (Elstein D, et al. Molecular Genetics and Metabolism 2019;126:S52). The PROM survey was proven to be accurate in encompassing disease-specific patient concerns. A Hebrew translated version of the GD-PROM was sent via mobile phone survey to 400 adult patients with type 1 GD followed in our Gaucher Unit. Clinical data and treatment status were extracted from the clinical charts. T-test and Mann-Whitney U test were used to compare normally and non-normally distributed data in independent samples, respectively. IBM SPSS version 25 was used for analysis. Results were considered to be statistically significant when two-tailed P-values were ≤0.01. Results: A total of 181 patients responded (45% response rate) of whom 65 (36%) were followed for at least 5 years in our unit without receiving GD specific therapy, i.e. enzyme replacement therapy (ERT) and/or substrate reduction therapy (SRT). The median (range) age of patients, 49 (20-91) years, was not significantly different between treated and untreated patients. The percentage of patients with the N370S/N370S genotype was significantly higher in untreated patients [55/65 (85%)] compared to treated patients [67/116 (57%)]. Significantly more treated patients reported that GD had restricted their education/job (38, 34%) and fun activities (29,25%) compared to untreated patients, (4, 6.5%) and (2, 3%), respectively. Compared to untreated patients, treated patients were more worried to be an emotional burden on others [27 (23%) vs. 3 (5%)], of being financial burden on others [57 (50%) vs. 16 (25%)] and more concerned regarding the risk of bone disease [82 (74%) vs. 26 (40%)], and the risk of Parkinson disease [72 (64%) vs. 27 (42%)]. Treated patients had a significantly higher score on VAS for questions on swollen abdomen, fatigue, physical weakness, severity of bone pain and worry regarding the future over the past week compared to untreated patients (Table 1). Patients concern regarding the risk for cancer (32%) and VAS score for a question on depression were similar between groups. Conclusion:The GD-specific PROM survey shows that asymptomatic or mildly affected untreated patients with GD1 have good functional status and HRQoL, supporting our practice that not all patients with GD1 require disease-specific therapy. Still, we advise a periodic (annual or bi-annual) follow-up, preferably at a referral center. Inclusion of GD-specific PROMs in the periodic assessments is important for better understanding patients' perspectives. It is important to note that mildly affected and asymptomatic patients are mainly found among Ashkenazi Jews and from this aspect our cohort reflects patients' populations in Israel, USA, UK, etc. but less relevant to non-Jewish and particularly to Asian cohorts. With the expected increase in early diagnosis via parental and/or newborn screening the understanding that not all subjects diagnosed with GD needs disease-specific therapy is all the more important. Despite the expected differences between the more severely affected treated patients and the by definition milder untreated ones, still a high percentage of the treated patients show good HRQoL parameters, reflecting the overall success of ERT/SRT. Larger cohorts and further analysis will evaluate potential predictors for differences in PROMs within the treatment group. Disclosures Revel-Vilk: Sanofi: Honoraria, Other: Travel, Research Funding; Pfizer: Honoraria, Other: Travel, Research Funding; Takeda: Honoraria, Other: Travel, Research Funding; Prevail therapeutics: Honoraria, Other: Travel, Research Funding. Zimran:Prevail Therapeutics: Consultancy; TAKEDA: Honoraria; Centogene: Other: research grant; Targeted Cell Therapies: Consultancy; Pfize: Honoraria, Research Funding; Shire: Consultancy, Honoraria, Research Funding; Bio-events: Honoraria.

Beschreibung: Key Points Deficiency of TPP2 is associated with Evans syndrome and viral infection susceptibility. TPP2 deficiency links premature immunosenescence of T and B cells with severe autoimmunity.

Beschreibung: Background: Anemia is a global public health problem affecting both developing and developed countries. Most literature on severe anemia in children is reported from developing countries, where malaria infection and malnutrition are the main causative factors. According to the world health organization (WHO) report, in Israel, as in many western countries, anemia is considered a mild public health problem (1). The aim of this study it to analyze the causative factors and management of severe anemia in children living in a country where anemia is not considered a major health problem. Methods: The electronic hospital records of all children (≤16 years) with hemoglobin 〈 7.0 g/dl presenting to two largest Emergency Department (ED) in Jerusalem from 2008 to 2013 were retrospectively reviewed. Data including demographic characteristics, presenting signs and symptoms, laboratory findings, causal factors and management were extracted from medical records and analyzed. Cases secondary to surgical bleeding, chemotherapy, known chronic anemia or developing during prolonged admission were excluded. The diagnosis of iron deficiency anemia was based on low plasma iron and ferritin levels with compatible blood smear, when available. If unavailable, the diagnosis was based on the findings of low MCV and MCH for age with increased RDW. Results: A total of 227 children (female 123, 54%) at a median (range) age at of 4.5 years (1 day-15.5 years) were included. The median (range) hemoglobin at presentation was 6.3 (2.6-6.9) g/dl. In the entire cohort the most common etiologies for severe anemia were iron deficiency anemia (IDA) (38%) and acute hemolysis; autoimmune (AIHA) (8.5%) or G6PD deficiency (8%). The distribution of etiologies for severe anemia differed between infants, pre-school age, school age and adolescents (Figure 1). While the diagnosis of IDA was the most common in all age groups, some diagnoses such as G6PD deficiency and congenital anemia were more common in the younger age groups (up to 6 years) compared to the older ages. Children diagnosed with IDA were significantly older; median (range) 9.5 years (4 months-15.5 years), compared to children with other diagnoses, 3 years (1 day-15.5 years) (p

