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Venous thromboembolism (VTE) is a life-threatening complication observed among patients with sickle cell disease (SCD) and also among those with severe COVID-19 infection. Although prior studies show that patients with SCD are at risk of severe COVID-19 illness, it remains unclear if COVID-19 infection further increases VTE risk for this population. We hypothesized that patients with SCD hospitalized for COVID-19 would have higher VTE rates than those hospitalized for other causes. Using electronic health record data from a multisite research network, TriNetX, we identified 2 groups of patients with SCD hospitalized during 2020: (1) with COVID-19 and (2) without COVID-19. We compared VTE rates using risk ratios estimated based on adjusted Poisson regression model with log link and robust error variances. Of the 281 SCD patients hospitalized with COVID-19 and 4873 SCD patients hospitalized without COVID-19 , 35 (12.46%) and 418 (8.58%) had incident VTE within 6 months of the index hospitalization respectively. After adjusting for differences in baseline characteristics, no significant differences in VTE rates within 6 months were found between the 2 groups (adjusted relative risk, 1.06 [95% confidence interval, 0.79-1.41]). These data suggest that hospitalization with COVID-19 does not further increase VTE risk in patients with SCD.

Background India suffers from a double burden of malnutrition and anaemia. The Karnataka anaemia project indicated that a counselling intervention delivered by community health workers improved anaemia cure rates. Objective To evaluate the effect of maternal counselling on nutritional aspects of anaemia prevention. Methods Secondary analysis of a cluster randomised controlled trial (55 simultaneously randomised villages using random number generator in Chamrajnagar district, Northern India). In the intervention group mothers of anaemic children received five monthly counselling sessions plus usual care (iron and folic acid supplements), while mothers of anaemic children in the control group received usual care alone. Daily intake of nutrients related to anaemia prevention, i.e. iron (mg) and vitamin C (mg), was estimated using the 24-h dietary recall method at baseline and 6 months follow-up. Linear and logistic mixed regression models were used to assess between-groups difference in changes in nutrients intake from baseline to end of follow-up. Data collectors and analysts were blinded to the group assignment. Results Participants were 534 (intervention n = 303; usual treatment n = 231) anaemic children, aged 1 to 5 years and their caregivers, of whom 521(intervention n = 299 from 28 villages; usual treatment n = 222 from 27 villages) were retained at 6 months follow-up and included in the analysis. This study provides inconclusive evidence of improvement in the intake of nutrients that prevent anaemia from baseline to follow-up among the intervention compared to the control group; increase in iron intake was 0.24 mg/day (95% CI -0.67; 1.15) and increase in vitamin C intake was 4.61 mg/day (95% CI -0.69, 9.91). Although encouraging, it is notable that the overall intake of nutrients that prevent anaemia remained well below the national recommended daily allowance. Conclusion This study provides inconclusive evidence of the effect of parental counselling on nutritional aspects of anaemia prevention. The results highlight the need to devise multi-component anaemia-prevention interventions that include facilitators of the availability of nutritious food and should be evaluated in studies that are adequately powered to detect nutritional changes. Trial registration International Standard Randomized Controlled Trial Number ISRCTN68413407, prospectively registered on 17/12/2013.

In countries with organized access to health care, survival of patients with sickle cell disease (SCD) has greatly improved, shifting the burden of care from a pediatrician to an internal medicine physician. As a consequence, cumulative disease complications related to chronic vasculopathy are becoming more apparent, adding to organ dysfunction from physiologic aging. The time has come for us to reevaluate the approach to managing the older adult with SCD by putting a greater emphasis on geriatric conditions while proactively considering curative options once previously offered only to younger patients, with comprehensive annual assessments and joint clinics with relevant specialists.

The pathophysiology of sickle cell disease (SCD) is driven by chronic inflammation fueled by damage associated molecular patterns (DAMPs). We show that elevated cell-free DNA (cfDNA) in patients with SCD is not just a prognostic biomarker, it also contributes to the pathological inflammation. Within the elevated cfDNA, patients with SCD had a significantly higher ratio of cell-free mitochondrial DNA (cf-mtDNA)/cell-free nuclear DNA compared with healthy controls. Additionally, mitochondrial DNA in patient samples showed significantly disproportionately increased hypomethylation compared with healthy controls, and it was increased further in crises compared with steady-state. Using flow cytometry, structured illumination microscopy, and electron microscopy, we showed that circulating SCD red blood cells abnormally retained their mitochondria and, thus, are likely to be the source of the elevated cf-mtDNA in patients with SCD. Patient plasma containing high levels of cf-mtDNA triggered the formation of neutrophil extracellular traps (NETs) that was substantially reduced by inhibition of TANK-binding kinase 1, implicating activation of the cGAS-STING pathway. cf-mtDNA is an erythrocytic DAMP, highlighting an underappreciated role for mitochondria in sickle pathology. These trials were registered at www.clinicaltrials.gov as #NCT00081523, #NCT03049475, and #NCT00047996.

The genetic and molecular basis of sickle cell disease (SCD) has long since been characterized but the pathophysiological basis is not entirely defined. How a red cell hemolytic disorder initiates inflammation, endothelial dysfunction, coagulation activation and eventually leads to vascular thrombosis, is yet to be elucidated. Recent evidence has demonstrated a high frequency of unprovoked/recurrent venous thromboembolism (VTE) in SCD, with an increased risk of mortality among patients with a history of VTE. Here, we thoroughly review the molecular basis for the prothrombotic state in SCD, specifically highlighting emerging evidence for activation of overlapping inflammation and coagulation pathways, that predispose to venous thromboembolism. We share perspectives in managing venous thrombosis in SCD, highlighting innovative therapies with the potential to influence the clinical course of disease and reduce thrombotic risk, while maintaining an acceptable safety profile.

Intracellular oxidative stress and oxidative modification of sickle hemoglobin (HbS) play a role in sickle cell disease (SCD) pathogenesis. Recently, we reported that Hb-dependent oxidative stress induced post-translational modifications (PTMs) of Hb and red blood cell (RBC) membrane proteins of transgenic SCD mice. To identify the mechanistic basis of these protein modifications, we followed in vitro oxidative changes occurring in intracellular Hb obtained from RBCs and RBC-derived microparticles (MPs) from the blood of 23 SCD patients (HbSS) of which 11 were on, and 12, off hydroxyurea (HU) treatment, and 5 ethnic matched controls. We used mass spectrometry-based proteomics to characterize these oxidative PTMs on a cross-sectional group of these patients (n = 4) and a separate subgroup of patients (n = 2) studied prior to initiation and during HU treatment. Collectively, these data indicated that band-3 and its interaction network involved in MPs formation exhibited more protein phosphorylation and ubiquitination in SCD patients than in controls. HU treatment reversed these oxidative PTMs back to level observed in controls. These PTMs were also confirmed using orthogonal immunoprecipitation experiments. Moreover, we observed specific markers reflective of oxidative stress, including irreversible oxidation of βCys93 and ubiquitination of Hb βLys145 (and βLys96). Overall, these studies strongly suggest that extensive erythrocyte membrane protein phosphorylation and ubiquitination are involved in SCD pathogenesis and provide further insight into the multifaceted effects of HU treatment.

