Academic literature on the topic 'D 3.5 UL 2013 T933'

AbstractObjective:Ready-to-eat (RTE) cereal is an important source of nutrients in the American diet. Recent regulatory changes to labelling requirements may impact the fortification of RTE cereal. We used an evidence-based approach to optimize the fortification of RTE cereal considering current dietary patterns and nutrition policy.Design:A US modelling study of cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) 2013–2014. The percentage of the population below the Estimated Average Requirement (EAR) and above the Upper Tolerable Intake Level (UL) was modelled under three scenarios: baseline, zero fortification and optimized fortification.Setting:USA.Participants:Toddlers aged 1–3 years, n 559; children aged 4–12 years, n 1540; adolescents aged 13–18 years, n 992; and adults aged ≥19 years, n 576.Results:Comparing current with optimized fortification, nutrient/100 g RTE cereal decreased for vitamin A, thiamin, riboflavin, niacin, vitamin B6, folic acid, vitamin B12, Ca and Fe (by 2–82 %). The amount of vitamins C and D increased (by 13 and 50 %, respectively). Among RTE cereal eaters, these changes resulted in modest increases in the percentage of the population aged ≥1 year below the EAR (+0·5 to +11·5 percentage points). Decreases were observed in the percentage of the population above the UL.Conclusions:Fortification of RTE cereal can be optimized to provide key nutrients and minimize the percentage of the population below the EAR and above the UL. Dietary intake modelling is useful to ensure that RTE cereal continues to help the population meet their nutrient needs.

Abstract Background: Hematopoietic stem cell release is regulated by the sympathetic nervous system through the β (3) adrenergic receptor [Mendez-Ferrer et al. Nature 2008]. Peripheral sympathetic nerve neurons express the G-CSF receptor and stimulation of peripheral sympathetic nerve neurons with G-CSF reduced norepinephrine (NE) reuptake significantly, suggesting that G-CSF potentiates the sympathetic tone by increasing NE availability [Lucas et al Blood 2012]. Based on preclinical data, we investigated the NE reuptake inhibitor desipramine in HSC mobilization. Despite augmentation with Plerixafor (CXCR4 inhibitor), 20% of all patients fail to mobilize 6*10^6 CD34 cells/kg in myeloma and the collection rate with G-CSF alone is 51.1% [Diperiso et al Blood 2012]. The cost of upfront plerixafor is $9,081 per patient while desipramine costs $40. We undertook a feasibility study of adult patients with MM undergoing autologous transplantation (ASCT) to study safety and efficacy of mobilization with desipramine and G-CSF. Patients & Methods: From 2013- 2014, 10 patients between the ages of 18-70, eligible for ASCT were enrolled. Desipramine 100mg daily was administered for 7 days, starting 4 days prior to starting G-CSF (D-3) and continue along with G-CSF for a total of 7 days. CBC and CD34 counts were determined on Day+5. If CD34 counts were > 10/ul, stem cell collection was commenced and if < 10/ul, plerixafor was added as salvage therapy. The endpoints were safety and efficacy in mobilizing CD34 cells for ASCT in patients with multiple myeloma. This trial was registered at clinicaltrials.gov as NCT01899326. Results Six of ten patients enrolled completed the protocol and underwent stem cell transplantation. Reasons for not completing were 1. Lack of insurance coverage 2. Non-compliance with study treatment 3. Disease relapse prior to ASCT. Five patients did not have any grade 3 or 4 adverse events and 1 had disease-related Grade 4 hypercalcemia and Grade 2 AKI at the time of stem cell mobilization. No patients had significant treatment related adverse effects. All 6 patients who completed the protocol achieved the target collection of 5*10^6 CD34 cells/kg. Four patients achieved 6*10^6 CD34 cells/kg or more and the remaining 2 patients achieved 5.52 and 5.92 *10^6 CD34 cells/kg respectively. Among the 6 patients, 2 patients received salvage plerixafor. The median time to achieve WBC >1000/ul, ANC >500/ul and platelets>20k was 11.5, 11, 13.5 days Table 1. Age Ind. Regimne Disease status P PB CD34/ul CD34 collected *10^6 / kg Total CD34/kg collected Engraftment (Days to) Adverse effects from desipramine D1 D2 D3 D4 D2 D3 D4 ANC >0.5 Platelets> 20k G1,G2 G3,G4 1 62 Free λ VRD VGPR N 45.8 66.0 7.01 7.01 12 13 none none 2 50 Free λ VRD VGPR N 88.0 143.5 12.22 12.22 12 12 none none 3 58 IgA VCD VGPR N 38.0 67.7 31.6 4.22 2.75 6.97 13 17 none none 4 70 IgAκ VRD VGPR Y 2.40 40.2 16.6 4.31 1.61 5.92 12 14 none none 5 56 IgGκ VCD VGPR Y 8.70 11.9 37.1 19.4 1.33 4.57 1.61 7.51 11 12 none none 6 70 IgGλ VD RD Relapse N 76.2 97.1 5.54 5.54 11 20 AKI hypercalcemia P-Plerixafor; V-Velcade; R-Lenalidomide; D-Dexamethasone; C-Cyclophosphamide Conclusions Overall G-CSF + Desipramine combination appears to be safe, well tolerated and shows signs of efficacy. G-CSF and desipramine was successful in 4/6 (66%) and all achieved the stem cell collection in 2 days or less. Desipramine, GCSF and Plerixafor was successful in all (6/6) patients to achieve a target of 5*10^6 CD34 cells/kg. The mean number of CD34 cells collected in the desipramine+ G-CSF mobilisers was 7.24*10^6 CD34 cells/kg which, based on historical data, is higher than what would be expected with G-CSF alone even though 3/4 of these patients had lenalidomide as induction therapy. Based on these results, a phase II clinical study evaluating the efficacy of G-CSF with desipramine with or without salvage plerixafor in multiple myeloma and lymphoma will be initiated. Disclosures Barta: Seattle Genetics: Research Funding.

