Mechanical treatment shows promise in thalassemia

By Laura Cowen
Vibration therapy may be an effective nonpharmacologic intervention to increase bone mass in patients with thalassemia, US researchers report.
The pilot study, conducted among nine adults (age >18 years) and nine adolescents (age 10-18 years), showed that standing on a vibrating platform (30 Hz, 0.3g) for 20 minutes per day for 6 months increased whole-body bone mineral content (BMC) by a significant 2.6% compared with baseline.
Areal bone mineral density (aBMD) and BMC/height, both measured by dual-energy X-ray absorptiometry, increased by a significant 1.3% and 2.6%, respectively, during the intervention period, and remained elevated at 12 months.
Furthermore, the rate of change in hip BMD during the 6-month intervention in adults was significantly greater than the change observed in the year before study entry (2.2 vs -2.7%).
"Though these data are preliminary, they suggest promise of a non-invasive intervention in a group of patients who have a significant risk of osteoporosis morbidity," remark Ellen Fung (Children's Hospital and Research Center, Oakland, California) and co-authors in the American Journal of Hematology.
Fung and team explain that patients with thalassemia have low bone mass, which can lead to fracture and decreased quality of life.
Patients are commonly treated for hypogondism through hormonal supplementation and encouraged to take calcium and vitamin D, but the majority continue to lose bone, as much as 1% to 2% per year, as they age.
Mechanical stimulation through whole-body vibration has been shown to promote bone formation in previous studies, the researchers therefore tested its efficacy in thalassemia.
The increases in aBMD and BMC were accompanied by significant increases in levels of the bone formation marker osteocalcin and decreases in the bone resorption marker serum collagen type 1 cross-linked C-telopeptide.
Of note, although aBMD and BMC increased during the intervention period among adolescents, the increase was no greater than that recorded in the 6 months prior to the intervention. This was possibly because adolescents were captured during a period of rapid growth and pubertal development, limiting the ability to observe change, Fung et al remark.
They conclude: "Future research is needed to confirm these findings in a larger sample for longer duration."

Licensed from medwireNews with permission from Springer Healthcare Ltd. ©Springer Healthcare Ltd. All rights reserved. Neither of these parties endorse or recommend any commercial products, services, or equipment.

Haploidentical bone marrow transplants for sickle cell disease: an interview with Dr. Javier Bolaños Meade

 Interview conducted by April Cashin-Garbutt, BA Hons (Cantab)

Please could you give a brief introduction to bone marrow transplants?

Bone marrow transplant (also called stem cell transplant) is a medical intervention that allows a physician to deliver very high doses of chemotherapy (if needed) but more importantly, deliver a new immune system to the patient to fight a disease (such as cancer).
For instance, if a patient has leukaemia, and I give that patient a transplant from a donor, he will get a new immune system that will fight the leukaemia, and will also get a new marrow to produce blood (the marrow is the part of the body in charge of making new blood).
In the case of patients with sickle cell disease (and related disorders) the important point is to replace the marrow that is producing defective red cells, for a new marrow that produces healthy red cells.

What exactly is a haploidentical bone marrow transplant?

Historically, in order to perform a bone marrow transplant, donor and recipient have to be 100% matched at the HLA genes level (human lymphocyte antigen). Many patients cannot get a transplant because they lack this matched donor.
But we have shown already in patients with cancer that they can receive a bone marrow transplant from a 50% match (or haploidentical). Over 90% of patients will have a sibling, child or parent that may be used as a donor and in the large majority (almost 100% but not quite) these first degree relatives will be at least 50% match. Therefore, if the patient’s sibling is not a perfect match but at last 50% may be still a good donor.

How did your work on haploidentical transplants for sickle cell disease originate?

Originally we start working on haploidentical transplants on patients with cancer (leukaemia, lymphoma, etc) at the end of the XX century – late 1990’s. Once we established that it was a safe procedure we wanted to test it in patients with non-malignant (non-cancer) conditions like sickle cell for which it is very difficult to find fully matched donors, either because their siblings are also affected, or they cannot find unrelated donors through registries like the National Marrow Donor Program. So, in these cases, a haploidentical transplant may be a good option.

How does a haploidentical bone marrow transplant eliminate sickle cell disease?

When we give new bone marrow to a patient, the donor’s immune system will allow the new marrow and immune system to establish its dominance in the recipient. Then, the donor’s marrow will start making new red cells that are healthy as opposed to those made by the sickle cell marrow.
The abnormal red cells in sickle cell cause many health problems. Once the new and healthy red cells are produced, one can expect that no new complications will develop. However, the damage already done by the sickle cell will not be reversed.

Does a haploidentical transplant always eliminate sickle cell disease or do some patients need a fully matched transplant?

We only performed a haploidentical transplant if the patient does not have a fully matched donor. But transplants do not always eliminate sickle cell. Approximately 50% of the haploidentical transplants done for sickle cell have been successful.

What are the benefits of a haploidentical bone marrow transplant?

Haploidentical transplant offers the possibility of finding donors for patients who otherwise would not be able to receive a transplant. Haploidentical donors (close relatives) are usually willing to donate and are usually readily available. It increases the pool of potential donors. In our study, a large majority of patients would not have received transplants without a haploidentical donor since they lacked a fully matched donor.

Are there any dangers of a haploidentical bone marrow transplant?