A key inflammatory mechanism recently identified in platelets involves the Nod-like receptor nucleotide-binding domain leucine-rich repeat containing protein 3 (NLRP3) and Bruton tyrosine kinase (BTK), which control activation of caspase-1 within inflammasome complexes. We investigated platelet caspase-1 activity in the context of sickle cell disease (SCD) directly in platelets isolated from SCD patients (n = 24) and indirectly by incubating platelets from healthy subjects with plasma obtained from SCD patients (n = 20), both in steady state and during an acute pain crisis (paired samples). The platelet NLRP3 inflammasome was upregulated in SCD patients under steady state conditions compared with healthy controls, and it was further upregulated when patients experienced an acute pain crisis. The results were consistent with indirect platelet assays, in which SCD plasma increased caspase-1 activity of platelets from healthy subjects in an NLRP3-dependent fashion. The damage-associated molecular pattern molecule high-mobility group box 1 (HMGB1) was elevated in plasma of SCD subjects compared with healthy controls and correlated with caspase-1 activity in platelets. Pharmacological or antibody-mediated inhibition of HMGB1, Toll-like receptor 4, and BTK interfered with sickle plasma–induced platelet caspase-1 activation. In Townes SCD mice, caspase-1 activity and aggregation of circulating platelets were elevated, which was suppressed by IV injection of an NLRP3 inhibitor and the BTK inhibitor ibrutinib. Activation of the platelet NLRP3 inflammasome in SCD may have diagnostic and therapeutic implications.

Introduction: Sickle cell disease (SCD) is a multisystemic disorder, the pathology being driven by recurrent inflammation particularly during a vaso-occlusive crisis. GlycA, a composite measure of protein glycation, is a sensitive biomarker for disorders associated with vascular inflammation. We determined the utility of GlycA as a biomarker of inflammation in SCD. Methods: Stored plasma samples from patients with SCD recruited to two clinical studies were analyzed. One study encompasses 488 patient samples with SCD (HbSS, HbSβ0 and HbSC) at steady state and 52 race-matched, healthy controls. The other study included paired plasma samples during steady state and acute pain crisis from (HbSS) patients with SCD. Plasma GlycA was measured using a proton NMR on the Vantera® Clinical Analyzer. We performed analysis comparing patients with SCD, healthy controls, and paired samples analysis. Results: The mean plasma GlycA level was lower in SCD compared with healthy controls (324.6 ± 70.4 μmol/L vs. 386.3 ± 74.6 μmol/L, P < 0.0001). Within the same patient, mean plasma GlycA during acute pain crisis was lower than steady state, although the difference was not significant (300.5 ± 36.3 μmol/L vs 314.2 ± 34.8 μmol/L, P = 0.020). Plasma GlycA correlated inversely with serum LDH (P = 0.009). Conclusion: GlycA is not a suitable biomarker of inflammation in SCD. We surmise that its signal is confounded by hemolysis leading to a depletion of haptoglobin, one of the major plasma proteins included in the composite NMR signal. Hemolysis is further exacerbated during an acute pain crisis, hence the lower GlycA levels in crisis compared to steady state.