Abstract Background: SCD is characterized by chronic vaso-occlusive crises and multiorgan failure resulting in poor quality of life and early mortality (Bhatia/Cairo et al, BMT 2014). There is presently no curative therapy for patients with high risk SCD other than HLA-identical sibling AlloSCT. (Freed/Cairo et al BMT 2012). However, less than 15% of eligible SCD patients have an unaffected MSD with a 10-15% increase of graft failure and TRM (Talano/Cairo et al, EJH, 2015). Similarly, most patients lack a matched related donor and UCB is an inferior source in SCD recipients (Radhakrishman/Cairo et al, BBMT 2013). Haploidentical familial donors with SCD trait offers an opportunity for a new donor source for children with high risk SCD. To overcome HLA barriers, Geyer/Cairo et al (BJH, 2012) demonstrated that T cell depletion using CD34 enriched HPC products with PB MNC addback transplanted in pediatric recipients utilizing MUD was associated with sustained engraftment, low risk of aGVHD but limited by delayed immune reconstitution. Efforts to use FHI donors and T replete AlloSCT in patients with SCD were associated with high rates of graft failure (Bolanes-Meade J et al Blood 2012; Ruggieri et al BBMT 2011). We previously reported FHI CD34 enriched/PB MNC addback AlloSCT is feasible and well tolerated in patients with high risk SCD (Abikoff/Cairo, ASBMT 2015). Objective: To characterize immunological reconstitution following FHI AlloSCT with CD34 enriched grafts with PB MNC addback in children and adolescents with high risk SCD. Methods: 15 patients were evaluatedpretransplant at D+30, 60, 100 and 180 following FHI AlloSCT. GCSF mobilized HPC were collected by apheresis (Spectra OPTIA, Terumo BCT) and products underwent CD34 enrichment using the CliniMACS cell separation system (materials generously supplied by Miltenyi Biotec, Cambridge , MA) with a PB MNC addback dose of 2x10*5 CD3/kg. Immune cell and subset reconstitution was assessed by flow cytometry. NK function was determined by cytotoxic activity against K562 tumor targets at 10:1 E:T ratio by europium release assay and intracellular LAMP-1 (CD107a) and granzyme B expression by flow cytometry. Whole blood, T cell and RBC chimerism (CD71) determined by flow cytometry and by STR. Results: Patients achieved neutrophil and platelet engraftment in a median time of 10 and 16 days, respectively. By D+30, median whole blood donor chimerism was ≥93% and ≥95% at most recent followup (D+30-730). Median donor chimerism in the erythroid lineage was 95% by D+60, with 7 of 13 patients ≥99% at D+30. This was maintained at most recent followup (D+30-730). Median T cell chimerism was 90% (D+60-550) and median NK cell chimerism was 90% by D+30 and maintained at ≥95% through D+730. NK (CD3-/56+) and NKT (CD3+/56+) cell reconstitution following FHI AlloSCT was rapid and peaked at D+30 (35.5±8.6%, 271x10*3/ul; 14.2±4%, 179x10*3/ul, respectively). Moreover, there was robust NK cell receptor expression reconstitution with high levels of activating receptors, NKp46, NKG2D and KIR2DS and inhibitory receptors NKG2A, CD94 and KIR2DL2/3 at D+30 [Fig 1]. NK cytotoxicity against K562 at E;T 10:1 peaked at D+30 (26±3%) and D+180 (28±3%) compared to pretransplant (16±2%, p<0.01). NK activation marker, CD107a, peaked at D+30 (37±9%) and D+180 (41±6%) and there was robust granzyme B degranulation at D+30. CD3+, CD4+, CD8+ and CD19+ immune reconstitution occurred between D+180 and D+270. One year absolute (mean±SEM) cells/ul of CD3+, CD4+, CD8+, CD19+ and CD56+ was 795±168, 408±102, 375±90, 815±352 and 204±37, respectively. [Fig 2] Conclusion: Immune reconstitution and donor chimerism was relatively rapid after FHI AlloSCT with CD34 enriched grafts with PB MNC addback in high risk SCD patients. The donor MNC addback after CD34 selection may in part contribute to rapid engraftment and immune reconstitution along with sustained donor chimerism. This research was supported by FDA grant 5R01FD004090. Disclosures Cairo: Celgene: Research Funding.