Beschreibung: Background: Essential thrombocythemia (ET) is a chronic myeloproliferative neoplasm. As it is extremely rare in children, data regarding its clinical course are scarce and pediatric treatment guidelines are lacking. Aim: To evaluate diagnosis, treatment and clinical outcome in a group of pediatric ET patients. Methods: Medical files of all pediatric patients (age 0-18 years) diagnosed with ET between January 2010 and February 2019 in three tertiary hospitals were reviewed. Study was approved by all institutional ethics committees. Diagnosis was established according to the WHO criteria of ET. All patients had undergone bone marrow biopsy (BMB) and molecular evaluation for JAK2V617F. Patients with wild type JAK2V617F were also tested for JAK2 exon 12 mutation, calreticulin (CALR) mutations and thrombopoietin receptor (MPL) mutation. Complete blood count parameters at first evaluation and follow up were collected. Lag in diagnosis, defined as the period between the time at which thrombocytosis was first noticed until diagnosis of ET was documented. Patients were evaluated for acquired von Willebrand syndrome (AVWS) by testing for von Willebrand antigen level and activity. Clinical data included any adverse events particularly those related to thrombosis or bleeding. Initial treatment strategies and any need for therapy modifications were recorded. Results: Twelve children (5 males and 7 females) followed for a median time of 27.5 months (range 4-108 months) were included. Table 1 displays their demographic and clinical data. Family history of thrombocytosis was negative in all patients. Median age at which thrombocytosis was first noted was 8 years (range 1-14.5 years). In 5/12 patients thrombocytosis was detected as an incidental finding. In 7/12 patients CBC was performed due to symptoms including headache, visual disturbances, seizure and acroparesthesia (table 1). Patients who suffered from neurological symptoms had undergone cranial MRI; all were interpreted as normal. The mean lag period between the time in which thrombocytosis was first noted until diagnosis of ET was 36 months (range: 0.1-120 months). Molecular diagnosis yielded 5/12 patients who were positive for JAK2V617F, one patient with a JAK2 exon 12 mutation and 2/12 patients with mutations involving CALR (one with type 1 and one with type 2 mutation). No subjects with CMPL mutation were detected. Four children tested negative for all mutations. Bone marrow biopsies were compatible with ET and no chromosomal aberrations were identified in our cohort. Evaluation for AVWS was performed in nine of the panties. It was diagnosed in 67% of assessed patients. Median VWF:Rco/VWF:Ag 0.18 (range: 0.01-0.76). At diagnosis treatment with Aspirin was initiated in 4/12 patients. Cytoreductive therapy with Hydroxyurea was added at diagnosis in 2/4 patients, both symptomatic at presentation. One Patient underwent plateletpheresis at presentation due to severe headache and extreme thrombocytosis. In 3/8 untreated patients, therapy was added during follow up, with either Aspirin (n=1, due to increased severity of headaches and raising platelet count) or Hydroxyurea (n=2, following TIA). During follow up period neither leukemia nor myelofibrosis evolved in our cohort. One patient developed a provoked DVT, secondary to a femoral CVL. Three patients experienced TIA during study period. Two females experienced excessive bleeding (heavy menstrual bleedings and bleeding due to a raptured corpus luteum), both diagnosed with AVWS. Conclusions: Our study suggests that pediatric hematologists should increase awareness to ET as delayed diagnosis is common. Among children with ET, AVWS may be more prevalent as compared to adults and may increase the risk of bleeding. Further collaborative multicenter studies are required for robust data collection and may facilitate future ET treatment in children. Table 1 Disclosures Kenet: Alnylam: Consultancy, Honoraria, Research Funding; CSL: Consultancy, Honoraria; Roche: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria, Research Funding; Bayer: Consultancy, Honoraria, Research Funding; Shire: Consultancy, Honoraria, Research Funding; Opko Biologics: Consultancy, Honoraria, Research Funding; BPL: Research Funding. Steinberg Shemer:Emendo bio: Consultancy. Revel-Vilk:Prevail therapeutics: Honoraria, Other: Travel, Research Funding; Sanofi: Honoraria, Other: Travel, Research Funding; Pfizer: Honoraria, Other: Travel, Research Funding; Takeda: Honoraria, Other: Travel, Research Funding.

