ALBERT

Description: The Ig heavy chain (IgH) gene was used as a marker to investigate clonal succession and the origin of the neoplastic cell in multiple myeloma. The polymerase chain reaction (PCR) was used to amplify a section of the rearranged IgH gene at diagnosis and at progression in 21 patients who had exhibited a plateau phase. A monoclonal PCR product was seen for 16 of the patients and the product present at progression was of the same molecular weight as that at diagnosis. This finding suggests that the IgH rearrangement present at diagnosis and progression was the same. This was confirmed by sequencing the IgH gene in 10 patients. The IgH genes were found to be hypermutated at diagnosis, but no further hypermutation occurred during the course of the disease. The results provide evidence that the neoplastic cell in myeloma may originate as a memory B cell, plasmablast, or plasma cell, and suggest that progression beyond the plateau phase is not caused by clonal succession.

Description: Metabolic studies were performed in a number of patients to determine the effect of anemia on tryptophan metabolism. Patients were given a tracer dose of DL-tryptophan-2-C14 or the tracer dose plus a loading dose (2 Gm.) of L-tryptophan. In those patients given the loading dose, the C14O2 production over a 24 hour period was lower than that usually obtained in normals receiving the same dose. The loading dose did not have any significant effect on the total urinary radioactivity level. In some cases the post tryptophan loading urinary level of kynurenine, quinolinic acid, N1-methylnicotinamide and N1-methyl-2-pyridone-5-carboxamide were elevated. Vitamin B6 administration returned the kynurenine and N1-methylnicotinamide levels to normal but not the quinolinic acid or pyridone. The results obtained here indicate that in anemias the activity of the hematin dependent enzyme, tryptophan pyrrolase, was depressed as well as the enzymes converting the amino acid into CO2. The data suggest that not only are the kynurenine catabolism enzymes vitamin B6 dependent but that vitamin B6 is very important to the conversion of the tryptophan metabolite 3-hydroxy-anthranilic acid into α-amino-β-carboxymuconic-ε-semialdehyde and the conversion of the semialdehyde into acetate and CO2. In addition vitamin B6 may be involved in the further metabolism of quinolinic acid into the pyridone.

Description: Abstract 2643 Children with sickle cell anemia (SCA) and abnormal transcranial Doppler (TCD) velocities receive chronic transfusion therapy in an effort to prevent a primary stroke. Typically the goal is maintaining sickle hemoglobin (HbS)