Abstract Background Erythrocytosis / polycythemia is divided into primary and secondary. Primary polycythemia can be either acquired; i.e. polycythemia vera (PV) due to somatic JAK2 mutation, or congenital due to germ-line DNA changes (erythropoietin (EPO) receptor and VHL mutations in Chuvash polycythemia). These mutations are expressed within erythroid progenitors, drive increased erythropoiesis and are detected by hypersensitive or autonomous EPO BFU-E responses. In contrast, secondary erythrocytosis (SE), such as seen with cardiopulmonary pathologies, is driven by the circulating EPO. Chronic mountain sickness (CMS) is characterized by high altitude pathological erythrocytosis and by cognitive and neurological impairments. CMS is found in subjects living in high altitude (2500 meters and higher). In La Paz, Bolivia, (3600m) there is 7% incidence of CMS erythrocytosis. Some human populations (Tibetans, Andean Quechuas and Aymaras, and Ethiopians) are adapted to very high altitudes and their adapted phenotypes and, in some instances, evolutionarily selected haplotypes, have been reported. Whole genome was evaluated in Andeans and two genes, SENP1 and ANP32D were found to be evolutionarily selected and correlated with presence or absence of erythrocytosis. The genes down-regulation in hypoxia had survival benefit in Drosophila ortholog (1).SENP1 desumoylate GATA-1 and other regulatory proteins and is critical for definitive erythropoiesis (2,3). Here we evaluated native Aymara La Paz dwellers with three types of polycythemia: CMS, SE secondary to cardiopulmonary disease, and PV, by clinical studies and by in vitro evaluation of erythroid progenitors, and compared them to non-polycythemic subjects. Patients and Methods Complete blood count was performed by automatic hematologic counter (Micro 60, USA). Serum EPO was measured by Elisa (R&D System, USA) and JAK2V617F mutation analysis by PCR assay. Erythroid progenitors were isolated by density gradient centrifugation and cultured in methylcellulose medium with and without EPO (Stem Cell technologies, Canada) at 370 C and 5 % CO2. BFU-E colonies reading was carried out according to standardized criteria at 7 and 14 days. Results Table. Normal Control(n=10) CMS (n=15) Secondary Erythrocytosis(n=10) PolycythemiaVera (n=5) 1.Gender M/F 10/0 15/0 10/0 3/2 Age (range) 42 (40-47) 48 (29-58) 53 (34-72) 67 (42-74) Hb g/dl (SD) 16.2 (+ 0.9) 20.3 (+ 0.9) 22.8 (+ 1.4) 20.0 (+ 2.5) Ret % (SD) 1.3 (+ 0.1) 2.9 (+ 1.3) 3.6 (+ 1.2) 2.1 (+ 0.3) WBC /ul (SD) 6300 (+ 1600) 7200 (+ 1900) 6600 (+ 1700) 16600 (+ 4800) PLT 103 ul (SD) 273 (+ 80) 229 (+ 58) 193 (+ 54) 604 (+ 177) sEPO mUI/ml (SD) 10.0 (+ 3.9) 10.5 (+ 2.2) 82.9 (+ 30.4) 3.0 (+ 1.2) JAK2 V617F, No. (%) 0 (0) 0 (0) 0 (0) 100 Apoptosis Normal Delayed Normal Delayed BFU-E: EEC 0 (0-0) 10 (2-25) 0 (0-0) 45 (25-70) References: 1. Yu L et al. J Exp Med., 2010, 207:1183. 2. Sharma D et al. Cell Report, 2013, 3:1640. 3. Zhou D et al. Am J Hum Genet. 2013, 93:452. 4. Kapralova K et al. Blood. 2014,123:391 Conclusions a) Endogenous erythroid colony (EEC) are present in Aymaras with CMS, indicating primary polycythemia. b) Endogenous EECs are higher in PV than in CMS. c) CMS subjects have normal serum EPO levels. d) The role of SENP1, and hypoxia-regulated RUNX1 and NF-E2 (4) that promote erythropoiesis, is being interrogated in native erythroid cells. e) It remains to be determined if the autonomous BFU-E growth is specific for Aymara's CMS or present in CMS individuals of other ethnicities. Disclosures No relevant conflicts of interest to declare.

