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   Table of Contents - Current issue
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October-December 2018
Volume 43 | Issue 4
Page Nos. 151-228

Online since Wednesday, April 10, 2019

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ORIGINAL ARTICLES  

Prognostic significance of tetraspanin (CD81) expression in patients with acute myeloid leukemia Highly accessed article p. 151
Ola A Elshoura, Rasha A Elkholy, Amal E Selim, Nesreen M Sabry
DOI:10.4103/ejh.ejh_24_18  
Objective The aim was to determine the prognostic significance of CD81 expression in patients with acute myeloid leukemia (AML) and its effect on patients’ survival. Patients and methods This study was carried out on 50 patients with newly diagnosed AML. Expression of CD81 was detected by flow cytometry, and then all the patients received chemotherapy and were observed for a period of 12 months regarding clinical and laboratory findings of remission and relapse. Results Our results showed that positive expression of CD81 was detected in 30/50 (60%) patients. Clinical remission was achieved in six (12%) patients with positive expression of CD81, whereas it was achieved in 12 (24%) patients with negative CD81 expression. Relapse occurred in 19 (38%) patients with positive expression of CD81, whereas it occurred in six (12%) patients with negative CD81 expression. Death occurred in five (10%) patients with positive expression of CD81 and in two (4%) patients with negative expression of CD81. Conclusion CD81 expression has a potential role as a prognostic marker as its expression was associated with patients with high-risk AML, with higher white blood cells, higher lactate dehydrogenase, and higher blast percentage in bone marrow, and M1 and M5 FAB subtypes. Decreased overall survival and disease-free survival in patients with CD81-positive expression than in patients with CD81-negative expression was also observed.
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Prognostic significance of programmed death ligand 1 expression in adult patients with de-novo acute myeloid leukemia p. 158
Nevine N Mostafa, Emad A Abdelmohsen, Amro M.S El-Ghammaz, Alia M Saeed, Mohammed T Hamza
DOI:10.4103/ejh.ejh_27_18  
Context Acute myeloid leukemia (AML) exhibits one of the therapeutic challenges to the clinician owing to unsatisfactory outcomes obtained by conventional chemotherapy protocols. Immune checkpoints have gained attention in the recent years in the field of oncology as a presumable mechanism of cancer to evade immunity, but their status in AML has yet to be investigated. Aims The aim was to measure programmed death ligand-1 (PDL-1) expression on the blast cells in patients with de novo AML at time of diagnosis, followed by investigating its relationship to different patients’ characteristics as well as disease prognostic variables and therapy outcomes. Setting and design A total number of 40 adult patients with de-novo AML were recruited. Materials and methods Surface expression of PDL-1 on the blast cells was evaluated by multicolor flow cytometry. The collected data were revised, coded, tabulated, and introduced to a PC using IBM SPSS version 20.0. Results PDL-1 has been expressed amongst the study cohort with a mean expression of 43.01±24.72. PDL-1 expression was not different among different risk categories of the disease and did not influence the therapeutic response. Despite a higher PDL-1 expression in refractory cases in comparison with responders, being 68.9 and 43.4%, respectively, this did not reach a statistical significance. Conclusions PDL-1 expression did not show a discernible relationship with any patients’ or disease parameters. Moreover, it did not influence patients’ response to treatment or survival. Refractory cases displayed higher expression, but they were too few to draw statistical inferences, with the need of a more ample sample size.
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Assessment of D-dimer and protein S in Egyptian patients with cirrhosis with and without ascites p. 166
Wesam A Ibrahim, Nesma A Safwat, Mohamed M.M Ibrahim, Millimi A Djibrin
DOI:10.4103/ejh.ejh_25_18  
Background Liver cirrhosis is characterized by complex hemostatic defects, leading to both hemorrhagic and thrombotic complications. It is also associated with ascites. Being a derivative of plasma that accumulates in the abdominal cavity from transudative leakage out of cirrhotic liver and because ascites re-enters the systemic circulation, cirrhotic ascites may be a pathological fluid that contributes to hemostatic derangement in these patients. The aim of study was to measure plasma levels of d-dimer and protein S (PS) activity as hemostatic parameters in patients with cirrhosis of varying severity with and without ascites to evaluate the role of ascites as a contributor of coagulopathy associated with liver cirrhosis. Patients and methods A total of 90 patients with cirrhosis with varying degree of severity owing to hepatitis C admitted to Ain Shams University hospitals from January 2017 to January 2018 were included in this study. Patients were categorized into two groups: group I included patients with cirrhosis complicated with ascites (n=38), and group II included patients with cirrhosis without ascites (n=52). The severity of liver disease was assessed according to the Child–Pugh classification. Plasma samples from each patient were analyzed for the level of d-dimer and PS activity. Results Plasma d-dimer levels showed a significant increase in patients with ascites (2.04±0.38 mg/l) when compared with those without. However, PS activity was significantly decreased in presence of ascites (45.79±1.66%). These changes appeared to be significantly accompanied by the progression of liver dysfunction. Upon performing regression analysis (backward method), it was proved that ascites formation was a significant independent factor that increases d-dimer levels and deteriorates PS activity in patients with cirrhosis. Conclusion Our results suggest that ascites contributes to the coagulopathy in decompensated liver disease, and the degree of coagulopathy was proportional to the severity of liver disease.