Description: Introduction:Children with sickle cell disease (SCD) and abnormal cerebral blood flow often receive cyclic blood transfusions (CTx) to reduce risk of stroke. While effective for stroke prevention, CTx causes systemic iron accumulation that may damage multiple organs (Harmatz P., Blood 2000). Iron toxicity from CTx is poorly described for the brain, in comparison to the liver and heart. Quantifying iron in the subcortical structures and the choroid plexus is of renewed clinical importance, due to recent findings that iron accumulation in these regions may predict CNS injury in neurodegenerative disorders. In this study, a new imaging protocol is applied to quantify iron levels and measure structural volumes for the subcortical structures and choroid plexus of children with SCD on CTx, using healthy children for comparison. Methods:SCD patients were eligible if at least 12 consecutive months of CTx were received for abnormal transcranial doppler. Patients with history of CVA were excluded, due to potential confounding effects of prior ischemic damage.Healthysiblings and relatives were used as ethnic- and age-matched controls.MRI scans of the liver and brain, using a Siemens 3T Trio scanner, was performed without sedation for all subjects. A modified pulse sequence (R2*) for the 3T scanner was used to determine liver iron concentration. T1-weighted imaging sequence with MPRAGE was used for anatomical identification and volume measurements of brain regions (Kirk G., Cerebral Cortex 2009). A 3D multi-echo gradient-echo sequence (FOV=256x192mm, Matrix=256x192, Slice thickness = 2mm, 72 slices, TR = 50 ms, first TE = 3.7ms, 12 echoes, echo spacing = 3.8ms) was used for the quantitative susceptibility mapping (QSM), a MRI method that is sensitive to tissue iron (Shmueli K., Magn Reson Med 2009). Iron levels were generated with a post-processing protocol developed for this application (modification of Qiu D., AJNR 2014). To compare iron levels between the two groups a general linear model (GLM) was used that incorporated the ages of the subjects into the comparison. For the patients, an additional GLM analysis was performed to determine if iron level when in each region when corrected for age was associated duration of transfusions, liver R2* and average serum ferritins. Results:MRI scans were evaluable for 25 SCD patients on CTx and 23 controls. There were no significant differences between patients and healthy controls with respect to age, sex or ethnicity. The average duration of CTx was 6.0 (1.5-12.6) yrs and the average serum ferritin and liver iron R2* were 2540 ng/ml and 819 Hz (~14.8mg/g dry weight), respectively. As anticipated, iron level in the choroid plexus was significantly elevated in patients compared to controls (p=1.4x10-7), and levels correlated well with serum ferritin (p=0.0003) and liver R2* (p=0.001) (panel a). While there were no significant differences detected between the groups with respect to iron levels in the subcortical structures, there was a trend to increasing differences between the groups with age in the Substanita Nigra, Red Nucleus and Dentate Nucleus (panels b,c,d). In the GLM analysis, age was significantly associated with iron levels in the subcortical structures, not in the choroid plexus. Although iron levels in some of the subcortical structures were associated with duration of CTx, ferritin and liver R2*, the significance was predominately lost when corrected for age. These observations suggest additional studies with older subjects may reveal increased differences. Volumetric analysis was performed to assess potential injury to deep gray matter. The measured volumes of the subcortical structures were not statistically different between the groups, with a noted exception of the caudate nucleus (p=0.021), a region of known predisposition to injury in SCD (Steen R., Ann Neurol 1999). Conclusions: The MRI protocol successfully quantified iron in brain structures, associated with neurodegenerative disorders. Iron accumulation in the choroid plexus was significant in SCD patients on CTx, and correlated with other markers of iron overload. While iron was detectable in subcortical structures, the levels were not significant different from controls after adjusting for age. These finding should be helpful in planning for a longitudinal study that includes a broader age range. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Description: Background: Pulmonary function is particularly susceptible to acute and chronic injury occurring in patients with sickle cell anemia (SCA). Acute Chest Syndrome (ACS), a common and potentially fatal complication of SCA, can be the cause or the consequence of abnormal pulmonary function (Siddiqui & Ahmed, 2003). Use of hydroxyurea therapy (HU) is increasing for children with recurrent pulmonary complications, following the findings that HU reduces risk of ACS in adults (Charache et al, 1995). How HU may improve pulmonary function in children with SCA is still ill-defined. The purpose of this study was to assess the change observed on serial pulmonary function tests (PFT) for children prescribed HU for abnormal pulmonary function. Methods: Over 240 children with pulmonary complications, such as acute chest syndrome, reactive airway disease, and chronic hypoxia, have been evaluated in the Sickle Cell Pulmonary Clinic at Children’s Healthcare of Atlanta since beginning in July 2000. As part of the Clinic’s standard of care, PFT were routinely attempted on children over the age of 5. A retrospective review of PFT results was done for the children with SCA and prior abnormal PFT. Children were included in the HU cohort (+HU) if repeat PFTs were available following 〉 3 months on HU therapy and if time on HU did not include frequent RBC transfusions. Children without history of HU therapy (−HU) were selected for comparison. PFTs were performed on a standard plethysmograph. Paired t-test was used to evaluate observed differences. Results: Thirty-one children with prior abnormal PFT had test before and following prescription of HU. Their mean age was 12.6 (range 6–20) years and mean duration of HU was 21 (range 4–47) months at the time of the repeat PFT. Hematologic changes expected on HU occurred for all 31 children. Twenty-four children followed for abnormal PFT had no history of HU (−HU) and matched the +HU group by gender, age (mean 12.3, range 7–19 years), duration followed at time of repeat PFT (mean 19, range 3–66 months; p=0.36), and initial hematologic parameters. Spirometry findings changed for +HU group, and remained stable for −HU group. Mean FVC and FEV1 values improved significantly on HU, when compared to initial (PreHU) PFT and to −HU controls. Conversion to a normal PFT, as interpreted by a pediatric pulmonologist masked to treatment status, occurred in 18 (58%) and 2 (8%) children in the +HU and −HU groups, respectively. Table 1: Serial PFT and hematologic parameters according to HU exposure −HU (n=24) +HU (n=31) Initial Repeat # PreHU Repeat 1 % predicted value for age, sex and height of subject. 2Mean (SD) #No significant changes compared to Initial, p 〉 0.05. *P value 〈 0.001 compared to PreHU; ++P value 〈 0.001 compared to −HU repeat. PFT parameter 1 TLC 88 (13.6)2 85 (11.7) 85 (13.4) 90 (13.5) FVC 78 (9.8) 79 (9.9) 75 (12.6) 90 (13.2)*,++ FEV1 75 (9.6) 74 (12.2) 72 (11.4) 86 (10.2)*,++ FEF 25-75 75 (22) 72 (28.0) 77 (23.4) 79 (26.8) FEV1/FVC (%) 85(6.7) 82 (9.8) 87 (11.8) 86 (11.1) Pulse oximetry (%) 95 (3.1) 96 (2.4) 94 (4.4) 97 (2.8)* WBC (x103/ul) 14 (3.8) 13 (2.9) 13.02 (2.9) 9.0 (2.1) *,++ Hb (g/dl) 8.0 (0.1) 8.0 (0.9) 7.8 (1.1) 9.1 (1.3) *,++ MCV (fl) 84 (9.2) 85 (10.0) 87.3 (8.1) 101.2 (10.1) *,++ HbF (%) 4.3 (1.5) 5.2 (5.2) 6.0 (3.8) 14.0 (7.3) *,++ Conclusions: Serial PFTs showed improved pulmonary function, following initiation of HU therapy in children with prior abnormal PFT. Routine PFT assessments of children prescribed HU may serve as an objective measure of clinical response in children with SCA and pulmonary complications. These results will help in the design of future prospective studies examining the clinical benefits of HU therapy for children at risk for long-term pulmonary complications.