Background: Individuals with sickle cell disease (SCD) are at risk of severe COVID-19 infection. Those with SCD are also known to be at risk of venous thromboembolism (VTE), with numerous mechanistic pathways likely at interplay. In general, prior studies indicate that COVID-19 infection is associated with a thromboembolic risk. However, it is unknown if COVID-19 infection increases the already high risk of VTE for individuals with SCD. Given the preexisting risk for thrombophilia associated with SCD, we hypothesized that COVID-19 infection would further increase the risk of a venous thromboembolic event. In this study, we leverage electronic health record data to determine, at a population level, whether individuals with SCD hospitalized for COVID-19 have higher VTE rates when compared to hospitalization for any other cause. Method: Using electronic health record data from a multisite research network, TriNetX (years 2010 - 2020) we identified two mutually exclusive cohorts of individuals with SCD between Jan 20, 2020 - Dec 31, 2020: 1) those with hospitalizations related to a diagnosis of COVID-19 and 2) those with hospitalization for other causes. COVID-19 related hospitalizations were defined as admissions occurring within a month of COVID-19 diagnosis. Overall, individuals were considered to have SCD if they had 3 or more instances of ICD coding for SCD during the time frame of years 2010 - May 20, 2021 and did not have any ICD code for sickle cell trait. The outcome of interest was VTE, which included either deep venous thrombosis (DVT), pulmonary embolism (PE) or both. We determined the VTE rates at 1 month, 3 months and 6 months post hospitalization. The VTE rates between the two groups were compared using measures of risk difference and risk ratios, along with the respective 95% confidence intervals. We also matched the groups using propensity scores based on the prevalence of VTE prior to the index event of hospitalization and compared the respective outcomes. Results: Within the TriNetX network, there were 223 (59% females) individuals with SCD hospitalized due to COVID-19, and 3,591 (54% females) hospitalized for causes other than COVID-19. Individuals with SCD hospitalized for COVID-19 were older than individuals with SCD hospitalized for other causes (mean age: 29.4 yrs, sd = 16.4 vs 26.3 yrs, sd = 16.8, p value = 0.006). A significantly higher proportion of individuals hospitalized for COVID-19 had a prior history of portal vein thrombosis (4% vs ~0%, p-value Conclusions: These data suggest that immunothrombosis accompanying SARS-COV-2 infection in individuals with SCD does not exacerbate the underlying known thrombophilia associated with SCD and provide support for current clinical guidelines in this population. Future prospective studies controlled for anticoagulant therapy exposures may provide more direct evidence to guide thromboprophylaxis in this unique population. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Introduction: Sickle Cell Disease (SCD) is characterized by chronic inflammation with innate immune cell activation, especially observed in neutrophils. Emerging evidence implicates the imbalance between neutrophil extracellular trap (NET) formation and degradation as having a central role in the pathophysiology of thromboinflammation and venous thrombosis. Although NETosis and NET formation influences venous thromboembolism (VTE) pathophysiology, little is known about baseline and agonist-induced NETosis in SCD. We hypothesized that systemic neutrophil activation would lead to higher baseline and agonist induced NETosis in SCD and would influence phenotypic variability. To test this hypothesis, we assessed baseline and agonist induced NETosis in patients with SCD and ethnic matched controls. We also investigated the anti-inflammatory effects of flavonoid Quercetin on neutrophil activation. Methods: Neutrophils negatively selected from citrate anticoagulated blood using an immunomagnetic bead based kit (MACSxpress® Miltenyi Biotec) were either fixed immediately to assess baseline NETosis or stimulated with fMLP (1 µM) for 1 hour to assess agonist-induced NETosis. To study flavonoid anti-inflammatory effects, neutrophils were pretreated with Quercetin (100 µM) for 30 min prior to fixation and fMLP stimulation. NETosis was assessed by flow cytometry. Extracellular DNA extrusion on neutrophils was detected by gating the neutrophil population staining with Sytox green. Sytox green positive neutrophils that were positive for both myeloperoxidase (MPO) and tri-Citrullinated Histones (H3Cit) were defined as undergoing NETosis. In some experiments, NET formation was independently confirmed by image flow cytometry (AMNIS). Results: Subjects included SCD patients (genotype SS n=11) and ethnic matched controls (genotype AA, n=11) with a median age of 49 years (p=0.58) and a predominance of males (70%). All SCD patients were at least 60 days remote from an acute painful vaso-occlusive crisis or blood transfusion and were receiving hydroxyurea. The white cell and absolute neutrophil counts were higher in SCD patients (mean ± SD 8.77 ± 1.52 and 5.07 ± 1.78 x 10 9/L) when compared with controls (mean ± SD 5.33 ± 1.05 and 2.8 ± 0.95 x 10 9/L). Subsequent data are presented as median percentages with interquartile ranges (IQR). A subgroup of the study population demonstrated spontaneous NETosis (27%; SS = 4; AA = 4) and were therefore excluded from our analysis. Contrary to expectations, SCD patients exhibited a lower percentage of NETosis at baseline compared to controls (20 % (11, 36) vs. 33 % (15, 58); p=0.22). Similarly, neutrophils from SCD patients exhibited lower agonist-induced NETosis compared to controls (42% (19, 47) vs. 51% (37, 70); p=0.15) (Fig 1 A and B) Pretreatment of neutrophils from SCD patients with Quercetin appeared to inhibit basal levels of NETosis (6%, (2, 26) vs. 20% (11, 36) p=0.08) although this effect was not appreciable in controls (33% (11, 58) vs. 33% (15, 58) p=0.41) (Fig 1 C and D). Neutrophils from SCD patients that were pretreated with Quercetin and then stimulated with fMLP demonstrated significantly reduced NETosis compared to untreated neutrophils (17.1% (10, 38) vs 41.7% (19, 47) p=0.007) although this effect was not significant in controls (35% (17, 72) vs 50.7% (37, 70) p=0.11) Fig 1 E and F. Our ongoing experiments will demonstrate the effects of more specific inhibitors of neutrophil activation (e.g. R406) in human and mouse models of SCD. Conclusion: These preliminary data suggest lowered NETosis in SCD patients despite neutrophil activation in the systemic inflammatory environment that are partially explained by hydroxyurea treatment. The results also support further evaluation of anti-inflammatory therapies to reduce neutrophil activation in SCD and ameliorate thrombo-inflammatory disease pathology. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Introduction: Altered erythrocyte physiology in Sickle Cell Disease (SCD) results in severe vascular complications, including vaso-occlusion (VOC) along with various other manifestations, such as thrombosis and end organ damage. Moreover, platelet activation endothelial dysfunction and fibrin formation, are critical processes implicated in thrombo-inflammatory vasculopathy in SCD. Since flavonoids intake is associated with lowered adverse cardiovascular disease outcomes and cancer associated thrombosis, we are evaluating the effects of the flavonoid Isoquercetin (IQ) on thrombo-inflammatory biomarkers in patients with SCD (NCT:04514510). Here we report the mechanistic effects of Quercetin (Que), an aglycone that differs from IQ by the absence of 3-linked glucoside moiety, on markers of erythrocyte and platelet activation in patients with SCD. Methods: We studied patients with SCD (Genotype SS, mean age: 39 yrs, N=8) and ethnic matched controls (Genotype AA, mean age: 42 yrs, N=8). Erythrocyte reactive oxygen species (ROS) was measured in washed red cells by flow cytometry using the fluorescent probe 2', 7'-dichlorofluorescein diacetate (DCFDA) in the presence or absence of Quercetin (Que) (100 µM). Effects of in vitro erythrocyte ROS induction by hydrogen peroxide (H 2O 2) and ROS inhibition by N-acetyl-L-cysteine (NAC) were evaluated. Baseline and agonist-induced (ADP 20 µM) platelet P-selectin expression in vitro in the presence or absence of Que (100 µM) was assessed by flow cytometry. Results: At baseline, SS erythrocytes demonstrated elevated levels of ROS reflected by greater florescent intensity with DCFDA when compared with erythrocytes from ethnic matched controls (SS mean= 1884, SD: 508.8 vs. AA mean: 1604, SD: 554.5; p value= 0.3798). Stimulation of AA erythrocytes in vitro with H 2O 2 led to accumulation of ROS that approached levels similar to those exhibited by SS erythrocytes at baseline (AA mean: 1890, SD: 748.3). Pre-treatment of SS and AA erythrocytes in vitro with the antioxidant NAC exhibited minimal effects on ROS in SS erythrocytes (SS baseline+NAC mean: 1942, SD: 526.8, p value 0.4609 and SS H 2O 2+NAC mean: 1889, SD: 437.4, p value 0.5469) but lowered ROS levels in both baseline and H 2O 2 treated AA erythrocytes (AA baseline+NAC mean: 1442, SD: 453.9, p value 0.1563 and AA H 2O 2+NAC mean: 1581, SD: 518.7, p value 0.078). Pre-treatment of SS and AA erythrocytes in vitro with Que substantially lowered erythrocyte ROS in patients and controls at the baseline (SS baseline ROS with Que mean: 1582, SD: 542.0, p value 0.0078; AA baseline ROS with Que mean: 1341, SD: 490.9, p value 0.0313; Fig. 1A), and after H 2O 2 stimulation (SS H 2O 2 induced ROS+Que mean: 1677, SD: 572.5, p value 0.0156; AA H 2O 2 induced ROS+Que mean: 1417, SD: 512, p value 0.0078). Pre-treatment of erythrocytes with a combination of Que and NAC did not reveal synergistic anti-oxidant activity (SS NAC+Que mean: 1616, SD: 464.8; AA NAC+Que mean: 1333, SD: 524.1). We simultaneously investigated the effects of Que on platelet P-selectin expression in the same subjects. As expected, baseline platelet surface P-selectin expression was higher in SS patients compared with controls (SS N=5, mean: 1.48%, Max: 4.9%, Min: 0.03%; AA N=4, mean: 0.89%, Max: 2.3%, Min: 0%; p value 0.55). Stimulation of platelet rich plasma (PRP) with ADP increased surface P-selectin expression in comparison with baseline, in both patients and controls (SS N=5, mean: 18.04%, Max: 40.4%, Min: 5.8%, p value 0.0047; AA N=4, mean: 20.60%, Max: 43.8%, Min: 5.4%; p value 0.0140). Pre-treatment of PRP with Que prior to ADP stimulation revealed a trend toward decreased platelet surface P-selectin expression in both patients and controls (SS N=5, mean: 10.49%, Max: 24.8%, Min: 3.1%; AA N=4, mean: 12.09%, Max: 21.9%, Min: 3.4%; Fig 1B) although this did not return to baseline. Conclusion: The flavonoid Quercetin appears to have a beneficial effect in lowering erythrocyte ROS and platelet surface P-selectin and warrant further evaluation as a strategy to ameliorate thrombo-inflammatory pathophysiology in sickle hemoglobinopathies. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Background: India suffers a double burden of undernutrition and anaemia. The Karnataka anaemia project indicated that a counselling intervention delivered by community health workers improved anaemia cure. Objective: To evaluate the effect of maternal counselling on overall child nutrition. Methods: Secondary analysis of a cluster randomised controlled trial (55 villages). Mothers in the intervention group received five monthly counselling sessions plus usual care (iron and folic acid supplements), while the control group received usual care only. The study included 1144 children (1-5 years old), of whom 534 were anaemic. 24-hour dietary recall and questionnaires were used to determine children’s dietary intake (primary outcome), maternal knowledge on nutritional aspects of anaemia (secondary outcome). Follow up was conducted at six months. Linear mixed regression models were used to assess between groups differences. Findings: Daily intake of all nutrients, except vitamin C, increased in both groups from baseline to follow up. The increase was higher among children in the intervention group compared to the control group for all nutrients except vitamin B12. Iron and vitamin C intake increased by 0·24 (95%CI -0·67; 1·15) mg/day and 4.61 (95% CI -0·69; 9·91) mg/day in the intervention group compared to the control group, respectively. Furthermore, children of mothers with low education also benefited from the intervention. Interpretation: The intervention resulted in modest improvements in child nutrition, however comparable between maternal education levels. Previously observed enhancement of anaemia cure rate was probably due to improved adherence to iron and folic acid supplements. Trial Registration: ISRCTN identifier: ISRCTN68413407. Funding: Wellcome Trust/DBT India Alliance. Conflict of Interest: Dr. Shet received a grant from the Wellcome Trust/DBT India Alliance while the study was conducted. No other disclosures are reported. Ethical Approval: The study was approved by the St. Johns National Academy of Health Sciences Institutional Ethical Committee (IEC 115/2012). Mothers and caregivers provided written informed consent to participate. An independent committee was employed to act as data safety and management board. This committee conducted an interim analysis looking at the side effects of IFA supplements. The reported side effects were minor.