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Role of circulating endothelial cells and platelet microparticles as markers of angiogenesis in chronic myeloid leukemia p. 171
Asmaa Nafady, Mostafa F. Mohammed Saleh, Hanaa Nafady-Hego, Mohammed M Wahman, Khalid A Nasif, Wael F Sedik
DOI:10.4103/ejh.ejh_22_18  
Background Circulating endothelial cells (CECs) and platelet microparticles (PMPs) are proposed as useful biosensors for angiogenesis and membrane damage in cancer. Moreover, PMPs can modulate cellular and humoral immunity. Objective To measure CEC and PMP levels in patients with chronic myeloid leukemia (CML) with and without imatinib therapy. Patients and methods Peripheral blood samples were obtained from 30 patients with CML at diagnosis (group A), 30 patients with CML on imatinib therapy of at least 1 year (group B), and 20 healthy controls (group C). Flow cytometry techniques were used to quantify CEC and PMP levels. Results PMP percentage significantly increased in groups A and B when compared with group C (P=0.001 and 0.001, respectively). Mean±SEM of groups A, B, and C was 48.67±2.88, 42.50±2.82, and 22.70±1.18, respectively. There was an increased number of CECs in group A and B when compared with controls (P=0.001 and 0.001, respectively). Mean±SEM of groups A, B, and C was 149.33±23.82, 70.96±9.58, and 22.70±1.18, respectively. Patients with advanced phase or higher risk disease had slightly more PMPs and CECs than patients with chronic phase or low risk. Patients on imatinib therapy who achieved a complete molecular response at 1 year showed fewer PMPs and CECs. Conclusion Higher PMPs and CECs number in patients with CML at diagnosis could indicate their pathogenic role as angiogenesis markers. However, their role of being prognostic factors and predictors of response to therapy in CML needs larger prospective studies.
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Prognostic significance of BCL6 and KI67 in patients with chronic lymphocytic leukemia p. 179
Maha Mohamed Adel Elgammal, Nabil Ahmed El-Halawani, Manal Abd El-Sattar El-Sorady, Shereen Mohamed El-Maghraby, Ghada Said Mahmoud Sallam
DOI:10.4103/ejh.ejh_26_18  
Background Chronic lymphocytic leukemia (CLL) is a heterogeneous disease; its prognosis depends on the disease stage at diagnosis as well as the presence or absence of high-risk markers to determine the treatment strategy. Aim To evaluate the expression of BCL6 and Ki67 in patients with CLL and to assess their clinical prognostic significance in relation to other established prognostic markers such as Zeta-associated protein of 70-Kd (ZAP70) and β2 microglobulin (β2M). Participants and methods BCL6 and Ki67 were measured using flow cytometry in thirty newly diagnosed CLL patients who presented to the Hematology units in Alexandria Main University Hospital and the Medical Research Institute, Alexandria University, they were also measured in 20 healthy age-matched and sex-matched controls. Results A statistically significant difference was found between cases and controls for both BCL6 and Ki67 expressions (P<0.0001). Significantly positive correlations were found between both BCL6 and Ki67 expressions and the following parameters: Rai staging (P=0.000 and 0.000, respectively), serum marker lactate dehydrogenase (LDH) (P=0.001 and 0.000, respectively), β2M (P=0.005 and 0.000, respectively), and ZAP70 expression (P=0.000 and 0.000, respectively). Similarly, a positive significant correlation was found between BCL6 expression and Ki67 expression (P=0.000). Rai staging showed a significant positive correlation with β2M, LDH, and ZAP70 (P=0.000, 0.001, and 0.003, respectively). Conclusion BCL6 expression and Ki67 expressions were positively correlated with the established prognostic markers (clinical staging, LDH, β2M, and ZAP70), so both of them may be considered as prognostic factors in patients with CLL.
