Vincenzo Voi

Haemoglobinopathies are an increasing health concern in Europe due to changing population demographics. In Italy, however, newborn screening (NBS) for haemoglobinopathies is not yet included in the national mandatory screening panel. The primary aim of this study was to estimate the prevalence of haemoglobinopathies in a population-based neonatal cohort from the Piedmont region; a secondary exploratory objective was to characterise neonatal HbA₀ distribution and its association with molecular findings in selected samples. We conducted a retrospective, multicentre study of 2002 anonymised dried blood spot samples collected from term newborns 48–72 h after birth. Haemoglobin fractions were analysed by high-performance liquid chromatography (HPLC). HbA₀ distribution was characterised in newborns without structural haemoglobin variants using descriptive statistics. Molecular analysis was performed in an intentionally selected subset of samples with HbA₀ < 12%. HPLC identified 29 structural haemoglobin variants (22 HbS and 7 other variants), corresponding to a prevalence of 1.4%. After exclusion of these cases, HbA₀ distribution was analysed in 1973 newborns. Mean HbA₀ was 16.1% (SD 5.3), median HbA₀ was 15.5% (Q1–Q3: 12.3–19.1), and the distribution showed moderate positive skewness. Overall, 448/1973 newborns (22.7%) had HbA₀ < 12%. Among 12 selected newborns with HbA₀ < 12% who underwent molecular testing, detectable β-globin gene mutations were identified in five. DNA extracted from stored dried blood spots was suitable for molecular analysis. Structural haemoglobin variants were identified in a non-negligible proportion of newborns in this Northern Italian cohort. HPLC provided effective first-line identification of the variants observed, whereas neonatal HbA₀ showed substantial variability and an asymmetric distribution, supporting cautious interpretation of fixed absolute thresholds for suspected β-thalassaemia carrier status. Larger, systematically genotyped cohorts are required to assess the diagnostic performance of candidate HbA₀ thresholds.

Sickle Cell Disease is among the top 20 causes of mortality worldwide. Hydroxyurea is one of the most readily available and economical solutions approved for the treatment of Sickle Cell Disease patients: it induces the synthesis of foetal haemoglobin and decreases the inflammatory phenotype. Hydroxyurea shows high interindividual variability, re-quiring individualized dosing to balance therapeutic efficacy against escalating toxicity. In addition to non-genetic factors, hereditary variables can also be investigated to adopt a more tailored dosing regimen according to each patient's demographic, pharmacokinetic and pharmacogenetic profile. This study evaluated the possible influence of different genetic variants on hydroxyurea pharmacokinetics, by conducting a retrospective analysis on 79 treated patients, stratified by ethnicity, age and sex. SLC22A3*698 C>G variant was found to be the most significantly associated with an en-hanced function of the encoded transporter, improving the drug elimination process. ABCB1 1236 C>T, ABCB1 2677 G>A, ABCB1 3435 C>T, CYP2B6 516 G>T, CYP2C19*2 G>A, CYP2C9*3A A>C, CYP2D6*10 A>G, MAP3K5 13257 C>T, MAP3K5 6292 C>A and OCT1 480 C>G gene variants were instead found linked to a general loss-of-function phenotype, reflecting slower and less efficient drug metabolism. These findings demonstrate the importance of assessing hydroxyurea pharmacogenetics while taking into account different ethnic and demographic variables, in order to support a more personalized and effective therapeutic approach for sickle cell disease patients.

