Munira Borhany

Factor VII deficiency (FVIID) is among the most common rare bleeding disorders. The ability of FVII coagulant activity (FVII:C) levels and genetic variants to predict clinical outcomes remain limited. We evaluated the discriminative performance of FVII:C levels, genotype-phenotype associations, and the accuracy of in silico tools in identifying pathogenic variants. In total, 422 patients from 3 international registries were analyzed. Overall, 61% experienced bleeding, predominantly spontaneous (73%); 20% had grade I, 27% had grade II, and 14% had grade III bleeding. Lower FVII:C levels showed a moderate inverse correlation with bleeding scores and were more common in individuals with spontaneous bleeding (r = −0.49; P< .0001). FVII:C levels showed moderate discrimination for asymptomatic status (area under the curve [AUC], 0.72) and strong discrimination for grade III bleeding (AUC, 0.84). Cutoffs of ≥19 IU/dLand <11 IU/dL identified asymptomatic individuals and those with grade III bleeding. We identified 90 variants, including 10 novel; 60% were missense, and 63% localized to the serine protease domain. According to the American College of Medical Genetics and Genomics criteria, 86% were pathogenic/likely pathogenic. The sensitivity of in silico tools was 96%, 85%, and 60% for REVEL, CADD, and AlphaMissense. Severe deficiency was more common in homozygous individuals (90%), whereas heterozygous individuals predominantly exhibited mild/moderate deficiency (92%). Consistently, bleeding phenotypes were frequent in individuals with homozygous/compound heterozygous variants, whereas most heterozygous variants were asymptomatic (71%). Overall, FVII:C levels moderately stratify bleeding severity. Homozygous/compound heterozygous variants are associated with lower FVII:C levels and more severe bleeding, whereas heterozygous variants are mostly asymptomatic. Among in silico tools, REVEL demonstrated the highest sensitivity.

Background: Sickle cell disease (SCD) is characterized by a chronic hypercoagulable state. Hydroxyurea (HU) is known to reduce the frequency of vaso-occlusive events and transfusion requirements in affected individuals. Objective: To assess the impact of hydroxyurea on biomarkers of coagulation (D-dimer) and endothelial activation (soluble VCAM-1) in SCD patients in Pakistan in their steady state. Methods: A prospective observational study was conducted in patients aged ⩾ 10 years with confirmed HbSS or HbSβ-thalassemia genotypes. Biomarkers were measured at baseline and after 6 months of HU therapy. Results: Twenty-five patients (HbSS = 15 [60%], HbSβ-thalassemia = 10 [40%]) with a median (IQR) age of 23 (16.5-27) years were enrolled. A significant decrease in D-dimer levels was observed after HU treatment: from a median of 1243 to 830 ng/mL ( P = .028), reflecting a 33% reduction. Soluble VCAM-1 levels showed no statistically significant change (532.6 vs 492.9 ng/mL, P = .381). HbF increased from 20.1% (12.6-27.5) to 28% (20-39) ( P < .001), with a strong positive correlation with HU treatment ( r = .845). Conclusion: This study demonstrates that HU therapy in Pakistani SCD patients significantly reduces D-dimer levels, suggesting reduced thrombotic activity. While the endothelial marker VCAM-1 showed no significant change, the rise in HbF is consistent with known HU effects.