Yes, bone marrow transplant is a dangerous procedure that can be life threatening. Infections, graft-versus-host disease, organ toxicities are commonly seen after transplant and these can be very dangerous.

Are there any plans to use haploidentical bone marrow transplants for other conditions?

Currently at Johns Hopkins we have clinical trials with haploidentical transplants available for patients with blood cancers such as leukaemia, lymphoma, etc. We also have it available to patients with sickle cell disease and other haemoglobinopathies such as thalassemia. There are plans to expand to other diseases but that will be in the future.

How do you think the future of bone marrow transplants will develop?

The transplant community is actively researching ways to perform transplants with less toxic approaches, decreasing the rates of complications such as graft versus host disease. I think the areas receiving more attention now are:

1. Alternative donors (such as haploidentical or cord cell grafts)
2. Reduction of graft versus host disease

What plans do you have for further research in this field?

We are currently studying if increasing the number of cells infused in the graft will increase the success in patients undergoing transplants for sickle cell disease.

Would you like to make any further comments?

Despite the fact that transplantation is the only curative therapy for patients with sickle cell disease, it is not the only available option. Not all patients are candidates (either because they do not have severe enough disease or because their overall health is poor).

Where can readers find more information?

http://www.cancer.gov/clinicaltrials/search/view?cdrid=675373&version=HealthProfessional&protocolsearchid=10925161
http://www.hopkinsmedicine.org/news/media/releases/half_match_bone_marrow_transplants_wipe_out_sickle_cell_disease_in_selected_patients

About Dr. Javier Bolaños Meade

Dr. Javier Bolaños Meade is the Associate Professor of Oncology at the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center.
His expertise includes:

• Bone Marrow Transplant
• General Internal Medicine
• Graft-versus-Host Disease
• Hematologic Malignancies

His group is researching into finding novel therapies for the treatment of both acute and chronic graft versus host disease (GVHD).

"We're driven to do big things." - Patient Profile of Robert Mannino

Source: http://www.thalassemia.org


Robert Mannino knows more about blood transfusions than most people.  Diagnosed with thalassemia when he was just six months old, he’s spent much of his life in clinics, hooked up to transfusion machines for treatment of the disorder – at least once every three weeks for six hours at a time. 
   

Now 20 years old and a junior at the Georgia Institute of Technology (Georgia Tech), Robert is turning that life experience into motivation for studying his chosen field: biomedical engineering.

“I’ve always been interested in science and math.  And being in a hospital all the time growing up, and getting to know a lot of people with blood-related illnesses, I wanted to use my talents to help others,” he says.

One of the people he most wants to help is his 15-year-old brother, Kevin, who also has thalassemia.  Robert says that theCooley’s Anemia Foundation (CAF) has been there for his family throughout his life, pioneering research and improving treatment centers to make transfusion days more bearable.  And, more recently, CAF helped Robert in another very significant way: providing a scholarship for him to study ways to help his fellow patients.

Robert wants to help his 15-year-old brother who also has thalassemia.

 This semester, Robert is enrolled in 17 hours of classes at Georgia Tech.  Each weekday, he typically spends three hours in the classroom, three hours in the lab and at least three hours on homework.  Part of his work in the laboratory involves hands-on work with the kinds of machines he encounters each time he goes for a blood transfusion.

“I’m working on a project where I choose a medical device, figure out its flaws and strengths, tear it apart and put it back together again,” he explains.  “There are a lot of engineering components, as well as mechanical and biological considerations.”

 As Robert works in the lab, answering questions for this story, his fellow researchers stop to ask him what the interview is about.

“I don’t know if you know this, but I have a medical condition called thalassemia, and these are guys from the Foundation that supports me,” he tells them.  This happens on several occasions and, each time, Robert is brave and patient in his explanation.

He says that research work in the lab is one of his favorite parts of the day; in fact, he enjoys it so much that he wants to go to graduate school to study hematology. Eventually, he’d like to work for a medical device company, building better products to improve the lives of those with blood disorders. It’s something that he knows, and feels, from a lifetime of experience.

	"We're driven to do big things."

 “There’s something different about people confronted with hardships like this,” Robert says.  “We’re driven to do big things.” 

"Thalassemia was emotionally taxing on my family, but we adapted" - Patient profile of Aaron Cheng,

My name is Aaron Cheng, and I’ve just completed my first semester of college at Harvard

University.

I don’t remember when I was diagnosed with beta thalassemia major, which is also known as Cooley’s Anemia, but my parents tell me it was when I was around one year old.  We were visiting Taiwan, and my mother and father noticed specks of blood in my diaper.  Soon afterward, doctors told my parents that I had Cooley’s anemia. 

I’ve been under treatment for as long as I can remember. From when I was an infant to when I became a middle-schooler, I took Desferal infusions four times a week.  The Desferal treatment would last for about eight hours every night, from when I went to sleep to when I woke up. Treatment now is definitely a lot more convenient: instead of having injections every night, I use the oral chelator Exjade every night, so my schedule is a lot more flexible now.  I am so thankful that treatment is becoming a lot more convenient for Cooley’s anemia patients; as a college student, I find taking a pill a lot easier than injecting a drug for eight hours every night. 

