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Background: Sickle cell disease (SCD) consists of a group of hemoglobinopathies in which individuals inherit hemoglobin variants derived from single point mutations. Asymmetric dimethylarginine (ADMA) contributes to limiting Nitric Oxide (NO) bioavailability in SCD. The aim of the present study was to assess the level of the Asymmetric Dimethyl Arginine in children with sickle cell. Methods: This cohort cross-sectional study was carried out on 60 children which were divided in to 3 equal groups. Group I: SCD children with sickle retinopathy. Group II: SCD children without retinopathy. Group III: healthy control children who were selected from the outpatient clinic. Results: There was a significant increase in ADMA level among participants withSCD. There was a positive significant correlation between ADMA level and family history as well as the incidence of hepatomegaly. There was no significant correlation between ADMA level and demographic and laboratory parameters except LDH. Conclusions: The level of ADMA is elevated in children with sickle cell anemia. High plasma ADMA level is a risk for hepatomegaly in children with sickle cell anemia.

Background: Thalassemia is a common genetic disorder associated with endocrine disorders. Iron deposition may start in the anterior pituitary gland, but clinical signs are usually not evident until puberty. Aim of the study was to evaluate pituitary iron overload in children with β thalassemia using MRI T2* and correlate MRI T2* and biochemical markers of iron overload with pituitary hormones. Patients and Methods: This study was carried out on 30 children with β-thalassemia major (19 females and 11 males ) with their age ranging from 10 - 18 years and mean age value of 12.8 ± 2.4 and 30 healthy children of matched age and sex as controls in the period from September 2018 to September 2019. For all patients the following were done: complete clinical evaluation including anthropometric data and Tanner staging, laboratory investigations including serum iron status, thyroid function, basal and growth hormone provocation test by clonidine, Follicle stimulating hormone (FSH) , Luteinizing hormone (LH) , and pituitary MRI T2*. Results: Weight, Z score of weight, height, Z score of height and Body mass index (BMI) were found significantly lower in patients compared with controls. Patients had delayed puberty compared with controls. Pituitary MRI T2* was found significantly lower in patients compared with controls (P=0.001). FSH, LH, and provocative growth hormone levels were found significantly lower in patients compared to controls (p

Although the phenotype and functions of exhausted T cells in several cancers have been identified, the involved molecular mechanisms remain to be further elucidated. In this regard, we have recently reported that the immunoregulatory cells, including myeloid-derived suppressor cells (MDSCs) and regulatory T cells (TIn this study, we aimed to further explore whether similar dysregulation in miRNA expression is linked to T cell exhaustion and dysfunctionality in B cell ALL patients.Peripheral blood samples from pediatric patients with ALL were recruited before and after induction chemotherapy as well as from healthy donors. Affymetrix microarray platform was used for miRNA profiling, and qRT-PCR was used to validate the expression of certain miRNAs that are related to T cell exhaustion. Bioinformatics analysis was performed to explore whether the dysregulated miRNAs were linked to T-cell exhaustion related pathways.A total of 516 miRNAs were dysregulated in ALL patients as compared to the healthy donor. Furthermore, among the total analyzed miRNAs, 10 were found to be linked to the key genes implicated in three exhaustion-related pathways; TGF-β, FOXO, and MAPK, as revealed by miR-pathway analysis. Moreover, qRT-PCR analysis showed similar expression pattern to those obtained by microarray analysis.Our pilot study suggests the implication of certain miRNAs in T cell exhaustion pathways via targeting the specific key genes in those pathways.

Incidence of intracranial hemorrhage (ICH) among children with primary immune thrombocytopenia (ITP) varies among different studies. We published data during the period of 1997-2007 of ICH in children with primary ITP, addressing risk factors and outcome. The aim of this study is to assess changes in incidence, risk factors, and outcome of ICH in children with ITP from last decade and to report the overall 20 years' experience. We compared 2008-2018 with the decade before it. Data of children with ITP and ICH during study period and ITP control cases were analyzed. Neurosurgical intervention and outcome were also reported. A total of 4340 children with primary ITP were evaluated. Twenty-five (0.63%) ICH events were reported over 2 decades. Head trauma, hematuria, and platelet counts 10 × 109/L were the risk factors mostly associated with ICH. Overall mortality was 24%, and a further 28% had neurologic sequelae. Neurosurgical intervention was done in 12% of cases with good outcome.Conclusion: Persistent platelet counts 10 × 109/L were a significant risk factor for ICH in both time periods, while head trauma and hematuria were more reported in the period of 2008-2018 as significant risk factors for ICH. Outcome was comparable in both periods. What is Known: • ICH is a rare complication of ITP; however, early recognition of risk factors and aggressive treatment might lead to complete recovery without sequalae. Platelet counts less than 10 × 109/L are the main risk factor for ICH. Few studies reported other significant risk factors. What is New: • Hematuria and head trauma are significant risk factors for ICH in ITP, in addition to having a persistently low platelet count 10 × 109/L. (more than 90 days in chronic ITP, 45 days in persistent and 21 days in acute ITP) • Combined treatment with IVIG and HDMP followed by platelet transfusion was associated with complete recovery without sequelae in almost 50% of patients.

Background Relapse remains a critical challenge in children with acute lymphoblastic leukemia (ALL). The emergence of immunoregulatory cells, including myeloid-derived suppressor cells (MDSCs), and T regulatory (Treg) cells, has been considered one potential mechanism of relapse in children with ALL. Aim This study aimed to address the microRNAs (miRNAs) related to MDSCs and Treg cells and to explore their targeted immunoregulatory pathways. Methods Affymetrix microarray was used for global miRNA profiling in B-ALL pediatric patients before, during, and after induction of chemotherapy. Bioinformatics analysis was performed on MDSCs and Treg cells-related dysregulated miRNAs, and miR-Pathway analysis was performed to explore their targeted immunoregulatory pathways. Results 516 miRNAs were dysregulated in ALL patients as compared to the healthy donor. Among them, 13 miRNAs and 8 miRNAs related to MDSCs and Treg cells, respectively, were common in all patients. Besides, 12 miRNAs were shared between MDSCs and Treg cells; 4 of them were common in all patients. Four immune-related pathways; TNF, TGF-β, FoxO, and Hippo were found implicated. Conclusion Our pilot study concluded certain miRNAs related to MDSCs and Treg cells, these miRNAs were linked to immunoregulatory pathways. Our results open avenues for testing those miRNA as molecular biomarkers for the immunosuppressive tumor microenvironment.