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The role of pre-B-cell colony-enhancing factor in Egyptian children with hemophagocytic lymphohistiocytosis p. 184
Wafaa E Ibrahim, Fatma S.E Ebeid, Reda M Mohamed
DOI:10.4103/ejh.ejh_31_18  
Background Hemophagocytic lymphohistiocytosis (HLH) is caused by a highly active but ineffective immune response, including impaired or absent function of natural killer cells and cytotoxic T cells, and the release of proinflammatory cytokines. Pre-B-cell colony-enhancing factor (PBEF) is an inflammatory cytokine involved in several inflammatory diseases, and it has been identified to react with several cytokines involved in HLH. Objective We aimed to study the clinicoepidemiological characteristics of Egyptian children with HLH and to evaluate the role of PBEF as a diagnostic and prognostic marker in Egyptian children with HLH. Patients and methods This is a cross-sectional study that recruited fifteen children with HLH from the Pediatric Hematology/Oncology unit. There were 11 male and four female, and their median age (interquartile range) was 13 months. Patients underwent thorough clinical assessment, laying stress on disease manifestation, classification, treatment, and prognosis. Plasma concentration of PBEF was determined using an enzyme-linked immunosorbent assay. Results Four patients were classified as having primary HLH, seven patients were as having secondary HLH and four patients had unknown classification owing to waiting for genotyping. The risk factors before presentation were as follow: four had viral infection, three patients had malignancy, and two patients had immune deficiency before presentation. Seven patients of the study group died and eight patients were still alive. PBEF was significantly increased in the patient group than the control group. PBEF level showed a significant positive correlation with serum ferritin and triglycerides level and a negative correlation with fibrinogen level. Conclusion The elevated PBEF level and its correlation with the widely available biochemical markers for diagnosis of pediatric HLH indicates that it may be involved in its inflammatory process.
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Clinical relevance of DNA methyltransferase 3a (dnmt3a) mutation in patients with acute myeloid leukemia p. 193
Amal Zidan, Amina M Elnaggar, Nahla I Zidan, Fouad M Abo-Taleb
DOI:10.4103/ejh.ejh_3_17  
Background Acute myeloid leukemia (AML) is a complex and heterogeneous hematopoietic tissue neoplasm caused by gene mutations, chromosomal rearrangements, deregulation of gene expression, and epigenetic modifications. DNA methylation is altered in leukemia and can affect cells in three main ways: hypomethylation, hypermethylation, and loss of imprinting. Global hypomethylation has frequently been reported in the blast cells, and it is postulated that this promotes transcription of oncogenes and genes concerned with cell replication. Studies of DNA methylation in AML have revealed a series of subgroups with specific methylation signatures. Patients and methods A total of 45 patients with newly diagnosed AML were included in the study. Moreover, 45 individuals matched for age and sex were selected as controls. Immunophenotyping, conventional cytogenetic analysis, and molecular detection of DNA methyltransferase 3A (DNMT3A) exon 23 mutations were performed. Patient follow-up was performed on day 28 after receiving induction therapy to evaluate the remission status. Results DNMT3A exon 23 mutations were identified in 17.8% of patients with AML. All the mutations were missense and heterozygous. DNMT3A exon 23 mutations were significantly associated with AML with monocytic differentiation (75%) than the wild-type group (27%) (P=0.01). All DNMT3A mutations were observed in patients with intermediate-risk karyotype. There was a statistically significant decrease in the probability of achieving complete remission with shorter overall survival in the mutated group compared with the wild type, whereas no statistically significant difference between both groups in the probability of disease-free survival (P=0.14). Conclusion DNMT3A mutations are associated with poor response to therapy conferring a poor outcome, and seem to add prognostic information in patients with AML harboring it with shorter overall survival. DNMT3A mutations can represent a valuable tool for making therapeutic decisions.