I remember that as a child thalassemia was a lot more painful for my family and me than it is now.  The most difficult aspect for me was feeling different from my friends, since I would be noticeably absent from school when I visited the doctor.  I think the hardest part for my parents was trying to deal with the disease and make sure I had a balanced life.  Thalassemia was emotionally taxing on my family in the early part of my life, but we quickly adapted to the new lifestyle, and now it feels like thalassemia is nothing more than an easily managed inconvenience. 

Besides keeping up with my medicine every day, I don’t think thalassemia greatly impacts my life.  I am still able to lead a perfectly normal college life and try new things every day.  Perhaps thalassemia might make me more tired than the average person when it gets close to a transfusion day, but I find college exciting enough that any physical effect that thalassemia has on me is usually barely noticeable. 

My family first found out about the Cooley’s Anemia Foundation when my doctor introduced my father to the association.  From then on, my family has been very involved, and I attend conferences as often as I can.  It has offered a great community through which I can share my experiences and learn from others who have thalassemia as well.  I find the Foundation to be an extremely helpful forum for patients and family; my family and I have met many friends and gotten a lot of help coping with thalassemia through the CAF.  

I decided to attend Harvard primarily because it had always been my dream school; I love the Boston area and thought it would be a great experience to live on the East Coast and learn in such an academically-driven community.  Furthermore, the Boston area is very convenient, and I am able to go to the Boston Children’s Hospital quickly every three weeks for my transfusions. 

It was such a surprise for me when I was accepted to Harvard and I knew right when I found out that I couldn’t turn this opportunity down.  It has been a great experience for me so far; I am involved in the Harvard Crimson (Cambridge’s daily newspaper), and the Harvard Square Homeless Shelter where I volunteer.  I’ve enjoyed all of my classes so far and learned so much.  Right now I am unsure what I will study for a major, but I am strongly considering molecular/cellular biology, neurobiology, or applied math with a focus on biology.  I am keeping my career options open until I find out in the coming years what I enjoy most.  

Adjusting to a new climate away from my family was easier than I imagined, partly because Harvard keeps me so busy and also because the people there are so friendly that it took a very short time for me to make a lot of new friends.  The weather is noticeably colder than sunny Southern California, but I’ve been having a lot of fun experiencing the new climate. 

The adjustment to Boston Children’s Hospital has been exceptionally smooth; every three weeks I go to the nearby clinic to get my blood drawn, then on the Saturday after I take a 20-minute bus ride to Boston for my transfusion. 

The future looks bright, and I’m looking forward to learning so much more and having the opportunity to give back to the community!

 

New gene transfer technique can treat beta-thalassemia, sickle cell anemia

A team of researchers led by scientists at Weill Cornell Medical College has designed what appears to be a powerful gene therapy strategy that can treat both beta-thalassemia disease and sickle cell anemia. They have also developed a test to predict patient response before treatment.
This study's findings, published in PLoS ONE, represents a new approach to treating these related, and serious, red blood cells disorders, say the investigators.
"This gene therapy technique has the potential to cure many patients, especially if we prescreen them to predict their response using just a few of their cells in a test tube," says the study's lead investigator, Dr. Stefano Rivella, Ph.D., an associate professor of genetic medicine at Weill Cornell Medical College. He led a team of 17 researchers in three countries.
Dr. Rivella says this is the first time investigators have been able to correlate the outcome of transferring a healthy beta-globin gene into diseased cells with increased production of normal hemoglobin -- which has long been a barrier to effective treatment of these disease.
So far, only one patient in France has been treated with gene therapy for beta thalassemia, and Dr. Rivella and his colleagues believe the new treatment they developed will be a significant improvement. No known patient has received gene therapy yet to treat sickle cell anemia.
A Fresh Approach to Gene Therapy
Beta-thalassemia is an inherited disease caused by defects in the beta-globin gene. This gene produces an essential part of the hemoglobin protein, which, in the form of red blood cells, carries life-sustaining oxygen throughout the body.
The new gene transfer technique developed by Dr. Rivella and his colleagues ensures that the beta-globin gene that is delivered will be active, and that it will also provide more curative beta-globin protein. "Since the defect in thalassemia is lack of production of beta-globin protein in red blood cells, this is very important," Dr. Rivella says.
The researchers achieved this advance by hooking an "ankyrin insulator" to the beta-globin gene that is carried by a lentivirus vector. During the gene transfer, this vector would be inserted into bone marrow stem cells taken from patients, and then delivered back via a bone marrow transplant. The stem cells would then produce healthy beta-globin protein and hemoglobin.

This ankyrin insulator achieves two goals. First, it protects delivery of the normal beta-globin gene. "In many gene therapy applications, a curative gene is introduced into the cells of patients in an indiscriminate fashion," Dr. Rivella explains. "The gene lands randomly in the genome of the patient, but where it lands is very important because not all regions of the genome are the same." For example, some therapeutic genes may land in an area of the genome that is normally silenced -- meaning the genes in this area are not expressed. "The role of ankyrin insulator is to create an active area in the genome where the new gene can work efficiently no matter where it lands," Dr. Rivella says. He adds that the small insulator used in his vector should eliminate the kind of side effects seen in the French patient treated with beta-thalassemia gene therapy.
The research team also discovered that the insulator increases the efficiency by which the beta-globin gene is transcribed during the process of making the red blood cells. "We found the gene is integrated into cells which have not yet begun to make red blood cells, and when they do, the beta-globin gene is activated," Dr. Rivella says. "We showed that if the insulator is present, activation of the curative gene is more efficient. This provides more curative protein to red blood cells."