Introduction: von Willebrand Disease (VWD) is the most common inherited bleeding disorder, exhibiting diverse clinical manifestations depending on subtype and severity. This study aimed to assess the distribution of VWD subtypes, evaluate the correlation between Bleeding Assessment Tool (BAT) scores and clinical symptoms, and examine treatment outcomes and quality-of-life (QoL) improvements at a Hemophilia Treatment Center (HTC). Methods: We conducted a prospective observational study of 147 VWD patients. Data were collected using the World Bleeding Disorders Registry (WBDR) on demographics, subtype classification, BAT scores, bleeding symptoms, and clinical outcomes. Annual bleeding rate (ABR) was calculated to quantify bleeding frequency. Treatment response and QoL changes were evaluated after twelve months. Statistical analysis included ANOVA and Kruskal–Wallis tests to assess differences in bleeding severity and disease burden. Results: Among 147 VWD patients (mean age 14.5 ± 10.9 years), type 3 was the most common (80.9%), followed by type 2 (12.2%) and type 1 (6.8%). Gum bleeding (80.7%) was the leading symptom, followed by heavy menstrual bleeding (63%) and hemarthrosis (35%). BAT scores (>12) occurred in 93.3% of type 3 and 16.7% of type 2 patients, with type 3 showing the highest ABR (>30/year in 91.6%). Joint scores were significantly higher in type 3 versus type 1 (p = .002) and type 2 (p = .004), and mean hemoglobin was lowest in type 3 (6.2 g/dL, p = .001). Treatment varied on the types. After management, ABR decreased across all subtypes; in type 3, >30 bleeds/year reduced from 91.6% to 57.1%, with improved joint scores, hemoglobin levels, and psychological well-being. Conclusion: Type 3 von Willebrand disease is associated with the highest clinical burden, characterized by frequent and severe bleeding requiring intensive management. In this cohort, individualized treatment was associated with reduced bleeding frequency, improved hemoglobin levels, and better patient-reported quality of life. These findings underscore the importance of comprehensive care approaches, including attention to psychological well-being, particularly in patients with severe disease.

Emicizumab is a humanized, bispecific monoclonal antibody that connects active factor IX and X to replace the function of absent factor VIII, restoring hemostasis. It has a long half-life with a subcutaneous route of administration and high bioavailability. Here, we assessed the efficacy of Emicizumab prophylaxis in terms of efficiency, safety, and quality of life of severe hemophilia A (HA) patients with and without inhibitors before and after this treatment. Methods: In this prospective study, severe HA patients were recruited from January 2022 to June 2023. Inhibitor positive and inhibitor negative patients with annual bleeding rate (ABR) 8 or greater and past histories of bleeding like intra-cranial, intra-abdominal, and pseudo-tumors were included. Emicizumab loading dose was 3 mg/kg in the first 4 weeks, and the maintenance dose was started at week 5 at 6 mg/kg/month. Patients’ detailed bleeding history and demographics were recorded. The five-level EuroQol five-dimensional questionnaire (EQ-5D-5L) was used to evaluate patients’ HRQoL. Furthermore, Hemophilia Joint Health Score (HJHS) and Functional Independence score in Hemophilia (FISH) were applied for the assessment of joints at different time points. Results were analyzed by SPSS version 21. Results: A total of 36 HA male patients with the mean age of 19.7 ± 14.42 years were recruited in the study; among them, 19 patients were inhibitor positive, while 17 were negative. Patients clinically presented with bleeding symptoms which included: hemarthrosis 95%, GI bleeding 13.8%, and bruises and gums bleeding 13.8%. Significant reduction was observed in the bleeding episodes after the therapeutic intervention, and joints assessment and Euro-Quality-of-life Visual Analog Scale showed a significant improvement in health after treatment. Similarly, there was a remarkable reduction in bleeding episodes and improved quality of life among HA patients. The ABR decreased from 53.6% episodes per year prior to treatment to 2.4% during Emicizumab therapy. Prior to initiating Emicizumab therapy, participants exhibited an average FISH score of 16 and HJHS score of 10, indicating moderate limitations due to joint-related issues. After treatment, the mean FISH score improved to 9 and HJHS score to 4 reflecting a substantial enhancement in participants’ ability to perform daily activities ( P < 0.057). Conclusion: Our results showed that HA patients on prophylactic treatment with Emicizumab were less restricted and had improved quality of life due to marked decrease in bleeding episodes which resulted in improved health and social lives. In addition, it was well tolerated, and no participant discontinued treatment because of adverse events.