Background: Children with sickle cell disease (SCD) are at increased risk of cerebrovascular complications, with elevated Transcranial Doppler (TCD) velocities predicting stroke. Reliable laboratory correlates of pathological TCD remain uncertain. This study applied machine learning (ML) to identify hematologic and biochemical predictors of abnormal TCD velocities in pediatric SCD. Methods: We conducted a retrospective analysis of 134 children with SCD (HbSS, HbSβ ⁰ , HbSβ ⁺ , HbSC) followed between 2015 and 2024. A Gradient Boosting Binary Classification model (H2O framework) was trained using demographic, hematologic, biochemical, and treatment variables. Model performance was evaluated using five‐fold stratified cross‐validation, assessed by the area under the receiver operating characteristic curve (AUC) and the precision–recall curve (AUCPR). Results: Across 3190 patient‐years, 447 TCD examinations were analyzed, of which 45 (10.1%) showed conditional or abnormal velocities (≥170 cm/s). The optimized model achieved an AUC of 0.776 and an AUCPR of 0.360, indicating moderate discriminative ability. Reticulocyte and neutrophil counts, hemoglobin, fetal hemoglobin, platelet count, and age were strong predictors, while ongoing therapy showed a protective effect. Conclusions: ML models offer an interpretable, exploratory framework to investigate associations with TCD findings in pediatric SCD, supporting hypothesis generation within guideline‐based care. The absence of systematic Internal Carotid Artery velocity assessment represents an important limitation of this analysis.

Objectives: To analyse demographic trends and decision-making patterns regarding prenatal diagnosis (PND) in couples at risk for hereditary haemoglobinopathies at the Thalassemia and Rare Haematological Disease Centre in Turin over a 40-year period. Design: Retrospective observational study analysing demographic and clinical data from 1983 to 2023. Setting: Tertiary care genetic service Centre in Orbassano (TO), Northern Italy. Participants: Couples seeking genetic counselling and PND for hereditary haemoglobinopathies. Selection criteria included couples at risk of having children affected by β-thalassaemia major or Sickle Cell Disease (SCD). Main outcome measures: Primary outcomes included acceptance rates of PND and pregnancy termination (TOP). Variables analysed included couples’ age at first consultation, age at first PND, birthplace, employment status, specific haemoglobinopathy risk and number of pregnancies. Results: The analysis identified three main factors influencing PND and TOP decisions: nationality, type of haemoglobinopathy risk and number of previous pregnancies. Age showed no significant correlation with decision-making patterns. The impact of education level and employment status could not be definitively determined due to unavailable or unfit data. Conclusions: The 40-year analysis of prenatal diagnosis for haemoglobinopathies in Turin shows evolving trends influenced by immigration patterns, improved medical treatments and cultural factors, leading to increased acceptance of affected pregnancies in recent years, particularly after 2015, due to better disease management and comprehensive healthcare support. This comprehensive analysis of our centre’s experience provides valuable insights that can serve as a model for similar institutions worldwide in supporting couples through carrier screening and PND processes.

Background. Children with sickle cell disease (SCD) are at risk for cerebrovascular complications, with abnormal transcranial Doppler (TCD) velocities serving as predictors of stroke. Reliable laboratory correlates of pathological TCD remain uncertain. This study applied a machine learning approach to identify hematologic and biochemical predictors of abnormal TCD velocities in pediatric SCD, aiming to improve risk stratification and clarify underlying pathophysiologic mechanisms. Methods. We conducted a retrospective study including 133 pediatric SCD patients (HbSS, HbS/β ⁰ , HbS/β ⁺ , HbSC) monitored between January 2015 and March 2024. A Gradient Boosting Binary Classification (GBbinclass) model was implemented using the H2O framework on the complete dataset, including demographic, hematologic, biochemical, and treatment variables. Model performance was evaluated by five-fold stratified cross-validation. Predictive accuracy was assessed by the area under the receiver operating characteristic curve (AUC), area under the precision–recall curve (AUCPR). The Shapley additive explanations (SHAP) method was used for visualizing model characteristics. Results. During 3190 patient-years of observation, 447 TCDs were analyzed, of which 45 (10.1%) showed pathological velocities (≥170 cm/s). The optimized model achieved an AUC of 0.776 and an AUCPR of 0.360, indicating moderate discrimination and improved precision relative to baseline prevalence (0.11). Reticulocyte and neutrophil counts, hemoglobin, fetal hemoglobin, platelet count, and age were the most influential predictors, while ongoing therapy exerted a protective effect. Conclusions. This exploratory study supports the feasibility of machine learning to model cerebrovascular risk in pediatric SCD, offering clinically interpretable insights that may complement standard screening and guide individualized prevention strategies.