The study further provides evidence that the vector had different rates of efficiency depending on the beta-thalassemia mutation it was used in -- thus providing the basis for a predictive test in patients. The investigators tested 19 different beta-thalassemia samples comprising the two types commonly found in patients -- "beta-zero" cells that do not produce any beta-globin (forcing patients to receive blood transfusions throughout life), and "beta-plus" cells that produce suboptimal levels of hemoglobin. On average, they found that one copy of the vector in beta-zero cells produced 55 percent of the adult hemoglobin seen in normal individuals. Beta-plus cells, after treatment, produced hemoglobin comparable to a healthy individual, and were thus cured.
"The variable nature of the beta-thalassemia mutations suggests that some patients would be better candidates for gene therapy than others, and that success of gene therapy depends on the ability of a specific vector to make hemoglobin," Dr. Rivella says. "This is something we can test in advance using a little bit of a patient's blood -- which is quite extraordinary."
The issue in sickle cell anemia is very different, Dr. Rivella says. The hemoglobin protein is made in the right quantities, but it is not normal -- the red cell is shaped like a sickle and is abnormal in function. "One of the problem in gene therapy of sickle cell anemia is to add a new gene without increasing too much the total amount of protein, both normal and sickle. This would cause other problems," he says.
By treating eight cell specimens taken from sickle cell anemia patients, the investigators discovered that attaching the ankyrin insulator to a normal beta-globin gene increases the amount of normal beta globin protein while reducing the quantity of sickled protein. "The total amount of protein stays the same, which is very important," says first author Dr. Laura Breda, pediatric research associate at Weill Cornell Medical College.
The researchers say that their advances will likely make a substantial impact on a number of fields, including gene regulation and transfer and the design of gene therapy trials. "This study represents a fresh departure from previously published work in the field of gene therapy," Dr. Rivella says.

Source: Weill Cornell Medical College

Age No Longer Should Be A Barrier To Stem Cell Transplantation For Older Patients With Blood Cancers

Age alone no longer should be considered a defining factor when determining whether an older patient with blood cancer is a candidate for stem cell transplantation. That's the conclusion of the first study summarizing long-term outcomes from a series of prospective clinical trials of patients age 60 and over who were treated with the mini-transplant, a "kinder, gentler" form of allogeneic (donor cell) stem cell transplantation developed at Fred Hutchinson Cancer Research Center. The findings are published Nov. 2 in JAMA, The Journal of the American Medical Association.

"Age is no longer a barrier to allogeneic transplant," said Mohamed Sorror, M.D., M.Sc., an assistant member of the Hutchinson Center's Clinical Research Division and corresponding author of the paper.

Sorror and colleagues found that the five-year rates of overall and disease-progression-free survival among mini-transplant patients were 35 percent and 32 percent, respectively. Patients in three age groups 60 to 64, 65 to 69 and 70 to 75 had comparable survival rates, which suggested that age played a limited role in how patients tolerate the mini-transplant. Increased medical problems unrelated to cancer (comorbidities) and a higher degree of cancer aggressiveness were the two factors that affected survival among those older patients. For example, patients who had less-aggressive cancer and fewer comorbidities had a five-year survival rate of 69 percent, while patients with more aggressive cancer and a significant number of comorbidities had a survival rate of 23 percent, regardless of age.

Although a long-term survival rate of one-third of patients may seem low, these patients all would have died of their diseases within a matter of months without a transplant. "The majority of patients were referred for a transplant after they had exhausted all forms of conventional therapy," said Sorror, who works in the research group led by Rainer Storb, M.D., who developed the mini-transplant.

"While there is much room for improvement, particularly with regard to relapse, these results are encouraging given the poor outcomes with non-transplantation treatments, especially for patients with high-risk AML (acute myeloid leukemia), fludarabine-refractory CLL (chronic lymphocytic leukemia) or progressive lymphoma," the authors wrote.

The mini-transplant, known in medical circles as nonmyeloablative transplantation, was developed by researchers at the Hutchinson Center for older and medically sicker patients who otherwise could not tolerate the standard, more-toxic, high-dose regimens used to prepare patients for transplantation.

FDA Approves New Treatment Option for Patients with Thalassemia

Gina Cioffi
Cooley's Anemia Foundation

The Cooley's Anemia Foundation Applauds FDA Approval of Ferriprox, Iron Chelator for People with Thalassemia. The Foundation Believes a Wider "Menu" of Treatment Options is Crucial for Each Individual Patient to Receive Optimal Treatment

New York, NY (PRWEB) October 14, 2011

The Cooley’s Anemia Foundation (CAF), the only national non-profit dedicated solely to fighting the genetic blood disorder thalassemia, applauds a Food and Drug Administration (FDA) decision today to approve the new drug application for the oral chelator, Ferriprox. This action follows a 10-2 vote on September 14, 2011 by the Oncology Drugs Advisory Committee to recommend the approval of this drug.

“As the premier voice of the thalassemia community in the United States, we are thrilled that our patients will have the benefit of this drug which has proven beneficial to patients throughout the world,” says CAF National President Anthony J. Viola. “The FDA clearly responded to the overwhelming need for this drug in our patient population and has provided those patients needing daily drug therapy to remove iron, an option that has improved cardiac health and prolonged life in thousands of patents over the past decade.”