Background: Early detection of neuropsychological changes in children with sickle cell disease (SCD) is essential to improve their quality of life. Aim of the Work: To assess neurological and psychological disorders in children with sickle cell disease (SCD) using multimodal approach through clinical, laboratory, neuroimaging and neurophysiological studies in a trial to detect etiological risk factors. Study Design: Cross-sectional study. Place and Duration of Study: Sample: Department of Pediatric (Hematology Unit) and Department of Neurology, Tanta University Hospital Egypt, between April 2016 and April 2018. Methodology: This study was conducted on 50 children (27 male and 23 female; age range 2-18 years) with SCD and 25 healthy children matched age and sex. All subjects were subjected to full history taking, neurologic examination using pediatric neurological sheet, laboratory investigations, neuroimaging including: CT and /or MRI, MRA and/or CT angiography, also MR, EEG and Stanford-Binet Intelligence scales-Fifth Edition. Results: Most of patients presented with headache 66%, cognitive decline 48%, seizures 28%, and visual affection 24%. Less common presentations were, ischemic and hemorrhagic stroke 6% and 4% respectively. SCD children showed many abnormalities on neurological examination and on different modalities of MR imaging on the brain with positive correlation (X2=7.641, p-value

Background Screening of β thalassemia among close relatives is more feasible in highly prevalent countries with limited resources. The purpose of this study is to determine the prevalence of β thalassemia carriers and iron deficiency anemia among relatives of β thalassemia patients in Mid Delta, Egypt. Methods This is a cross-sectional multi-center study conducted on 2118 relatives of patients with β thalassemia from different Egyptian governorates in the Mid Delta region. They were subjected to history taking with precise determination of geographic location, general examination, and the following investigations: complete blood counts, serum ferritin for those who showed microcytic hypochromic anemia, and high-performance liquid chromatography for those who were not diagnosed as iron deficiency anemia. Results The total prevalence of iron deficiency anemia among close relatives of confirmed β thalassemia patients in the Nile Delta region was 17.19%. The highest prevalence of iron deficiency anemia (45.05%) was reported in Al-Gharbia Governorate, followed by Al-Menoufia Governorate (21.67%), and the lowest prevalence was that of Al-Sharkia Governorate (4.91%). The differences were highly statistically significant (p < 0.001). β thalassemia carrier prevalence rate in the studied relatives was 35.84%, with the highest prevalence detected in Al-Sharkia Governorate (51.32%), followed by Kafr-Alsheikh and Al-Dakahilia Governorates (41.78%, 37.13%) respectively, while Al-Menoufia Governorate had the lowest prevalence rate (25.00%). These differences were also highly statistically significant (p < 0.001). Conclusion More than one-third of relatives of patients with β thalassemia are carriers of the disease, while 17.19% suffer from iron deficiency anemia. This study demonstrates the importance of tracing the high number of beta thalassemia carriers among relatives of patients with β thalassemia in Egypt.

BACKGROUND Early detection of metastasis and recurrence of Ewing sarcoma (ES) is important for early management. This work aimed to detect CD99+ , CD45- cells in peripheral blood by flow cytometry (FC) before and during chemotherapy and evaluate their prognostic significance. PROCEDURE This prospective cohort study was carried out on 60 children newly diagnosed with ES at Children Cancer Hospital-Egypt 57357 and 40 healthy children control group. Detection of CD99+ , CD45- cells in peripheral blood was accomplished by FC at baseline before treatment and after five cycles of chemotherapy. Samples were classified as positive if they had more than the upper limit of cells observed in the control cases. Correlation between FC results and relapse and overall survival (OS) after one year was performed. RESULTS Median percentage of CD99+ , CD45- cells was significantly increased in patients compared with controls (0.002% vs 0%, respectively, P

Asymmetric dimethylarginine (ADMA) level may play a role in the pathogenesis of cerebrovascular stroke in Children with Sickle Cell Anemia (SCA). To assess the plasma level of ADMA in children with SCA and its correlation to cerebral blood flow. This is a cross sectional study was carried out on 30 children with homozygous SCA under follow up in the Out Patients Clinic, Pediatric Department at Tanta University Hospital and 30 healthy children as a control group. Both groups had undergone the following investigations: Complete blood count, lactate dehydrogenase enzyme, and plasma level of ADMA by a commercial ADMA ELISA Kit. Trans-cranial Doppler were done for both groups. ADMA plasma level was significantly higher in-patient group in comparison to the control group (p

Background: In developing countries, cytomegalovirus (CMV) seropositivity has been widely propagated. Following hematopoeitic stem cell transplantation, the apparent risk of CMV reactivation increases. With effective surveillance and study of the effect of some factors on CMV reactivation, timely treatment with anti-viral treatment may decrease morbidity and mortality associated with CMV reactivation. Aim: This study aimed to evaluate the effect of some factors on CMV reactivation in allogeneic hematopoietic stem cell transplantation (HSCT). Materials & Methods: We retrospectively analyzed 25 patients with Serostatus positive of CMV IgG antibodies who underwent allogeneic hematopoietic stem cell transplantation at two Bone Marrow Transplantation centers in Egypt from November 2016 to June 2017. Results: In our study, the patient male percentage was 57.1% in CMV reactivation group with the most common pre-transplantation diagnosis was FA, CML and βTM. All donors in the reactivation group (100 %) were positive for CMV IgG ab. This group had 42.9% matching donors in sex and blood groups. While the stem cell source was 92.9% peripheral blood source with a median dose of 7.0 cells ×106 ∕ kg. Conclusion: The incidence of CMV infection following hematopoietic stem cell transplantation is comparable to that recorded in Western literature because of a higher seroprevalence rate in developing countries. More research is needed to study factors affecting cytomegalovirus reactivation in allogeneic hematopoietic stem cells transplantation (HSCT).