Beschreibung: Key Points Developed a targeted sequencing platform covering 63 genes linked to heritable bleeding, thrombotic, and platelet disorders. The ThromboGenomics platform provides a sensitive genetic test to obtain molecular diagnoses in patients with a suspected etiology.

Beschreibung: The role of glucosylsphingosine (lyso-Gb1), a downstream metabolic product of glucosylceramide, for monitoring treated and untreated children with Gaucher disease (GD) has not yet been studied. We reviewed the clinical charts of 81 children (

Beschreibung: Background: Blood transfusions save lives and improve health; however, unnecessary transfusion practice exposes patients to immediate and long-term negative consequences. One of the 2013 Choosing Wisely®recommendations focused on avoiding liberal red blood cell (RBC) transfusion. The specific recommendation was that in situations where transfusion of RBCs is necessary, transfuse the minimum number of units required to relieve symptoms of anemia or to return the patient to a safe hemoglobin (Hb) range (7-8 gr/dl in stable, non-cardiac inpatients). As part of an initiative to improve the quality of RBC transfusion practice we performed this study to examine RBC transfusion practices by patient- and admission-related characteristics. Methods: A cross-sectional survey of RBC transfusions was conducted at three Jerusalem hospitals in the following departments: intensive care (general, adult), internal medicine, orthopedics, hematology and cardiothoracic surgery. These departments were chosen based on their high volume of RBC use. RBC transfusions were identified from the list of RBC units discharged from the hospital's blood bank within a specified 30-day period and data were collected daily by trained nurses. Exclusion criteria included patients who underwent liver transplants, patients with solid tumors, patients requiring massive transfusions (≥6) and transfusions given during surgery. Orthopedic and cardiothoracic departments were grouped together as surgical departments and compared to all others (i.e. non-surgical). Off-protocol RBC transfusion was defined in this study as patients receiving〉1 RBC unit consecutively or transfusion given to non-bleeding, non-active cardiac patients with Hb levels ≥8 gr/dl. Generalized estimating equations (GEE) method was applied to assess the separate associations of each selected characteristic with off-protocol RBC transfusion, taking into account clustering of observations due to repeated transfusions per patient. Results: During the study period 584 RBC transfusions met inclusion criteria. These transfusions were given to 302 patients, mean age of 67 (±19.5, range 14 to 100) years, of which 162 (53.6%) were female. Mean number of transfusions per patient was 1.9 (±1.3) [range from 1 (in 52.6%) to 8 (in 2) patients]. Nearly all patients (291, 96.4%) had at least one underlying medical condition; hypertension (48.3%), malignancy (33.1%), heart (44.7%), nephrology (32.1%) and pulmonary diseases (32.1%). Antithrombotic therapy was taken by 142 (47%) patients. Of the 584 RBC transfusions, 498 (85.3%) were given in the non-surgical departments and 247 (42.3%) were given to patients who underwent invasive procedures/surgery during the current admission, of which 137 (55.5%) were considered major operations (e.g. open laparotomy, open heart, etc.). Pre-transfusion Hb level was ≥8 gr/dl in 229 (39.2%) transfusions and〉1 RBC unit was given consecutively in 96 (16.4%) transfusions. The prevalence of off-protocol RBC transfusion, as defined in this study, was 48.1%. Mean age of patients receiving off-protocol RBC transfusion was higher than those receiving by protocol (67.8±18.2 vs. 60.7±21.8, OR=1.02, 95% CI 1.01-1.03). Off-protocol RBC transfusion was more common in the surgical departments vs. non-surgical (OR=7.4, 95% CI 3.7-14.7). In patients undergoing invasive procedure/surgery, major operations were associated with higher odds of off-protocol RBC transfusion compared to minor procedures (OR=1.7, 95% CI 1.1-2.8). Off-protocol RBC transfusion was not related to presence of underling malignancy, heart, nephrology and pulmonary diseases, but was more common among patients taking antithrombotic therapy (OR=1.7, 95% CI 1.2-2.4). Pre-transfusion recording of patients' blood pressure, pulse rate and saturation were not associated with off-protocol RBC transfusion. Conclusions: This study demonstrates that almost half of RBC transfusions are not given based on suggested guidelines. Although clinical considerations, such as underlying diseases or patient's pre-transfusion signs, may explain non-adherence to guidelines, no clear pattern was observed in the current study to support this explanation. The study findings highlight the need to further our understanding of clinical decision making leading to RBC transfusion and call for establishing clear guidelines to facilitate wise transfusion-related choices. Disclosures No relevant conflicts of interest to declare.