Description: The evolution of a tandem accelerator 14C dating system at Chalk River is recounted. Background problems and sources of instability are discussed and solutions are described. Details of sample chemistry and source preparation are presented.

Description: Canadian deuterium uranium (CANDU) pressurized heavy-water reactors produce 14C by neutron activation of trace quantities of nitrogen in annular gas and reactor components (14N(n,p)14C), and from 17O in the heavy water moderator by (17O(n,α)14C). The radiocarbon produced in the moderator is removed on ion exchange resins incorporated in the water purification systems; however, a much smaller gaseous portion is vented from reactor stacks at activity levels considerably below 1% of permissible derived emission limits. Early measurements of the carbon speciation indicated that 〉90% of the 14C emitted was in the form of CO2. We conducted surveys of the atmospheric dispersion of 14CO2 at the Chalk River Laboratories and at the Pickering Nuclear Generating Station. We analyzed air, vegetation, soils and tree rings to add to the historical record of 14C emissions at these sites, and to gain an understanding of the relative importance of the various carbon pools that act as sources/sinks within the total 14C budget. Better model parameters than those currently available for calculating the dose to the critical group can be obtained in this manner. Global dose estimates may require the development of techniques for estimating emissions occurring outside the growing season.

Description: The Chalk River Tandem Accelerator Mass Spectrometry System has reached a state of reliable measurement of 14C using 2 to 5mg elemental carbon prepared by Mg reduction of CO2. For two comparisons of a near-modern unknown with the NBS oxalic acid standard we obtain a total error of ∼±4.5%, consisting of a random system error of about ±3.5% combined with the statistical counting error. Measurements have been made on 70 samples in 30 days of running time during the past year. Samples included deep rock carbonates, cosmogenic 14C in meteorites, charcoal from earthquake fault zones, collagen of bone artifacts and fossil beetle-fragments.