Abstract Introduction Outcomes have improved in treating lymphoid malignancies but relapse remains an ongoing issue. The mTOR inhibitor, everolimus (RAD) and lenalidomide (LEN) have both shown clinically significant activity as single agents in patients with relapsed and refractory (R/R) Hodgkin (HL) and non-Hodgkin (NHL) lymphomas. The low toxicity and differing mechanisms of action were explored further by combining these active agents. A phase I/II clinical trial of the mTOR inhibitor everolimus (RAD) and lenalidomide (LEN) was designed to explore the tolerability, toxicity and to determine the MTD of this combination for Phase II study. The phase I data is reported here. Methods This Phase I/II trial for patients with R/R lymphoid malignancy opened at Mayo Clinic between January 2011 and May 2013 and utilized a standard cohort of 3+3 design to determine the MTD of the combination. Eligibility required age≥18, biopsy proven relapsed or refractory NHL or HL, ECOG PS 0, 1 or 2, measurable disease, Hb >9g/dl, ANC ≥1200/uL, platelet ≥ 50,000/uL, creatinine ≤1.5xULN and willingness to sign informed consent. Women of child bearing potential had pregnancy testing and all patients followed recommendations for contraception. Dose limiting toxicity was defined in cycle 1 as Gr 4 neutropenia ≥7days or platelets ≤ 25,000 ≥7days, grade 4 infection or grade ≥3 non-Heme toxicity at least possibly related to treatment per CTCAE v4.0. The starting dose (level 0) was RAD 5mg daily + LEN 10 mg/d X 21d in a 28-day cycle. Results Twenty-five patients were enrolled on the phase I portion and 23 are evaluable for analysis. The median age was 63 years (23-82) and 18 (78%) were male. Sixty-five percent had stage IV disease and 43% had 4 or more prior treatments (1- ≥5) including stem cell transplantation in 39%. Histologies included HL (n=3) and NHL (n=20)(DLBCL = 11, FL-III = 2, LPL = 3, MCL = 1, MF = 1, and other = 2). Two DLTs (rash, Gr4 neutropenia) were reported at the starting dose (level 0) and the protocol was amended for DLT definition change. At dose level -1 (RAD 5mg daily + LEN 5mg/d X 21d) a DLT (Gr4 neutropenia) was seen in only 1 of 6 patients so the study was re-opened to dose level 0 and 3 additional patients were treated without developing a DLT. At dose level +1 (RAD 5 mg daily + LEN 15mg/d X 21d) 1 Gr3 rash occurred and 2 patients experienced Gr4 neutropenia. Therefore the MTD was determined to be RAD 5mgdaily + LEN 10 mg/d X 21d. At least 1 Gr≥3 adverse event was seen in 91% of patients. The most common Gr≥3 toxicities were neutropenia (57%), leucopenia (52%), thrombocytopenia (39%), fatigue (22%), and anemia (13%). Eight of 23 patients (35%) had Gr≥3 infection. Five patients discontinued study due to adverse events. One death on study occurred due to disease progression. Three patients continue on therapy. Responses have been seen in 4 patients and 10 patients have stable disease, encouraging signs in this heavily pretreated population. Conclusions This phase I/II trial of everolimus and lenalidomide in malignant lymphoma shows the combination to be tolerable with neutropenia as the main dose limiting toxicity. The MTD of this combination is RAD 5mg daily and LEN 10 mg/d X 21 d. Encouraging responses were seen. The phase II study has opened with 2 patients accrued to date. Updated results will be presented. This trial is sponsored by Novartis and Celgene Disclosures: Reeder: Celgene: Research Funding; Novartis: Research Funding; Millenium: Research Funding. Off Label Use: lenalidomide and everolimus are not approved for treatment of lymphoma. Nowakowski:Celgene: Membership on an entity’s Board of Directors or advisory committees, Research Funding. Witzig:Celgene: Research Funding.