Background and objective Allogeneic hematopoietic stem cell transplantation (alloHSCT) provides curative treatment for several hematological illnesses. In this study, we evaluated the impact of ABO compatibility and incompatibility on outcomes and complications related to hematopoietic stem cell transplantation (HSCT) performed for various hematological disorders at our center. Methodology This was a retrospective, single-center, cohort study in which patients were categorized according to the ABO match and mismatch status. The mismatch group was further subcategorized into major, minor, and bidirectional groups. Results A total of 117 patients underwent alloHSCT, out of which 82 (70.1%) were male and 35 (30%) were female. The median age of the patients was 9.5 years (range: 46 years). The most common indications for stem cell transplant were beta-thalassemia major (BTM; n=58, 49%) and aplastic anemia (AA; n=42, 35.8%). However, the outcomes in match and mismatch groups showed significant results for positive direct Coombs test (DCT), indicating the occurrence of hemolysis. Despite the increased need for blood transfusions, ABO blood group incompatibility (ABOi) had no negative impact on the clinical results. Conclusion Based on our findings, ABO incompatibility does not affect the outcomes in patients undergoing alloHSCT. Patient monitoring can aid in early detection and treatment, thereby minimizing the frequency of fatal events.

Introduction: Prophylactic clotting factor infusion regimens to prevent bleeding and joint deformity has become the standard of care in severe hemophilia A patients. Aim: To assess low-dose factor prophylaxis in our population as an alternative approach to managing severe hemophilia A. Methods: A prospective cohort study that included 68 hemophilia A patients divided into two groups, i.e., Prophylaxis and on-demand. The two groups were compared for annualized bleeding rate (ABR), hospitalization, units of factor VIII (FVIII) infused, or plasma products transfused, i.e., fresh frozen plasma (FFP) and cryoprecipitate (CP), and development of FVIII inhibitors. Results: Of the 68 patients recruited in this study, 25 (36.7%) were in the prophylaxis group, and 43(63.3%) were in the on-demand group. The on-demand group presented a higher median-IQR ABR [8(20-3) vs. 5(10-1.5), p-value 0.024], several hospitalizations (39.7% vs. 0, p-value 0.001), and inhibitor development (9.3% vs. 0, p-value 0.289) compared to the prophylaxis group. The prophylaxis approach demonstrated a significant negative correlation of ABR with FVIII prophylaxis (r=-0484, p=value=0.014). Moreover, no hospitalizations or inhibitor development was observed in the prophylaxis group. The estimated annual consumption of FVIII was 328 IU/kg/year in the on-demand group and 1662.6 IU/kg/year in the prophylaxis group. However, a highly significant difference in plasma product utilization was observed between the two groups, i.e., p-value <0.001 and 0.038 for FFP and CP, respectively. Conclusion: Low-dose factor prophylaxis resulted in improved outcomes compared to on-demand treatment in terms of ABR, joint bleeding, hospitalization, and the development of inhibitors. This treatment approach should be adopted as an economically feasible alternative to high-dose Prophylaxis in resource-constrained countries.