Description: Abstract 7 BABY HUG [Clinical Trials #NCT00006400], an NIH-NICHD sponsored randomized placebo-controlled trial showed that hydroxyurea (HU) administered to 9–18 month old children with sickle cell anemia (SCA) provides substantial clinical benefit. Benefits include a decrease in pain crises, acute chest syndrome events, need for transfusion and hospital admission; hematologic improvement include higher total and fetal hemoglobin concentration, larger red cell size, and lower WBC counts with toxicity limited to transient reduction in absolute neutrophil count (ANC) [Lancet 2011; 377:1663–72]. The parent or guardian of all 176 children who completed at least 18 months of randomized treatment were offered participation in an initial observational BABY HUG Follow-Up Study and 163 (93%) consented to participate. Clinical and laboratory data were collected every 6 months by structured abstraction of the medical record regarding use of clinically prescribed HU (dose escalation recommended), blood counts, clinical imaging, and sickle cell-related events. At the time of enrollment the family did not know their child's randomized study treatment assignment; 133 (82%) initially chose clinical prescription of open-label HU. Acceptance of HU has remained high through 36 months of follow-up; during each 6 month data collection period 68–75% of participants reported having taken HU. Only 2 patients have left the study (due to relocation) and more than 93% of expected data have been collected. Preliminary analyses as of May 2011, including 417 patient years (pt-yrs) of follow up, demonstrate that in comparison to participants not taking HU, children who continue to take HU have statistically lower rates of pain crises requiring emergency department (ED) visits, episodic transfusions, and hospital admissions for any reason, including acute chest syndrome or febrile illness (see table). The substantial decrease in acute chest syndrome episodes is similar to the effect demonstrated with HU use in the randomized BABY HUG trial in younger infants and consistent with published trials detailing the benefit of HU therapy in older children and adults. The decrease in the rate of admission for febrile events in HU-treated patients is also comparable to that in the randomized trial, but the reason for this benefit is uncertain. There was no difference in hospitalization rates for painful events including dactylitis. Two patients in the non-HU group had a stroke. There were no differences between groups in the frequency of a palpable spleen or rate of acute splenic sequestration crises. Through 36 months of follow up children taking HU had persistently higher hemoglobin and MCV, and lower WBC and ANC than those not taking HU. Results of these analyses including growth and development assessments will enhance our understanding of the impact of HU use in children with SCA starting at a very young age. The accruing data from the BABY HUG Follow-Up Study demonstrate a continuation of the substantial benefits of early HU therapy with no discernable additional toxicities. Ongoing follow up of this cohort is essential to fully define these benefits as children grow, and to observe for late toxicity.Event Rate per 100 pt-yrsHUNo HUp valueED visit for Pain Crisis28.853.60.004Episodic Transfusion18.334.00.010Hospital Admission (any cause)74.9133.20.001Acute Chest Syndrome (admission)9.522.30.0001Febrile Illness (admission)30.764.3

Description: Abstract 4834 Over the past half century, the course of sickle cell disease has been transformed in the United States through the conduct of rigorous biomedical research and broad application of the results. Universal newborn screening with comprehensive medical care has dramatically reduced death and disability in childhood, and increased the numbers of patients surviving into adulthood. However, access to health care has not kept up with the changing demographics of those affected by sickle cell disease. Health care often becomes fragmented when patients transition from pediatric to adult health care providers. Access to comprehensive care has impeded both conduct of clinical and implementation of research results. To address these needs in this changing environment, HHS Secretary Kathleen Sebelius has charged six agencies of HHS – NIH, CDC, HRSA, FDA, AHRQ and CMS – and the Offices of Minority Health and Planning and Evaluation, to improve the health of people with SCD. The agencies are coordinating their programs and collaborating with the Office of the Secretary, to achieve the following goals:create a comprehensive database of individuals with SCD to facilitate the monitoring of health outcomes and clinical research;improve the care of adults and children through development and dissemination of evidence-based guidelines, which are anticipated in Spring, 2012, with broad implementation plans;identify measures of quality of care for individuals with SCD and incorporate them into quality improvement programs at HHS;increase the availability of medical homes to improve patient access to quality primary and specialty care;provide State Medicaid officials, health care providers, patients, families and advocacy groups with information about resources related to SCD care and treatment;work with the pharmaceutical industry and academic investigators to increase the development of effective treatments for patients with SCD;support research to improve health care for people with SCD;support research to understand the clinical implications of SC trait;engage national and community-based SCD advocacy organizations and experts in ongoing discussions to ensure that issues of importance to persons affected are addressed. Organizational and strategic actions are being taken at each agency to enhance implementation of research advances; provide evidence-based guidelines to families, health care providers, and payers; facilitate new drug development; and provide public health data to impact both the health care delivery and research agendas. The enthusiastic support of the American Society of Hematology and its members is essential for long-term success of this endeavor. Disclosures: No relevant conflicts of interest to declare.