Objective miRNA considers a small non-coding RNA molecule that has tumor suppressor or oncogenic functions and regulates gene expression. miRNA may be involved in the pathogenesis of acute lymphoblastic leukemia (ALL). miRNA was evaluated in patients with ALL to correlate their importance in the clinical prediction and the response to chemotherapy. Subject and methods The study population included 30 healthy control and 71 children with ALL is divided into 4 groups: healthy, newly diagnosed, remitted, and relapsed groups. We quantify miRNA 92a, miRNA 638 expression using real-time PCR in childhood ALL. Results plasma miRNA 92a and miRNA 638 expressions were elevated in ALL cases at the time of diagnosis (2.51 and 2.19 folds), and relapsed (2.1 and 1.61 folds) than that of patients with remitted ALL. There was a positive correlation between miRNA 92a and miRNA 638 patients with ALL. Also, total leukocyte and blast correlated with miRNA 92a and miRNA 638 unlike hemoglobin, and platelets didn't correlate with miRNA 92a and miRNA 638. The sensitivity of miRNA 92a and miRNA 638 were 41.5% and 54.7% respectively while the specificity was 100 % of miRNA 92a and miRNA 638. Conclusion miRNA 92a and miRNA 638 are recommended to be used as potential predictive and follow-up markers in children with ALL remitted and relapsed cases.

Thalassemia is a major health problem in affected children due to iron overload, increased oxidative stress, atherogenic lipid profile and tissue-damage. This study aims at investigating the cardioprotective and tissue-protective benefits of Al-hijamah and their impact on cell-mediated immunity for treating thalassemic children. This study aimed also at investigating the tissue-clearance principle of Taibah mechanism: whenever pathological substances are to be cleared from the human body, Al-hijamah is indicated. Al-hijamah was done to thalassemic children (15 males and 5 females having a mean age of 9.07 ± 4.26 years) using sterile disposable sets in a complete aseptic hospital environment. Prior ethical committee agreement (in addition to written patient’s consents) was obtained from Tanta Faculty of Medicine, Egypt. Twenty thalassemic children received iron chelation therapy plus Al-hijamah for one session (30-60 minutes) versus an age and sex-matched thalassemic control group treated with iron chelation therapy only. Al-hijamah is a quite safe outpatient hematological procedure that significantly decreased serum cholesterol (from 129.75 ± 3.67 to 103.5 ± 4.18 mg/dl) and decreased serum triglycerides (from 109.25 ± 8.96 to 91.95 ± 7.22 mg/dl). Interestingly, Al-hijamah exerted significant tissue-protective effects (it decreased serum GPT from 98.65 ± 12.27 to 71.65 ± 32.78 U/L and serum GOT from 96.35 ± 14.33 to 69.35 ± 34.37 U/L). Al-hijamah-induced ferritin excretion caused decreased serum ferritin (high serum ferritin negatively correlated with cell mediated immunity). Al-hijamah exerted cardioprotective and tissue-protective and hypolipidemic effects. Al-hijamah decreased serum cholesterol and is cardioprotective for thalassemic patients as it protects against atherogenesis and atherosclerosis. Medical practice of Al-hijamah is strongly recommended in hospitals. Al-hijamah cleared blood significantly from causative pathological substances e.g. serum ferritin resulting in enhanced cell-mediated immunity (in agreement with the evidence-based Taibah mechanism).

BACKGROUND: The achievement of optimal number of CD34(+) umbilical cord stem cells is essential for successful umbilical cord stem cell transplantation. So the aim of this study was to assess the potential effect of both maternal and neonatal factors on the umbilical cord blood CD34(+) cell count. METHODS: The study was done on umbilical cord blood samples obtained from 20 mothers during labor. Their ages ranged from 22 to 34 years and were subjected to history taking, physical examination of the baby and assessment of the CD34(+) cells count in umbilical cord blood. RESULTS: Number of previous live births and weight of the baby had a significant effect on CD34(+) cells count while the sex of the baby, delivery route, maternal age and gestation period had no significant effect on CD34(+) cells count. CONCLUSIONS: Umbilical cord blood-derived CD34(+) cell count is better with good weight and first babies and decreased with subsequent babies.

Background: About 80% to 85% of lung cancers are non-small cell lung cancer (NSCLC), which are believed to secrete mediators that may lead to disorders in the immune system and tumor immune surveillance. This disorder may include dysfunction in CD8+ T cells and NK cells, which play critical role in fighting against cancer. Aim: Evaluate the impact of lung cancer on the numbers and function of CD8+ T cells, NK and NK T cells as well as the inflammatory milieu. Materials and Methods: Peripheral blood samples were collected from healthy volunteers (n=5) and early diagnosed lung cancer patients (NSCLCs; n=5). The numbers of CD8+ T cells, NK cells and NK T cells were analyzed by flow cytometry after staining with the relevant antibodies. Plasma was prepared from the blood to measure the proinflammatory cytokines and chemokines by Lumiex® protein array. Results: Compared to healthy controls, lung cancer patients showed significant decrease in numbers of CD8+ T cells and NK cells. NK cells showed considerable reduction in their expression levels of the cytolytic molecule granzyme-B. Marked higher levels of IL-1 and CCL2 was detected in the plasma of lung cancer patients as compared to healthy controls. Conclusion: Early diagnosed lung cancer patients showed dysfunction not only in the numbers of cytolytic immune cells but also their function that correlated with inflammatory microenvironment.