Abstract Introduction New treatment strategies are improving outcomes for patients with Hodgkin (HL) and non-Hodgkin lymphoma (NHL) but achieving durable responses and cure in the relapsed patient remain a challenge. Both the mTORC1 inhibitor everolimus (RAD001) and the IMiD, lenalidomide (LEN) have efficacy as single agents in patients with relapsed and refractory (R/R) HL and NHL. Individually, LEN and RAD present a low toxicity profile and in combination may offer synergistic therapeutic efficacy by unique mechanisms of action. A phase I/II clinical trial of RAD and LEN was designed to explore the tolerability, toxicity and to determine the maximum tolerated dose (MTD) of this combination for the Phase II study. The results of phase I/II data are reported here. Methods MC0981 was activated on January 10, 2011. In phase I, the study enrolled a total of 25 patients and RAD 5 mg daily + LEN 10 mg/d X 21d in a 28-day cycle was defined as the MTD. The phase II opened on May 14, 2013, and closed on Feb 19, 2014, during which 33 patients were enrolled and were treated until progression of disease. Eligibility required age ≥18, biopsy proven relapsed or refractory NHL or HL, ECOG PS 0- 2, measurable disease, Hb >9g/dl, ANC ≥1200/uL, platelet ≥ 50,000/uL, creatinine ≤1.5xULN and willingness to sign informed consent. Women of child bearing potential had pregnancy testing and all patients followed recommendations for contraception. Follow up data was analyzed as of July 2014. Results A total of 58 patients were enrolled to this study and fifty five are evaluable for analysis (2 never started therapy, 1 deemed ineligible). The median age was 62 years (21-82) and 38 (69.1%) were male. Sixty-five percent had stage IV disease and 42% had 4 or more prior treatments including stem cell transplantation in 49%. Histologies included HL (n=10) and NHL (n=45 with 23 DLBCL, 2 FL-III, 5 LPL, 3 MCL, 2 MF, and 3 other). At least 1 Gr≥3 adverse event was seen in 74.5% of patients. The most common Gr≥3 toxicities were hematologic - neutropenia (30.9%), and thrombocytopenia (21.8%), and anemia (10.9%). Nine of 55 patients (16%) had Gr≥3 infection; 2 with skin infection, 1 with cholecystitis, 1 with lung infection, 1 with pharyngitis 1 with otitis externa, 1 with otitis media, and 1 with pleural infection and 1 with upper respiratory tract infection. Seven patients discontinued treatment due to adverse events. At this time, 44% (25/55) remain progression-free. A documented tumor response, as overall response rate (ORR) was seen in 20% (11/55) with 1CR, 8PR, and 2MR; 17 remain on therapy; and 22 deaths have occurred with a median survival of 15.0 months (95% CI 7.5-NR). Median follow up time was 5.5 (range, 0.7- 41.0) months. The median duration of response (DOR) in those responding is 19.4 months. Conclusions In a heavily pretreated population with baseline compromised bone marrow function, the combination of everolimus and lenalidomide is feasible with a modest ORR and a surprisingly long DOR. Future studies in more defined groups of NHL or HL are necessary to better predict which patients will be long-term responders. This trial is sponsored by Novartis and Celgene Disclosures Off Label Use: mTORC1 inhibitor (Everolimus) and the Immunomodulatory (IMiD) drug Lenalidomide for patients with Heavily Pretreated Relapsed Lymphoma . Mikhael:Onyx: Research Funding; Celgene: Research Funding; Sanofi: Research Funding; Novartis: Research Funding. Nowakowski:Celgene, Morphosis: Consultancy. Witzig:Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Research Funding. Reeder:Millennium, Celgene, Novartis: Research Funding.

Abstract Background: The vast majority of births with sickle cell anemia occur in Africa 1 and early-life mortality, generally before age five years, is as high as 90% 2,3. Hydroxyurea was approved for sickle cell anemia by the US FDA in 1998 but is not commonly used in Africa due to fear of toxicity, lack of awareness and limited availability. Hemoglobin F is a protective factor that decreases severity of sickle cell anemia, and hydroxyurea treatment leads to an increase in hemoglobin F. In the US, hydroxyurea is typically initiated at a dose of 15 mg/kg followed by dose escalations of up to 35 mg/kg if tolerated with a goal of maximal tolerated dose and maximal response in hemoglobin F. Neutropenia and thrombocytopenia are the usual limitations to achieving maximal dose. In the landmark Multicenter Study of Hydroxyurea, the clinical response to hydroxyurea correlated strongly with a reduction in the neutrophil count as well as an increase in the fetal hemoglobin concentration as reflected in percentage of F cells. A striking decrease in pain crises was observed in the first three months of therapy, before dose escalation and before maximal increase in hemoglobin F levels 4. Furthermore, hydroxyurea in the range of 10-15.9 mg/kg/day was reportedly effective in decreasing the frequency of pain episodes in children and adolescents in Oman 5, and hydroxyurea 10 mg/kg/day decreased pain episodes in children and adults with sickle cell anemia in India 6. From these perspectives, we reasoned that a fixed dose of hydroxyurea 10 mg/kg/day is reasonable to investigate in the African setting where the safety in relationship to the resources and infectious exposures is not known. Methods: We assigned 48 sickle cell anemia patients to hydroxyurea 500 mg/day for 24 weeks to determine safety and efficacy; 28 had high-risk disease based on hemoglobin F&lt;8.6% and absence of alpha-thalassemia. We defined a clinically meaningful adverse outcome category as ≥10% of patients developing platelets &lt;50,000/uL, granulocytes &lt;500/uL, clinical malaria and/or active tuberculosis. Picking up refills every four weeks was the adherence metric. We analyzed the results on an intent-to-treat