The pathophysiology associated with sickle cell disease (SCD) includes hemolytic anemia, vaso-occlusive events, and ultimately end organ damage set off by the polymerization of deoxygenated hemoglobin S (HbS) into long fibers and sickling of red blood cells (RBCs). One approach toward mitigating HbS polymerization is to pharmacologically stabilize the oxygenated (R) conformation of HbS and thereby reduce sickling frequency and SCD pathology. GBT440 is an α-subunit-specific modifying agent that has recently been reported to increase HbS oxygen binding affinity and consequently delay in vitro polymerization. In addition, animal model studies have demonstrated the potential for GBT440 to be a suitable therapeutic for daily oral dosing in humans. Here, we report an optimized method for detecting GBT440 intermediates in human patient hemolysate using a combination of HPLC and mass spectrometry analysis. First, oxygen dissociation curves (ODCs) analyzed from patient blood showed that oxygen affinity increased in a dose dependent manner. Second, HPLC and integrated mass spectrometric analysis collectively confirmed that GBT440 labeling was specific to the α N-terminus thereby ruling out other potential ligand binding sites. Finally, the results from this optimized analytical approach allowed us to detect a stable α-specific GBT440 adduct in the patient's hemolysate in a dose dependent manner. The results and methods presented in this report could therefore potentially help therapeutic monitoring of GBT440 induced oxygen affinity and reveal critical insight into the biophysical properties of GBT440 Hb complexes.

The incidence of venous thromboembolism (VTE) in adult patients with sickle cell disease (SCD) is high. However, overlapping features between the clinical presentation of VTE and SCD complications and a low index of suspicion for thrombosis can influence patient management decisions. VTE in SCD can therefore present management challenges to the clinical hematologist. Herein, we present 3 distinct clinical vignettes that are representative of our clinical practice with SCD patients. These vignettes are discussed with specific reference to the hypercoagulable state in SCD patients, recent VTE diagnosis and anticoagulant therapy guidelines from the general population, and evaluation of the risk of bleeding as a result of long-term exposure to anticoagulant therapy. We examine current diagnostic and treatment options, highlight limitations of the existing clinical prognostic models that offer personalized guidance regarding the duration of anticoagulation, and propose a clinical approach to guide the decision to extend anticoagulation beyond 3 months.

The detection of iron deficiency anemia is challenged by the paucity of diagnostic tests demonstrating high sensitivity and specificity. Using two biomarkers, zinc-protoporphyrin/heme and hepcidin, we established the diagnostic cut-off values for iron deficiency anemia in preschool children and women. We randomly selected non-anemic individuals (n=190; women=90, children=100) and individuals with iron deficiency anemia (n=200; women=100, children=100) from a preexisting cohort of healthy preschool children and their mothers. The diagnostic performance of these biomarkers was estimated by analyzing receiver operating characteristic curves. Diagnostic cut-offs with a high predictive value for iron deficiency anemia were selected. Median zinc-protoporphyrin/heme and hepcidin values in non-anemic children were 49 μmol/mol heme and 42 ng/mL, respectively, and in non-anemic women these values were 66 μmol/mol heme and 17.7ng/mL, respectively. Children and women with iron deficiency anemia had higher zinc-protoporphyrin/heme ratios (children=151 μmol/mol heme and women=155 μmol/mol heme) and lower hepcidin levels (children=1.2ng/mL and women=0.6ng/mL). A zinc-protoporphyrin/heme ratio cut-off >90 μmole/mole heme in children and >107 μmole/mole heme in women was associated with a high diagnostic likelihood for iron deficiency anemia (children, likelihood ratio=20.2: women, likelihood ratio=10.8). Hepcidin cut-off values of ≤6.8ng/mL in children and ≤4.5ng/mL in women were associated with a high diagnostic likelihood for iron deficiency anemia (children, likelihood ratio=14.3: women, likelihood ratio=16.2). The reference ranges and cut-off values identified in this study provide clinicians with guidance for applying these tests to detect iron deficiency anemia. Erythrocyte zinc-protoporphyrin/heme ratio is a valid point-of-care biomarker to diagnose iron deficiency anemia.

Iron deficiency anemia is a global health issue affecting a significant population worldwide. Fortification of food with iron compounds is a widely used strategy to prevent iron deficiency anemia. To overcome sensory effects, water insoluble and white colored compounds, like ferric pyrophosphate, are used to fortify infant cereals. Ferric pyrophosphate is poorly bioavailable due to its low solubility even in an acid medium. Nanosized iron salts find potential applications in food fortification, since solubility increases with decrease in the particle size. However, limited knowledge exists about the effect of nanoparticles in a biological system. The present study addresses the efficacy of synthesized ferric pyrophosphate in its nano form (10–30 nm) as a potential food fortificant in iron deficiency anemia and measures its toxicity in a rat model. Additionally, the effect of the nanoparticle in vivo has been explored using a mass-spectrometry-based plasma proteomics approach. The relative bioavailability of ferric pyrophosphate nanoparticle, calculated using hemoglobin regeneration efficiency was found to be 103.02% with respect to the reference salt, ferrous sulphate. Histopathological examinations of different organs did not show any significant toxicity attributable to nanoparticle ferric pyrophosphate. However, plasma proteomics analysis showed a decreasing trend in Fetuin-B concentration with increasing dose levels of nanoparticle ferric pyrophosphate. In conclusion, the nanoparticle ferric pyrophosphate could be a promising food fortificant in combating iron deficiency anemia, while Fetuin-B, a negative acute phase protein, might be a potential candidate for detecting biological responses to the nanoparticle exposure in vivo.

Background Lay health workers (LHWs) are increasingly used to complement health services internationally. Their perceptions of the interventions they implement and their experiences in delivering community based interventions in India have been infrequently studied. We developed a novel LHW led intervention to improve anemia cure rates in rural community dwelling children attending village day care centers in South India. Since the intervention is delivered by the village day care center LHW, we sought to understand participating LHWs’ acceptance of and perspectives regarding the intervention, particularly in relation to factors affecting daily implementation. Methods We conducted a qualitative study alongside a cluster randomized controlled trial evaluating a complex community intervention for childhood anemia control in Karnataka, South India. Focus group discussions (FGDs) were conducted with trained LHWs assigned to deliver the educational intervention. These were complemented by non-participant observations of LHWs delivering the intervention. Transcripts of the FGDs were translated and analyzed using the framework analysis method. Results Several factors made the intervention acceptable to the LHWs and facilitated its implementation including pre-implementation training modules, intervention simplicity, and ability to incorporate the intervention into the routine work schedule. LHWs felt that the intervention impacted negatively on their preexisting workload. Fluctuating relationships with mothers weakened the LHWs position as providers of the intervention and hampered efficient implementation, despite the LHWs’ highly valued position in the community. Modifiable barriers to the successful implementation of this intervention were seen at two levels. At a broader contextual level, hindering factors included the LHW being overburdened, inadequately reimbursed, and receiving insufficient employer support. At the health system level, lack of streamlining of LHW duties, inability of LHWs to diagnose anemia and temporary shortfalls in the availability of iron supplements constituted potentially modifiable barriers. Conclusion This qualitative study identified some of the practical challenges as experienced by LHWs while delivering a community health intervention in India. Methodologically, it highlights the value of qualitative research in understanding implementation of complex community interventions. On the contextual level, the results indicate that efficient delivery of community interventions will require streamlining of LHW workloads and improved health system infrastructure support. Trial registration This trial was registered with ISRCTN.com (identifier: ISRCTN68413407 ) on 23 September 2013.