Beta-thalassemia major (β-TM) in children is associated with an increase in the risk of premature cardiovascular complications caused by accelerated atherosclerosis which significantly contributes to morbidity and mortality. The molecular mechanisms underlying β-TM associated atherosclerosis and its relation to biochemical risk factors still remain obscure. We aimed to investigate the association between SIRT1 single nucleotide polymorphism (SNP), lipid profile, ferritin, malondialdehyde (MDA), 8-hydroxydeoxy guanosine (8-OHdG) and total antioxidant capacity (TAC) in relation to carotid intima media thickness (CIMT) trying to explain some mechanisms of cardiovascular complication in beta-Thalassemia major (β-TM) children. This study was carried out on 100 Egyptian children with β-TM (Group II) subdivided equally according to CIMT into Group IIa, with CIMT

Background & aim: Iron overload in thalassemia major (TM) leads to excessive iron deposition in a wide variety of tissues especially the heart leading to iron-overload cardiomyopathy, which is the major determinant of survival in those patients. Our goal was to study effects of Amlodipine and Spirulina on iron loading when added to chelation therapy in patients with TM. Method: Forty patients with TM undergoing chelation therapy were randomized into two groups (1:1); group 1 received Amlodipine 5 mg/day, and group 2 received Spirulina 250 mg/kg/day for 3 months. Patients were assessed for MRI examination (cardiac T2*) and laboratory data including ferritin, troponin I, and NT-proBNP levels at baseline and after 3 months. Results: After 3 months, cardiac T2* increased significantly from 21.8 ± 7.7 ms to 22.94 ± 7.1 ms (p = 0.03) in Spirulina group, and from 21.9 ± 8.7 ms to 24.6 ± 9.4 ms (p = 0.007) in Amlodipine group. There was significant reduction in ferritin levels in Spirulina group (p = 0.007), but not in Amlodipine group (p = 0.09). In addition, NT-proBNP level decreased significantly in both groups. There was no statistically significant difference between both groups concerning cardiac T2*, serum ferritin, troponin I, and NT-proBNP levels at 3 months. Conclusion: Our findings suggest that the use of Amlodipine or Spirulina as a complementary treatment with standard chelation therapy could reduce iron overload in patients with TM.This trial was registered at www.ClinicalTrials.gov as #NCT02671695. Keywords: Amlodipine, Spirulina, Cardiac iron overload, β-thalassemia, MRI, NT-proBNP

Background: MicroRNAs (miRNAs) are endogenous non-coding RNAs, which play an essential role in the regulation of gene expression.Aim of the work: To analyze miRNA expression profile in the childhood B acute lymphoblastic leukemia (B-ALL). To understand the functional regulatory effects of differential miRNAs on their targets and its clinical significance and novel analytical method to combine their expression profiles.Patients and Methods: In this study, we determined the relative expression analysis of miRNA and mRNA profiles in 20 childrenB-ALL patients. Through the use of miRNA microarray technology and according to their miRNA pro-file.The best characterized non-coding RNA family consists in humans of about 1400 microRNAs for which abundant evidence have demonstrated fundamental importance in normal development, differentiation, growth control and inhuman diseases such as cancer.Results: miR-100, miR-146a, miR-128a, miR-128b, miR-181a, miR-34, miR-193a, miR-193b, miR-151, miR-130b, and miR-125b were found to be the most consistently upreg-ulated miRNAs in B-acute lymphoblastic leukemia patients as compared with healthy control.Conclusion: To analyze miRNA in B-ALL children patients before and after induction of chemotherapy and measure the correlation of these results using microarray technique.

Acute lymphoblastic leukemia (ALL) is the most common cancer diagnosed in children. The precise mechanism behind the relapse in this disease is not clearly known. One possible mechanism could be the accumulation of immunosuppressive cells, including myeloid-derived suppressor cells (MDSCs) and T regulatory cells (TIn this study, we aimed to analyze the numbers of these cells in a population of B-ALL pediatric patients.Peripheral blood samples withdrawn from B-ALL pediatric patients (n = 45 before, during and after the induction phase of chemotherapy. Using multi parametric flow cytometric analysis. MDSCs were identified as LinEarly diagnosed B-ALL patients showed significant increases in the numbers of MDSCs and TOur results indicate that B-ALL patients harbor high numbers of both MDSCs and T

Background: Cardiac dysfunction is a risk factor for death in patients with sickle cell disease (SCD). Aim of the Work: Aim of the work is to evaluate the right ventricular systolic and diastolic functions by tissue Doppler and speckling tracking imaging in children with SCD. Subjects and Methods: Thirty children with SCD and thirty controls were subjected to clinical, laboratory evaluations, and echocardiographic study using GE Vivid 7 (GE Medical System, Horten, Norway with a 3.5-MHz multifrequency transducer) including; Two-dimensional and tissue Doppler echocardiographic study (lateral tricuspid valve annulus peak E' velocity, lateral tricuspid valve annulus peak A' velocity, E'/A' ratio, isovolumetric relaxation time, lateral tricuspid valve annulus S' and septal S' waves and peak longitudinal systolic strain [PLSS] and time to PLSS) were done in six right ventricular segments. Results: There was a significant decrease in right ventricular systolic and diastolic function in patients group when compared to controls. Conclusions: Children with SCD have impaired right ventricular systolic and diastolic functions when compared to healthy children with early evaluation of the systolic dysfunction by speckle tracking imaging technique.

Background Thalassemia is a major health problem due to iron overload, iron deposition and oxidative stress-induced tissue damage. Here, we introduce Al-hijamah (a minor surgical excretory procedure) as a novel percutaneous iron excretion therapy. Al-hijamah is a wet cupping therapy of prophetic medicine, and prophet Muhammad, peace be upon him, strongly recommended Al-hijamah, saying: “The best of your treatment is Al-hijamah”. Aim of the study Our study aimed at investigating the safety, iron chelation, pharmacological potentiation and oxidant clearance effects exerted by Al-hijamah to thalassemic children. Patients and methods Ethical committee’s approval and patients’ written agreement consents were obtained. We treated 20 thalassemic children (15 males and five females aged 9.07±4.26 years) with iron chelation therapy (ICT) plus Al-hijamah (using sterile disposable sets and in a complete aseptic environment) vs a control group treated with ICT only. This clinical trial was registered in the ClinicalTrial.gov registry under the name “Study of the Therapeutic Benefits of Al-hijamah in Children with Beta Thalassemia Major” (identifier no NCT 02761395) on 30 January 2016. Results Al-hijamah was quite simple, safe, effective, tolerable (with no side effects) and time-saving procedure (30–60 minutes). A single session of Al-hijamah significantly reduced iron overload (P, Video abstract