basis. Results: The median (interquartile range) age was 25 (22-27) years and the median hydroxyurea dose 9.8 (9.1-10.4) mg/kg per day. The patients complied with treatment for a median of 20 (16-24) weeks. Four (8.3%) developed a pre-specified adverse outcome: clinical malaria (N=2), thrombocytopenia in combination with malaria (N=1), pulmonary tuberculosis (N=1). During therapy the median hemoglobin increased by 9.0 g/L, mean corpuscular volume by 11.2 fL and body weight by 3.0 kg while median white blood cells declined by 2600 per uL and platelets by 127,000 per uL (P&lt;0.001). The median hemoglobin F increased from 4.1% (2.3-6.3%) at baseline (N=27) to 8.5% (6.3-12.9%) during therapy (N=24) (P&lt;0.001). Conclusion: Our results suggest that low, fixed-dose dose hydroxyurea for sickle cell anemia in Nigeria is associated with a low adverse outcome rate and with improvements in blood counts, hemoglobin F and body weight. The effects on vaso-occlusive episodes and on the risks of recrudescent tuberculosis and malaria-associated thrombocytopenia should be assessed in further studies. Acknowledgment: Supported by a grant from the Doris Duke Foundation. References 1. Williams TN, Obaro SK. Sickle cell disease and malaria morbidity: a tale with two tails. Trends Parasitol 2011;27:315-20. 2. Grosse SD, Odame I, Atrash HK, Amendah DD, Piel FB, Williams TN. Sickle cell disease in Africa: a neglected cause of early childhood mortality. Am J Prev Med 2011;41:S398-405. 3. Makani J, Cox SE, Soka D, et al. Mortality in sickle cell anemia in Africa: a prospective cohort study in Tanzania. PLoS One 2011;6:e14699. 4. Charache S, Barton FB, Moore RD, et al. Hydroxyurea and sickle cell anemia. Clinical utility of a myelosuppressive "switching" agent. The Multicenter Study of Hydroxyurea in Sickle Cell Anemia. Medicine (Baltimore) 1996;75:300-26. 5. Sharef SW, Al-Hajri M, Beshlawi I, et al. Optimizing Hydroxyurea use in children with sickle cell disease: low dose regimen is effective. Eur J Haematol 2013. 6. Patel DK, Mashon RS, Patel S, Das BS, Purohit P, Bishwal SC. Low dose hydroxyurea is effective in reducing the incidence of painful crisis and frequency of blood transfusion in sickle cell anemia patients from eastern India. Hemoglobin 2012;36:409-20. Disclosures Ezekekwu: American Society of Hematology: Other: The Visitor training program was sponsored by ASH. Hsu: AstraZeneca steering committee for HESTIA trial: Research Funding. Gordeuk: Emmaus Life Sciences: Consultancy.

Abstract Mortality from relapsed disease remains a significant barrier to long term survival (OS) after HI HSCT despite presumed heightened alloreactivity from the mismatched graft. The Jefferson group uses a 2 step approach to HI HSCT where patients are typically conditioned with 12 Gy total body irradiation (TBI) in 8 fractions of 1.5 Gy over 4 days, immediately followed by an infusion of 2 x 108/kg donor CD3+ cells (DLI). After 2 rest days, cyclophosphamide (CY) 60 mg/kg daily x 2 is given for bidirectional tolerization, followed a day later by a CD34 selected stem cell infusion. In an attempt to maximize graft versus tumor (GVT) effects, we changed the timing of the TBI in the 2 step approach. In this updated regimen, TBI was given in 6 fractions of 2.0 Gy over 3 days, resulting in a 24 hour delay between conditioning and DLI. Theoretically, the extra time reduced residual disease burden prior to the introduction of the DLI, in turn reducing the number of donor T cells activated by tumor, thus avoiding their elimination by CY. Major HSCT endpoints of OS (Kaplan Meier), relapse and non-relapse mortality (NRM), acute and chronic graft-versus-host disease (GVHD) [cumulative incidence (CI)-EZR Software v 1.37] were assessed using this updated 2 step HI HSCT approach. Forty patients, median age 51 (range 19-65) years with AML (13), MDS (7), B ALL (7), PH+ ALL (4), T cell ALL (2), Burkitt (2), and other heme malignancy (5) with revised disease risk assessment scores of intermediate (21), high (17), and very high (2) were treated from 2013 to 2017. Median follow-up is 36 (range 15 to 56) months. At 24 months, probability of OS was 59%, CI NRM and relapse were 34% and 15% respectively. CI aGVHD (grades 2-4), (grades 3-4), and cGVHD were 38%, 5%, and 20%. Median d+28 T cell chimerism of 36 patients engrafted and alive was 100% (range 97% to 100%). Median CD3/4 and CD3/8 counts at d +28 were 49 (range 9-417) and 54 (8-1329) cells/ul. Of the 4 remaining patients, two without donor specific antibodies rejected their graft, one with a large burden of CMML at the time of HSCT. An additional patient relapsed prior to the attainment of sustained donor T cell chimerism and one patient died of sinusoidal obstructive syndrome prior to d+28. Causes of death were infection (7), regimen toxicity (4), GVHD (2), and disease (3). This updated 2 step regimen was associated with a highly acceptable 2 year OS rate and low rates of disease recurrence. Of the patients that died, cause of death was primarily due to NRM and not relapsed disease suggesting that the added extra day may have enhanced GVT effects. In the absence of donor specific antibodies, the 2 early and 1 late graft rejections are atypical for a 2 step MA HI HSCT approach and were potentially caused by a rebound recipient hematopoiesis allowed by the delay in the DLI in a minority of patients. While formal comparison to prior patient cohorts is not feasible, this relapse rate compares favorably to the 2 year 27% relapse rate in similar patients treated on our initial trial.(Grosso, et al., Blood, 2011, 118:47320). The concept of allowing time for malignancy burden to decline in high risk patients prior to introduction of DLI warrants further evaluation going forward in efforts to reduce relapse after HSCT. Table. Table. Disclosures Porcu: Innate Pharma: Consultancy.