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Influence of splenectomy on CXCL8 and T lymphocyte subsets in children with β-thalassemia major: single center Egyptian study p. 198
Nahed Hablas, A Fakhereldin, Sheren Awny, Sarah A Hamam
DOI:10.4103/ejh.ejh_29_18  
Background After splenectomy, the immune system is modified; there are numerous quantitative and functional defects involving T and B lymphocytes and blood anomalies of serum level of cytokines. The present study aimed to evaluate immuneinflammatory status interactions with thalassemia pathogenesis, especially after splenectomy, which can provide new modalities for the management of the disease and its complications. Patients and methods The present study was conducted on 40 children with β-thalassemia major under follow-up at the Hematology Unit, Pediatric Department, Tanta University. There were 24 (60%) male and 16 (40%) female patients; they were blood transfusion dependent and underwent splenectomy for more than 6 months. Their ages ranged from 6 to 17 years. Besides, 40 healthy children served as the control group. All children included in the study were subjected to complete blood count, iron profile, T-cell subsets including CD3, CD4, and CD8 and serum interleukin (IL)-8 levels. Results There were significantly higher IL8, CD3, CD4, and CD8 and significantly lower CD4/CD8 ratio in patients than controls. There were significantly higher IL8, CD3, CD4, CD8, serum ferritin and iron levels and significantly lower total iron binding capacity (TIBC) level after splenectomy than before. Moreover, there was a significant positive correlation between serum ferritin and the immunological markers. Conclusion and recommendations Children with β-thalassemia major had significant abnormalities of the serum levels of CD3, CD4, CD8, and IL8 before and after splenectomy. These changes were associated with increased tendency to infections. Hence, evaluation of serum levels of IL8, CD4, and CD8 may be a useful tool and can help to provide new modalities for management.
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von Willbrand factor Thr789Ala gene variant determines the type of myocardial ischemia in Egyptian patients p. 206
Nahla F Osman, Marwa A Younes, Reehab I Yaseen, Amro Fathy
DOI:10.4103/ejh.ejh_8_17  
Objective von Willbrand factor antigen level (vWF: Ag) was shown to contribute to the risk of cardiovascular disease. vWF Thr789Ala single nucleotide polymorphism was thought to affect the factor level and function. This study aimed to investigate the impact of genetic variants at that position on the risk of acute coronary syndrome (ACS). Patients and methods The study included 112 patients of ACS; 31 with unstable angina (UA) and 81 with myocardial infarction (MI) as well as 118 healthy controls. vWF: Ag level was measured by enzyme-linked immunosorbent assay. The gene analysis was carried out by PCR using restriction fragment length polymorphism principles. Results vWF: Ag levels were significantly higher in patients (111.29±24.43 IU/dl) compared to the controls (71.13±13.72 IU/dl, P<0.001). The majority of patients with UA (80.6%) were Ala789 homozygous, 6.5% were Thr789Ala heterozygous, and 12.9% were Thr789 homozygous. With respect to the MI group, Ala789 genotype was present in 34.6% of the patients, Thr789Ala genotype was the predominant genotype and was seen in 48.1% of the patients, and Thr789 homozygous was present in 17.3% of the patients. The genotype frequency in the control group was as follow; 47.4% were Ala789 homozygous, 33.1% were heterozygous, and 19.5% were Thr789 homozygous. The difference in genotype distribution was significantly different among the three groups (P<0.001), and between the groups with UA and MI (P<0.001). Ala789 homozygous genotype was an independent risk factor for UA while the Thr789Ala genotype was shown as an independent risk factor of MI. Conclusion vWF Thr789Ala polymorphism is an independent risk factor for ACS and has significant impact on the type of myocardial ischemia. It should be incorporated in the risk assessment model to identify and guide the management in these patients.
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Effect of enteral bovine lactoferrin on neonatal iron status p. 212
Mohammed El Barbary, Nancy A Shady, Hebatallah A Shaaban, Menat A.A Shaaban, Ola Y Ahmed
DOI:10.4103/ejh.ejh_30_18  
Background All infants experience a decrease in hemoglobin (Hb) soon after birth, which results in varying degrees of anemia. Oral bovine lactoferrin (LF) supplementation, an iron-binding glycoprotein, is a promising therapy for iron-deficiency anemia. Objectives To evaluate the effect of enteral LF supplementation on the levels of Hb, hematocrit, and serum ferritin in infants admitted in the neonatal intensive care units. This was an interventional double-blind trial conducted on 52 neonates who were randomized into LF group (n=26) and placebo group (n=26). LF was administered at a dose of 100 mg/day once by enteral route starting from birth to 30th day of life. Complete blood count and serum ferritin were assessed in patients at 7th and 30th day of life. Results There were no significant differences between both the studied groups as regards serum ferritin, Hb, hematocrit, mean corpuscular volume, red cell distribution width, platelet count, and total leukocytic count on day 7. There were statistically significant higher serum ferritin, Hb, hematocrit, and mean corpuscular volume, and lower red cell distribution width and total leukocytic count in the LF group than the placebo group on day 30. The placebo group had significantly higher mortality than LF group (19.2% vs. zero; P=0.051). Conclusion Bovine LF is an effective and safe therapy to prevent anemia in neonates.