Ferriprox is an iron chelator, which is a drug that is used to help rid the body of excess iron, a serious and often fatal complication in thalassemia. Because individuals with the severe form of thalassemia are born with a life threatening anemia, they require lifelong blood transfusions as often as every two weeks. These transfusions overload the body with iron; if it is not removed, it settles in the organs, causing heart and liver failure, as well as numerous other complications.    

For many years, the only FDA-approved chelator was Desferal, which must be administered by pumping the drug into the body for 8-12 hours, 5-7 nights per week. In 2005, the FDA approved Exjade, a chelator that is administered orally.

Ferriprox is also an oral chelator. In addition to being easier to administer than Desferal, Studies published in Europe demonstrate that use of Ferriprox has been shown to protect the heart from iron accumulation, a crucial concern for individuals with thalassemia.

“The major cause of death in our patient population is iron-related heart failure,” says Viola. “And with a very significant percentage of our population unable to use either Desferal or Exjade, there is a vital need for another option; that option is Ferriprox.”

“We have seen too many patients die too young,” Viola concludes. “Our patients’ lives depend upon having more treatment options available to them. The FDA addressed the unmet medical needs of these desperately ill patients and provided approval for a drug that will help them. Their decision has the opportunity to extend our patient’s lives and significantly improve their quality of life.”

Founded in 1954, the Cooley’s Anemia Foundation (http://www.cooleysanemia.org; (212-279-8090) is the only national non-profit organization dedicated solely to thalassemia. The Foundation’s mission is advancing the treatment and cure for this fatal blood disease, enhancing the quality of life of patients and educating the medical profession, trait carriers and the public about Cooley's anemia/thalassemia major.

Thalassemia in Pregnancy - Organ Functions

 

Cardiac function and transfusion requirements

During pregnancy, the fluid component of the blood normally increases. This can increase the degree of anemia, which leads to the need for more frequent blood transfusions. Increased anemia can also result in the heart having to work harder to get adequate oxygen to all of the body's tissues. Increased blood volume can also put stress on the heart. In thalassemia, the heart may already be under stress from the damaging effects of iron overload. Therefore, it is important to have cardiac function checked prior to and throughout pregnancy. Regular attend-ance at scheduled transfusion appointments is also critical in order to reduce anemia and lessen the work that the heart must do.

Liver function

A liver biopsy may be indicated prior to pregnancy to assess the degree of iron overload. This information may be helpful in deciding whether or not to discontinue iron chelation. A liver biopsy can also help determine if there has been damage from iron deposition or previous hepatitis infection. Blood tests throughout pregnancy can also assess liver function.

Endocrine function

Individuals with thalassemia have an increased chance of developing insulin-dependent diabetes as a result of iron overload. The stress of pregnancy can worsen this condition, which can be detrimental to the health of the mother and developing baby. It is important to stabilize diabetes prior to becoming pregnant and to maintain adequate treatment throughout pregnancy. Thyroid function can also be impaired due to iron overload in the woman with thalassemia.

Splenic function

The spleen removes abnormal red blood cells from the circulation and performs important immune functions. Individuals who have thalassemia have unusually large numbers of abnormal red blood cells. The spleen becomes very active in removing these cells. This activity can enlarge the spleen making it more effective at removing even larger numbers or cells, causing a hemolytic anemia. During pregnancy, there is a greater need for hemoglobin both for normal growth and development of the fetus and due to the fact that the blood volume of the mother will increase dramatically. During this time, transfusion requirements in the pregnant woman is increased, particularly during the last trimester of pregnancy. If transfusion in adequate, the bone marrow will be suppressed and the work of the spleen can be decreased. Occasionally, this will lead to some decrease in spleen size and activity.