Early detection of myocardial dysfunction is essential for the management of patients with thalassemia. Four-dimensional echocardiography imaging technique may be useful for detecting subclinical cardiovascular disease. To evaluate the 4-dimensional echocardiographic strain in children with beta thalassemia major with no cardiac manifestation and correlate it with other echocardiographic parameters. This is a prospective cross-sectional cohort Study included 200 children, 1–18 years-old. They were divided into: One hundred children with p-Thalassemia major with no clinical cardiac manifestations and 100 healthy children as a control group. They were subjected to the following investigations: Complete blood count, serum ferritin and Four-dimensional echocardiographic strains (Longitudinal, Circumferential, Radial and Area strains). There was no significant difference between the two groups as regard mitral annulus systolic velocity (S wave), E/A ratio and iso-volumic acceleration, but there was a significant difference as regard to ejection fraction, left ventricle mass, sphericity index and myocardial performance index. The mean values of Left Ventricular Strains (Longitudinal, Circumferential, Radial and Area strains) were significantly lower in patients with thalassemia (− 14.86 ± 12.13, − 8.01 ± 3.829, 33.13 ± 10.61, − 19.45 ± 6.866) than controls (− 19.13 ± 1.502, − 16.32 ± 1.34, 37.28 ± 4.209, − 22.94 ± 3.06) than controls respectively with a positive correlation with 2-Dimensional strain. Strain parameters of the left ventricle obtained by four-dimensional.

Background Early vascular alteration, atherosclerosis and coronary artery disease have emerged as important cardiovascular complications among beta-thalassemia major (B-TM) patients. The aims of the current study were to assess the prevalence of premature atherosclerosis among our B-TM patients, and to investigate the diagnostic value of serum Osteoprotegerin assay as an early biomarker for atherosclerosis. Methods This cross-sectional study was conducted at Hematology unit - Pediatric Department, Zagazig University Children Hospital- Egypt in the period from March 2014 to March 2015. A total of 115 children were enrolled in the current study; as sixty-five (65) children with beta thalassemia major aged 5–18 years, on regular blood transfusion regimen represented the patient group. While fifty (50) healthy children, with comparable age and gender, were assigned as control group. All participants were subjected to history taking, thorough clinical examination and laboratory investigations including; complete blood count, liver and kidney function tests, C- reactive protein, lipid profile, serum ferritin and serum Osteoprotegerin (OPG) assay. Also, carotid artery intima media thickness (CAIMT) was performed by duplex ultrasound for patients and controls. Results Our B-TM patients were transfusion-dependent for as long as 8.5 ± 3.8 years with significantly higher serum ferritin levels (2490 ± 1579 ng/dl vs 83 ± 32 ng/dl, p = 0.001), C-reactive protein (5.7 ± 5.7 vs 0.9 ± 0.9), liver enzymes and bilirubin when compared to controls. Significantly higher serum triglyceride (128 ± 20 vs 101 ± 7 mg/dL, p = 0.009) and atherogenic index of plasma (0.45 ± 0.12 vs 0.22 ± 0.04, p = 0.001) were recorded in patients than comparisons. On the contrary, total serum cholesterol (116 ± 16 vs 143 ± 5, p

Background: 35 million children < 18 years; approximately 1800 new cases of ITP were diagnosed annually in Egypt. Intracranial hemorrhage (ICH) is a rare devastating complication of childhood immune thrombocytopenia (ITP). Incidence of ICH among children with ITP varies markedly in different studies from 0.2 up to 1.0 %. Intracranial hemorrhage after head trauma in children with ITP leads to significant morbidity and mortality. We published data during 1997 - 2007 (10 ICH) in children with primary ITP; risk factors and outcome. Aim & Methodology: A follow-up study to assess any change in outcome of ICH from last decade; whether new therapies might change the landscape of ICH. Centers treating > 25 child with prim ITP /year and offered a complete data of >150 children with ITP over 2 decades were enrolled. We compared 2008 - 2018 with the decade before it; variation of ICH reporting from center to center and outcome in relation to therapy. All children with ITP and ICH during study period had been treated, within < 24 hours and referred to neurosurgical hospital complex facility for consultation and intervention. Time elapsed till receiving platelet enhancing therapy and neurosurgical intervention was assessed, Outcome whether a complete recovery, permanent sequalae or death was reported. Results: Four thousand, three-hundred and forty primary ITP were evaluated, ( 380 were excluded due to incomplete data ) Twenty-four (0.6%) ICH were reported over 2 decades (14 in this decade with 20% increase incidence) and 48 matched ITP control subjects were evaluated. Platelet counts were less than 10 x 10(9)/L in 90% of children with ICH. Four (16.2%) children developed ICH within 14 days of diagnosis of ITP; one of these, was the presenting feature of ITP. four were from 3-12 months and sixteen (66.6%) of children had chronic ITP. Centers treating > 50 case/year had a higher frequency of reporting 0.8 % compared to 0.2 % in centers < 50 cases/year. Outcome is better on early intervention as well as aggressive platelet enhancing therapy with 70% complete recovery compared with 30% complete recovery on delayed intervention. Head trauma and hematuria and PC < 10 were the mostly associated with ICH, identified in 33%, 25% and 90% respectively of the patients with ICH and in 1, none and 50% of the controls (P < .001). Bleeding beyond petechiae and ecchymoses was also linked to ICH. Mortality was 25%; a further 25% had neurologic sequelae. Neurosurgical intervention was done in 25% of cases with good outcome. Reporting was more in this decade with better outcome in bigger centers. Conclusion: A rise in the incidence of ICH in Children with severe thrombocytopenia over last decade; high risk for ICH among those with PC< 10,000 plus head trauma and/or hematuria. Platelet enhancing agents whether HDMP or IVIG or TPO-RAs could not prevent ICH. However they had a good impact on survival and lessen sequalae if used in combination. Strategies by which high-risk children could be identified and well managed in small centers. Disclosures No relevant conflicts of interest to declare.