Background: Research capacity is scarce in low- and middle-income country (LMIC) settings. Social determinants of health research (SDH) is an area in which research capacity is lacking, particularly in Asian countries. SDH research can support health decision-makers, inform policy and thereby improve the overall health and wellbeing of the population. In order to continue building this capacity, we need to know to what extent training exists and how challenges could be addressed from the perspective of students and staff. This paper aims to describe the challenges involved in training scholars to undertake research on the SDH in four Asian countries – China, India, Oman and Vietnam.Methods: In-depth interviews were conducted with research scholars, research supervisors and principal investigators (n = 13) at ARCADE partner institutions, which included eight universities and research institutes. In addition, structured questionnaires (n = 70) were used to collect quantitative data relating to the courses available, teaching and supervisory capacity, and related issues for students being trained in research on SDH. Simple descriptive statistics were calculated from the quantitative data and thematic analysis applied to the qualitative data.Results: We identified a general lack of training courses focusing on SDH. Added to this, PhD students studying related areas reported inadequate supervision, with limited time allocated to meetings and poor interpersonal communication. Supervisors cited interpersonal communication problems and student lack of skills to perform high quality research as challenges to research training. Further challenges reported included a lack of research funding to include SDH-related topics. Finally, it was suggested that there was a need for institutions to define clear and appropriate standards regarding admission and supervision of students to higher education programs awarding doctoral degrees.Conclusions: There are gaps in training for research on the SDH at the surveyed universities and research institutes, which are likely to also be present in other Asian countries and their higher education institutions. Some of the barriers to high quality research and research training can be addressed by improved training for supervisors, clearly defined standards of supervision, finances for student stipends, and increased use of information and communication technology to increase access to teaching materials. Increased opportunities for online learning could be provided.

Summary Over the past 20 years, cancer research in India has grown in size and impact. Clinicians, scientists, and government and state policy makers in India have championed cancer research, from studies to achieve low-tech, large-scale health outcomes to some of the most advanced areas of fundamental cancer science. In this paper, we frame public policy discussions about cancer with use of an in-depth analysis of research publications from India. Cancer research in India is a complex environment that needs to balance public policy across many competing agendas. We identify major needs across these environments such as those for increased research capacity and training and protected time for clinical researchers; for more support from states and enhanced collaborative funding programmes from government; for development of national infrastructures across a range of domains (ie, clinical trials, tissue banking, registries, etc); and for a streamlined and rational regulatory environment. We also discuss improvements that should be made to translate research into improvements in cancer outcomes and public health.

HYDROXYUREA REVERSES DYSFUNCTIONAL UBIQUITIN-PROTEASOMAL SYSTEM IN SICKLE CELL DISEASE AND SUPPRESSES POSTTRANSLATIONAL ALTERATIONS IN HEMOGLOBIN AND CELL MEMBRANES Sirsendu Jana, PhD1, Michael Brad Strader, PhD1, Fantao Meng, PhD1,Michael Heaven, PhD2, Arun Shet, MD3, Swee Lay Thein, MD3, and Abdu I. Alayash, PhD1. 1Laboratory of Biochemistry and Vascular Biology, Center for Biologics Evaluation and Research, Food and Drug Administration (FDA), 2Vulcan Analytical, Birmingham Al, 3Sickle Cell Branch, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH). Introduction: Intracellular oxidative stress and oxidative modifications of sickle cell hemoglobin (HbS) play an important role in the pathogenesis of sickle cell disease (SCD). We recently reported transgenic mice studies revealing microparticles (MP) proteome differences between SCD and control mice expressing human HbS and HbA, respectively. Hb-dependent oxidative reactions and consequent posttranslational modifications of Hb βCys93 were central to red cell membrane changes that included modification of band3, and ubiquitination of proteins (Jana S et al., JCI Insights, 2018 3:120451). Ubiquitination is an important post-translational modification required for several biological functions including degradation by the ubiquitin-proteasomal system (UPS) proteolytic pathway. Proteins susceptible to oxidative damage are therefore likely degraded by UPS machinery. When these animals were treated with hydroxyurea (HU) they were able to reduce oxidative stress by controlling Hb oxidation side reactions. As a follow-up study, we have characterized human RBC derived MP proteomes of control, untreated and HU treated SCD patient samples to identify the mechanistic basis of how HU treatment reduces oxidative stress. Methods: We used a variety of biochemical and hematological methods to investigate a group of sickle cell disease (SCD) patients (n= 22) who are either on HU treatment (n=10) or without HU treatment (n=12) and a group of ethnically matched controls (n=4). We also performed an additional proteomic analysis on a subset of these patients, including a separate longitudinal study in which SCD patients (n=2) were followed before and after treatment with HU. Results: Immunoprecipitation experiments on RBCs obtained from untreated SCD patients revealed the presence of extensive ubiquitination contrary to those samples obtained from HU treated patients and controls. High proteasomal activity was found in SCD RBCs suggesting accumulated polyubiquitinated proteins found in these samples were not a byproduct of proteasomal inhibition but rather due to imbalance in the redox state of SS RBCs. In addition to Hb oxidation and oxidative modifications (including βCys93), our results revealed differences in the SCD proteome (from both control and untreated groups) including upregulation of phosphorylation and ubiquitination of proteins that are known to interact directly with band3 and are functionally involved in MP formation. Ubiquitination of Hb βLys145 and βLys96 were more abundant in SS patient's samples as well as phosphorylation of band3 (a prerequisite process for band3 clustering and MPs release). As revealed by the separate longitudinal study, HU treatment uniformly reversed ubiquination and phosphorylation of proteins involved in SCD induced MP formation. Conclusion: These mechanistic analyses of SCD RBC derived MPs suggest a potential involvement of ubiquitination and phosphorylation in SCD pathogenesis and provide additional insight into the therapeutic mechanisms of HU treatment. Disclosures No relevant conflicts of interest to declare.