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Monitoring response rate of blood donors concerning positive screening tests for HIV and syphilis: an institutional approach toward donor hemovigilance p. 217
Maria Ali, Farheen Karim
DOI:10.4103/ejh.ejh_17_18  
Objective To investigate the response rate among our blood donors when notified about their positive screening results of HIV and syphilis. Study setting An observational study conducted at a Division of Hematology, Department of Pathology and Laboratory Medicine, Aga Khan University Hospital from January 2013 to December 2014. Materials and methods Computerized donor inventory data were retrieved. The frequency of screening-positive donors for HIV and syphilis was calculated and the donors were informed through telephone to provide fresh samples for confirmatory tests. The frequency of those donors who responded by providing fresh blood sample was computed. Results Of the total 1684 screening-positive doors, 255 were reactive for syphilis and 11 were reactive for HIV. Only 232 (91%) of the venereal disease research laboratory positive were successfully contacted, out of these only 65 (28%) gave fresh samples and treponema pallidum particle agglutination (TPHA) test results confirmed 56 (86%) donors as positive and nine (14%) as negative for syphilis. On the other hand, of the11 anti-HIV-reactive donors 10 (91%) were successfully approached, five (50%) donors showed a positive response by giving fresh samples for Western blot confirmatory test, which affirmed three (60%) donors to be positive and two (40%) donors to be negative for HIV. Conclusion The results reverberate the lack of awareness among our blood donors. Better predonation counseling can improve the overall outcome.
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Predictive value of the proliferation marker Ki-67 in patients with acute leukemia undergoing hematopoietic stem cell transplantation p. 222
Hoda Gadallah, Hani Hegab, Walaa Elsalakawy, Mohamed A Samra, Botheina A.T Farweez, Ahmad E Saad
DOI:10.4103/ejh.ejh_21_18  
Introduction Hematopoietic stem cell transplantation (HSCT) is increasingly used in cases of acute leukemia. Ki-67 protein is an excellent marker of proliferation in many solid tumors and hematological malignancies. Aim The aim was to evaluate the utility of Ki-67 as a prognostic marker before HSCT. Patients and methods The study included 40 adult Egyptian patients with acute leukemia undergoing HSCT. Plasma Ki-67 levels were measured by enzyme-linked immunosorbent assay before transplant and after (at the date of engraftment or day 30 if engraftment failure occurred). Results The median levels and (range) of plasma Ki-67 before and after transplant were 1.85±5.48 and 1.19±3.22 ng/ml, respectively. We found higher plasma Ki-67 levels (before and after transplant were correlated with more delayed engraftment (r=0.425,P=0.007 before transplant; r= 0.361 P=0.024 after transplant), and more prolonged neutropenic fever duration (r=0.377, P=0.017 before transplant; r=0.387, P=0.014 after transplant). Patients having acute graft-versus-host disease (GVHD) during the first month of HSCT also had higher levels of plasma Ki-67 before and after HSCT compared with patients who did not develop acute GVHD, with median (range) of 15.85 (0.20-27.40) ng/ml vs 0.30 (0.10-1.70) ng/ml (P=0.029) before transplant and 6.15 (3.90-18.90) ng/ml vs 0.20 (0.10-2.80) ng/ml (P= 0.001) after transplant. Plasma Ki-67 levels of greater than or equal to 6.4 ng/ml before transplantation (75% sensitivity and 100% specificity) and greater than or equal to 3.35 ng/ml after transplantation (100% sensitivity and specificity) are predictive values for detection of occurrence of acute GVHD. Conclusion High levels of plasma Ki-67 in patients with acute leukemia undergoing HSCT may be a predictor of delayed engraftment, prolonged neutropenic fever and occurrence of acute GVHD.
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