Background: Primary immune thrombocytopenia (ITP) has been treated with steroids or immune-suppressive. Thrombopoietin receptor agonists (TPO-RAs), changed the treatment landscape for ITP. Romiplostim and Eltrombopag were FDA approved for use in pediatric patients ≥1 year with ITP of >6 months' duration and insufficient response to previous therapy. Following the guidelines is not always feasible in practice. Aim and Methodology Centers treating more than 25 new cases/year with good recording system were included; aiming to report outcome, adverse events (AEs) and deviation from guidelines. Newly diagnosed ITP children were excluded. Data was collected from January 2017- June 2019; children age >1 to 18 years with persistent ITP (3- 1 to 12 years; or in 50 mg/day for those >12-18 years; dose was escalated to 50 or 75mg/day for those 6-12 and >12 years respectively on failure to have PC > 50 x 109/L. Weekly CBC and self-record of bleeding for 1st 24 week then bi-weekly. Failure to show a good response; Eltrombopag dosing should be adjusted to achieve that goal and not to exceed 200 × 109/L. Romiplostim was used in 1 ug/kg and escalated up to 10 ug/kg according to response. Serious AEs were reported to ethical committee within 24 hours. Results Two years Observational study of 204 out of 1080 primary ITP (268 persistent and 812 chronic); 55% females median age 8 years, received Eltrombopag (n=186), Romiplostim (n= 18) from 3-30 months was prescribed after failure of 1-5 lines of therapy in 15% of Persistent ITP and 20% of chronic ITP. Adequate response at 24 weeks in 60% on Eltrombopag or Romiplostim had a significant reduction in both skin-related and non-skin-related bleeding symptoms). However 50% discontinued treatment; (40% due to inadequate response, 8% irregular availability and 2% due to SAEs). Deviation from guidelines in 40%; (15% started Eltrombopag early between 3-6 months who showed a higher response rate; half of them could stop it without drop of PC); while 20% continued Eltrombopag for >12 month with lack of response after dose escalation at 24th week and 5% were not following the described dose or the regular monitoring. 40% of chronic ITP patients achieved platelet counts of >50 x 109/L or more at least twice. Common adverse events included; headache (10%). myalgia (10%), rhinitis (8%), diarrhea 8% Serious adverse events occurred in 4 (1 elevated transaminases, one unrelated life-threatening bleeding and two high PC; >1000 x109/L). Conclusion: TPO-RAs were used in almost 15% of persistent and 20% of chronic ITP as 2nd line or more therapy and in 90% was Eltrombopag; which produced an excellent response for those 3-6 months; deviating from guidelines. It showed a sustained platelet response in 40% of patients with chronic ITP, however it should be stopped if showing poor response after dose escalation. Disclosures No relevant conflicts of interest to declare.

Introduction Thalassemias are treated by regular blood transfusions and iron chelation therapy. Iron overload-induced oxidative stress helps the pathogenesis of thalassemia-induced anemia, atherogenesis, immune suppression and tissue damage. Nigella sativa (NS) is a safe medicinal plant that has exhibited immune stimulant, antioxidant and tissue-protective effects that may benefit thalassemic patients. It is widely used in Arabic prophetic medicine Patients and methods 25 blood transfusion-dependent children having homozygous β-thalassmia major (11 Males and 14 females ranging from 6 to 18 years) received oral NS powder (2 g/day added to foods or drinks) for 3 consecutive months. Investigations carried out for all children included evaluating: complete blood count, serum ferrtin, T cell subsets determination (CD4 and CD8), malondialdehyde (MDA) level and total antioxidant capacity (TAC). Results NS significantly increased blood hemoglobin (from 7.50 ± 0.22–9.48 ± 0.6 g/dl) (p Conclusion NS decreased iron overload-induced oxidative stress and hemolytic anemia. NS is a promising treatment for thalassemia to potentiate therapeutic effects and alleviate side effects of iron chelation therapy. Limitations to this study included the small number of patients and the relatively short post treatment follow-up time. Future research regarding the use of NS for the treatment of thalassemia is highly recommended This clinical trial was registered in: ClinicalTrials.gov. Trial ID: NCT02816957

Multidrug resistance (MDR) is a phenomenon by which cells become resistant to unrelated chemotherapeutic agents. The prognostic value that lung resistance protein (LRP) and multidrug resistance-related protein 1 (MRP1) have in the setting of pediatric acute lymphoblastic leukemia (ALL) is controversial. The aim of this study was to investigate the expression of LRP and MRP1 and effect on clinical outcome and prognosis. The mRNA expression of LRP and MRP1 were analyzed in leukemic blasts of 34 pediatric ALL patients. LRP and MRP1 mRNA expression were detected in 41.2% and 35.3%, respectively. Eleven (91.7%) of 12 patients without LRP achieved CR compared with 9 (50.0%) of 18 with LRP expression. Similarly, 11 (100%) of 11 patients without MRP1 expression achieved CR compared with 9 (47.4%) of 19 with MRP1 expression and higher LRP expression rate or MRP1 expression rate was present in patients with relapse than MDR genes negative patients. The expression of either of two genes was associated with poorer 2-year survival. Also, patients expressing both genes had poorer outcomes and had worse 2-year survival. We suggest that MDR expression affects complete remission and survival rates in ALL patients. Thus, diagnosis appears to provide prognostic information for pediatric ALL.

Mobilizing hematopoietic stem cells may be a promising intervention for the treatment of idiopathic dilated cardiomyopathy (IDCM) in infant and children. So the aim of the work is to evaluate the efficacy of granulocyte-colony stimulating factor (G-CSF) as a therapeutic modality in pediatric IDCM.A randomized clinical trial was conducted on 40 pediatric patients with IDCM. They were subjected to history taking, clinical examination, serum lactate dehydrogenase (LDH), total creatinine phosphokinase (CPK), creatinine phosphokinase isoenzyme B (CK-MB) isoenzyme, and peripheral blood CD34(+) cell assessment before and at day 7 after subcutaneous G-CSF injection for 5 consecutive days. Echocardiography was done before and 1, 3 and 6 months after therapy.Clinical improvement in the form of regression of patients Modified Ross heart failure (MRHC) classification classes. Increased percentage of CD34(+) mobilized cells from the bone marrow, and significant increase in blood counts especially white blood cells 7 days after G-CSF injection. Significant improvement was found in echocardiographic data evaluating systolic function of the heart [Ejection fraction, Fractional shortening and systolic velocity at mitral annulus (Sm)].Administration of G-CSF may be beneficial in improving systolic functions of the heart in pediatric IDCM and more studies with a large number of patients are needed.