IMPORTANCE: Iron deficiency anemia, the largest cause of anemia worldwide, adversely affects cognitive development in children. Moreover, the imperceptible childhood anemia prevalence reduction in response to anemia control measures is associated with tremendous social and economic cost. OBJECTIVE: To evaluate the effects of community-based parental education/counseling when combined with usual treatment on children’s anemia cure rate. DESIGN, SETTING, AND PARTICIPANTS: A pragmatic cluster randomized clinical trial in children aged 12 to 59 months from 55 villages from the rural Chamrajnagar district in southern India was conducted between November 2014 and July 2015; 6-month follow-up ended in January 2016. Villages were randomly assigned to either usual treatment (n = 27) or to the intervention (n = 28). Among 1144 participating children, 534 were diagnosed as having anemia (hemoglobin levels 7.9 g/dL; to convert to grams per liter, multiply by 10) and constituted the study sample in this analysis. Data were analyzed between July 2016 and September 2017. INTERVENTIONS: Iron and folic acid (IFA), 20 mg/d, 5 times daily per week, for 5 months (usual treatment) or health worker–delivered education/counseling combined with usual treatment (intervention). MAIN OUTCOMES AND MEASURES: The primary outcome was anemia cure rate defined as hemoglobin level at or greater than 11 g/dL during follow-up. RESULTS: Of the children included in the study, the mean age was 30 months, with a slightly higher ratio of boys to girls. Of 534 children with anemia (intervention n = 303; usual treatment n = 231), 517 were reassessed after 6 months (intervention n = 298; usual treatment n = 219) while 17 were lost to follow-up (intervention n = 5 and usual treatment n = 12). Anemia cure rate was higher in children in the intervention group compared with children receiving usual treatment (55.7% [n = 166 of 298] vs 41.4% [n = 90 of 219]). The risk ratio derived through multilevel logistic regression was 1.37 (95% CI, 1.04-1.70); the model-estimated risk difference was 15.1% (95% CI, 3.9-26.3). Intervention-group children demonstrated larger mean hemoglobin increments (difference, intervention vs control: 0.25 g/dL; 95% CI, 0.07-0.44 g/dL) and improved IFA adherence (61.7%; 95% CI, 56.2-67.3 vs 48.4%; 95% CI, 41.7-55.1 consumed >75% of tablets provided). Adverse events were mild (intervention: 26.8%; 95% CI, 21.8-31.9 vs usual treatment: 21%; 95% CI, 15.6-26.4). To cure 1 child with anemia, 7 mothers needed to be counseled (number needed to treat: 7; 95% CI, 4-26). CONCLUSIONS AND RELEVANCE: Parental education and counseling by a community health worker achieved perceivable gains in curing childhood anemia. Policy makers should consider this approach to enhance population level anemia control. TRIAL REGISTRATION: ISRCTN identifier: ISRCTN68413407

OBJECTIVES: Previous research has demonstrated a relationship between maternal nutrition and inflammatory mediators in breast milk which may stimulate an immune response in breastfed children. The objective of this study is to explore the relationship between maternal malnutrition, breastfeeding, and child inflammation in a sample of children in India. METHODS: Data were collected from a cross-section of 401 mothers and children 12 to 23 months of age in India. Anthropometric information was collected from mothers and used to compute body mass index (BMI). Household demographics and information on breastfeeding practices were collected as part of a survey. Blood samples were drawn from mothers and children and tested for hemoglobin (mother and child) and C-reactive protein (CRP; child only). Anthropometric measurements were performed on children and used to compute length-for-age z-scores (LAZ). Logistic regression models were fit to estimate unadjusted and adjusted associations between current breastfeeding status (yes or no) and child inflammation (CRP > 3 mg/L), stratified by maternal underweight status (BMI

Summary Background WHO estimates that about 170 000 deaths by suicide occur in India every year, but few epidemiological studies of suicide have been done in the country. We aimed to quantify suicide mortality in India in 2010. Methods The Registrar General of India implemented a nationally representative mortality survey to determine the cause of deaths occurring between 2001 and 2003 in 1·1 million homes in 6671 small areas chosen randomly from all parts of India. As part of this survey, fieldworkers obtained information about cause of death and risk factors for suicide from close associates or relatives of the deceased individual. Two of 140 trained physicians were randomly allocated (stratified only by their ability to read the local language in which each survey was done) to independently and anonymously assign a cause to each death on the basis of electronic field reports. We then applied the age-specific and sex-specific proportion of suicide deaths in this survey to the 2010 UN estimates of absolute numbers of deaths in India to estimate the number of suicide deaths in India in 2010. Findings About 3% of the surveyed deaths (2684 of 95 335) in individuals aged 15 years or older were due to suicide, corresponding to about 187 000 suicide deaths in India in 2010 at these ages (115 000 men and 72 000 women; age-standardised rates per 100 000 people aged 15 years or older of 26·3 for men and 17·5 for women). For suicide deaths at ages 15 years or older, 40% of suicide deaths in men (45 100 of 114 800) and 56% of suicide deaths in women (40 500 of 72 100) occurred at ages 15–29 years. A 15-year-old individual in India had a cumulative risk of about 1·3% of dying before the age of 80 years by suicide; men had a higher risk (1·7%) than did women (1·0%), with especially high risks in south India (3·5% in men and 1·8% in women). About half of suicide deaths were due to poisoning (mainly ingestions of pesticides). Interpretation Suicide death rates in India are among the highest in the world. A large proportion of adult suicide deaths occur between the ages of 15 years and 29 years, especially in women. Public health interventions such as restrictions in access to pesticides might prevent many suicide deaths in India. Funding US National Institutes of Health.

The age-specific mortality rates and total deaths from specific cancers have not been documented for the various regions and subpopulations of India. We therefore assessed the cause of death in 2001-03 in homes in small areas that were chosen to be representative of all the parts of India.At least 130 trained physicians independently assigned causes to 122,429 deaths, which occurred in 1·1 million homes in 6671 small areas that were randomly selected to be representative of all of India, based on a structured non-medical surveyor's field report.7137 of 122,429 study deaths were due to cancer, corresponding to 556,400 national cancer deaths in India in 2010. 395,400 (71%) cancer deaths occurred in people aged 30-69 years (200,100 men and 195,300 women). At 30-69 years, the three most common fatal cancers were oral (including lip and pharynx, 45,800 [22·9%]), stomach (25,200 [12·6%]), and lung (including trachea and larynx, 22,900 [11·4%]) in men, and cervical (33,400 [17·1%]), stomach (27,500 [14·1%]), and breast (19,900 [10·2%]) in women. Tobacco-related cancers represented 42·0% (84,000) of male and 18·3% (35,700) of female cancer deaths and there were twice as many deaths from oral cancers as lung cancers. Age-standardised cancer mortality rates per 100,000 were similar in rural (men 95·6 [99% CI 89·6-101·7] and women 96·6 [90·7-102·6]) and urban areas (men 102·4 [92·7-112·1] and women 91·2 [81·9-100·5]), but varied greatly between the states, and were two times higher in the least educated than in the most educated adults (men, illiterate 106·6 [97·4-115·7] vs most educated 45·7 [37·8-53·6]; women, illiterate 106·7 [99·9-113·6] vs most educated 43·4 [30·7-56·1]). Cervical cancer was far less common in Muslim than in Hindu women (study deaths 24, age-standardised mortality ratio 0·68 [0·64-0·71] vs 340, 1·06 [1·05-1·08]).Prevention of tobacco-related and cervical cancers and earlier detection of treatable cancers would reduce cancer deaths in India, particularly in the rural areas that are underserved by cancer services. The substantial variation in cancer rates in India suggests other risk factors or causative agents that remain to be discovered.BillMelinda Gates Foundation and US National Institutes of Health.

In this report, the prevalence and multifactorial etiology of anemia among Indian human immunodeficiency virus (HIV)-infected children are described. HIV-infected children aged 2–12 years were prospectively enrolled in 2007–2008. Measured parameters included serum ferritin, vitamin B12, red-cell folate, soluble transferrin receptor, and C-reactive protein. Children received antiretroviral therapy (ART), iron and, folate supplements as per standard of care. Among 80 enrolled HIV-infected children (mean age 6.8 years), the prevalence of anemia was 52.5%. Etiology of anemia was found to be iron deficiency alone in 38.1%, anemia of inflammation alone in 38.1%, combined iron deficiency and anemia of inflammation alone in 7.1%, vitamin B12 deficiency in 7.1%, and others in 9.5%. Median iron intake was 5.7 mg/day (recommended dietary allowance 18–26 mg/day). Compared to nonanemic children, anemic children were more likely to be underweight (weight Z-score −2.5 vs. -1.9), stunted (height Z-score −2.6 vs. -1.9), with lower CD4 counts (18% vs. 24%, p < 0.01), and higher log viral load (11.1 vs. 7.1, p < 0.01). Hemoglobin (Hb) improved significantly among those who started ART (baseline Hb 11.6 g/dl, 6-month Hb 12.2 g/dl, p = 0.03). Children taking ART combined with iron supplements experienced a larger increase in Hb compared to those receiving neither ART nor iron supplements (mean Hb change 1.5 g/dl, p < 0.01). Conclusion Anemia, particularly iron deficiency anemia and anemia of inflammation, is highly prevalent among children with HIV infection. Micronutrient supplements combined with ART improved anemia in HIV-infected children.