Anemia in Postmenopausal Women Linked With Poor Nutrition

Emma Hitt, PhD
Anemia is linked to poor nutrition in postmenopausal women, according to a recent observational study of the Women's Health Initiative (WHI).
Cynthia A. Thomson, PhD, RD, with the University of Arizona, in Tucson, and colleagues reported their findings in the April issue of the Journal of the American Dietetic Association.
According to the researchers, nutritional anemia includes those types associated with prolonged inadequate intake of folate, vitamin B₁₂, iron, protein, and vitamin C.
Dr. Thomson and colleagues hypothesized that a greater number of dietary inadequacies of these nutrients would be associated with a greater risk for incident and persistent anemia.
To evaluate their hypothesis, the researchers used data from the WHI observational cohort study (WHI-OS), which contained a longitudinal sample of postmenopausal women. A total of 93,676 postmenopausal women between the ages of 50 and 79 years were recruited at 40 clinical sites across the United States. Women were enrolled from 1993 until 1998, and data collection was completed in 2000.
Diet was assessed by a food frequency questionnaire for iron, vitamin B₁₂, folate, red meat, and cold breakfast cereal. Dietary intake for women older than 50 years was used as a reference to measure inadequacies. Anemia was defined as a blood hemoglobin concentration of less than 120 g/L in women. Persistent anemia was defined as anemia present at each measurement.
Anemia was identified in 3979 (5.5%) of the participants. Inadequate intake of anemia-associated nutrients was less frequent in non-Hispanic whites (7.4%) vs other racial or ethnic groups (14.6% - 16.3%).
Smoking, age, and body mass index were associated with anemia. Women with anemia reported a lower dietary intake of red meat, folate, vitamin B₁₂, vitamin C, and iron. In addition, deficiencies in dietary intake of 1 nutrient were associated with a 21% greater risk for persistent anemia (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.05 - 1.41), whereas 3 deficiencies in dietary intake resulted in a 44% increase in the risk for persistent anemia (OR, 1.44; 95% CI, 1.20 - 1.73).
Deficiencies in total intake of 1 nutrient were associated with a 34% increased risk for persistent anemia (OR, 1.34; 95% CI, 1.14 - 1.56). Regarding deficiencies in total intake of 3 nutrients, the risk increased to 56% (OR, 1.56; 95% CI, 1.25 - 1.95).
Editorial: Nutrient Measurements Costly
According to editorialists Lisa Tussing-Humphreys, PhD, RD, with the US Department of Agriculture–Agriculture Research Service, in Los Angeles, California, and Carol Braunschweig, PhD, RD, with the University of Illinois, in Chicago, this study provides "one of the largest prospective assessments of diet and anemia in US postmenopausal women."
They add that the findings "lend credibility to the use of an FFQ [food frequency questionnaire] for large epidemiological studies investigating the relationship between diet and anemia risk."
However, according to the editorialists, the mean nutrient intakes reported indicate that "a portion of the anemia observed in the WHI-OS cohort was not diet-related," they write. "For example, it is well known that decreases in hemoglobin occur from nutrient deficiencies only when stores are nearly exhausted."
In addition, although the accurate assessment of anemia allows clinicians to classify the type of anemia and recommend suitable treatment options, inclusion of these measurements in large epidemiologic studies is "cost-prohibitive and unlikely."

Hemoglobinopathy and thalassemia detection

Traditional methods and a novel method — capillary electrophoresis technology

By Aigars Brants, PhD

In humans, two pairs of unlike globin chains combine with four heme groups to form hemoglobin (Hb), a protein that is carried by red cells and picks up oxygen in the lungs and delivers it to the peripheral tissues. One of the globin chain pairs in hemoglobin is always alpha (with the exception of the very first weeks of embryogenesis), while the second pair is “non-alpha.” That is, it can be made of beta- (ß), delta- (d), or gamma (g) chains.

In the healthy newborn, Hb F (a2g2) is the major hemoglobin (~75%). Fetal hemoglobin (Hb F) is replaced by Hb A (a2ß2) and Hb A2 (a2d2) during the first six to 12 months of life. In healthy adults, hemoglobin is comprised of Hb A (~97%) and Hb A2 (~2.7%), with only trace amounts of Hb F, if any.

Two types of disorders may affect globin chains—qualitative and quantitative. Qualitative disorders, i.e., hemoglobinopathies, result from any of the following: i) substitution of one amino acid for another (as in Hb S and Hb C); ii) deletion of a portion of the amino acid sequence (as in Hb Gun Hill); iii) abnormal hybridization between two chains during meiosis (as in Hb Lepore); and iv) abnormal elongation of the globin chain (as in Hb Constant Spring). Obviously, any alterations listed above lead to changes in molecule structure or charge and they can be detected with the appropriate methodology.

Currently, over 1,400 Hb variants are listed in the globin chain database, with the majority of them being beta chain variants.

Thalassemias are quantitative disorders affecting the rate of otherwise normal hemoglobin synthesis. The ß-thalassemia carrier state is a benign condition with mild anemia, red blood cell hypochromia and microcytosis, and an elevated Hb A2 level. In comparison, severe disease (ß-thalassemia major) requires lifelong blood transfusions and chelation therapy.

Since increase in Hb A2 concentration is indicative of beta-thalassemia, it is useful to obtain an accurate relative Hb A2 value. With many testing methods, common Hb variants can interfere with an accurate Hb A2 quantitation. It is also important to account for delta chain Hb variants in the sample; if any are present, the delta chain variant concentration (percentage) must be added to the Hb A2 value to obtain an accurate total Hb A2 concentration.

Alpha-thalassemia affects the synthesis of alpha globin chains, and the severity of disease is dependent on the extent of gene deletion. Loss of two out of four alpha-chains encoding genes results in an a-thalassemia trait, characterized by microcytosis with little or no anemia. Loss of three genes results in Hb H (4ß chains) disease, a moderate hemolytic anemia, while loss of all four genes is incompatible with independent life.

Electrophoretic hemoglobin separation methods

Electrophoresis has long been the method of choice in hematological laboratories for qualitative and quantitative hemoglobin analyses. Currently, four different techniques are routinely used in the lab setting: 1) alkaline and acid gel electrophoresis; 2) isoelectric focusing (IEF); 3) high-pressure liquid chromatography (HPLC); and 4) capillary electrophoresis (CE).

Sebia Electrophoresis provides multiple platforms for the detection of hemoglobinopathies and thalassemias—fully automated capillary electrophoresis systems and a semi-automated agarose gel system to accommodate both alkaline and acid agarose gel electrophoresis.