Beschreibung: (PS and UF contributed equally to this work.) Introduction: The Autoimmune Lymphoproliferative Syndrome (ALPS) is caused by inefficient clearing of T lymphocytes. Patients are thus characterized by lymphadenopathy, hepatosplenomegaly, autoimmune cytopenias and an elevated number of double negative T cells (CD3+, TCRα/β+, CD4-, CD8-). Patients suffering from ALPS typically harbor germline or somatic mutations in genes involved in the apoptotic FAS death receptor signaling pathway (FAS, FASLG or CASP10). For 20-30% of patients, however, the genetic cause is still unknown. Methods: The objective of this study was to identify novel gene candidates underlying ALPS of unknown genetic cause. To this end, 25 patients with clinical ALPS symptoms, but without classical mutations were analyzed by whole-exome sequencing. The list of potential candidates was narrowed down using an in-house developed bioinformatic analysis pipeline for patient-based gene prioritization based on protein-protein interaction networks. Resulting candidates were validated by Sanger sequencing and their impact on Fas signaling was studied. Results We identified a de novo germline mutation of the Signal Transducer And Activator Of Transcription 3 (STAT3, c.833G〉A, p.R278H) in one of the analyzed patients. The patient presented at the age of nine with Coombs positive hemolytic anemia, thrombocytopenia, generalized progressive, non-infectious, non-malignant lymphadenopathy and splenomegaly. Immunophenotyping revealed increased numbers of double negative T cells (20% in peripheral blood) and over time the patient developed panhypogammaglobulinemia. We performed immunoblot analyses and could demonstrate that the level of phosphorylated STAT3 (pSTAT3-Tyr705) was elevated in the patient's lymphocytes. This finding indicated that the mutation leads to constitutive activation of STAT3. Consistently, we detected an increased expression of STAT3 target genes (including SOCS3, MMP7 and the anti-apoptotic factors BCL2 and BCL2L1) compared to wild-type controls using quantitative real-time PCR. We could also show a decreased expression of the pro-apoptotic genes BAK1 and BAX that is in accordance with the known negative regulation by STAT3. Thus, in the analyzed patient we found that the balance of pro- and anti-apoptotic factors inside the cell was skewed towards apoptosis resistance. Consistently, we could induce apoptosis in vitro applying recombinant Fas ligand, IL21 or staurosporine efficiently in cells derived from healthy controls, but only to a significantly lesser extent in cells from the patient. Moreover, in healthy cells we observed a concurrent downregulation of anti-apoptotic BCL2/BCL2L1 and an upregulation of pro-apoptotic BAX/BAK1 expression upon treatment that was completely absent in the patient's cells. Next, we tried to rescue the effect of constitutively activated STAT3 by application of a STAT3 specific inhibitor: S3I-201. When we treated the patient's lymphocytes with S3I-201 the expression levels of pro- and anti-apoptotic genes were similar to healthy controls and the sensitivity to apoptosis was restored. Conclusion: We report here a novel germline dominant STAT3 gain-of-function mutation that caused a clinical phenotype mimicking ALPS. Recent studies indicated that dominant germline STAT3 gain-of-function mutations lead to autoimmunity, hypogammaglobulinemia, and lymphoproliferation. STAT3 gain-of-function patients therefore share some clinical characteristics with ALPS patients. The clinical presentation of the patient described here differed from the phenotypes previously reported and thus extends the spectrum of STAT3 -associated diseases. The mechanism underlying the clinical symptoms of STAT3 gain-of-function patients has not yet been determined. Here, we demonstrate increased activation of STAT3 and STAT3 target genes, leading to a skewed balance of pro- and anti-apoptotic factors and apoptosis evasion as a cause for lymphocyte accumulation and resulting autoimmunity in a STAT3 gain-of-function patient. Similar to ALPS patients, diminished responsiveness of lymphocytes to apoptosis seems to be a major characteristic. The clinical phenotype may differ because mutations in STAT3 or Fas signaling genes, respectively, affect overlapping, but also distinct signaling pathways. Disclosures No relevant conflicts of interest to declare.

Beschreibung: This paper reports on the use of a high-throughput diagnostic genetic screening for coagulation, platelet, or thrombotic disorders in a series of more than 2000 patients.