Background: Hydroxyurea is approved for the treatment of paediatric and adult sickle cell disease patients. It causes the synthesis of foetal haemoglobin and decreases platelets and granulocytes, but with a high interindividual variability, requiring higher dosages and escalating toxicity. Hereditary variables should be investigated to personalise treatment. We evaluated the possible influences of OCT1 and MAP3K5 gene polymorphisms on hydroxyurea pharmacokinetics. Methods: We conducted a retrospective analysis on 79 treated patients. The polymorphisms of OCT1 (rs683369 G > C) and MAP3K5 (rs9376230 C > A and rs9483947 C > T) were genotyped. Results: Sub-Saharan patients with the OCT1 rs683369 GG genotype showed a lower drug half-life, compared to those with the GC genotype. In sub-Saharan paediatric female patients, the OCT1 rs683369 GG genotype was associated with a lower t1/2 than the GC genotype. Conclusions: The findings demonstrate for the first time how crucial it is to assess the pharmacogenetics of hydroxyurea by taking into account the two sexes in different groups. Additionally, the data were evaluated with consideration for ethnic groups and individually for adults and children. Pharmacogenetic studies could improve the clinical management of hydroxyurea.

Background: Hydroxyurea (HU), also known as hydroxycarbamide, is an oral ribonucleotide reductase inhibitor. In 1999, the United States Food and Drug Administration (FDA) approved HU for the treatment of sickle cell disease (SCD). Since then, it has become the cornerstone in the management of SCD patients, helping to reduce vaso-occlusive crises, acute chest syndrome, the need for blood transfusions, hospitalizations and mortality. There is considerable variability among individuals in HU pharmacokinetic (Pk) parameters that can influence treatment efficacy and toxicity. The objective of this work is part of a clinical study aimed at investigating HU Pk and determining the optimal sampling time to estimate the Area Under the Curve (AUC) in SCD patients. Methods: HU plasma concentration in 80 patients at various time points (2, 4, 6, 24 h) following a 48-h drug washout was quantified using High-Pressure Liquid Chromatography (HPLC) coupled with an ultraviolet (UV) detection method previously described in the literature and adapted to new conditions with partial modifications. Results: The mean HU administered dose was 19.5 ± 5.1 mg/kg (range: 7.7–37.5 mg/kg). The median AUC quantified in plasma patients was 101.3 mg/L/h (Interquartile Range (IQR): 72.5–355.9) and it was not influenced by the weight-based dose. However, there was a strong positive correlation between AUC and Body Mass Index (BMI) as well as dose per Body Surface Area (BSA). Along with a three-point approach for AUC determination present in the literature, we show results obtained from a four-point sampling strategy, which is more useful and effective for better optimizing dose escalation to the maximum tolerated dose (MTD). Moreover, we observed that most patients achieved the maximum HU plasma concentration two hours after drug administration, regardless of age differences. Conclusions: HU treatment, which represents a milestone in the treatment of SCD due to its ability to reduce disease complications and improve patients’ quality of life, requires careful monitoring to optimize the individual dose for saving potential side effects and/or adverse events.