Alkaline and acid agarose electrophoresis

Because of its simplicity, alkaline gel electrophoresis is one of the most popular methods for Hb screening. Semi-automated agarose gel electrophoresis is also cost-effective for low- to medium-volume laboratories. However, the technique is relatively laborious, requiring manual sample preparation. Red blood cells must be washed in saline to remove plasma proteins and to eliminate non-hemoglobin bands on the gel. Electrophoresis at alkaline pH (8.5) allows for the separation of the major hemoglobins and a number of less common Hb variants. Visualization of the Hb bands is done by automated staining of the gel with amido black. The clear background of the gels enables measuring the concentration of individual fractions by densitometric scanning. However, due to the precision and accuracy of Hb in low concentrations (Hb A2 for example), the College of American Pathologists (CAP) no longer recommends the use of  densitometric scanning for quantification of Hb A2. With alkaline agarose gel testing, some common Hb variants comigrate, such as Hb C, Hb E, Hb A2 & Hb O-Arab and Hb S, Hb D and Hb G.

In order to separate some Hb variants that commonly comigrate at alkaline conditions, the sample may also be analyzed on gel at an acidic pH (6.0). In these conditions, molecular charge will differ and migration patterns will change. As a result, Hb S can be differentiated from Hb D, and Hb C can be differentiated from Hb E.

Isoelectric focusing

IEF provides excellent separation of many hemoglobin variants and detects fast-migrating or low concentration hemoglobin variants such as Hb H, Hb Bart’s, and delta chain variants.

IEF gels contain special molecules—ampholytes—that  create a pH gradient in an electrical field. When a pH gradient is present, hemoglobin molecules migrate to a position on the gel where the net charge equals zero (0), resulting in very narrow and focalized bands. On IEF gels, Hb C separates from Hb E and Hb O-Arab, and Hb S from Hb D and Hb G. IEF gels, however, are processed manually and require a significant amount of technical time. Additionally, IEF results are qualitative, and interpreting results requires significant experience.

High pressure liquid chromotagraphy

HPLC is a pressure-driven technique. Hemoglobin samples are injected into a resin column and retained based on the charge. The eluting solution that competes for the negatively charged resin is added in increasing concentration. Hemoglobin variants elute from the column and are detected at 415 nm, then at 690 nm to correct the baseline of the result. The hemoglobin retention time (from injection until the maximum point of each peak) is calculated and plotted on a chromatogram.

HPLC instruments are primarily indicated for the measurement of Hb A2 and F, but also provide data (retention times) on many Hb variants. However, HPLC should not be used as the sole method for identification of hemoglobin variants.¹ HPLC is very complementary to CE technology; together these two automated methodologies provide valuable data for result interpretation.^2,3 HPLC techniques result in patterns that are relatively complex and require training and experience for interpretation of results.⁴

Capillary electrophoresis

CE technology utilizes liquid flow electrophoresis—buffer replaces agarose gel as the medium. Hemoglobin variants are separated by electroosmotic flow at an alkaline pH (9.4) using negatively charged silica capillaries and high voltage. Multiple samples undergo an eight-minute high-resolution separation, concurrently. A high-resolution hemoglobin separation is obtained, similar to IEF separation. The ideal wavelength of 415 nm is utilized for hemoglobin detection with CE. The result, or electropherogram, is made up of 300 consecutive readings (dots) and is divided into 15 zones. To facilitate interpretation, results are automatically positioned with regard to the Hb A and Hb A2 fraction in the sample. Hemoglobins (normal and variant) are displayed as peaks, and the zone to which a variant belongs is identified automatically by the system. An on-board hemoglobin library is present in the form of a drop-down list and lists all of the normal and variant hemoglobins that may be present within a particular zone.

With Sebia’s CE systems, packed red blood cell samples are utilized for analysis. Plasma is removed from samples, and the bar-coded primary sample tube is loaded onto the instrument; all other steps in sample processing and separation are performed automatically by the system.

More features of CE technology

• In one analysis, separation of Hb S from Hb D, and Hb C from Hb E (and from Hb A2).
• Precise, quick quantification of Hb F and Hb A2, even in the presence of Hb S.⁵
• Posttranslational Hb variants (such as glycated HbS1c) do not separate from the main fractions.⁶  
• Delta chain variants, alpha chain variants, and other minor Hb fractions are readily visualized.⁸
• Hb H and Hb Bart’s are more readily detected and measured by CE than by the HPLC method .⁴

Multiuse instrument

Sebia systems may be used for other types of analysis, including serum/urine protein electrophoresis, immunotyping (automated immunofixation alternative), and CDT (a marker for chronic alcohol abuse)⁸

CAP requires the use of a second, complementary technique for abnormal hemoglobin results. CE is most complementary with acid gel electrophoresis and HPLC. By combining CE and HPLC methodologies, one can significantly reduce the number of unusual hemoglobin variants that can be confused with normal hemoglobins or common Hb variants (2).

Newborn screening with dried blood spot samples

Sebia’s newest FDA-cleared CE assay for hemoglobinopathy testing is Capillarys Neonat Hb Fast. It is used for the screening of newborn blood samples collected on Guthrie Cards. Newborn dried blood spot samples are screened for the presence of normal hemoglobins (F and A) and common hemoglobin variants to include S, C, D, E, and Bart’s. The system is fully automated and fast, with an instrument throughput of 96 results in two hours. The fast throughput is accomplished due to eight simultaneous analyses taking place; a high-resolution seven-minute migration occurs for each newborn sample with results similar to IEF separation. Result interpretation is aided by automatically color-coded curves (normal or abnormal results) and on-board hemoglobin library by zone. All normal hemoglobins and common variants migrate in different zones—Bart’s, A, F, D, S, E, A2, and C.