Introduction: Aplastic anemia (AA) is characterized by pancytopenia and hypocellular marrow in the absence of an abnormal infiltrate or increase in reticulin fibrosis. The diagnosis of AA is challenging at times due to decreased cellularity and overlapping morphological features with other bone marrow failure syndromes. Hepatitis-associated aplastic anemia (HAAA) is a rare variant in which patients typically present with jaundice and hepatitis followed by pancytopenia almost within 6 months. Post-hepatitis AA accounts for approximately 1-5% of cases, and invariably such cases are negative for the known hepatitis virus as well. There is limited literature available to understand the correlation of AA with hepatitis with none reported at the national level in our region. As AA is relatively more prevalent in Southeast Asia as compared to the western world and hepatitis is a prevalent disease in our population, the main purpose of this study was to assess the hepatic profile and determine the association of hepatitis in AA at the time of diagnosis. Materials and methods: A cross-sectional study was carried out at the National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, from November 2019 to December 2020 after the informed consent from patients. The study included all treatment-naïve patients of acquired AA with no prior history of taking steroids, immunosuppressive treatment, or chemoradiation therapy. Liver function tests, complete blood count, prothrombin time (PT), and activated partial thromboplastin time were performed, along with viral profiles (HAV, Hep B, Hep C, and HIV). SPSS version 23 (IBM Corp., Armonk, NY) was used for statistical analysis. Mean and standard deviations were computed for quantitative variables while percentages and frequencies were reported for qualitative variables. T-test was used to observe the main difference between groups and a p-value <0.05 was considered to be significant. Results: Out of a total of 351 patients, 29 (8.2%) patients with AA tested positive for viral hepatitis. Hepatitis A was the most prevalent hepatitis (4.0%), followed by hepatitis C (3.7%). The comparison of platelet counts in patients with and without hepatitis was reported to be of statistical significance (p-value < 0.05). A significant statistical difference (p-value < 0.0001) was found in platelet count and PT in patients of AA with and without hepatitis. Conclusion: Overall, this study revealed that <10% of patients of AA had a positive screening for hepatitis A, B, and C and low platelet count, and PT was statistically significant when compared between the patients with and without hepatitis. Hepatitis being prevalent in our part of the world might have an important causal association with AA. Patients with AA should be screened for liver functions and viral hepatitis at the time of diagnosis. In addition to hepatitis A, B, and C and HIV, other causes of hepatitis should also be screened such as parvovirus B19, human herpes virus 16, and adenovirus which are not included in routine diagnostic viral testing panel.

Objectives: This study aimed to determine the impact of prognostic markers on the outcomes of Hodgkin lymphoma. Methods: It is a cross-sectional, single-center study. A total of 60 patients diagnosed with Hodgkin lymphoma were recruited for the study over five years between 2016 to 2020. The study setting was the National Institute of Blood and Bone Marrow Transplant in Pakistan. The Statistical Package for Social Sciences (SPSS) version 23 (IBM Corp., Armonk, NY, USA) was used for statistical analysis. Results: In the study population, 63.3% of the patients were male (38/60), and 36.7% were female (22/60). Hodgkin lymphoma was divided into four stages: stage I (18.3%), stage II (18.3%), stage III (46.7%), and stage IV (16.7%). Patients in stage III had a higher value of hemoglobin (Hb) than in other stages of the disease. The erythrocyte sedimentation rate was high in 56.7% of stage III patients than in patients of the other stages. The lactate dehydrogenase (LDH) levels were not under the normal range in 51.6% of patients. Only 20% of patients in stage III had LDH values within the normal range, whereas 26.6% did not. Conclusion: There was a significant impact of prognostic factors on the survival of patients with Hodgkin lymphoma.

Objective: The aim of our study was to find the frequency of Intron 22 inversion (Inv22) in severe hemophilia A (HA) patients and to evaluate the association between Inv22 and FVIII inhibitor formation. Method: Data analysis was carried out on IBM SPSS Statistics Version 23.00 (IBM Corp, Armonk, NY). Descriptive statistics were applied to measure the frequencies, percentages, and mean ± SD of the clinical and general history of HA patients, including age, family history, inhibitor status, intron22 inversion, and FVIII levels. Chi-square was applied to evaluate the association between Inv22 and F8 inhibitor formation. Results: A total of 62 HA patients were enrolled in the study with mean±SD age of (14.39±13.2) years. A family history of HA was observed in 36 (58.1%) patients. Out of 62 patients, 28(45.2%) were reported as Inv22 positive while inhibitor status was observed as positive in three (4.83%) patients. However, an insignificant association was observed between the inhibitor and Inv22 positive patients with a p-value=0.443. Conclusion: In our study, Inv22 was found to be the major cause of severe HA in our patients, i.e., 45.1%. However, no significant relation was computed between Inv22 and inhibitor formation.