Abstract Backgrounds and Aims The classic hallmarks of Upshaw Schulman syndrome (USS) are severe newborn jaundice with a negative Coombs test that requires an exchange transfusion and repeated childhood episodes of thrombocytopenia and microangiopathic hemolytic anemia that are reversed by infusions of fresh frozen plasma. But now, it is well established that USS is a hereditary deficiency in the activity of von Willebrand factor (VWF)-cleaving protease, termed ADAMTS13. The inheritance mode is autosomal recessive, and their parents are usually asymptomatic carriers having one disease-causing mutation (DCM) of the gene. In the absence of ADAMTS13, unusually large VWF multimers (UL-VWFMs) released from vascular endothelial cells are inappropriately cleaved, leading to platelet hyperagglutination under high shear stress. Thus, USS is alternatively called congenital thrombotic thrombocytopenic purpura (TTP). But, unlike acquired TTP, clinical signs of USS patients are usually mild during childhood and often an isolated thrombocytopenia is found. Further, now it is known that TTP-bouts are aggravated or initiated by the following factors: 1) severe infections such as influenza, 2) pregnancy, 3) 1-deamino-8-D-arginine vasopressin (DDAVP) administration, 4) interferon therapy, 5) heavily drinking alcohol, and 6) aging. So far, in worldwide approximately 150 patients with USS have been found, of which we identified 51 patients in Japan. Among them, 48 patients were received ADAMTS13 gene analysis, and a pair of DCMs, either homozygotes or compound heterozygotes, was identified in all patients except for one. Interestingly, these DCMs are quite different from those found in patients of Western countries and United States, but several DCMs in Japanese patients are also found in Korean and Chinese patients. Thus, it appears that Caucasians and Asians have two different DCM routs for ADAMTS13. Further, since USS is an extremely rare disease, no one can predict the life-long clinical outcome in these patients. Thus, in this study using our cohort of 51 Japanese USS patients, we have extensively analyzed a long-term phenotype, with special references to pregnancy and renal failure that requires hemodialysis. Methods and Patients ADAMTS13 activity and its neutralizing antibodies (inhibitors) were determined by chromogenic ADAMTS13-act-ELISA [Kato et al. Transfusion, 2006], and the IgG type binding antibodies were assayed as described [Ferrari et al, JTH 2009]. Fifty-one patients with USS (19 males and 32 females, born in 1931-2013) were enrolled in this study. None of the patients had the neutralizing antibodies, but 6 patients (6/51, 12%) developed the IgG type non-neutralizing antibodies. Results and Discussion Pregnancy: We identified 26 episodes of pregnancy in 15 patients with USS (Table 1). Briefly, 22 pregnancies were identified before a diagnosis of USS, and as consequence 3 episodes are related to abortion, 10 episodes to stillbirth, and 9 episodes to live birth, in which 6 babies were premature. In contrast, 4 pregnancies were after a diagnosis of USS, and they all had the planned FFP infusions from the early phase of pregnancy, resulting in all successful deliveries, but with 2 premature babies. Renal failure: We identified that 6 male patients finally fell into the end-stage severe renal diseases that required hemodialysis, of which 4 patients were deceased (Table 2). Median time from a diagnosis of USS to dialysis initiation was 15 years (range 1-25). Curiously, all these patients except for one had received FFP infusions biweekly after a diagnosis of USS. Causes of death in these 4 patients were the followings: heart failure (n=1), renal failure (n=1), and sudden death (n=2). The reason why all the patients, who fell into severe renal dysfunction, are male left unaddressed. Disclosures: Fujimura: Alexion Pharma: Membership on an entity’s Board of Directors or advisory committees; Baxter BioScience: Membership on an entity’s Board of Directors or advisory committees. Matsumoto:Alexion Pharma: Membership on an entity’s Board of Directors or advisory committees.