There are few good biomarkers of iron deficiency anemia (IDA). Since IDA patients have evidence for increased oxidative stress, we used mass spectrometry (MS) [i.e. matrix-assisted laser desorption/ionization (MALDI) and electrospray ionization] to identify novel biomarkers. Using MALDI-MS, the following oxidative modifications of hemoglobin with the following mass-to-charge ratios were identified: 1,087.5 (α32–40), 1,545.7 (α17–31), 1,290.0 (β31–40) and 2,076.1 (β41–59). On electrospray ionization MS, the IDA patients had significantly elevated glutathionyl hemoglobin (GSHb) compared with the controls (16.9 ± 9.6 vs. 7.7 ± 3.7%; p = 0.002). GSHb levels correlated inversely with serum ferritin (Spearman rho –0.485; p = 0.003) and positively with serum transferrin receptor (0.460; p = 0.002). GSHb also demonstrated inverse correlations with hemoglobin (–0.512; p = 0.001), mean cell volume (–0.419; p = 0.026), serum iron (–0.446; p = 0.008) and transferrin saturation (–0.460; p = 0.008). For the first time, we show that GSHb is elevated in patients with IDA and has potential as a biomarker of this form of anemia.

OBJECTIVE: More than 75% of Indian toddlers are anemic. Data on factors associated with anemia in India are limited. The objective of this study was to determine biological, nutritional, and socioeconomic risk factors for anemia in this vulnerable age group. METHODS: We conducted a cross-sectional study of children aged 12 to 23 months in 2 rural districts of Karnataka, India. Children were excluded if they were unwell or had received a blood transfusion. Hemoglobin, ferritin, folate, vitamin B12, retinol-binding protein, and C-reactive protein (CRP) levels were determined. Children were also tested for hemoglobinopathy, malaria infection, and hookworm infestation. Anthropometric measurements, nutritional intake, family wealth, and food security were recorded. In addition, maternal hemoglobin level was measured. RESULTS: Anemia (hemoglobin level < 11.0 g/dL) was detected in 75.3% of the 401 children sampled. Anemia was associated with iron deficiency (low ferritin level), maternal anemia, and food insecurity. Children's ferritin levels were directly associated with their iron intake and CRP levels and with maternal hemoglobin level and inversely associated with continued breastfeeding and the child's energy intake. A multivariate model for the child's hemoglobin level revealed associations with log(ferritin level) (coefficient: 1.20; P < .001), folate level (0.05; P < .01), maternal hemoglobin level (0.16; P < .001), family wealth index (0.02; P < .05), child's age (0.05 per month; P < .005), hemoglobinopathy (−1.51; P < .001), CRP level (−0.18; P < .001), and male gender (−0.38; P < .05). Wealth index and food insecurity could be interchanged in this model. CONCLUSIONS: Hemoglobin level was primarily associated with iron status in these Indian toddlers; however, maternal hemoglobin level, family wealth, and food insecurity were also important factors. Strategies for minimizing childhood anemia must include optimized iron intake but should simultaneously address maternal anemia, poverty, and food insecurity.

Berkeley sickle cell mice are used as animal models of human sickle cell disease but there are no reports of platelet studies in this model. Since humans with sickle cell disease have platelet abnormalities, we studied platelet morphology and function in Berkeley mice (SS). We observed elevated mean platelet forward angle light scatter (FSC) values (an indirect measure of platelet volume) in SS compared to wild type (WT) (37+/-3.2 vs. 27+/-1.4, mean+/-SD; p0.001), in association with moderate thrombocytopenia (505+/-49 x 10(3)/microl vs. 1151+/-162 x 10(3)/microl; p0.001). Despite having marked splenomegaly, SS mice had elevated levels of Howell-Jolly bodies and "pocked" erythrocytes (p0.001 for both) suggesting splenic dysfunction. SS mice also had elevated numbers of thiazole orange positive platelets (5+/-1% vs. 1+/-1%; p0.001), normal to low plasma thrombopoietin levels, normal plasma glycocalicin levels, normal levels of platelet recovery, and near normal platelet life spans. Platelets from SS mice bound more fibrinogen and antibody to P-selectin following activation with a threshold concentration of a protease activated receptor (PAR)-4 peptide compared to WT mice. Enlarged platelets are associated with a predisposition to arterial thrombosis in humans and some humans with SCD have been reported to have large platelets. Thus, additional studies are needed to assess whether large platelets contribute either to pulmonary hypertension or the large vessel arterial occlusion that produces stroke in some children with sickle cell disease.

Cancer related anemia (CRA) adversely affects patient Quality of Life (QoL) and overall survival. We prospectively studied the prevalence, etiology and the impact of anemia on QoL in 218 Indian cancer patients attending a tertiary referral hospital. The study used the sTfR/log Ferritin index to detect iron deficiency anemia and assessed patient QoL using the Functional Assessment of Cancer Therapy-Anemia (FACT-An) tool, standardized for language. Mean patient age was 51±13 years and 60% were female. The prevalence of cancer related anemia in this setting was 64% (n = 139). As expected, plasma ferritin did not differ significantly between anemic (n = 121) and non-anemic cancer patients (n = 73). In contrast, plasma sTfR levels were significantly higher in anemic cancer patients compared to non-anemic cancer patients (31 nmol/L vs. 24 nmol/L, p = 0.002). Among anemic cancer patients, using the sTfR/log Ferritin index, we found that 60% (n = 83) had iron deficiency anemia (IDA). Interestingly, plasma sTfR levels were significantly higher in cancer patients with CRA+IDA (n = 83) compared with patients having CRA (n = 38) alone (39 nmol/L vs. 20 nmol/L, p

Murine blood coagulation factors and function are quite similar to those of humans. Because of this similarity and the adaptability of mice to genetic manipulation, murine coagulation factors and inhibitors have been extensively studied. These studies have provided significant insights into human hemostasis. They have also provided useful experimental models for evaluation of the pathophysiology and treatment of thrombosis. This review contains recommendations for obtaining, processing and assaying mouse blood hemostatic components, and it summarizes the extensive literature on murine coagulation factor structure and function, assays and genetic alteration. It is intended to be a convenient reference source for investigators of hemostasis and thrombosis. © 2007 International Society on Thrombosis and Haemostasis. Chemicals / CAS: antithrombin, 9000-94-6; blood clotting factor 10, 9001-29-0; blood clotting factor 13, 9013-56-3; blood clotting factor 5, 9001-24-5, 9013-23-4; blood clotting factor 7, 9001-25-6; blood clotting factor 8, 9001-27-8; blood clotting factor 9, 9001-28-9; fibrinogen, 9001-32-5; heparin cofactor II, 81604-65-1; protein C, 60202-16-6; prothrombin, 9001-26-7; thrombin, 9002-04-4; thrombomodulin, 112049-68-0; tissue factor pathway inhibitor, 116638-34-7; von Willebrand factor, 109319-16-6; Fibrinogen, 9001-32-5

Central nervous system (CNS) lesions in newly diagnosed, advanced Hodgkin's disease (HD) commonly suggest intracranial involvement with HD. However, occasionally this could be the result of a CNS infection. We report a case of concurrent CNS tuberculosis in a patient with stage III E HD the first reported in the English literature. Management of this case and the literature pertaining to infectious complications of HD are reviewed.