The following table lists HPLC migration characteristics in the presence of common variants.

Hb present	Hb A2 result	Hb F result	Comments
S	falsely elevated		coelution of Hb S1c fraction with A2 (4)
E	falsely elevated		coelution of Hb E with A2 (4)
D	underestimated		(3)
G-Philadelphia	falsely elevated		coelution of G-Philadelphia with A2
Lepore	falsely elevated		coelution of Lepore with A2 (3)
A1c (elevated)		falsely elevated	(3)

Poor Eating Habits May Lead to Anemia in Older Women

Study finds that as nutrient intake declines, risk rises

By robert preidt

FRIDAY, March 25 (HealthDay News) -- A poor diet is associated with a greater risk of developing anemia among postmenopausal women, a new study has found.
Researchers analyzed data from 72,833 older women in the United States and found that deficiencies in more than a single nutrient were associated with a 21 percent increased risk of persistent anemia. Risk increased 44 percent with deficiencies in three nutrients.
Women with anemia consumed less protein, folate, vitamin B12, iron, vitamin C and red meat than did others, the study found. The results are published in the April issue of the Journal of the American Dietetic Association.
Inadequate nutrient intake was less frequent among whites than in other racial or ethnic groups: 7.4 percent, compared with 14.6 percent of Asian/Pacific Islanders, 15.2 percent of Native Americans/Alaskans, 15.3 percent of blacks and 16.3 percent of Hispanics.
The researchers also found that the use of multivitamin and mineral supplements was not associated with lower rates of anemia. Age, body mass index and smoking were associated with anemia.
Anemia has been linked to an increased risk of death and, "anemia, particularly iron deficiency, has been associated with reduced capacity for physical work and physical inactivity, injury related to falls and hospitalizations, making this an important health-care concern in the aging," lead investigator Cynthia A. Thomson, associate professor of nutritional sciences at the University of Arizona in Tucson, said in a journal news release.
"Efforts to identify anemia that may be responsive to modifiable factors, such as diet to improve health outcomes, are needed," the researchers concluded. "Additional efforts to regularly evaluate postmenopausal women for anemia should be considered and should be accompanied by an assessment of dietary intake to determine adequacy of intake of anemia-associated nutrients, including iron, vitamin B12 and folate," they wrote.
"While the type of anemia is often designated by a more comprehensive biochemical assessment than hemoglobin alone, nutritional therapy to improve overall nutrient-density and quality of the diet should also be a clinical focus," Thomson and colleagues said.

4-year-old cured of Thalassemia major with stem cell transplant

Ahmedabad doctorshave carried out a rare successful stem cell transplant on a four-year-old girl suffering from Thalassemia major, relieving her of life-long blood transfusions.
Isha Gohel from Saurastra, who was diagnosed of suffering from advanced stages of Thalassemia, had started receiving blood transfusions at the age of 18 months.
When she was brought to Apollo hospital in Ahmedabad, doctors after investigations found that she was a case of class 3 Thalassemia Major. Since she did not get good quality blood transfusion, her condition was very poor. She had developed marked enlargement of the spleen leading to further poor response to blood transfusions.
Terming Isha's case as challenging, Dr Chirag A Shah, haematologist, Apollo hospital here, said that they followed the style of treatment of Dr G Lucarelli from the Mediterranean Institute of Haematology - an international centre for transplantation in thalassemia and Sickle Cell Anaemia - in Italy who has successfully treated advanced cases of thalassemia.
Her spleen was removed and stems cells from Isha's two-year-old brother were transplanted. "We followed his (Lucarelli's) formulae for treatment of Isha and we were successful," he said.
"Stemcell transplant in advanced cases of thalassemia results in poor outcome. Such patients are not advised a transplant as they frequently have poor results and have high risk of complications," Shah said.
He said that Isha's case was difficult for them as her spleen had blown out of proportion and her liver too was damaged due to iron deposits.
Giving details of her treatment, he said, "We first surgically removed her spleen in January and the following month we started on a special protocol of medicines to reduce her risk of being Class 3. This continued for over one month until finally she underwent stem cell transplant procedure in April. The stem cells were from her younger brother."
Isha is now on the road to recovery and and will be transfusion free forever as her underlying Thalassemia major is now cured after stem cell transplant.

"Behavioral Strategies for Parents" Webinar Available Online

Dr. Lauren Mednick's presentation on "Behavioral Strategies for Parents of Children with Thalassemia," CAF's March 2 webinar, is now available for watching.

Lauren Mednick, PhD, is an assistant in Psychology at Children’s Hospital Boston and is on the faculty at Harvard Medical School.  She received her B.S. in Psychology from the University of Illinois and both her Master of Philosophy and her PhD in Clinical Child Psychology, with an emphasis on behavioral medicine, from The George Washington University.    Her subsequent clinical, teaching and research efforts have focused on helping children and families cope with medical stressors.  The majority of her time is spent in direct clinical care, conducting outpatient therapy with children and adolescents diagnosed with acute and chronic medical conditions, including thalassemia.    Dr. Mednick also has an interest in how a parent is coping impacts a child’s physical and emotional well-being and focuses much of her work on investigating stress and coping in parents of children diagnosed with various medical conditions.  CAF is thrilled to be able to offer the experience and knowledge that Dr. Mednick has learned working with families with thalassemia, as well as with other chronic conditions.