Abstract Introduction. Allogeneic hematopoietic stem cell transplantation using UCB is an alternative approach for pts (pts) with hematological malignancies lacking an HLA matched donor. However, for pts with severe aplastic anemia (SAA), UCB transplants are associated with delayed engraftment, high graft failure rates and poor survival. Ex-vivo expanded UCB using nicotinamide (NAM) can engraft in NOD/SCID mice, and in pilot studies in pts with hematological malignancies, results in rapid engraftment and durable hematopoiesis. Here we investigated a novel transplantation approach using NAM-expanded UCB in refractory SAA pts who lacked an HLA matched donor, hypothesizing this regimen would accelerate engraftment and immune reconstitution compared to conventional UCB transplants. PTS AND Methods. Eligible pts had SAA with severe neutropenia (ANC<1000) unresponsive to immunosuppressive therapy (IST) underwent a NAM-expanded UCB-transplant at a single center in a phase II trial (NCT03173937). Pts were conditioned with cyclophosphamide (60 mg/kg x 2), horse ATG (40 mg/kg x 4), fludarabine (25 mg/m2 x5) and 200cGy of TBI. GVHD prophylaxis included tacrolimus and MMF. Cohort I is designed to transplant six pts with a single NAM-expanded unit combined with 3 x 106 CD34+ cells/kg from a haploidentical donor as a backup stem cell source. Once adequate cord engraftment is established in Cohort 1, the study will proceed to Cohort 2 to transplant a NAM-expanded unit alone without haplo-CD34+ cells. Engraftment, chimerism, and immune recovery were assessed and compared with SAA pts who received a conventional non-expanded UCB transplant combined with haplo-CD34+ cells using the identical conditioning and GVHD prophylaxis. Results. From 2017 to 2018, two SAA pts (22 years male and 45 years female, pre-transplant ANC ≤300/uL, and had failed ATG/CSA/Eltrombopag) were successfully transplanted with a single ≥ 6/8 HLA-matched NAM-expanded UCB unit combined with haplo CD34+ cells from a relative. The UCB units before expansion contained a median total nucleated cell (TNC) dose of 2.8 x 107/kg and 1.7 x 105 CD34+ cells/kg. At transplant, the cultured NAM-expanded units contained a median 6.0 x 107 TNCs/kg and 96.4 x105 CD34+ cells/kg, representing a median post TNC and CD34+ cell expansion of 2-fold and 52-fold, respectively. At 12 months and 5 months post-transplant, both pts survive with stable engraftment, transfusion independence, and without acute or chronic GVHD. The median time to neutrophil recovery (ANC > 500/ μL) was only 6.5 days (range 6-7), and platelet recovery was 35.5 days (31-40); chimerism studies showed that both pts achieved >95% cord donor myeloid chimerism and T-cell chimerism at a median 6.5 (6-7) and 23.5 days (21-26) respectively . Immune recovery in both pts receiving NAM-expanded UCB was brisk (Figure 1): absolute CD4+ count > 200 cells/μL occurred at 17 and 60 days; at day 100, median CD4+ numbers was 382/μL and median IGA was 92 mg/dL. In comparison to 16 SAA pts transplanted sequentially at our institute from 2013-2016 using a single unexpanded CBU combined with haplo CD34+ cells, median cord graft doses were 3.6 x 107 TNCs/kg and 1.2 x105 CD34+ cells/kg; b) median time to ANC and platelet recovery was 10 and 51 days; c) median time to >95% cord donor myeloid chimerism was 63 days; d) at day 100, only 3/16 (19%) unexpanded UCB recipients had CD4+ count > 200 cells/μL, and the median CD4+ number was only 74 cells/μL and the median IGA was only 31 mg/dL. This first in human transplant trial suggests neutrophil engraftment, platelet recovery, and post-transplant immune recovery are superior inSAA pts transplanted with NAM expanded UCB compared to conventional nonexpanded UCB (all P<0.05, Figure 1). Conclusion. These encouraging preliminary results show for the first time that NAM-expanded UCB results in rapid cord engraftment, sustained hematopoiesis and accelerated immune recovery in treatment refractory, neutropenic SAA pts. The high numbers of transplanted CD34+ progenitor cells in NAM-expanded grafts could potentially overcome graft failure associated with conventional UCB transplantation for SAA, obviating the need for co-transplanting haplo CD34+ cells as a stem cell back-up. Disclosures No relevant conflicts of interest to declare.