Background Despite several publications covering patients from multiple centers, no international registry covered all patients with red blood cell diseases (RBCD) affected by COVID-19. The ERN-EuroBloodNet’s registry provided real-time registration of SARS-CoV-2 patients with RBCD, promoting timely disease-specific knowledge sharing during the pandemic’s early stages. Procedures The study evaluated patient distribution, the infection across different RBBDs, and severity risk factors across similar healthcare systems, using data collected from the ERN-EuroBloodNet’s REDCap platform. Results From April 2020 to April 2023, 681 infections were recorded among 663 patients, of which 373 had transfusion-dependent thalassemia or non-transfusion-dependent thalassemia (TDT/NTDT), and 269 had sickle cell disease (SCD). SCD patients had a higher incidence of COVID-19 than those with TDT/NTDT (10.5 vs. 4.8 COVID/100 patients). Notably, 92% of the cases were mild, with neither age nor the specific RBCD affecting severity. The number of comorbidities, notably obesity and hypertension, that patients had prior to infection was associated with more severe COVID-19. During the infection, the presence of vaso-occlusive crises, acute chest syndrome, kidney failure, and ground-glass opacities on chest tomography scans were associated with a more severe clinical picture. The vaccination rate (32%) mirrored that of the general population and showed a protective effect against severe COVID-19. The observed mortality rate was 0.7%, aligning with Europe’s general population. Conclusion: SARS-CoV-2 infection in SCD and TDT/NTDT patients is mild and without higher mortality than the general population. The ERN-Eurobloodnet’s registry collaborative structure exemplifies the power of international cooperation in tackling rare diseases, especially during health emergencies

Background. Hemoglobinopathies, among which thalassemic syndromes (transfusion-dependent and non-transfusion dependent thalassemias) and sickle cell disease (SCD), are the most widespread monogenic diseases worldwide. Hemoglobinopathies are endemic and spread-out all-over Italy, as result of internal and external migration flows. Nowadays, the increase therapeutic options associated to the general aging of patients with hemoglobinopathies related to the improvement in clinical management, contribute to the abnormalities in kidney function going from blood and urine test alterations to chronic kidney disease and end stage renal disease. Methods. Here, we carried out a revision of the literature as panel of recognized experts in hemoglobinopathies with the consultancy and the revision of two nephrologists on kidney alteration and kidney disease in patients with TDT, NTDT and SCD. This is part of the action of the Italian society for the study of thalassemia and hemoglobinopties (SITE). The purpose of this “good practice (GP)” is to provide recommendations for follow-up and therapy for the management of kidney alterations in patients with TDT, NTDT and SCD. The literature review covers the period 1.1.2016 to 31.12.2022. In consideration of the rarity of these diseases, the analysis was extended from 5 to 7 years. Moreover, in the absence of relevant scientific papers in the identified time frame, we referred to pivotal or population studies, when available. Finally, in the absence of evidence-based data from prospective and randomized trials, the authors had to refer to expert opinion (expert consensus) for many topics. Results. We generated question and answer boxes to offer a friendly consultation, using color code strategy and focused answers. Conclusions. The present GP will help in improving the clinical management, and the quality of care of patients with hemoglobinopathies.

Introduction: Avascular necrosis (AVN) is a severe complication of sickle cell disease (SCD) and involves principally the femoral head. Few data exist about the prevalence of lesions in other segments.Methods: In this cross‐sectional study, 42 children (20 males and 22 females) underwent a magnetic resonance imaging (MRI) of the spine, upper arms, and femurs. The primary outcome was to define the prevalence and locations of bone infarcts.Results: Forty‐two patients completed the study; the total median age was 11.9 years (interquartile range = 9.5–13.9). Eleven patients (26.2%) were positive for altered bone findings for a total of 32 lesions. Most of the lesions were in the humerus 17 (53.1%), 11 (34.4%) in the femurs, and 4 (12.5%) in the vertebrae. The median number of vaso‐occlusive crises (VOCs) was two and four for patients without and with bone lesions, respectively (p = .01). The annual rate of VOC is the best marker for the positive MRI (odds ratio = 82.6; p = .03), and it is correlated with the number of sites involved (p = .02).Conclusions: Our study highlights that the prevalence of skeletal lesions could be underestimated, and it provides the basis for clinical reasoning and tailored therapy in SCD children.