Hereditary Elliptocytosis is a heterogeneous group of disorder with regard to clinical presentation, protein defects and mode of inheritance. Parvoviral induced transient aplastic crisis in the form of sudden onset anemia is said to be a rare manifestation of this hereditary hemolytic anemia. The authors describe a case of parvoviral induced transient aplastic crisis in a patient with hereditary elliptocytosis and review the pathogenic mechanisms of parvoviral hemolytic disease.

Chronic myelogenous leukemia (CML), characterized by the BCR-ABL gene rearrangement, has been extensively studied. Significant progress has been made in the area of BCR-ABL-mediated intracellular signaling, which has led to a better understanding of BCR-ABL-mediated clinical features in chronic phase CML. Disease progression and blast crisis CML is associated with characteristic non-random cytogenetic and molecular events. These can be viewed as increased oncogenic activity or loss of tumor suppressor activity. However, what causes transformation and disease progression to blast crisis is only poorly understood. This is in part due to the lack of a good in vivo model of chronic phase CML even though animal models developed over the last few years have started to provide insights into blast crisis development. Thus, additional in vitro and in vivo studies will be needed to provide a complete understanding of the contribution of BCR-ABL and other genes to disease progression and to improve therapeutic approaches for blast crisis CML. ispartof: Leukemia vol:16 issue:8 pages:1402-11 ispartof: location:England status: published

Thrombotic complications are known as accepted feature of acute myeloid leukemia and tend to occur in patients with hyperleucocytosis. Acute myocardial infarction, though reported is a rare clinical presentation in patients with this subtype of leukemia. We describe an unusual case of acute myeloid leukemia in a patient with leucopenia presenting with an acute myocardial infarction. The possible mechanisms underlying the pathogenesis of myocardial infarction in a patient without atherosclerotic coronary artery disease are reviewed.

Porcine factor VIII (pFVIII), which is used to control bleeding in patients with congenital or acquired haemophilia who have high-titre neutralizing antibodies to human FVIII, is not known to increase the risk of arterial or venous thrombosis. We have recently encountered a patient with acquired haemophilia who developed a thrombotic left middle cerebral artery distribution stroke while being treated with pFVIII. To our knowledge, this is the first such reported thrombotic event. We speculate that platelet activation induced by pFVIII may have contributed to thrombosis and suggest that pFVIII be used with caution in elderly patients with pre-existing cardiovascular risk factors.

Background: Determinants of vitamin B-12, folate, iron, and vitamin A concentrations in young children in rural south Asia are poorly understood. These micronutrients are crucial for the production of hemoglobin and have other important physiologic functions. Objective: We sought to develop explanatory models for concentrations of vitamin B-12, folate, ferritin, and retinol binding protein (RBP) in children aged between 1a nd 2yi n rural Karnataka, India. Design: We performed a cross-sectional study in 12–23-mo-old toddlers who lived in 2 rural districts of Karnataka, India. For each child, data concerning dietary, food security, and sociodemographic and maternal factors were obtained and serum vitamin B-12, folate, ferritin, and RBP were measured. Multiple regression and structural equation modeling were applied to determine associations with micronutrient concentrations. Results: Of 396 sampled children, 254 children (65.6%) had at least one micronutrient deficiency. With the use of multiple regression, continued breastfeeding was independently associated with the concentration of each micronutrient [(log) vitamin B-12: standardized coefficient of 20.30 (P , 0.001); folate: standardized coefficient of +0.20 (P , 0.001); (log) ferritin: standardized coefficient of 20.18 (P = 0.004); (log) RBP: standardized coefficient of20.21 (P , 0.001)]. Children who continued to breastfeed received less nutrition from complementary foods and belonged to poorer families with higher food insecurity. A structural equation model for children’s vitamin B-12 concentrations was developed that highlighted the interrelation between wealth, continued breastfeeding, complementary diet, and vitamin B-12 concentrations in children. Conclusions: Micronutrient deficiencies are common in this population. Rural Indian children between 1 and 2 y of age who continue to breastfeed should be especially targeted during micronutrient-supplementation programs. This trial was registered in the Australian and New Zealand Clinical Trials Registry as ACTRN12611000596909. Am J Clin Nutr doi: 10.3945/ajcn.111.018580.

Background Anaemia is an important problem amongst young children living in rural India. However, there has not previously been a detailed study of the biological aetiology of this anaemia, exploring the relative contributions of iron, vitamin B12, folate and Vitamin A deficiency, inflammation, genetic haemoglobinopathy, hookworm and malaria. Nor have studies related these aetiologic biological factors to household food security, standard of living and child feeding practices. Barriers to conducting such work have included perceived reluctance of village communities to permit their children to undergo venipuncture, and logistical issues. We have successfully completed a community based, cross sectional field study exploring in detail the causes of anaemia amongst young children in a rural setting. Methods and design A cross sectional, community based study. We engaged in extensive community consultation and tailored our study design to the outcomes of these discussions. We utilised local women as field workers, harnessing the capacity of local health workers to assist with the study. We adopted a programmatic approach with a census rather than random sampling strategy in the village, incorporating appropriate case management for children identified to have anaemia. We developed a questionnaire based on existing standard measurement tools for standard of living, food security and nutrition. Specimen processing was conducted at the Primary Health Centre laboratory prior to transport to an urban research laboratory. Discussion Adopting this study design, we have recruited 415 of 470 potentially eligible children who were living in the selected villages. We achieved support from the community and cooperation of local health workers. Our results will improve the understanding into anaemia amongst young children in rural India. However, many further studies are required to understand the health problems of the population of rural India, and our study design and technique provide a useful demonstration of a successful strategy.

Platelets play an important role in hemostasis, thrombosis and several other biological processes. The adaptability of mice to genetic manipulation and their genetic similarity to humans has resulted in a plethora of murine models to study platelet function. Although murine platelets differ from human platelets with regard to size, number and structure, functionally they are very similar. Thus, studies which employed these model systems have greatly improved our current understanding of the contribution of platelets to hemostasis and thrombosis. This review presents general recommendations with respect to collection, isolation and processing of murine platelets. It also describes the assays currently available to study platelet function and critically assesses their utility. The extensive literature on the effects of genetic alterations on murine platelet function is considered in detail. This review is intended to provide a convenient source of reference for platelet investigators.

INTRODUCTION: The etiology of HIV- associated anemia is multifactorial. We previously found a high prevalence of anaemia of inflammation and anemia due to micronutrient deficiencies in HIV patients (Eur J Pediatr 2012, 17:531). Inflammatory disease confounds the value of standard diagnostic markers, posing a challenge to the detection of iron deficient and iron-restricted erythropoiesis. Using serum hepcidin as a biomarker, we tested the hypothesis that total body iron stores like inflammatory signals would also influence serum hepcidin levels in patients with HIV infection. METHODS: Healthy subjects, patients with pure iron deficiency anemia (IDA) andpatients with HIV infection were prospectively enrolled after obtaining informed consent. Using sex adjusted WHO values for anemia diagnosis, ferritin

6542 Background: India bears approximately ten percent of the global burden of breast cancer but has lower survival rates than developed countries possibly due to delays in diagnosis and treatment....