Prevention programs for β-thalassemia based on molecular diagnosis of heterozygous carriers and/or patients require the use of reliable mutation screening methods. The aim of this study was to compare between direct DNA sequencing, and reverse dot-blot PCR in detection of different β-globin gene mutations in Egyptian children with β-thalassemia. Forty children with β-thalassemia were subjected to mutation analysis, performed by both direct DNA sequencing and β-globin Strip Assay MED™ (based on reverse dot-blot PCR). The most frequent mutant alleles detected by reverse dot-blot PCR were; IVSI-110 G>A (31.25 %), IVS I-6 T > C (21.25 %), and IVS I-1 G>A (20 %). Relatively less frequent mutant alleles detected by reverse dot-blot PCR were "IVSII-1 G>A (5 %), IVSII-745 C>G (5 %), IVSII-848 C>A (2.5 %), IVSI-5 G>C (2.5 %), -87 C>G(2.5 %), and cd39 C>T (2.5 %)", While the genotypes of three patients (6 alleles 7.5 %) were not detected by reverse dot-blot PCR. Mutant alleles detected by direct DNA sequencing were the same as reverse dot-blot PCR method except it revealed the genotypes of 3 undetected patients (one patient was homozygous IVSI-110 G>A, and two patients were homozygous IVS I-1 G>A. Sensitivity of the reverse dot-blot PCR was 92.5 % when compared to direct DNA sequencing for detecting β-thalassemia mutations. Our results therefore suggest that, direct DNA sequencing may be preferred over reverse dot-blot PCR in critical diagnostic situations like genetic counseling for prenatal diagnosis.

Objectives: Thalassemic children with repeated blood transfusion are at higher risk of suffering transfusion relatedinfections including hepatitis B virus (HBV). HBV vaccine immunogenicity in several studies showed variable responserates. The aim of this study is to evaluate the immunogenic effect of hepatitis B vaccine in thalassemic children at differentage groups.Materials and methods: After ethical approval and informed parent consent, 125 diagnosed thalassemic patients wererecruited from the Hematology/Oncology Unit, Pediatric Department, Tanta University Hospital. Patient’s transfusion,and vaccination history, clinical data, and blood samples were obtained. Patient’s sera were stored at -20°C till tested forAnti-hepatitis B surface (anti-HBs) by ELISA. Patients with titers 10IU/L). Significantly higher percentage of protected patients (40.1%) were younger than 3 years of age, while age groupsabove 3years showed a significant trend towards having non protective titers (p=0.003). Anti-HBs titers weren’t correlatedto age, ferritin, liver enzymes, and duration of transfusion or number of transfused packs.Conclusion: Protective Anti-HBs titer was reduced after age of 3 years in our patients. So, we recommend screeningof thalassemic patients at age of 3 years to evaluate the need of a booster dose. J Microbiol Infect Dis 2012; 2(2): 44-49Key words: Thalassemia, HBV, vaccination, immunogenicity

Background Pulmonary hypertension (PH) is an increasingly recognized life-threatening complication in sickle cell disease (SCD), with associated high mortality in adults. The prevalence of PH in children with SCD is still unknown. The etiology and pathophysiologic mechanisms are still not well understood. Aim of the study To assess the plasma levels of asymmetric dimethylarginine (ADMA) in children with SCD and its correlation with elevated tricuspid regurgitant jet velocity and other hemolytic markers. Subjects & Methods This study was carried out on a cohort of patients (30) with SCD and 30 healthy children as a control group. Certain investigations were carried out for all subjects: CBC, lactate dehydrogenase (LDH), ferritin, reticulocytic count, bilirubin, AST, ALT, and plasma levels of ADMA. Doppler echocardiography was carried out for all subjects. Results The prevalence of high tricuspid regurgitant velocity (TRV) was 30% in SCD patients. ADMA mean plasma level was significantly higher in patients than in controls (0.79 ± 0.15 μmol/L and 0.46 ± 0.11 μmol/L, respectively, P

Background: Transfusion dependant patients are at a higher risk of acquiring bloodborne infections even under conditions of safe transfusion. This study was designed to determine sero-prevalence of hepatitis C infection and possible associated risk factors in thalassaemic children. Methods: One hundred and twenty five children with b thalassaemia major (b-TM) were recruited from the Haematology/Oncology Unit, Paediatric Department, Tanta University Hospital, Egypt, between April 2010 and October 2011. Patients underwent history taking, full clinical examination, routine investigations and venous blood sampling. Serum was stored at 2208C till tested for hepatitis C (HCV Ab) and B (HBsAg) by ELISA. HCV Ab positive cases were confirmed by PCR. Results: All patients were HBsAg negative. HCVAb ELISA was positive in 76%, negative in 20% and equivocal in 4%. Fifty patients (40%) had positive PCR for HCV. PCR showed low viraemia in 78%, moderate viraemia in 20% and high viraemia in 2%. A positive family history of HCV, history of minor operative intervention and/or dental procedures were significantly associated with higher frequency of HCV infection in thalassaemic children, while amount and frequency of transfused blood, age at transfusion and chelation state were not. Conclusion: HCV infection is highly prevalent in children with b-TM in Egypt despite strict pre-transfusion blood testing. This should arouse the attention for environmental and community acquired factors. Quality management to insure infection control in minor operative procedures and adding more sensitive tests for blood screening are recommended.

Background Acute lymphoblastic leukemia (ALL) is the most common cancer diagnosed in children. The precise mechanisms behind the relapse in this disease are not clearly known. One possible mechanism could be the accumulation of regulatory cells including myeloid-derived suppressor cells (MDSCs) and T regulatory cells (Tregs) which we and others have reported to mediate suppression of anti-tumor immune responses. Few previous studies investigated the roles of Treg cells in ALL, while no studies reported the emergence of MDSCs in ALL. Aim Therefore, we aimed to analyze the frequencies and phenotype of these cells in a group of Egyptian B-ALL pediatric patients (n=45). Materials and methods MDSCs were identified as Lin− HLA-DR− CD33+CD11b+; and Treg cells as CD4+CD25+CD127−/low using multiparametric flow cytometer. Results We found significant increases in the numbers of MDSCs and Treg cells in B-ALL patients as compared to healthy control volunteers. B-ALL patients showed significant increased numbers of MDSCs and Tregs before chemotherapy when compared to healthy volunteers. The numbers of MDSCs were more increased while the numbers of Treg cells were more decreased in patients during induction of chemotherapy. The highest increase in the numbers of MDSCs was observed in patients after induction of chemotherapy, while Treg cells showed the most significant decreased numbers after induction of chemotherapy. Conclusion Our results indicate that B-ALL patients harbor both MDSCs and Treg cells, opening a new avenue to investigate the mechanism mediating the emergence of these cells in larger numbers of patients at different treatment stages.

Background Adriamycin (ADR) is a potent chemotherapeutic agent widely used in the treatment of childhood acute lymphoblastic leukemia (ALL); its clinical use is limited owing to its marked cardiotoxicity. The present study investigated the possible protective role of carvedilol on ADR-induced left ventricular dysfunction in children with ALL. Methods and Results Fifty children with newly diagnosed ALL were included in this study. They were divided into 2 equal groups: 1) ADR; and 2) ADR + carvedilol. Patients were evaluated with conventional 2-dimensional echocardiographic examination (2D), pulsed tissue Doppler (PTD), and 2-dimensional longitudinal strain echocardiography (2DS) before and after therapy. Plasma lactic dehydrogenase (LDH), creatine phosphokinase (CPK), and troponin I levels were also determined before and after therapy. ADR treatment reduced left ventricular systolic dysfunction as assessed by a significant decrease in fractional shortening (FS) (2D) and global peak-systolic strain (GPSS; 2DS). In addition, ADR treatment significantly increased plasma troponin I and LDH. Pretreatment of ADR-treated patients with carvedilol resulted in a significant increase in FS (2D) and GPSS (2DS). Furthermore, carvedilol pretreatment inhibited ADR-induced increase in plasma troponin I and LDH. Conclusions These results suggested a protective role of carvedilol against ADR-induced cardiotoxicity.

Background: Acute lymphoblastic leukemia (ALL) is considered as one of the most common cancer in pediatric malignancies. Among ALL, B-cell Acute Lymphoblastic Leukemia (B-ALL) represents 80% to 85% of the childhood ALL. Problem: Although anti B-ALL chemotherapy kill B-ALL, it associates with alteration in the numbers of CD4+ and CD8+ T-cells, and thus impacts the overall immunity. Aim: To evaluate the impact of anti B-ALL on the numbers of CD4+ and CD8+ T-cells in correlation to the numbers of CD10+ B cells in B-ALL pediatric patients. Materials and Methods: Peripheral blood samples were drawn from previously diagnosed B-ALL before (n = 10 cases) and after (n = 10 cases) chemotherapy as well as from healthy controls (n = 10 cases). The numbers of CD4+, CD8+ T-cells and CD10+ B cells were measured in these samples by flow cytometry. Results: As expected, the numbers of CD10+ B-cells were increased in B-ALL patients before chemotherapy which were associated with increases in the numbers of CD4+ and CD8+ T-cells. Chemotherapy of B-ALL patients, during the induction phase, induced dramatic decreases in the numbers of CD10+ B cells, which were associated with decreases in the numbers of CD4+ and CD8+ T-cells. Tin spite of this alteration, the ratio of CD4/CD8 in B-ALL patients were remained similar before and after chemotherapy as compared to those in healthy controls. Conclusion: Anti B-ALL chemotherapy induces alterations in the frequencies of T-cell subsets. Given the importance of these cells in anti-tumor immunity, our data may lead to further studies to investigate the different subsets of these cells, in particular regulatory T-cells.

Background: Acute lymphoblastic leukemia (ALL) is biologically and clinically considered as a heterogeneous neoplasm of lymphoid progenitor cells. About 85% of children with ALL are diagnosed as B-ALL, expressing CD19; the typical marker of normal B cells. Problem: Given that the chemotherapy associated with leucopenia, in particular myeloid cells (CD33+ cells), Aim: the main aim of this study was to analyze the numbers of these cells in children with B-ALL before and after induction of chemotherapy. Materials and Methods: The frequencies of CD33+ myeloid cells and CD19+ B-cells were analyzed in the peripheral blood patients before (n = 10) and after (n = 10) induction of chemotherapy as well as in healthy volunteers (n = 10) using multiparametric flow cytometry. Results: As expected, B-ALL patients showed high numbers of CD19+ cells before induction of chemotherapy; where the numbers of these cells were reduced upon the induction of chemotherapy. CD33+ myeloid cells showed decrease in numbers in B-ALL patients before chemotherapy as compared to healthy control volunteers. Interestingly, treatment of B-ALL patients with chemotherapy-induced almost recovery of the numbers of these cells. Conclusion: CD33+ myeloid cells are increased in numbers after induction of chemotherapy, indicating to a dynamic mobilization or differentiation of their precursors into circulation. This study opens a new avenue to characterize the phenotype and function of these cells in different hematological malignancies; in particular, they may harbor regulatory cells.

Abstract 4520 Objective In β-thalassemia major, Identifying early myocardial insult is important since significant cardiac involvement may predate a decrease in left ventricular systolic functions. The aim of this study is to clarify the value of 2 D-strain (2DS) in early detection of segmental and global left ventricular systolic dysfunction in thalassemic children. Subjects and Methods This study included two age-matched groups:Group 1 (n=30) thalassemic children and Group 2 (n=10) healthy control children. They undergo conventional echo-Doppler measures of left ventricular (LV) systolic and diastolic functions. The pulsed tissue Doppler of lateral mitral annulus was recorded. Longitudinal 2D strain in 18 left ventricular segments using 2 dimensional (2DS) speckle-tracking imaging from apical 4, 2, and 3-chamber views, using a Vivid 7 ultrasound system. The images were analyzed using Echopac soft ware. Results There was no significant difference among thalassemic patients and controls in LV fraction shortening, peak systolic and diastolic tissue velocities of lateral mitral annulus. But by the 2 D strain study there were a significant multi-segmental affection of the LV mainly the posterior, anterior walls with predilection mainly to the apical segments, also there was a significant affection of the peak global LV systolic strain with a median value (-17.7 versus -20.75; P = 0.008.). There was no significant correlation between all segmental or global LV systolic strain and the serum ferretin. Conclusion 2DS is a sensitive and accurate tool for early detection of segmental and global cardiac insult in thalassemic children. Disclosures: No relevant conflicts of interest to declare.